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NY Times Article Questions Value of Orthotics

Discussion in 'Biomechanics, Sports and Foot orthoses' started by CamWhite, Jan 19, 2011.

  1. CamWhite

    CamWhite Active Member

  2. Sounds all very normal and well written to me.

    Whats your concern Cam ?

    ps B Nigg Biomechanical Genius in my option worth nothing

    but I agree alot of Pods and other people who prescribe orthotics for a living might get upset by what they read, but there the one still "correcting" flat feet.
  3. CamWhite

    CamWhite Active Member

    I also thought the article was well written, and I found the research cited in the article to be quite interesting. My concern is that articles like this can cast doubt on the value of orthoses to those who might really benefit from them.

    Barefoot zealots are already using this article to bolster their argument that orthoses and padded shoes make the foot "lazy". Many consumers may read this article and purchase cheap OTC gel products at the grocery store, and assume they will provide the same benefit of expensive "custom" orthoses.

    Not everyone needs orthoses, and some professionals "over-prescribe" custom orthoses purely for personal profit. Sometimes it is merely a matter of finding the right shoe for the individual. Most people don't understand why they are in pain, and a trained, caring professional can provide the proper assessment and guide them to a solution that helps them alleviate their pain. My concern is that this article, while well written, casts doubt on the real value of professionals dedicated to the well-being of their clients.
  4. Just finished writing a lecture on "How foot orthotics work" which I shall be presenting in Portugal in a couple of weeks time. It addresses the same research results and problems that are discussed in the NY Times article. When I read the chapter in Niggs book on orthotics and inserts I thought some of the conclusions drawn were a little overstated. And some statements a little odd, for example: "Another surprising result was the reaction of individual test subjects with respect to the path of the centre of pressure (COP). We expected the full lateral insert to shift the COP path to the medial side" p.148. Really? I'd expect a lateral wedge to pull the COP laterally, not medially. Regardless, it pulled some medially and some laterally!!!
  5. Griff

    Griff Moderator

    I have read this article and also slight variations of it over the last few days. Unsurprisingly a lot of barefoot advocates are tweeting about it, and will no doubt pick tag lines from it to use as ammo in the future. That aside it's a good article -nothing less than we'd expect from Benno. No new information in it for those that read here regularly, but I'm pleased that this sort of information (e.g. orthoses don't 'realign' the skeleton, responses are subject specific etc etc) is now 'out there' for all to read. Makes a nice change from the same old **** being printed by Runners World every 4 weeks.
  6. Benno has been saying this stuff for over five years so it is nothing new. In speaking to Benno privately, he readily acknowledges that he knows orthoses work for many people. I think, however, this article was written with the "research bias" that "we don't really know how they work" angle, rather than the "clinician bias" of "we know that they do work better than anything else for many problems, but we really aren't sure of how they do work" angle.

    I had three people send me the link for this article privately yesterday.....sorry, I just can't get too excited about old information coming from a researcher that I know the work of very well. I wish they would have interviewed me for the article also to give a more "balanced" outlook on how valuable orthoses for treating a multitude of difficult-to-treat pathologies.
  7. Craig Payne

    Craig Payne Moderator

    The simple fact is that EVERY single outcome study, patient satisfaction study, randomized control and even the controlled studies has shown foot orthotics work; patients get better. When will those who think they don't actually come up with some evidence that they don't?
    I noticed that as well. Did you also notice how many of them have some sort of reading disability? They keep quoting the article as saying things that it did not say. Why do they keep doing that sort of thing for?
  8. DaVinci

    DaVinci Well-Known Member

    I read the article a day ago and too came across some of those comments. I had to go back and re-read the article as I did not remember it saying what some of them were claiming it said. I just do not get how some could be so blind as to interpret it the way they did. I guess they did it because they have an agenda and we know their track record in getting things wrong, so I guess it just continues. To paraphrase Tom Cruise "Swow me the evidence!"
  9. Mac

    Mac Member

    I decided to contact the author directly with a little constructive criticism.

    My opinion is that this article could and would mislead the public. Particularly regarding the following:

    1) What is an orthotic? With regards to Nigg's studies, many have used wedges, modified insoles and, to a lesser extent, custom foot orthoses (i.e. Mundermann). I suggested that several studies have been conducted since 2000 that have looked at the dynamic influence and have incorporated custom foot orthoses. Mundermann, Williams and our studies were all done by a collaboration between academia, industry and Podiatry/Physical Therapy.

    2) Send me the reference for the study that has reported that foot orthoses decrease musckle strength.

    3) If you want a really compelling story, let's talk about all of the types of devices available to the patient, let's talk about who is manufacturing what, and who is telling the truth about what they are manufacturing.

    4) Foot Orthoses are over-prescribed, and they are also under-prescribed for those who either don't have access to a foot care specialist or education on the provision of this modality is lacking in their community.

    5) As a Scientist, who does not have a financial interest in a Lab, we (as Biomechanists) are interested in figuring out how they influence dynamics. This is initiative is so we can figure out to design and build better devices.

    Much like KK, I feel the media has the responsibility to present a balanced story that discusses the relationship between clinician-industry-academia. All have their limitations.
  10. Craig Payne

    Craig Payne Moderator

    Mac - did you get a response?
    Only two studies have looked at this. One showed an increase and the other showed no difference. Why do we keep reading that foot orthotics weaken muscles?
  11. DaVinci

    DaVinci Well-Known Member

    Paynie, you know the answer: Those with an agenda never let facts get in the way of their propaganda!
  12. Mac

    Mac Member


    Yes, I received response. And I have since responded to her response: Here's response #1:

    Thanks for writing. It is unfortunate that shoe inserts and custom orthotics are so often just called "orthotics" but the point of my column was that the science behind orthotics and their effects on injuries does not yet support the widespread belief that orthotics can correct biomechanical problems and that will reliably prevent injuries.

  13. Craig Payne

    Craig Payne Moderator

    So why does every single outcome study, patient satisfaction study and randomised controled trial show that people get better with foot orthotics? Why does not one study show that they do not get better. Journalist need to do a better job than that. What is the agenda driving this article?
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  15. Craig Payne

    Craig Payne Moderator

    No sooner than I write that, there is a third study published. It showed foot orthotics increased peroneal activation. I would love for those who are claiming foot orthotics weakens muscles to explain how remotely an increased activation of a muscle with the use of foot orthotic could lead to a weakness.
    Here is the study:
  16. Jenene Lovell

    Jenene Lovell Active Member

    all i want to say is... Go Craig!! I do like reading your posts, and how they are always backed by research.
  17. markjohconley

    markjohconley Well-Known Member

    hear, hear Mac
  18. efuller

    efuller MVP

    Except for the above I thought it was well written. In my experience when muscles work harder they get stronger not weaker.

    I'll show my bias by saying that those on the arena have a better understanding of how orthotics work. I'm not so sure about the average podiatrist that muddled through neutral position theory when they were in school and haven't read anything since. So, it might be true that most podiatrists have no idea how they work.

  19. In the book, he draws two conclusions: that if muscle activity is reduced by orthotics, it could result in weakness; if muscles activity is increased by orthotics then they may be useful as a training aid. Which is fair enough. However, if memory serves the references he cited to draw those conclusions all showed an increase in the activity of the muscles tested. Do we know if muscle activity is reduced by orthotics?
  20. Here you go:
  21. podcare

    podcare Active Member

    Most Podiatrists in 2011 are not trying to "correct biomechanical defects". Most will try and redirect ground reaction forces to accommodate for structural problems contributing to musculoskeletal symptoms and overuse injuries.

    Two major tools we have at our disposal include orthoses and exercises. Most Podiatrists would use these tools every single day within their practice.

    I, personally, use force altering devices (including orthotic appliances) to assist people with symptom relief. The body is dynamic and these forces require tweaking from time to time which may explain why the author's friend, Jason, at the NY Times received such varying opinions.

    I personally think the article displays a very limited viewpoint and understanding of what most Podiatrists are trying to achieve. It displays the viewpoint of one Podiatrist. I, personally, am not trying to correct flat feet. I'm helping patients to relieve symptoms and improve their health. I use orthoses to redirect biomechanical forces which contribute to injury. These orthoses accommodate for damaging biomechanical forces. I don't believe they correct biomechanical defects. However, the author seems to think correcting perceived biomechanical defects is our primary goal.

    This is an article with a clear bias. It would have been nice to see a more balanced report within the article with viewpoints from Kevin Kirby, Craig Payne and the like.
  22. krome

    krome Active Member

    I would like to put across my views of this newspaper cutting. I must emphasise to colleagues that this is a newspaper story, it is not a peer-reviewed publication so some information produced needs to be carefully synthesised.

    It is quoted in the newspaper that BN undertook a critical review. In fact, BN was asked to ask for his comments which we included into the review. Most, in fact all of the review was undertaken by colleagues here in New Zealand and only included articles up to 2007. The newspaper quotes:
    “In one recent review of published papers, Dr. Nigg and his colleagues analyzed studies on orthotics and injury prevention. Nearly all published studies, they report, lacked scientific rigor.”
    However, the summary from the article (Hume P, Hopkins W, Rome K, Maulder. P, Coyle G, Nigg B (2008): Effectiveness of foot orthoses for treatment and prevention of lower limb injuries: A systematic review. Sports Medicine 38: 9: 759-779):
    “The effects of FOs for treatment of pain or injury prevention were mostly trivial. FOs were not effective in treating or preventing patellofemoral pain syndrome. Some studies showed moderate effects for treatment of plantar fasciitis. Only a few studies showed moderate or large beneficial effects of FOs in preventing injuries.
    Customized semi-rigid FOs have moderate to large beneficial effects in treating and preventing plantar fasciitis and posterior tibial stress fractures, and small to moderate effects in treating patellofemoral pain syndrome. Given the limited randomized controlled trials or clinical controlled trials available for the injuries of interest, it may be that more or less benefit can be derived from the use of FOs, but many studies did not provide enough information for the standardized effect sizes to be calculated. Further research with randomized controlled trials is needed to establish the clinical utility of a variety of FOs for the treatment and prevention of various lower limb injuries.”

    As you can see the newspaper cutting does not reflect our summary.

    In summary, I believe there is very strong evidence to support the use of FOs across a range of conditions that include long term chronic foot conditions.
  23. An enjoyable article which raised a few questions for me.

    Firstly there is the issue of what is written vs what is read. Human brains are funny things, and in my experience things people say and write are much like orthoses. The effect they have are subject specific. One must consider not only what was written but what will be read!

    The headline of the article is

    The title of this thread is

    Having doubts about how something works is not the same as questioning its value. I don't know how my car works, but I know it does! Generally.

    As Ian said, one can just see the cynics leaping on this and overextrapolating it to death! But what is actually said is fairly innocuous. This may become one of the most misquoted writings in podiatry (after "that" liebermann study).

    The article, for me, does not question the use of orthoses, it questions the presumptions and mechanisms we use when prescribing them.


    I don't know where you work, podcare, but in my experience this is EXACTLY what most podiatrists are trying to do in 2011. The concept of making feet function in their normal, healthy, functional, sub talar neutral position rather than their nasty, bad overpronated position is alive and well, in spite of our best efforts to beat hell out of it. I can think of 3 of these for every tissue stress biomechanist, and I know a lot of tissue stressors. Not least because I've made them that way. I fear you are either optimistic or misinformed. Or perhaps its different on your side of the pond.

    To that end, anything which points and laughs at the emporers new clothes has some value in my view.

  24. Do you get a t-shirt that says

    I'm a tissue stressor made by Robert.;) ?
  25. You get a badge. These are hard times.

    My students can also be recognised by their haunted, haggard eyes a slight nervous tic and a violent stammer whenever they say a word beginning with over.
  26. Good idea though.

    Do I feel a pod arena competition coming on?;)

  27. blinda

    blinda MVP

    They also tend to be avoided by former friends and colleagues at conferences.....no idea why.
  28. Speaking of load-deformation curves.....my question is....even though load-deformation curves have been around for well over a half century, why was I never taught about the load-deformation curve during my four years of podiatry school, during my year of surgical residency and during my year of biomechanics fellowship?!

    I now introduce the load-deformation curve, elastic deformation mechanics, plastic deformation mechanics, stress-strain, viscoelasticity and their importance to the second year podiatry students at the California School of Podiatric Medicine and they don't seem to have a problem understanding their basics. The mechanical significance of the load-deformation curve is probably one of the more important concepts to understand for the clinician treating musculoskeletal injuries on a daily basis......other than, of course, "foot typing"!NOT!!

    I suppose it was more important to teach us, when I was a second year podiatry student, how to calculate the subtalar joint neutral position by giving us the total range of motion of the subtalar joint and then dividing by three........:bang::wacko::dizzy:
  29. Griff

    Griff Moderator

    Do it! It could be up there with such gems as the demotivational posters or the graphjams.
  30. TedJed

    TedJed Active Member

  31. Until researchers realize that reducing the abnormal internal stresses that occur from the maximally pronated position of the subtalar joint is one of the largest positive kinetic effects of foot orthoses, and also that the "corrective" action of the orthosis may actually involve no kinematic changes in rotating the foot out of the maximally pronated rotational position of the subtalar joint, we will continue to have researchers failing to understand the true function and therapeutic potential of custom foot orthoses.

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