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The Genesis of the Foot Orthotic Consensus Project

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Craig Payne, Jul 28, 2009.

  1. Craig Payne

    Craig Payne Moderator


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    Re: Foot orthoses: how much customisation is necessary?

    {ADMIN NOTE: The posts below have been split off from the thread: Foot orthoses: how much customisation is necessary?}

    This thread started with a challenge from an Editorial Written by Hylton:
    He continued the challenge:
    ...and again in response to posts:
    Others chipped in:
    I added:
    and then:
    to which Hylton responded:
    Kevin responded:
    Phil responded:
    Lets take up the challenge.

    Here is what I propose:

    1. Can we agree with my statement above in 101047 (or a modified version of it):
    2. I will set up a sub forum here at Podiatry Arena specifically to discuss a consensus

    3. If and when we agree on something to start from (I using my suggestion above as an eg), we then use that subforum to go through all the different clinical tests that can possibly be done that are used to derive prescription variables. We can look at the evidence; the anecdotes; the rationale; etc etc to see if we can arrive at a consensus on that clinical test indicating a particular prescription variable. If no consensus can be reached, then we note that and where the differences are.

    4. Once we gone through all the clinical tests we come up with, we can then work our way through all the different design variables and what the evidence; rationale; theory; anecdotes; indications are for each of them to reach a consensus. If no consensus can be reached, then we note that and where the differences are.

    5. I have registered a domain name and will set up a separate website to document the outcome of each discussion (with links back to the discussion, so modifications can be made to the consensus).

    What say you?
    Last edited by a moderator: Aug 10, 2009
  2. Re: Foot orthoses: how much customisation is necessary?

    Craig, I should very much like to be involved in this sub-forum. I've kept quite on this thread for reasons that will become apparent when the paper that I and others have been writing is published!
  3. Re: Foot orthoses: how much customisation is necessary?

    Great ides Craig and a logical development for the Arena. No reason other areas of clinical development and research can follow on a similar model. It just gets better....:drinks
  4. cpoc103

    cpoc103 Active Member

    Re: Foot orthoses: how much customisation is necessary?

    Craig will this be a seperate private forum? as I would like to follow the discussion.


  5. efuller

    efuller MVP

    Re: Foot orthoses: how much customisation is necessary?

    I will admit there are many parameters that people can look at. The working group that we are talking about can perhaps agree, or suggest, which ones are the most important. We can limit those somewhat by looking at what variable in the prescription orthotic is changed. (For example, I measure standing arch height and others measure the absence or presence of equinous. Some of those who measure equinous will cast the foot in a more pronated position, which lowers the height of the arch of the finished orthosis.) So, if two different parameters effect only one part of the finished orthosis (arch height) we may be able to narrow down the research.

    Once we choose a few parameters then we can move on to performing research. This is where the hard work comes in. Because there are many orthotic parameters we will have to do studies on large numbers of subjects to get trends, because some individuals will not get all of the prescription variables that an experienced clinician would add to that particular device. Or, perhaps, the subject could get two devices with many prescription variables the same on both except for one variable that changes. For example, an orthotic with all the bells and whistles with or without a medial heel skive.

    I'd like to be part of the group discussing the prescription variables.


  6. Re: Foot orthoses: how much customisation is necessary?

    It will interesting to see if we can actually develop a consensus with the widely divergent theories that are present within the podiatric profession . It all depends on who is on the panel. As long as we don't have widely diverging opinions on how the foot works, how foot orthoses work, how injuries in the foot and lower extremity are caused, and what the goal for foot orthoses should be, then we should be fine and a consensus should easily be developed. However, having seen many theories wax and wane during my practice career, it will be a very difficult task to come to a consensus unless we can all have some basic agreements regarding the function of foot orthoses and the biomechanics of the human foot and lower extremity (i.e. pronation is not the cause of all foot problems).
  7. Craig Payne

    Craig Payne Moderator

    Re: Foot orthoses: how much customisation is necessary?

    I have no doubt what I am proposing is going to be a challenge. It will be a subforum open to all. I will activly invite people who do not normally contribute here to participate.

    While I have no doubt in many areas there will be differences; but lets document those differences with a consensus as to the differences with a non-emotive statement.

    The challenge will be can we incorporate things like MASS position and functional foot typing into it? and non-emotively come to a consensus on it.

    The eg of how I hope this would work, is that for eg:
    Lets take the clinical test of 'supination resistance' as I think this would be an easy one to get consensus on. There is stuff published on its reliability; I have unpublished data on it (eg relationship to injury etc); I think we have a sound rationale for the test; I think we can get a consensus on this test.

    So the idea would be to have a discussion on this test, bring all the info and opinions we have on it together and reach a consensus --- then formulate a concise consensus statement (and this would go in the site that I will build to summarise this).

    For eg (and without prempting the discussion), the consensus statement would include something like the use of supination resistance testing to determine how much force is needed from the orthotic. This is what I kept meaning earlier on about using a systematic clinical assessment to derive the prescription variables. How much force is needed is the prescription variable.

    In a later discussion we can look at the design parameters to deliver that prescription variable and reach a consensus on that. eg if the decide the prescription variable of supination resistance is high, then the design parameter would be more rearfoot wedging. Assuming we first agree that this is the design parameter to deal with high supination resistance (especially in the context of the lack of evidence; but relying on a good rationale; good clinical expereince and consensus of opinion), we can then decide how best to deliver that design parameter ... or maybe not how best, but what are the options there are to deliver that design parameter (currently we have things like, rearfoot wedging a prefab; blake inverted; kirby medial skive; the DC wedge; the MOSI orthotic; etc) .... so you can see the challenge.

    The threads discussing each clinical test, prescription variable and design parameter can stay open indefinitily and the consensus modified as more experience, theory and evidence becomes available.

    Is this the way forward?
  8. Secret Squirrel

    Secret Squirrel Active Member

    Re: Foot orthoses: how much customisation is necessary?

    yes it is
  9. Re: Foot orthoses: how much customisation is necessary?

    I don't think it needs to be a goal of ours to include every casting technique or foot classification system invented by someone with a financial interest in it. in addition, our goal should not be to please everyone just because they have had some new idea. Our goal, should be, instead to work together to find a way to use the most common and accepted methods of evaluation and orthosis design techniques to arrive at optimum therapeutic design for foot orthoses.

    As long as the supination resistance test is understood as having its own set of limitations then this should present no problem. However, this test needs to be used in conjunction with the knowledge that the tissue stress on one part of the foot/lower extremity will be increased when the tissue stresses are decreased by using the results of this test to design the optimum foot orthosis for the patient.

    Possibly.....should be interesting to see how much fur flies in the process!:eek::boxing:
  10. admin

    admin Administrator Staff Member

  11. efuller

    efuller MVP

    Re: Foot orthoses: how much customisation is necessary?

    As I see it we don't necessarily have to create a unified theory of foot biomechanics. We have to create individual tests and then look to see if modifications to orthoses in response to those measurements improve outcomes. For example, we have a foot with a high force needed to cause supination. We then change the heel cup of the orthosis to a more varus wedge shape and assess if that is better than a heel cup without a varus wedge.

    As I understand MASS there is no underlying measurment parameter. Everyone is supposed to get casted that way. I know from personal experience that everyone should not be casted this way. I would suggest that if there is a large change in MASS arch height to standing arch height then the MASS cast might be contraindicated. Another predictor of who will hurt when wearing MASS devices might be the lunge test. Which is a similar parameter to what Root, Weed, et al. were describing when they looked at equinus and then casted the foot more pronated.

    In the discussion on functional foot typing I've asked how the typing changes the shape of the finished orthotic and not gotten any ansers. If the orthotic shape is the same for each foot type, then there is nothing to study.

    I don't think we are going to get a consensus on every test from proponents of each theory. In my discussions with Ed Glasser he had a problem with adding a medial heel skive to a MASS casted device. I don't see where the problem is. If we come up with a parameter to test, we don't have to have everyone on board as to it being valid. If a study shows that a medial heel skive is better for people with posterior tibial dysfunction there is no reason that you cannot add that to your MASS casted device.

    It is a great way forward. We don't have to let consensus get in the way of promising ideas.


    Eric Fuller
  12. We should also attempt to list and ideally rank, methods of obtaining the required measurements, from the gold-standard (most valid and reliable), to the least valid and reliable.

    I hope that makes sense!
  13. I agree with Simon. I also believe we should rank the tests and measurements relative to their validity and reliability in designing foot orthoses and determining the patient's structural and functional orthopedic makeup.

    Possibly we could rank the test/measurements at three levels:

    Level A: Tests/measurements with the best validity and reliability.
    Level B: Tests/measurements with midrange validity and reliability.
    Level C: Tests/measurements with the least validity and reliability.

    We should also precisely and specifically describe what these tests and measurements should be used for (and maybe also what they should not be used for).

    For example:

    Subtalar range of motion: To determine the frontal plane range of motion within the subtalar/ankle joint complex. This measurement may be used by the clinician to help identify asymmetries within the range of motion and/or whether adequate range of motion is available for normal gait function within the subtalar/ankle joint complex.

    Supination resistance test: To determine the force required to initiate supination of the rearfoot by manually exerting a lifting force to the plantar aspect of the medial navicular. This test may be used by the clinician to identify the resistance of the rearfoot to supination which may be used to estimate either the amount of internal force that the posterior tibial muscle would need to initiate supination of the rearfoot or the amount of external force a foot orthosis would need to initiate supination of the rearfoot.
  14. But first we need to identify what the prescription variables for foot orthoses are, so we can then determine which tests relate to which prescription variables. Time for a new thread me thinks...
  15. Adrian Misseri

    Adrian Misseri Active Member

    G'day everyone,

    This sounds to be a brilliant step forward in bringing together podiatric biomechanics and orthoses prescription in a clinically relevant way. Kudos Craig! :drinks

    May I make a small suggestion as to the format, and can we structure each idea/concept/vaiable/objective test etc. in a systematic review format. i.e pick up on Kevin's idea of quantifying the reliabilaity/validity, and have a grading system, such as one may fing in a systematic review of the literature/guideline paper. This will count for the type of available evidence, as well as the quality of the evidence. Of course this is going to be difficult, as the published evidence for biomechanical practices/tests is, at times, sketchy, and there is a vast amount of grey literature (Craig has already stated that he has unpublished literature on supination resistance test), and an enormus amount of undocumented clinical experience which will prove of immeasurable value.

    Do we need to agree on a heriachy of evidence structure and a qualitative assessment tool for the evidence supportingteh conclusions of this project? Do we go witha published one, or do we, granted that we are going to have a lot of evidence further down on the heirachy of evidence ladder, establish our own heriachy of evdence and qualitative assessment tools?

    This is a huge task, and a brillinat idea, and it seems that there are a lot of people keen to make a goer of this, so why not look at producing some sort of guideline with the relevant evidence backing?

    Looking forward to getting involved in some fascinating ideas and a huge step forward!
  16. Chris Gracey

    Chris Gracey Active Member

    From Spooners' Thread...

    I'd like the psychedelic Tissue Stress black light poster please! 19.95 available exclusively through Podiatry-Arena...

    Bruce has the right idea. Sounds like we're developing a protocol and after all, you have to begin with a particular school of thought and what is considered WNL for the foot within that doctrine. Classify Bone vs. soft tissue. Then derive a Dx based on that thought using known tests and measures that will adhere to that ideal. Throw out the ones that do not mesh with that particular philosophy. What are the possible outcome measures? Are you looking to improve ROM? Reduce pain? Subjective reports of comfort? Which orthotic elements will bring about the desired change? Which methods of fabrication should be used to produce those elements? Which retest is best to determine structural/functional outcome?
    Did it work? Yes. You're done. No. Where to flow back to? Philosophy? Dx? Fabrication? etc.

    1) Define the Ideology
    2) Define Fields
    3) Define Items within those fields
    4) Define a method for prioritizing items to go in fields
    5) Propagate defined fields with defined items
    6) Define outcomes
    7) Define tests for outcomes (True/False, +/-, Worked/Didn't work, etc)
    8) Define true/false weight in the case of multiple scenarios (did this, but not that)
    9) Determine level of target field to return to in case of False based on weighted priority.
    10) Run a feasibility study, get it published in the literature to disseminate it to the masses.
    11) It goes to 11! So put on some Grateful Dead (2/11/70 Filmore East comes to mind) Turn out the lights and just smile, smile, smile!

    So, to make this more tangible, I propose we design a flowchart using 1 school of thought. Work it to completion and make the mistakes we are going to make on that one. THEN, we can introduce a new Philosophy and plug it into the system. Most of the work is already done so we should have a foot orthotic consensus in no time!
    I volunteer to design an Excel Spreadsheet but since I'm new, perhaps it's inappropriate. I'll bet someone else already has one.

    Peace and Props,

  17. Graham

    Graham RIP


    I'm not keen on working with any school of thought. We need to examine measurable and testable parameters. See which are valid and reproduceable and which can be shown to have a certain reliable effect when applied to a foot orthoses.

    I would fully expect us to disagree as to theory why things happen and why things work, but at least agree to what is a valid test and measure and what it's effect will be when applied to a foot orthoses.
  18. Agreed. Sounds like some people are hoping for a cook-book approach to foot orthoses to come out of this. We've been there... I think Craig needs to decide what this is about, where it is going, and who should be involved. At the moment, its a mess with anyone and everyone attempting to jump on the bandwagon and steer this to their own ends. I'm backing off this for now.
  19. Chris Gracey

    Chris Gracey Active Member

  20. Like Graham said, I don't think we should necessarily pidgeon-hole ourselves into using only one treatment paradigm if we are to produce something useful for our profession. Since the vast majority of the tests and measures we use on a daily basis have not been subjected to adequate reliability and validation trials, I would suggest that if these tests and measures are listed as ones that the clinician could use, we also classify the test with Level A, B, and C as I suggested earlier. In this way, if the clinician wanted to use a test/measure that had not been shown good reliability or validity, then they would be doing so being fully aware of the limitations of that test/measure.

    One other benefit of grading the tests/measures in regard to reliability/validity is that it may give some of our younger research-oriented podiatrists the motivation to do research on the tests/measures that have had the least research devoted to them so that, over the coming years, we will hopefully start to develop a much better idea of which tests/measures are, indeed, the best to perform for our patients. Certainly this will be much better than the current system where everyone has their favorite tests/measures but no one has sufficient research behind their favorite tests/measures to conclusively show that their tests/measures are any better than anyone elses.

    I believe, that if this project is done right, then it could end up being a very important one for the foot-health care professions for generations to come.
  21. Chris Gracey

    Chris Gracey Active Member

    Me Too! But only if a method of guidance is borne of it. You will have this ranked list. It is necessary and I applaud your design. Who is to say the most valid is necessarily the most clinically appropriate for a particular patient? Well, by ranking them and dissiminating them, those of the project are. Then, how will you guide the user in their decision making? Additionally, how will this impact the vast orthotic options available to choose from? You could call it " The Unified Theory" or "The Reliability and Validity Doctrine of Foot and Ankle Care", but right now, students are learning the current philosophies. And they are going to use those philosophies in their clinical decision-making. If you do not tie this into what the kids are learning and wait for osmosis to take effect, I fear we will wait a long time before we find out which one works and why.

    The root of civilization is found in it's ideology. An Ideology is a set of ideas proposed by the dominant class of a society to all members of this society. (Sound familiar?) Don't you see what this project is proposing? Even if you do not address it, or proclaim it, or agree or believe it is so, it still exists. If all you are proposing is the list, it is worthless if not taught. Even If you solely base your rank decisions on the research, it is still an ideology. Someone has to teach it. Someone also has to believe it is so. I'm only suggesting we not throw the baby out with the bathwater, and bear in mind where these tests, device elements, and clinical decision-making methods came from.

    Please don't get me wrong. I'm not suggesting we promote this as a new philosophy or only keep to one school of thought. I'm asking that we organize the items, ranked as you suggest (A,B,C), and tagged with their corresponding known theories and where there is no known theory, it goes in the "wild card" pile...or something...so that a Doc can be led by multiple theories and NOT just one, within each ranked field. This way, we won't have to provide the guidence, the multiple theories will.

    Look, read at least the first two paragraphs of this editorial (hopefully the whole thing) and begin to truly see the impact a study like this could make:


    With much respect, and a promise to go away for awhile if I don't get a shout out,

    Last edited: Aug 21, 2009
  22. Graham

    Graham RIP


    Regardless of our theoretical bias we are all using the same measures and tests just interpreting them diferently. We can't put the cart before the horse. The research question has to be broken down to its simplist form. Currently we do not know the reliability, validity and repeatability of the tests and measures we use. We have to know this before we can look at the effect of their application.
  23. Another way of approaching this is to work backward from the end-product, i.e. the foot orthosis (whatever that is). Once we know all of the possible design permutations and their mechanical effects we can look at what clinical tests are needed to define them and the pathologies they might be useful for. Some tests may not even exist yet.

    For example, if we take Roberts suggestion of dividing the foot orthoses into segments we have the superior surface of the shell, which we can divide into probably nine areas:

    Heel Area Lateral
    Heel Area Central
    Heel Area Medial

    Midfoot Area Lateral
    Midfoot Area Central
    Midfoot Area Medial

    Metatarsal Area Lateral
    Metatarsal Area Central
    Metatarsal Area Medial

    The inferior surface of the shell could be similarly divided.

    Then the Forefoot extension area.

    So what are the design prescription variables that fit into each area?
  24. Chris Gracey

    Chris Gracey Active Member

    Data which seem to be in poor agreement can produce quite high correlations.

    I understand your point of view. Thank you for the discussion, it was worthwhile.

  25. Graham

    Graham RIP


    Which comes first? The chicken or the egg?

    I always thought it was the chicken because eggs can't!

    I'm quite happy to leave those sort of decisions to you and the other accademics here. It's a complicated business but a lot of fun:drinks

  26. I guess I'm reverse engineering from the end product. All orthoses have mechanical properties which are defined by their morphological characteristics. If we assume orthoses work via mechanical effects, then we have to understand how changing their morphology changes their mechanical effects if we are to learn how to control these effects. Clinical tests should be employed to dictate the morphology of our orthoses, but if we don't understand the mechanical effects of morphological variation of orthoses... We're pissing in the wind.
  27. Graham

    Graham RIP


    That makes a lot of sense. thankyou.
  28. I think you'll be pleased to hear that I believe the answer lies partially with in-shoe measurement of kinetics at the foot-orthosis interface:drinks. But don't get too excited, there a whole host of issues that need to be overcome first.:bash:
  29. Now that we have enough research and work proposed within this thread to last at least a lifetime, maybe we should try to propose one project that we can complete within a year.:drinks
  30. The question is, who's going to do it and (unfortunately) more importantly who's going to fund it?

    In my opinion, what's needed is some good quality FEA. I've tinkered with this, but my FEA software is a little too limited to really do it justice. I'd love to be able to do more, but can't justify purchasing the required software for the love of it. Indeed, I still have to do the day job to pay the rent.
  31. My problem is the time. It seems every week or two that I am needing to turn down little projects here and there that could easily occupy all my time. I am at a time in my career where I need to be very selective in what I will volunteer for so I hope that if and when this project starts, I will be able to help if Craig needs it.
  32. Craig Payne

    Craig Payne Moderator

    This thread and the other current one show the complexity of the task ahead.

    I have had some off line dialogue on moving this forward. A number of us are to be in Atlanta in early October, so its a good chance to meet and discuss the issues before moving forward.
  33. Sorry, Craig, this will be the first one of the PFOLA seminars that I won't be lecturing at or attending. I already had committed to lecturing at Don Green's San Diego Podiatry Institute seminar the same weekend. I heard the attendance at this year's PFOLA so far isn't great...maybe the economy?
  34. I won't be there either :-(
  35. Charlie Baycroft

    Charlie Baycroft Active Member

    Hi All. I got a message that I had not posted for a while and thought that I would risk offending someone by adding some comments to this thread.
    IMHO. One of the basic things that needs to be addressed is the definitions of the terms that are being used.
    Just what is a foot orthosis? At the moment all manner of insoles, plain or customizable in theory (most) or reality (some) are being labelled and even patented by Podiatrists as foot orthoses. It seems to me that we are at a point in time when the term foot orthosis is has actually become a "synonym" for insole or "arch support".
    I tend to like the definition proposed by Collins et al which relates the use of the term foot orthosis to a device that has desirable effects in relieving or preventing pain, deformity or disability and most importantly actually improves and enhances the function of the foot and lower extremity. Is any shoe insert that does not provide such benefits to an individual (regardless of marketing claims, method of prescription or manufacture, theoretical basis or cost) worthy of being called a foot orthosis?

    It also seems to me that most of the studies of efficacy only deal with relief of pain and this is not the proper determinant of efficacy. Tissue stress theory and practical experience incline me to believe that almost any alteration of the surface beneath the foot can produce direct and indirect mechanical and neuromotor effects that are likely to randomly alter the forces acting on the site of a patient's pain and produce at least temporary relief. It is also not uncommon for a patient to have one pain relieved by a device and subsequently get another pain because of the device.
    One should also ask how to classify expensive hard devices that are impossibly uncomfortable for the patient to wear. Are these worthy of the name custom foot orthoses or should the prescribers come clean and refund the poor poor patient their money on the basis that what was actually provided were unsuitable insoles?

    If we are going to define foot orthoses that enhance the function of the foot and leg then we should begin by reaching consensus on just what functions of the foot and leg we want to enhance and how we can clinically determine that the therapy provided has actually enhanced said functions.

    I suggest that we use the model that Panjabi proposed for the function of the segments of the spine and consider foot function in terms of passive, active and neural components, which can actually be clinically assessed. Such elements of function are accepted by other professions who deal with musculoskeletal medicine and there are clinical methods of assessing lower extremity function in terms of these three subsystems.

    A further thought is that according to Benno Nigg and others the subjective perception of "comfort" is a reliable indicator of improved and efficient function just as pain and discomfort are common and reliable indicators of dysfunction. Should we include in our definition of a therapeutic foot orthosis that it is is device which the wearer perceives as comfortable?

    Just in case it is not obvious from the above that I have no idea at all what the outcome of a consensus view of therapeutic foot orthoses could be I am clearly admitting that I do not know the answer but do encourage the process especially in the light of the current confusion engendered by our current studies of efficacy and the potentially negative effects related to people's unsubstantiated marketing claims for their various types of insoles.

  36. I´m just wondering if anything was discussed at the PFOLA which I guess was a couple of weeka ago now.
  37. I should also like to know what, if anything, was discussed and with whom with regard to this at the PFOLA conference. Anything to report, Craig?
  38. Anything to report from the background dealings Craig ?
  39. Ian posted a link to the Consesus project on another post.

    It´s been a few months is there anything to report or was this a nice idea thats to big a project to start and ever finish ?
  40. Gordon@pier.com

    Gordon@pier.com Welcome New Poster

    hi to Craig and all.
    I am a newcomer to the site but impressed by the value of the majority of content.
    DISCLOSURE: I am the marketing consultant for a Major European [ highly technical] Custom footwear manufacturer.
    I am not here to advertise but to learn.
    During my initial investigations I was quite confused by the methods used by pod and ortho physicians to diagnose and prescribe corrective footwear and orthotics.
    I made appointments as a patient to study the process with the goal of establishing a standard that could be suggested as a model for our centres worldwide and supply credible data for our product manufacturing.
    First let me say that individual professional integrity is not in question. Only that in 5 appointments I was given variables that gave me a feeling that the prescriptions would be " an experiment" and the 2 castings that were made would have resulted in very different final prescriptions when studied by our technicians.
    I am extremely interested in following your progress and am also working with doctors and clinical professionals locally to document and standardize a process [and equipment] that feeds consistent data to our facility.
    with kind regards
    Gordon Robinson

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