Why Not Orthotics?

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As a practicing Podiatric Physician and researcher for over 50 years, I have had a passion for understanding the link between foot mechanics and overall body health. I can still remember my professor in biomechanics saying ‘the patient’s manner of walking not only affects the overall health of the feet, but also the overall health of the body’. At that time I did not fully appreciate how prophetic his statement was.

How the foot functions, referred to as biomechanics, is a major determinant in the overall wellness of the patient. From an engineering point of view, this is easy to understand. An unstable foundation can produce problems in the entire building. Likewise, an unstable (pronated) foot can produce problems in the entire body.

For years I attempted to stabilize foot mechanics by using a supportive type insoles (orthoses). These orthoses typically incorporated an arch support with forefoot posting (wedging). They were very effective for controlling foot, knee and low back pain, but at a very high price. Over the years, it became apparent to me that by supporting the foot I was weakening it (e.g., inner arch collapsed more and more). As long as my patients wore their orthoses, their body pain was less. However, their pain quickly returned when the orthoses were not worn. It appeared I was addicting my patients to their orthoses!

The link between foot function and musculoskeletal health can not be overstated. However, I recently discovered another important link between the foot and the body: Posture. My research indicates that a weak and unstable foot can and often results in postural distortions (poor posture). And these postural distortions occur in young children. It also became clear that postural distortions are a harbinger in the development of chronic body pain. The child with poor posture is the adult with chronic body pain.

In my pursuit to reverse and correct these postural distortions, I continued to use orthotics. The long term results were less then desirable: These orthotics definitely improved posture. However, when the orthoses were not worn, the postural gains were quickly lost. And alarmingly, in many cases, the posture appeared even worse when compared to pre-therapy photos. This suggested a disturbing link between supporting the foot and weakening the posture.

Obviously, a different approach in therapy was needed!



Above patient has a PreClinical Clubfoot Deformity. He was treated using traditional orthotics, a varus heel post and high rise arch support.

Note the deterioration (increased stance phase pronation) subsequent to the use of supportive orthotics. This is a similar occurrence when a cast is placed around the leg. The muscles atrophy.

 

The disappointing outcomes I experienced using Root Biomechanics motivated an investigation into alternative Podiatric interventions to resolve chronic musculoskeletal pain.

I published an online paper in 2011 discussing this alternative approach using insoles, not as a supportive device, but as a proprioceptive insole (analogous, in some ways, to reflexology). The results eclipsed my expectations.

• Rothbart BA 2011. Twisting Foot and Musculoskeletal Pain: Root's Biomechanical Model vs Rothbarts Neurophysiological Model. Positive Health, Issue 186, September.

 

What foot strengthening exercises do you recommend for patients with weakened foot muscles ?

 

Below is a postural evaluation using (1) Ks Italia insoles and (2) Rothbart Insoles. This patient has the PreClinical Clubfoot Deformity.

Postural Lean Test - baseline of comparison is no insoles

• Using Ks Italia insoles
  • pronation increased
  • forward body lean increased
• Using Rothbart Insoles
  • pronation decreased
  • forward body lean decreased

Ks Italia insole is a proprioceptive insole. It's counter indicated to treat a PreClinical Clubfoot Deformity.
Rothbart insole is a proprioceptive insole. It's designed specifically to treat the PreClinical Clubfoot Deformity.

 

Is foot/ankle muscle atrophy associated with proprioceptive deficits ? If so, how do you combat this in your treatment plans ?

If your insoles have a proprioceptive effect, is this effect as great with a weakened foot as it would be with a stronger ,less atrophied foot ?

Would foot strengthening complimented your insoles ?

 

The difference in design between Supportive Type Orthotics vs Proprioceptive Insoles

 

Proprioceptive stimulation how ? What's the functional difference between your non proprioceptive figure and your proprioceptive example . Where are the sensory organs located ?

 

Brian , assuming your insoles do help reduce pronation, have you considered that the mechanism by which they achieve this might be a simple mechanical one .
If you put a wedge under the hallux then, during midstance, surely there will be early engagement of the windlass mechanism, greater tension in medial aspect of the plantar fascia, and reduced pronation ?

 

If you have questions regarding:

• the theory on how proprioceptive insoles work,
• the location of mechanical receptors on the bottom of the feet,
• how proprioceptive signals are generated etc.,

I encourage you to read Chapter 5 in my book The Foot to Brain Connection.

 

No further questions ,IMO the mechanism seems to be a straight forward mechanical one rather than " proprioceptive " .
Toe up , windlass engagement .

 

Some of my compeers have suggested that the proprioceptive insoles are, in fact, mechanical insoles: raise the big toe, engage the windlass mechanism, pronation attenuated.

As compelling as this explanation first appears, problems arise:

1. An inordinate decrease of gravity drive pronation with a wedge thickness, at times, of 1mm or less, doesn't correlate
2. Pronation at heel contact diminished when the windlass mechanism is not engaged.

So back to the hypothesis of proprioception as the mode of action.

 

I like to think I have an open mind about most things .
Do you have a link to research that demonstrates, specifically, that a wedge of 1mm or less under the hallux will measurably reduce pronation ?

 

Gerald,

The last 15 years or so, my practice has shifted from biomechanics to Posturology. If you do a Google search you will find a plethora of courses being offered.

It is quite common to use stimulation points underneath the feet of 1mm or less (and not just under the 1st metatarsal/hallux) to correct postural distortions (which to me is synonymous with attenuating gravity drive pronation).

You might consider matriculating into one of these courses. They could direct you to the current research in this area.

 

Answer - Apparently not

 

Start with the below publication (in PubMed). From there you can access a plethora of publications.

Carini F, Mazzola M et al. 2017. Posture and posturology, anatomical and physiological profiles: overview and current state of art. Acta Biomed Apr 28,88(1):11-16.

 

That paper is about TMJ dysfunction .

Still no .

 

Many publications on Posturology. Choose the one(s) that interest you.

 

The intrinsic foot muscles seem to be important in balance and posture . How do you assess these in practice and what exercises do you use to correct deficits .

 

Controlling Posture and Vergence Eye Movements in Quiet Stance: Effects of Thin Plantar Inserts.
Foisy A, Gaertner C, Matheron E, Kapoula Z.
PLoS One. 2015 Dec 4;10(12):e0143693. doi: 10.1371/journal.pone.0143693. eCollection 2015.
PMID: 26637132 Free PMC article. Clinical Trial.

 

Still no .

Changes in eye movement caused by 3mm inserts under the medial and lateral foot is not remotely the same as a 1mm thick wedge under the hallux giving reduced pronation .