Do custom made foot orthoses work and are they expensive? Part 1

I raise this question, as only recently I read an article on line, but published in the Sydney Morning Herald ‘Expensive orthotics no better than a sham, review finds’, 31st March 2018, by Liam Mannix, which questioned the value of custom made foot orthoses. He compared them to simple off the shelf devices and even ‘sham’ innersoles, in treating chronic heel pain (plantar fasciitis/ plantar fasciopathy). The article cited a Cochrane Review and a recent review of the literature by an Australian researcher, Dr Glen Whittaker, looking at the best evidence available on the topic.

In this section (PART ONE) I will discuss if foot orthoses work; if I believe they are expensive; what is involved in producing a pair of custom-made foot orthoses; and why there is only a modest amount of evidence supporting their effectiveness and use?

Do foot orthoses work?

In my view, the short answer, is yes and not only for conditions of the foot. They are also effective in treating certain types of lower limb, knee and back pain.

I simply do not buy into the notion that custom-made foot orthoses are no better than a sham or a prefabricated device. There are simply too many patients, around the world, reporting too much improvement in symptoms, in the clinical setting, for this to be the case.

It is more important to consider this question in a broader context. That is, do they work, when prescribed by a qualified practitioner, following a thorough medical history and examination. Following a diagnosis, are they being prescribed as part of a sensible, balanced treatment regime? The focus should be on obtaining the most from your practitioner in terms of their expertise.  Treatment options should be tailored to suit your specific needs.

We must assess, diagnose then treat. Foot orthoses do work, but they are only one type of intervention and should be considered that way.

See what Dr Whittaker has to say about the effectiveness of foot orthoses in this link.

He states, it is important that an orthotic contour the foot appropriately… and there is no better way of achieving this, than with a mould or scan of the foot. He also comments on the possibility of trialling a prefabricated device and in some instances, I recommend this to my patients. I have found great success, for example in treating many cases of sever’s disease (growth plate related heel pain) in children, with prefabricated foot orthoses.

Often however, by the time I see my patients  they have already trialled prefabricated innersoles and their pain has progressed in severity, greatly limiting their mobility. It is at this point, a variety of treatment options should be considered, including ortho-mechanical intervention (ie- custom made foot orthoses, footwear changes, walking boots), pharmacology, physical therapy and in certain cases, surgery.

Are custom made foot orthoses expensive?

No… not if one looks at the labour and expertise involved in constructing a pair, the cost of materials and the expertise required to ensure the devices are appropriate for a patient’s needs. Foot orthoses can last for years, up to 10-years, with intermittent refurbishment. This equates to them being very, very inexpensive.

What is involved in producing a pair of custom-made foot orthoses?

The practitioner, usually a podiatrist should be well trained in the field of lower extremity biomechanics. They should have an understanding of what constitutes the abnormal in movement and function and how this compares to the normal or typical. Understanding human movement and lower extremity biomechanics is difficult and this represents the most important component of what will constitute a good design in a custom-made pair of foot orthoses.

So, what constitutes a custom-made pair of foot orthoses? A custom-made pair of foot orthoses is like a custom-made pair of prescription glasses. Each set of glasses is different from person to person and has been designed on the characteristics attributable to the individual. The same for foot orthoses. Before they are designed, a pair of casts (called negative casts) or a 3-D image, is taken of the patient’s feet. Refer to the following link to view one method of achieving a negative cast impression and used by our practice.  Following this, the devices are manufactured. Custom made foot orthoses may be more or less flexible, be made of softer or harder materials and incorporate different degrees and types of correction (following modification to the positive casts or 3-D mould or image of the feet). They come in a choice of length and top cover and are designed to fit into different types or styles of shoes etc.

One method of manufacture is show in the following link.

Please refer to the following link to obtain further information on what foot orthoses are and what is involved in orthotic therapy.

Why is there only a modest amount of evidence supporting the use and effectiveness of foot orthoses?

Because of differences in custom made foot orthotic design, the variability in the cause of foot pain and the need to follow patients over at least a reasonable amount of time (a few years or more), studies on foot orthoses are limited. The issue of, ‘do custom made foot orthoses work or not’, is more about the research on the topic, rather than a problem with this type of treatment intervention.

Limitations in research are not restricted to the field of podiatric medicine, but to medicine as a whole. There are many clinical and surgical practices, which clearly work, with consistent and effective patient outcomes, but are yet to be supported by high level evidence. For example… ‘There is gold standard evidence’, according to the Cochrane Review, ‘that arthroscopic debridement has no benefit for undiscriminated osteoarthritis (mechanical or inflammatory causes).’ That outcome is amazing, when one considers how commonly performed this procedure is, in treating osteoarthritis of the knee. But again, it is simply very hard to obtain high level evidence, so it is important not to throw the baby out with the bath water. Should arthroscopic procedures of this type be stopped, because of the findings of the Cochrane Review? I don’t think so. Instead, it is important to build on the available evidence so that we can be certain clinical outcomes match the research, using methods without bias. But, this takes time and research designs need to improve, such as incorporating larger sample sizes, better methodology (including reliable and valid measurement tools and longer follow-up periods), with appropriate statistical analysis, to achieve meaningful outcomes.

Please look out for PART TWO, coming soon, for my additional view about this topic.

For now…keep on moving!

Dr Clayton Clews
(podiatric surgeon)