Do custom made foot orthoses work and are they expensive? Part 2

This relates to the article (also available online) 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 vs simple off the shelf devices and even ‘sham’ innersoles, in treating chronic heel pain (plantar fasciitis). 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 TWO) I will discuss the question of ‘can foot orthoses be ineffective and why’ and ‘are they over supplied/prescribed?’

Can custom made foot orthoses be ineffective and why?

Like any form of treatment, foot orthoses can be ineffective and I would only want mine prescribed by a well-trained, qualified and experienced practitioner. This is important, as it is common place to have to adjust custom made foot orthoses, to optimise their fit into footwear and to ensure they are comfortable. Sometimes they have to be adjusted to reduce or increase their correction. Sometimes a patient feels their devices are not working when really, all that is required is an adjustment. As I say to my patients, if an orthotic is uncomfortable, it is difficult for it to be therapeutically effective. Any orthotic or prosthetic which is not worn, because of ‘accommodative or comfort issues,’ has absolutely no therapeutic value.

Therefore, a practitioner has to have the skills to be able to adjust or modify a device and if they can’t, then they should not be prescribing an orthotic as a form of treatment. Currently in Australia, there no limitations on who can dispense a pair of innersoles (whether customised or not) to you. As such, you may be uncertain about how good or customised your devices are and may be uncertain as to the qualifications of the person issuing them to you. As they say…’buyer beware’!

Podiatrists in Australia are well trained in the field of foot, ankle and lower extremity biomechanics, pathomechanics and orthotic therapy, some better than others… and some with a greater interest and expertise in the field, than others. The differences between practitioners, is no different to any other health care provider in the country. Sometimes a foot orthotic doesn’t work, simply because a disorder or complaint has progressed beyond that type of treatment. There is nothing wrong with the treatment, it is simply the disorder has progressed to requiring another type of intervention, possibly surgery. This is common with foot and ankle pathology. 

Back to plantar heel pain, the focus for the Sydney Morning Herald article by Mr Mannix. This usually responds very well to custom made foot orthoses (in the presence of abnormal foot mechanics) in combination with other interventions (such as stretching, rest, ice, compression, elevation and anti-inflammatory medication… but sometimes it doesn’t. It may be time for more aggressive types of non-surgical treatment, such as the use of a below knee walking boot, combined with injection therapy, or maybe it is time to seek a surgical opinion. See what Dr Aaron Bean DPM has to say about flat feet, custom made foot orthoses and plantar heel pain.

The point I am making, and supported by Dr Aaron Bean (DPM), is it is silly to look at only one type of treatment, such as foot orthoses, in isolation. And this is what the Sydney Morning Herald article did. Sure, the Cochrane Review assessed the effectiveness of foot orthosis in one type of heel pain, but only as a finding, not to draw conclusions from. Again, consider their finding on arthroscopic debridement of the knee discussed in part one. Where is the article from the Sydney Morning Herald on this?

The article by Mr Mannix reported correctly, that after 12-months, the pain associated with plantar fasciitis went away in 80% of patients, no matter what type of treatment. In other words, ‘time’, was an effective form of treatment. Sure, most foot pain will reduce if we cut back on our standing, walking and sports…but is that a good thing? I think not! Children often do this, when they have leg pains associated with flat feet, but that is not a good thing. It is important to keep active whilst getting better…that is how it needs to be done.

Are foot orthoses over prescribed?

Anything that lends itself to a monetary transaction can be abused. Orthoses in my view are over supplied and/or prescribed, but not necessarily by podiatrists… although I am sure, by some. Over prescribing however, is a different issue… as compared to ‘if they work or not’ and ‘are they expensive’? Over prescribing, is an issue of professional integrity, as is any type of over-servicing.

If my dentist tells me I require a filling, I trust his judgement and take his advice. If my GP recommends a blood test or other type of intervention, I take his advice. I think highly of their training… and their integrity. I also value the training and integrity involved with podiatric medicine, to ensure our patients are treated effectively.

As a final point, always ask questions. Test your practitioner. I appreciate questions from my patients. It tells me they are thinking about their treatment… and are motivated. It may be time to move on, if your practitioner displays little interest in answering your questions.

For now…keep on moving!

Dr Clayton Clews
(podiatric surgeon)