The$Foot$Orthoses$Paradox$

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Slide!1!(The!Foot!Orthotic!Paradox):!
•! Welcome!to!the!first!module.!What!I!want!to!cover!here!is!some!of!the!theoretical!
background.!The!problems!that!I!see!that!need!to!be!solved,!and!if!we!can!solve!these!
problems!we!could!do!it!better.!I!also!apologise!to!those!of!you!who!have!heard!me!
speak!before!because!a!lot!of!what!I!am!about!to!talk!about,!I!have!spoken!many!many!
times!over!many!many!years!in!many!different!places.!But!the!problems!still!the!same!
and!the!problems!still!there.!
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Slide!2!(Why!my!hair!fell!out):!
•! I!also!like!to!subtitle!this!bit!'Why!my!hair!fell!out'.!!
•! What!I!am!going!to!cover!has!led!to!a!lot!of!head!scratching!on!my!part.!So!many!
questions!raised,!how!are!we!going!to!solve!this!problem?!If!we!can!solve!it,!we!can!do!
it!better.!
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Slide!3!(Stereotype):!
LNow!the!stereotype,!now!I!don’t!like!to!talk!about!podiatry!which!is!obviously!my!
background.!I!like!to!talk!about!the!foot!orthotic!industry.!And!the!stereotype!of!what!foot!
orthotics!are!for!is!for!the!flat!pronated!foot.!
LNow,!we!know!that!is!not!the!case!but!that!is!the!stereotype!or!the!perception!that!people!
outside!the!industry!or!profession!have!of!what!foot!orthotics!are!for.!
LAnd!as!a!consequence!of!"overLpronation"!we!develop!a!set!of!pronatory!pathologies!or!
symptoms.!
LNow!I'm!not!going!to!get!into!the!endless!debates!about!overLpronation.!I!agree!it!is!a!
nonsensical!term,!I!have!a!blog!post!literally!called!that,!others!have!written!about!it!as!well.!
LWhat!is!overLpronation?!Is!it!the!subLtalar!joint?!The!MidLtarsal!joint?!What!is!over!verses!
normal?!It!is!a!normal!motion,!so!what!is!over?!And!is!over!even!a!problem.!!
LI!don't!necessarily!want!to!go!that!way!except!you!know!it!when!you!see!it.!Like!
pornography,!you!might!not!be!able!to!define!it!but!you!know!it!when!you!see!it.!So,!when!I!
talk!about!a!pronated!foot!you!know!what!I!mean.!It’s!that!calcaneal!or!rearfoot!eversion,!
it's!the!arch!collapse,!it's!the!midfoot!bulging!medially,!it's!the!bowing!of!the!tendon!
Achilles,!it's!the!forefoot!abducting.!It's!that!thing,!you!know!it!when!you!see!it!and!you!
know!what!I!mean!without!getting!into!debates!about!exactly!what!it!is!and!where!it!is.!
LBut!this!is!the!stereotype!of!what!people!have!of!the!foot!orthotic!industry.!And!obviously!
associated!with!this!pronated!foot!is!a!range!of!pathologies!that!can!develop.!
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Slide!4!(Pronatory!pathology!(1)):!
•! Were!all!pretty!familiar!with!the!plantar!fasciitis,!the!posterior!tibial!tendonitis!and!
posterior!tibial!dysfunction,!anterior!knee!pain!in!runners,!sinus!tarsi!syndrome,!1st!
MPJ!pain.!A!whole!range!of!symptoms!that!quite!legitimately!have!probably!been!
linked!to!the!success!of!pronation!of!the!foot,!we'll!get!into!the!evidence!of!that!later.!
•! Unfortunately,!a!lot!of!people!who!really!try!to!push!it,!try!to!link!overLpronation!to!so!
much!more!because!then!you!can!use!foot!orthotics!in!so!much!more!because!that's!
all!we!do!with!foot!orthotics!is!stop!overLpronation.!
 •! Now,!what!is!on!the!next!slide,!please!don't!write!anything!down,!please!don't!tell!
anyone!or!quote!me!as!having!said!this!because!I!don't!want!any!of!this!to!come!back!
and!haunt!me.!
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Slide!5!(Pronatory!Pathology!(2)):!
•! But!I!have!seen!these!pathologies!related!to!excessive!pronation!at!one!time!or!
another!some!a!bit!more!legitimate!then!others.!
•! Hyperhidrosis!a!sweaty!foot,!the!rational!here!is!as!the!foot!pronates!more!the!
muscles!have!to!work!harder,!the!harder!a!muscle!works!the!more!heat!it!generates!
therefore!the!foot!sweats!more.!So!we!can!use!orthotics!and!sweaty!feet.!Believe!me!
people!have!tried!to!argue!that.!
•! Ingrown!toe!nails,!the!rational!here!is!that!when!the!foot!pronates!it!rotates!the!
hallux,!so!that!pushes!the!nail!into!the!skin!or!pushes!the!skin!up!around!the!nail.!So!
the!pronated!foot!can!cause!an!ingrown!toe!nail.!Therefore,!as!well!as!doing!nail!
surgery!we!can!convince!someone!to!spend!a!whole!lot!more!money!and!have!a!foot!
orthotic!as!well,!people!have!tried!that.!
•! Venous!disorders,!now!I'm!sure!you!are!all!familiar!with!the!calf!muscle!venous!pump!
that!facilitates!venous!return!with!the!rhythmic!contraction!of!the!calf!muscles,!the!
venous!return!is!helped.!
•! Well!that!also!is!in!the!foot,!within!the!intrinsic!muscles!the!rhythmic!contraction!and!
relaxation!of!the!intrinsic!muscles!help!that!venous!return!that!foot!venous!return!
pump.!Now!the!theory!here!is!that!if!you!had!a!foot!orthotic!pushing!up!on!that!arch!
so!every!time!the!foot!hit!the!ground!you!will!get!that!added!compression!to!help!
facilitate!venous!return.!Therefore,!we!can!use!foot!orthotics!to!treat!venous!
disorders.!
•! Now!hopefully!you!can!see!where!I!am!heading!with!this.!People!have!tried!to!grasp!
and!link!this!over!pronation!to!everything…temporomandibular!joint!disorders!and!
headaches.!!
•! Now,!some!people!whose!opinions!I!actually!respect!have!actually!tried!to!link!TMJ!
and!headaches.!So!you!know,!there!is!potentially!a!link!there…!But!you!have!to!be!so!
careful!how!you!phrase!it!and!link!them!together.!
•! Just!going!back!to!venous!disorders,!there!is!one!study!that!has!looked!at!"pain"!in!
those!with!chronic!venous!insufficiency!and!did!an!RCTL!an!orthotic!group!and!nonL
orthotic!groupL!well!the!orthotic!group!did!get!"less!pain",!but!with!anything!to!do!
with!facilitating!venous!return!or!what!exactly!was!causing!the!pain!wasn’t!clear.!
•! Now!the!last!one!there!'infertility',!I'm!far!from!being!an!expert!in!that!but!there!is!
apparently!a!position!of!the!uterus!that!is!associated!with!a!higher!degree!of!infertility.!
Believe!it!or!not!the!reference!for!that!is!actually!for!'Medical!Journal!of!Tanzania".!
Now!that!position!of!the!uterus!is!associated!with!a!more!anterior!tilt!to!the!pelvis.!So!
foot!pronates,!the!legs!internally!rotate,!they!tilt!the!pelvis!forward.!So!overLpronation!
is!a!risk!factor!for!infertility,!so!we!can!use!a!foot!orthotic!to!treat!that!as!well.!
•! Now!hopefully!you!can!see!where!I!am!heading!with!this,!this!is!what!has!happened!
historically.!!Also!bet!you're!thinking!about!using!orthotics!to!help!people!get!
pregnant,!because!if!it!is!associated!with!an!anterior!tilt!to!the!pelvis!does!that!mean!
you!have!to!be!standing!on!the!foot!orthotics!when!you!are!trying!to!get!pregnant.!
Let's!move!on.!
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Slide!6!(The!'History'):!
•! So!historically!this!overLpronated!foot!was!linked!to!everything,!which!led!to!ridicule!
and!poking!fun.!
•! Now!there!is!no!doubt!that!for!podiatry!that!sports!medicine!and!the!late!70's!and!the!
80's,!the!use!of!foot!orthoses!to!treat!overLuse!injuries,!was!an!extraordinary!boost!to!
the!profession.!There!is!no!doubt!about!that,!but!unfortunately!that!has!led!to!the!
abuse!and!over!utilisation!of!foot!orthotics!which!has!brought!in!the!critics.!
•! Hopefully!you!can!see!where!I!was!going!with!that.!
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Slide!7!(email):!
•! Even!this,!this!was!an!email!forwarded!to!me!by!an!orthotic!company,!from!a!doctor!in!
Romania!so!the!English!is!not!the!best.!!
•! Yesterday!I!had!a!13LyearLold!girl,!diagnosed!with!"4!strokes"!her!speech!was!unclear!
and!limited.!After!treatment!with!these!particular!orthotics!with!appropriate!posting!
she!started!to!speak,!was!dancing,!her!eyes!become!brighter.!Her!fascial!asymmetry!
improved.!She's!previously!had!5!MRI's!done!so!he's!going!to!get!another!one!done!to!
see!what's!changed.!And!that!last!sentence!there!"This!may!provide!some!evidence!
basis!for!the!influence!of!foot!orthotics!on!the!brain".!
•! Now!I!assume!their!understanding!of!evidence!is!very!different!to!what!my!
understanding!of!evidence!is.!
!!
Slide!7!(Evidence!based!or!commonly!accepted!wisdom?):!
•! Is!it!evidence!based!or!just!commonly!accepted!wisdom?!Now,!I've!been!doing!this!for!
a!very!long!time.!I!have!been!making!foot!orthoses!to!try!and!stop!that!rearLfoot!
pronating,!that!arch!collapsing,!medial!midLfoot!bulging,!the!foreLfoot!abducting.!And!I!
know!and!you!know!that!patients!get!better!when!you!do!that,!there!is!no!doubt!
about!that;!therefore,!excessive!pronation!must!have!been!the!cause.!!
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Slide!8!(no!doubt!this!is!what!we!have!been!trying!to!do):!
•! So!is!that!a!correlation!or!a!causorelation.!There!is!no!doubt!when!we!see!the!feet!on!
the!left!we!want!to!do!what's!on!the!right!to!change!that!alignment!and!we!know!
when!we!do!that!clinically!people!get!better.!
•! But!what!is!the!difference!between!a!correlation!and!a!causation?!
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Slide!9!(white!board):!
•! Probably!not!the!best!analogy!in!the!world!but!I!often!like!illustrate!this!concept!of!
causation!and!correlation!by!this!example!here.!
•! If!you!were!to!do!study!on!the!number!of!drownings!at!a!particular!beach!and!then!
look!at!how!much!iceLcream!got!consumed!at!the!local!shop!you!will!probably!find!a!
pretty!straight!line!relationship.!Now!what's!going!on?!Why!is!there!a!straightLline!or!a!
very!high!correlation!between!iceLcream!consumption!and!the!number!of!drowning’s?!
Is!there!something!in!iceLcream!that!effects!breathing!in!water?!Or!is!there!when!
someone!drowns!people!go!and!buy!a!lot!of!iceLcream!out!of!sympathy.!Like!what!on!
earth!is!going!on?!!
•! Well!what!it!is!warm!weather!increases!both.!And!warm!weather!there's!going!to!be!
more!people!in!the!water!and!more!people!drown!and!more!iceLcream!consumed!at!
the!local!shop!and!so!when!you!map!one!against!the!other!you!are!going!to!get!a!
 correlation!obviously!it!is!a!spurious!correlation.!But!it!illustrates!the!point!of!we've!
got!to!very!very!careful!about!correlations,!our!brains!are!hardLwired!to!find!them!
even!when!they!might!not!exist.!And!to!me!this!illustrates!the!point!quite!nicely.!
!!
Slide!10!(tylervigen.com):!
•! Now!I!just!want!to!take!you!to!this!website,!this!is!a!website!where!someone!has!an!
extraordinary!amount!of!time!on!their!hand,!perhaps!too!much!time!on!their!hand.!
And!they!go!looking!for!correlations.!!
•! And!you!can!see!here!a!perfect!correlation!between!U.S.!spending!on!science,!space!
and!technology,!and!that!correlates!perfectly!with!suicides!by!hanging,!strangulation!
and!suffocation.!!
•! Now!obviously!there!is!no!relationship!but!they!do!correlate.!
•! The!bottom!one,!the!number!of!people!who!drowned!by!falling!into!a!pool,!correlates!
pretty!damn!closely!with!the!films!Nicholas!Cage!has!appeared!in.!
•! And!then!I!always!find!this!one!interesting,!this!is!the!per!capita!cheese!consumption!
correlates!perfectly!with!the!number!of!people!who!died!by!becoming!tangled!in!their!
bed!sheets.!Now!if!you!look!down!the!right!hand!column,!look!how!many!people!per!
year!in!the!U.S.!die!by!becoming!tangle!in!their!bed!sheet,!it's!almost!eight!hundred,!I!
just!find!that!extraordinary!to!believe.!
•! Another!recent!correlation!I!saw,!and!this!comes!into!the!quackery!surrounding!autism!
and!vaccines!and!things!like!that.!That!the!incidence!of!autism!correlates!almost!
perfectly!with!the!sales!of!organic!foods.!So!is!there!a!correlation!or!causation,!like!the!
drowning!and!iceLcream!consumption!example.!
!!
Slide!11!("standard"!Protocol):!
•! !There!is!no!doubt!that!standard!protocol,!certainly!the!one!I!grew!up!with,!was!that!
we!would!work!out!where!subtalar!joint!neutral!was.!And!we!would!have!a!bisection!
of!the!calcaneus!and!a!bisection!of!the!leg!and!we!would!probably!measure!that!ankle,!
then!we!would!take!a!plaster!cast!of!the!foot!in!that!subtalar!joint!neutral!position,!
and!unlock!and!load!the!midLtarsal!joint.!We!would!then!instruct!the!lab!to!make!a!
foot!orthoses!to!hold!the!foot!in!that!subtalar!joint!neutral!position.!Or!we!would!use!a!
prefabricated!or!over!the!counter!device!to!try!and!move!the!foot!closer!to!that!
theoretical!subtalar!joint!neutral!or!that!ideal!normal!position!or!alignment.!
!!
Slide!12!(photo!of!correct!angle):!
•! There!is!no!doubt!Lthe!top!pictureL!we!have!this!neutral!calcaneal!stance!position,!this!
is!the!ideal!position!we!want!the!foot!to!be!in,!subtalar!joint!in!neutral.!
•! And!that!bottom!picture!that!resting!calcaneal!stance!position!is!the!position!we!don't!
want!the!foot!to!be!in.!
!!
Slide!13!(Can!we!test!what!actually!happens):!
•! Now!one!of!the!very!first!experiments!I!ever!did!around!this,!was!this!one!here.!Now!
can!we!test!that!that!actually!happens.!!
•! So!we!recruited!12!people,!now!all!12!of!these!people!got!better.!Now!this!was!done!
so!long!ago!I!had!never!even!heard!of!validated!outcome!measures,!we!just!know!all!
12!of!these!people!their!symptoms!improved.!
 •! Now!both!myself!and!another!clinician!measured!that!subtalar!joint!neutral!angle,!for!
liability!purposes,!and!the!mean!of!the!two!of!us!was!what!we!wrote!on!the!
prescription!form!for!the!lab.!
•! I!took!the!neutral!position!plaster!cast,!and!we're!going!to!make!the!assumption!that!
I'm!reliable,!so!I!took!the!cast,!we!measured!the!angle!and!we!sent!that!cast!of!to!the!
lab!with!instructions.!Pretty!much!stripping!away!all!the!extra!stuff,!"please!make!an!
orthotic!to!hold!the!foot!in!this!position!that!we!measured",!and!have!cast!the!foot!in.!
•! We!asked!the!lab!to!send!a!positive!cast!back!when!they!made!the!orthotic.!Like!I!said!
all!these!people!got!better.!!
!!
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Slide!14!(results):!
•! LSo!what!did!we!find?!Well!the!top!result!their,!the!'resting!calcaneal!stance!position'!
on!average!was!1.3!degrees!everted,!i.e.!very!very!slightly!pronated.!
•! When!we!measure!their!'neutral!calcaneal!stance!position'!the!mean!was!3.4!degrees!
inverted.!
•! Now!that!was!the!number!we!wrote!on!their!prescription!form,!we!didn't!write!3.4!on!
all!of!them!we!wrote!whatever!their!measurement!was.!But!the!mean!was!3.4.!
•! The!third!result!there,!and!I!don’t!have!a!picture!of!this,!is!that!we!put!the!plaster!cast!
on!top!of!the!orthotic,!the!positive!cast,!and!carefully!bisected!the!heel!and!measured!
the!angle!of!the!calcaneus!in!the!cast!and!we!call!the!CSPL!'cast!stance!position'.!It!was!
3.2!degrees!inverted.!Pretty!damn!close!to!the!3.4!that!we!had!measured!in!the!foot,!
so!the!lab!had!done!exactly!what!we!asked!the!orthotic!was!holding!the!foot!in!that!
exact!position!that!we!asked!the!lab!to!make!that!orthotic.!
•! The!problem!that!arose,!and!that!is!the!bottom!result!here,!when!we!put!the!foot!on!
top!of!the!orthotic!it!would!still!point!7!degrees!everted,!pretty!damn!close!to!the!1.3.!
What!that!said!to!me!was!that!the!foot!orthotic!was!working!on!the!plaster!cast,!
wasn't!working!on!the!foot.!This!when!you!start!to!scratch!your!head,!what!on!earth!is!
going!on!here?!
•! All!these!people!got!better,!now!okay!I!fully!acknowledge!that!this!is!static!and!not!
dynamic,!I!full!acknowledge!that!there!may!be!some!issues!with!reliability!but!most!of!
the!measurements!were!done!twice!by!two!people,!and!we!took!the!mean!so!
hopefully!that!wasn’t!too!bad.!
•! But!the!result!was!the!result.!The!orthotic!worked!on!the!plaster!cast,!it!did!not!work!
on!the!foot!on!animate!object.!
!!
Slide!15!(the!problem)!
LIf!you!take!an!inanimate!model!of!the!foot!and!put!a!10Ldegree!wedge!under!it,!you!tilt!the!
foot!10!degrees.!!
!!
Slide!16!(correct!eversion!with!a!post):!
•! Sorry!the!foot!model!10!degrees.!
•! Do!that!to!a!foot,!it!doesn't!necessarily!happen.!
•! !Now!I!fully!acknowledge!that!this!was!static!and!not!dynamic,!but!I!am!going!about!
some!dynamic!data!later.!
!!
Slide!17(Static!stance!response!to!foot!orthoses):!
 •! Then!another!study!we!did,!and!this!was!I!reckon!got!to!be!close!to!the!most!minor!
piece!of!research!I've!done,!really!unimportant,!at!least!thought!so!at!the!time.!
•! !And!what!we!effectively!did!was,!put!a!bisection!on!someone's!calcaneus,!and!got!
them!to!stand!on!6!different!prefabricated!foot!orthotics,!and!measured!how!the!
calcaneal!angle!changed.!!
•! Now,!these!are!Australian!devices,!and!a!lot!of!you!will!not!be!familiar!with!some!of!
them.!
•! I!full!acknowledge!that!this!is!static!and!not!dynamic.!
•! You!can!effectively!see!there!that!a!simple!EVA!heel!wedge!on!average!changed!the!
calcaneal!angle!to!.8!degrees.!
•! A!little!rubber!arch!cookie!did!not!change!the!calcaneal!angle,!the!result!there!of!.44!
was!not!statistically!different!from!0.!
•! Now!the!proLthotic!now!this!is!the!Australian!proLthotic,!there!is!a!north!American!
brand!that!is!very!very!different!from!this!one,!but!this!is!a!prefabricated!orthotic!that!
is!very!common!in!Australia,!and!it!is!really!aggressively!wedged!like!almost!20!degrees!
in!the!heel.!So!standing!on!that!on!average!changed!the!calcaneal!angle!to!2.66!
degrees.!And!dropping!down!to!the!formthotic!and!the!Vasyli!product!.47!and!.54,!
they!weren't!statistically!different!from!no!change.!
•! But!at!the!end!of!the!day!what!we!showed!was!if!you!used!a!wedge!device!at!the!
rearfoot!you!change!the!calcaneal!angle,!and!if!you!used!a!device!that!wasn't!wedged!
in!the!rearfoot!you!didn’t!change!the!calcaneal!angle.!
•! As!I!said!not!exactly!earth!shattering!compelling!science,!but!we!published!it!and!the!
data!is!there.!
•! !What!I!actually!find!interesting!is!that!I!actually!typed!up!this!table!and!there!is!
something!that!I!didn’t!notice.!
!!
Slide!18!(table!circled):!
•! And!it!wasn’t!till!I!visited!till!a!few!years!later!and!that!was!the!range.!
•! The!top!one!there!2.54!each!measurement!was!done!3!times!by!3!people,!so!that!is!
the!mean!of!9!measurements.!So!you!take!that!simple!EVA!medial!wedge.!You!can!see!
that!that!medial!wedge!actually!pronated!someone!two!and!a!half!degrees!more,!or!
everted!the!calcaneus!two!and!a!half!degrees!more.!It!inverted!another!person!six!
degrees!more.!If!we!take!that!aggressive!prothotic!that’s!very!inverted!in!the!heel,!it!
everted!or!pronated!someone!.75!degrees!more,!it!inverted!someone!else!6.7!degrees!
more.!
•! So!think!about!that,!here!is!a!medial!heel!wedge!or!a!very!aggressively!medially!
wedged!over!the!counter!prefabricated!orthotic,!on!average!inverting!the!rearLfoot,!
but!on!someLpeople!actually!pronating!and!everting!the!rearLfoot!some!more!so!
incredibly!counterintuitive.!Even!down!the!bottom!the!Vasyli!product,!it!pronated!
someone!3!degrees!more!and!inverted!or!supinated!someone!else!4!degrees.!So!on!
average!it!statistically!didn’t!change!the!calcaneal!angle!at!all.!
•! So!you!can!see!some!quite!unusual!responses!there!to!these!prefabricated!devices.!
•! Again!this!is!static!not!standing!but!we!will!talk!about!dynamic!later.!
•! Here!is!a!posed!photo!for!the!point!of!illustration.!
!!
Slide!19!(posed!photo!with!the!orthotics):!
•! In!the!left!hand!image,!there!is!someone!standing!with!a!slightly!everted!calcaneus.!!
 •! They!stand!on!that!prothotic,!the!very!wedged!in!the!rearfoot!and!you!can!see!how!
the!calcaneal!angle!has!straightened!up.!On!average!that!is!what!happens.!
•! But!the!photo!on!the!right,!you!can!see!in!that!one,!now!this!is!obviously!posed,!they!
are!more!everted!and!in!a!few!people!that!is!what!happens.!And!even!to!this!day!I!
can't!explain!it,!I!have!a!few!guesses!as!too!why!but!some!people!do!pronate!more!
when!standing!on!an!inverted!device.!It!was!consistent!across!the!board.!
•! Like!I!said!you!scratch!your!head!some!more.!What!on!earth!is!going!on!here?!
!!
Slide!20!(the!problem):!
•! So!what!I!want!to!do!is!build!up!this!problem!slide.!
•! So!there!is!no!doubt!that!we!clinically!use!foot!orthoses!to!alter!that!pattern!of!rearL
foot!motion,!support!the!arch!and!treat!that!excessive!foot!pronation.!
•! And!we!have!been!doing!that!clinically!for!a!very!very!long!time,!and!we!know!in!our!
own!clinic!or!practice!people!get!better!when!you!do!it.!
•! But!what!is!the!evidence!that!"overLpronation"!is!even!a!problem?!
!!
Slide!21!(What!is!the!evidence!of!foot!pronation!is!even!a!problem):!
•! Now!if!we!look!at!these!crossLsectional!studies,!these!like!the!drowning!and!ice!cream!
consumption!type!study,!and!again!they!are!mixed.!
•! A!number!of!studies!have!linked!bunions!or!hallux!valgus!to!flat!pronated!feet.!
•! And!metrick!gave!a!very!good!explanation!as!to!how!a!pronated!foot!could!cause!it.!
The!rearLfoot!pronates,!the!midLtarsal!joint!unlocks,!the!first!row!becomes!hyperL
mobile.!You!know!that!mechanism.!
•! But!I!could!argue!maybe!someone!develops!a!bunion!or!hallux!valgus,!and!because!of!
that!bunion!the!medial!column!of!the!foot!gets!weak!then!the!foot!flattens!or!
pronates.!I!am!not!for!one!minute!saying!that!that!is!what!happens!but!you!can't!draw!
a!conclusion!one!way!or!the!other!from!a!crossLsectional!design.!
•! MedialLtibial!stress!syndrome!in!pronated!feet.!Several!crossLsectional!studies!and!
even!some!more!recent!ones,!have!linked!arch!height,!calcaneal!eversion,!navicular!
drop.!A!number!of!pronation!parameters!too!medialLtibial!stress!syndrome.!Therefore,!
medialLtibial!stress!syndrome!is!caused!by!flat!pronated!feet,!therefore!use!orthotics!
to!treat!it,!to!treat!that!over!pronation!to!treat!the!medialLtibial!stress!syndrome.!
•! But!I!could!argue!that!maybe!someone!gets!medialLtibial!stress!syndrome!and!because!
of!the!pain,!the!posterior!tibial!muscle!gets!weaker!then!the!foot!starts!to!pronate.!So!
the!medialLtibial!syndrome!or!shin!splints!cause!the!flat!pronated!foot.!Now!I'm!not!
saying!that!is!what!happens,!I'm!saying!we!can’t!draw!those!kind!of!conclusions.!
•! Other!studies!have!found!no!correlations,!and!other!studies!have!found!less!injuries!in!
the!pronated!or!flat!footed!group.!
•! So!like!the!drowning!and!ice!cream!example,!you!can!only!infer!a!mechanism!by!which!
causation!may!exist.!To!really!determine!causation,!you!need!a!perspective!study.!
•! Now!in!a!perspective!study!you!take!a!group!of!people!and!you!measure!a!whole!of!
parameters!in!them.!
•! In!the!drowning!and!ice!cream!example,!some!how!get!it!past!and!ethics!committee,!
you'll!give!half!the!people!on!the!beach!ice!cram!and!the!other!half!no!ice!cream,!and!
then!just!wait!and!see!how!many!drown!in!each!group.!
•! For!our!purposes,!you!take!a!group!of!people,!measure!the!whole!lot!of!parameters:!
arch!height,!calcaneal!eversion,!medial!midLfoot!bulging,!navicular!drop.!Whatever!
 parameters!that!are!of!interest!and!follow!them!through!time.!If!the!group!with!more!
pronated!feet!get!more!injures!and!problems,!then!that!is!causation.!We!can!safely!
say,!that!flat!pronated!feet!is!a!cause!of!problems.!
!!
Slide!22!(What!is!the!evidence!that!foot!pronation!is!even!a!problem):!
•! Well!what!does!the!evidence!say?!
•! Well!it's!not!looking!to!good!and!it!hasn’t!looked!good!for!quite!some!time.!
•! The!first!studies!were!starting!to!come!out!in!the!late!90's.!Telling!us!the!prospective!
studies!were!not!showing!a!relationship!between!overLpronation!or!pronated!feet!and!
increased!risk!of!injuries.!
•! There!were!few!studies!that!showed!there!was!and!it!was!a!weak!relationship.!
•! Even!I!wrote!a!paper!in!1988!called!"Is!excessive!pronation!of!the!foot!really!
pathologic?"!You!know!alarm!bells!were!going!off!in!the!late!90's!that!there!is!a!
problem.!
•! Now!I!do!apologies!I!haven't!updated!this!slide!in!quite!some!time.!If!I!had!there!would!
be!a!few!more!studies!showing!no!link!and!more!studies!showing!there!is!a!link.!But!
they!only!show!a!weak!relationship.!
•! So!we!have!known!for!quite!some!time,!and!I!have!been!preaching!for!quite!some!time!
or!had!been!preaching,!that!over!pronation!is!not!a!problem,!it!is!not!an!issue,!it!is!not!
something!that!is!linked!to!injuries.!
!!
!!
Slide!23!(led!to!study):!
•! That!led!to!this!study!a!couple!years!ago!that!the!researchers!found,!or!claimed!to!
have!found!foot!pronation!was!not!a!risk!factor.!And!they!put!out!a!press!release,!
'researches!explode!the!myth!about!running!injuries'.!We've!known!this!for!a!very!long!
time,!for!at!least!the!mid!to!late!90's.!
•! I!don't!know!what!myth!they!thought!they!were!exploding,!but!this!press!release!went!
viral!in!the!running!community,!especially!in!the!()!communities,!because!this!is!
evidence!orthotics!are!no!good!because!pronation!is!not!a!problem.!
•! !!It!really!took!off,!the!last!time!I!checked!it!was!carried!on!over!20,000!websites.!This!
press!release!was!picked!up!on,!it!really!got!a!lot!of!mileage.!And!even!now!I!still!see!
people!post!about!it!on!social!media.!
•! It!wasn't!a!bad!study,!it!took!a!larger!group!of!women!training!for!a!10!kilometre!run,!
and!measured!foot!posture!index!which!is!a!pretty!good!measure!of!foot!pronation!or!
foot!alignment!of!which!some!will!be!pronated!and!some!won't!be!and!followed!them!
through!time.!And!their!pronated!group!did!not!get!more!injuries.!
•! But!their!cut!off!point!on!the!foot!posture!index!was!7.!so!7!and!above!was!considered!
a!pronated!foot!and!7!and!below!was!not,!in!a!subsequent!video!we're!going!to!get!
into!a!bit!more!detail!of!this!issue!and!the!foot!posture!index,!but!when!I!ask!any!
group!of!clinicians!who!are!familiar!with!the!foot!posture!index!they!all!say!7!is!a!
pronated!foot.!Pretty!much!most!clinicians!who!are!familiar!with!the!foot!posture!
index!would!take!0L4!as!normal.!So!that!study!had!a!lot!of!pronated!feet!in!their!
normal!group.!
•! Now!in!fairness!their!cut!of!point!of!7!was!based!on!normative!data.!So!there!was!a!
rational!for!it.!
 •! But!despite!that!issue,!this!really!went!viral,!and!again!I!often!respond!to!this!on!social!
media.!Because!around!the!same!time!that!study!came!out,!this!study!came!out.!
!!
Slide!24(challenger!study)!
•! And!they!actually!concluded!that!foot!pronation!was!a!risk!factor!for!injury!or!
pathology.!But!they!didn’t!put!out!a!press!release.!It!didn’t!gain!any!traction,!I!blogged!
about!it!on!my!blog,!but!that’s!as!far!as!it!went.!
•! So!if!you!are!very!active!on!social!media,!you!are!going!to!get!the!perception!that!overL
pronation!is!not!a!problem,!when!this!study!showed!it!was.!
•! So!again!its!getting!quite!murky,!I!sometimes!enjoy!baiting!people!some!what!who!
might!promote!the!study!that!explodes!the!myth.!And!normally!they!link!to!the!press!
release!and!not!the!study.!Normally!they!have!no!idea!about!the!foot!posture!index,!
but!they!will!promote!usually!in!the!context!of!trying!to!prove!orthotics!don't!work.!!
•! And!I!quite!cheekily!respond!by!saying!things!like!I'm!curious!as!to!why!you!chose!this!
study!and!not!this!other!study!from!the!same!time!that!showed!the!opposite.!And!
usually!the!discussion!goes!down!hill!from!there.!
•! But!I've!gone!from!believing!and!basing!my!clinical!practice!on!treating!this!overL
pronated!foot!its!served!me!very!well!in!my!clinical!practice,!to!having!to!start!saying!
well!it's!not!really!a!problem!because!that!is!what!the!evidence!is!starting!to!show,!and!
studies!have!supported!that!view!and!but!other!studies!have!said!it!is!a!risk!factor,!so!
what!do!we!do?!
•! Well!at!the!end!of!the!day!we!have!to!start!relying!on!the!systematic!reviews!of!all!the!
evidence!that!pulls!all!the!data!from!all!these!multiple!studies.!
!!
Slide!25(pulling!data):!
•! This!was!the!first!one!to!do!that.!And!it!did!conclude!that!pronation!or!overLpronation!
was!a!risk!factor,!but!it!was!only!a!very!small!risk!factor!but!it!was!still!statistically!
significant.!
•! This!is!what!I!like!to!quote,!and!this!subsequent!review!using!a!different!data!set!pretty!
much!concluded!the!same!thing.!
!!
Slide!26(cont.):!
•! That!pronation!was!a!risk!factor!for!certain!pathologies!but!it!wasn’t!an!overpowering!
one,!it!was!small!but!still!statistically!significant.!
•! So!whenever!I!get!into!discussions!or!debates!about!these!issues!I!say!defer!to!the!
systematic!reviews!of!all!the!studies.!Don't!cherryLpick!one!study!that!might!support!
your!view,!or!cherryLpick!another!study!just!because!you!want!to!make!a!point.!
•! Systematic!reviews!and!metananalysis!are!the!ones!I!tend!to!give!the!weight!on.!
•! Now!I!fully!acknowledge!that!there!my!be!issues!with!a!lot!of!these!studies,!what!
parameter!of!pronation!did!they!measure?!
•! Did!they!measure!calcaneal!eversion,!or!did!they!measure!arch!collapse!by!navicular!
drop,!did!they!measure!navicular!drift,!medial!midLfoot!bulging,!the!arch!angle.!
•! You!may!get!pronation!as!a!risk!factor!if!you!take!one!measurement,!but!it!doesn’t!
come!out!as!measurement!if!you!take!another!measurement!of!a!different!parameter.!
!!
Slide!26!(human!movement!science):!
 •! And!to!complicated!things!even!more,!this!more!recent!study!that!came!out!after!
those!two!systematic!reviews,!now!this!was!a!crossLsectional!study,!but!I!did!find!this!
quite!intriguing.!
•! In!the!uninjured!group!the!eversion!range!of!motion!and!eversion!velocity,!how!fast!
pronation!happened,!was!greater!in!the!uninjured!group.!But!peak!ankle!eversion!was!
greater!in!the!injured!group.!
•! So!again!like!I!said,!which!parameter!are!you!going!to!take!as!a!measure!of!pronation!
to!determine.!
!!
Slide!27!(the!politics):!
•! Again!there!is!a!lot!of!politics!around!this!people!want!to!believe!a!certain!paradime!or!
certain!belief.!Hopefully!you!can!see!I!keep!changing!when!the!evidence!tells!me!I!
should!change.!
•! People!want!to!believe;!people!have!their!agendas.!There!is!a!very!strong!antiLorthotic!
movement!on!social!media!and!who!will!take!the!studies!that!show!that!pronation!is!
not!a!risk!factor,!as!evidence!for!orthotics!don’t!work,!I!understand!how!they!might!
reach!that!conclusion.!But!then!there!is!people!who!might!cherryLpick!the!studies,!that!
pronation!is!a!risk!factor,!what!are!their!motives?!They!have!agendas.!We've!got!to!set!
aside!these!preLconceived!agendas!that!we!have!or!that!anyone!has!and!look!at!the!
totality!of!the!evidence.!
•! !!
•! !!
Slide!28!(What!do!we!do!with!this!information?):!
•! Whatever!we!cannot!ignore!this,!these!studies!exist.!The!conclusions!of!metaLanalysis!
show!what!they!show,!they!show!pronation!is!a!very!small!risk!factor,!but!is!still!
statistically!significant,!but!means!there!is!a!hell!of!a!lot!more!going!on!then!just!that!
pronation.!
•! We!can't!ignore!that!and!hope!it!goes!away.!
!!
Slide!29!(problem!slide!cont.):!
•! So!back!to!the!problem!slide,!we!clinically!use!foot!orthoses!to!treat!overLpronation;!
but!the!perspective!studies!are!showing!us!that!it!is!not!a!risk!factor,!if!it!is!it!is!a!very!
very!small!one.!
•! So!where!is!the!evidence!that!suggest!foot!orthoses!even!change!motion!or!
alignment?!Well!again!I!apologise!I!have!not!updated!this!slide!in!quite!a!few!years.!
!!
Slide!30!(Do!foot!orthoses!change!even!change!rearLfoot!motion):!
•! The!evidence!is!the!same.!
•! Half!the!studies!say!they!do!change!kinematics,!or!alignment,!or!posture!or!motion!of!
the!rearLfoot.!
•! The!other!half!say!they!do!not.!
•! Pretty!much!spilt!down!the!middle.!
•! If!I!were!to!update!this!slide!they!will!still!pretty!much!show!the!same!thing.!
•! Even!when!they!do!change!rearLfoot!Kinematics,!the!results!show!usually!about!1!
degree!on!average.!So!what's!the!biological!significance!of!1!degree?!Over!the!course!
of!a!marathon!maybe.!
 •! !Now!you!could!probably!pick!anyone!of!these!studies!and!find!something!wrong!with!
it.!But!if!you!step!back!and!look!at!the!totality!of!the!evidence,!it!is!all!over!the!place.!
•! We!could!pick!on!anyone!of!them!for!arguments!sake,!for!example!one!of!them!uses!
little!rubber!arch!cookies!and!calls!them!orthotics!and!found!that!they!didn't!work.!
Again!I!am!not!surprised.!
•! But!to!say!that!foot!orthotics!don't!change!kinematics!based!on!rubber!arch!cookie!is!
somewhat!problematic.!
•! Another!study!used!a!silicon!insert,!which!people!tend!not!to!use!clinically,!I!mean!
they!are!widely!available,!but!who!uses!them!clinically?!And!they!actually!found!they!
do!change!rearLfoot!kinematics.!
•! When!you!look!closely!what!sort!of!orthotics!are!they!using?!And!the!criteria!I!like!to!
use!is!are!the!orthotics!used!in!this!study!of!the!type,!nature!and!prescription!that!are!
commonly!used!in!clinical!practice.!There!are!times!when!I!might!not!agree!with!what!
they!have!used,!but!I!acknowledge!that!it!is!quite!widely!used!so!I'll!accept!that.!
•! But!when!you!start!applying!that!you!can!eliminate!a!lot!of!those!studies.!
•! I!also!like!to!joke!that!there!is!a!secrete!code!in!those!studies,!like!the!Da!Vinci!code,!
and!when!you!read!the!results!or!the!methods!section!they!talk!about,!!
'the!mean!age!is!21!years!plus!or!minus!2.3!or!something!like!that'!that!is!secrete!code!
for!healthy!undergraduate!student.!
•! So!most!of!these!studies!are!done!on!healthy!undergraduate!students.!
•! How!representative!are!they!of!the!whole!population!who!may!or!may!not!need!foot!
orthotics.!None!of!these!people!had!foot!problems.!We!have!no!idea!if!they!had!overL
pronation!or!not,!so!there's!all!these!kinds!of!issues.!
•! So!the!conclusion!to!anyone!of!these!studies!could!be,!foot!orthotics!of!the!type!that!
we!used!in!this!study,!that!noLone!else!actually!uses!in!clinical!practice,!do!or!do!not!
change!the!kinematics!of!normal!healthy!undergraduate!students!who!probably!don't!
need!foot!orthotics.!
•! Can!you!see!the!point!I'm!making?!But!if!we!put!that!too!one!side!and!step!back!and!
look!at!the!big!picture,!yes!they!are!changing!alignment!not!they!aren't.!!
•! This!is!more!of!one!where!they!should!have!got!it!right!for!Chris!Maclean.!
!!
Slide!31!(Maclean,!Davis!&hamil):!
•! It!took!a!group!of!again!healthy!people,!who!had!gone!6!months!without!an!injury!or!
runners.!They!gave!us!no!data!on!their!foot!type!to!know!if!they!were!pronated.!
•! But!what!they!did!do!was!use!proper!custom!made!orthotics!of!the!type!that!is!
commonly!used!in!clinical!practice.!!
•! But!you!usually!finding!there,!and!this!is!the!point!I!made!about!one!degree,!is!that!
maximum!rearLfoot!eversion!without!the!orthotics!was!6.28!degree,!maximum!
eversion!with!the!orthotics!was!5.2!degrees.!1Ldegree!difference,!that!is!statistically!
significant.!What!is!the!biological!significance!of!that!1!degree?!
•! But!the!important!thing!here!is!that!the!rearLfoot!eversion!angle!was!reduced!in!only!
10!out!of!the!15,!so!there!is!still!5!out!of!the!15!that!didn’t!change.!
!!
Slide!32!(problem!slide!cont.):!
•! Back!to!this!problem!slide.!We!clinically!use!foot!orthoses!to!treat!overLpronation,!the!
perspective!studies!are!telling!us!that!overLpronation!is!not!really!a!risk!factor!or!if!it!is!
 it’s!a!small!one.!But!the!kinematic!studies!are!telling!well!we're!not!really!changing!the!
motion!with!the!foot!orthotics!and!if!we!are!only!by!a!very!small!amount.!
•! So!what!is!the!evidence!that!foot!orthoses!improve!clinical!outcomes?!Its!unequivocal.!
•! !!
Slide!33!(RCTs,!outcomes!studies,!patient!satisfaction!studies!e.g.):!
•! !By!orthotics!working!I!mean!make!people!better,!symptoms!get!reduced.!
•! There's!probably!over!a!hundred!studies,!I!haven't!bothered!to!collect!them!all!
together,!that!have!shown!foot!orthotics!work!and!make!people!better.!
•! These!include!badly!done!studies!show!they!work,!well!done!studies!show!they!work,!
patient!satisfaction!studies!show!people!are!happy!with!them,!outcome!studies!have!
shown!patients!get!better.!There's!only!1!study!that!shows!they!didn't!work!and!that!
was!on!bunions!in!kids!and!we!could!probably!debate!that!another!time.!
•! So!its!unequivocal,!there!is!a!Cochrane!review!that!concludes!they!work!or!make!
people!better.!
•! I've!just!put!up!3!patient!satisfaction!surveys!here!for!a!reason!that!I'll!come!back!to!in!
a!later!video.!But!if!you!look!at!that!first!one,!definitely!helped!70%,!the!second!one!
91%!satisfied!with!their!foot!orthoses,!83%!satisfied!with!their!foot!orthotics.!!
•! There!is!actually!no!doubt!foot!orthotics!work,!they!make!people!better.!The!evidence!
is!very!clear,!we!have!a!systematic!review,!we!have!a!Cochrane!review!confirming!all!
that.!They!work,!they!make!people!better.!
!!
Slide!34!(problem!slide!cont.):!
•! So!back!to!the!problem!slide.!!
•! We!use!foot!orthoses!to!try!an!treat!that!pronation,!that!rearLfoot!eversion,!the!arch!
collapse.!!
•! The!perspective!studies!are!telling!us!that's!not!really!a!problem.!
•! The!kinematic!studies!are!telling!us!that!when!we!try!and!do!it!the!orthotics!aren't!
really!quite!doing!it.!
•! But!all!the!outcome!studies!are!showing!us!that!when!we!do!try!and!do!it!people!get!
better.!
•! So!hopefully!you!can!see!the!problem!that!I've!been!trying!to!wrestle!with!for!a!very!
long!time,!that!we!are!treating!something!we!think!is!a!problem,!that!the!evidence!is!
telling!us!that!its!not!really!a!problem,!the!evidence!is!telling!us!that!the!foot!orthoses!
aren't!really!correcting!that!problem!anyway,!but!the!important!thing!is!when!we!try!
to!do!it!people!get!better.!
•! The!last!point!there.!So!what!do!orthotics!do!to!different!people?!
!!
Slide!35!(foot!orthoses!and!knee!pain):!
•! I!just!want!to!side!track!to!patellaLfemoral!pain,!we!have!a!whole!module!video!coming!
up!on!patellaLfemoral!pain.!
•! There!is!no!doubt!we!have!this!model!where!foot!pronation,!increased!internal!tibial!
rotation,!increases!the!q!angle,!causes!the!patella!maltracking.!
•! We!want!to!use!a!foot!orthoses!to!train!and!straighten!up!that!alignment!so!that!
doesn’t!happen.!
•! Now!we!have!two!pretty!good!RCTs!that!that!works!clinically.!
!!
Slide!36!(foot!orthoses!and!knee!pain):!
 •! Foot!orthotics!work!in!patellaLfemoral!pain!or!anterior!knee!pain!in!runners.!So!the!
evidence!is!quite!clear!
•! But!when!you!look!at!this!study!by!Chris!powers.!
!!
Slide!37!(but):!
•! It!was!a!group!of!runners!with!patellaLfemoral!pain!and!a!group!without.!And!he!found!
that!the!group!with!patellaLfemoral!pain!weren't!more!pronated!then!the!group!
without!it.!
•! So!that!is!a!crossLsectional!study,!like!the!drowning!and!the!ice!cream!but!it!does!put!a!
question!mark!over!that!foot!model!causing!knee!pain.!
!!
Slide!38!(and):!
•! And!then!we!have!this!prospective!study!done!by!the!Israeli!military,!that!found!those!
with!pronated!feet!did!not!get!more!anterior!knee!pain.!
•! So!here!we!have!this!model!of!how!foot!pronation!can!cause!knee!pain!we!have!two!
RCT's!that!show!if!we!apply!that!model!and!use!foot!orthoses!people!get!better.!
•! But!I've!only!put!up!1!crossLsection!and!1!perspective,!I'll!show!more!later,!showing!
the!models!wrong.!
•! So!something!scratch!your!head,!what!on!earth!is!going!wrong?!
!!
Slide!39!(effect!of!inverted!foot!orthoses!on!EMG!of!vastus!muscle!timing):!
•! Now!I!just!want!to!show!you!this!study!or!experiment!that!I!was!involved!in.!It's!not!
the!one!you!can!see.!
•! But!from!this!study!here,!early!firing!of!VMO!is!considered!a!good!thing!in!those!with!
patellaLfemoral!pain.!
•! So!in!this!little!experiment!here!we!wanted!to!use!the!proLthotics!that!I!talked!about!
before.!
!!
Slide!40!(cont.):!
•! Or!the!very!inverted!orthotics!to!see!what!they!did!too!the!firing!of!VMO.!
•! Now!you!can!see!subject!number!1!the!orthotics!brought!VMO!on!earlier!by!33!
milliseconds.!
•! In!subject!number!2!it!brought!VMO!on!earlier!by!25!milliseconds.!
•! Let’s!say!for!arguments!sake!subject!number!3!had!no!change.!
•! In!subject!number!4!the!orthotics!delayed!VMO!!
•! And!in!subject!number!5!they!delayed!VMO!even!more.!
•! !!So!hopefully!you!can!start!to!see!subject!specific!responses.!!
•! We!brought!VMO!on!earlier!in!two!people!which!is!a!good!thing!if!they!had!patellaL
femoral!pain.!And!delayed!in!two!people!which!is!a!bad!thing!if!they!have!patellaL
femoral!pain.!
•! This!was!a!proof!of!concept!type!experiment,!where!we!put!these!5!people!into!a!
graph!for!a!grant!application!that!we!never!got.!
•! Let's!just!assume!the!5!was!an!adequate!sample!size.!If!we!were!to!work!out!the!mean!
of!those!5,!I!reckon!it!will!be!around!8L10!milliseconds.!
•! Our!conclusion!would!be!'inverted!orthotics!bring!on!VMO!earlier,!by!8L10!
milliseconds'.!Great!use!inverted!orthotics!to!treat!patellaLfemoral!pain.!
 •! But!you!can!see!there!we've!made!it!worse!in!to.!Scratch!your!head,!what!is!going!on!
there?!
!!
Slide!41!(Nigg!et!al):!
•! Then!we!might!look!at!studies!like!this!one.!This!wasn't!really!on!foot!orthotics!but!one!
a!full!length!medial!wedge!in!the!shoe,!and!looking!at!the!abduction!movement!of!the!
knee.!
•! I'll!focus!on!the!medial!wedged!one!for!this!talk.!See!that!there!were!increases!and!
decreases!in!that!knee!abduction!moment!with!the!medial!wedge.!
•! So!if!we!assume!medial!wedge!equals!foot!orthotics,!we’ve!increased!the!abduction!
moment!in!some,!we've!decreased!it!in!others.!
•! The!mean!response!looks!pretty!close!to!0.!
•! A!conclusion,!'medial!wedge!doesn't!really!effect!knee!abduction!moment'.!
•! Now!this!crucial!because!changes!or!increases!in!that!abduction!moment!are!one!of!
two!risk!factors!for!knee!OA.!
•! We're!going!to!visit!knee!OA!and!foot!orthoses!in!a!subsequent!module!later.!
•! But!for!here,!is!the!same!thing!going!in!the!shoe!and!two!different!effects!at!the!knee.!
!!
Slide!42!(What!do!we!do!with!this!information?):!
•! What!do!we!do!with!this!information?!We!can't!ignore!the!fact!that!this!is!happening,!
that!foot!orthoses!are!doing!different!things!to!different!people.!
!!
Slide!43!(problem!cont.):!
•! I!won't!go!through!this!slide!again!but!just!to!add!on!that!subject!specific!responses!
are!in!different!directions.!
!!
Slide!44!(studies!comparing!different!types!of!foot!orthoses):!
•! What!about!comparing!different!types!of!orthoses?!
•! I!just!want!to!use!Karl!Landorf's,!this!was!his!Phd!study!quite!some!years!ago,!to!
illustrate!the!point!I'm!making.!
•! Now!one!of!the!earlier!studies!that!looked!at!custom!made!versus!preLmade!orthotics.!
Effectively!recruited!people!with!plantar!fasciitis,!this!group!was!given!the!
prefabricated!device,!this!group!had!a!plaster!cast!taken,!had!low!dye!strapping!
applied!and!two!week's!later!got!their!custom!made!device.!This!group!did!better,!but!
was!it!because!of!the!custom!made!device!or!two!weeks!of!low!dye!strapping?!
!!
Slide!45!(landorf!et!al):!
•! So!what!Karl!did!for!his!Phd,!this!was!a!12!month!randomised!control!trial!of!a!custom!
made!foot!orthoses,!a!prefabricated!and!a!placebo.!
•! So!effectively!when!people!came!into!this!study!all!of!them!had!a!plaster!cast!was!
taken.!So!they!could!have!assumed!they!were!in!the!custom!made!group.!They!were!
then!sent!away!for!two!weeks,!at!the!end!of!the!two!weeks!a!third!of!them!were!
randomised!to,!a!custom!made!neutral!position!cast!was!taken!the!plastic!was!heat!
moulded!and!posted!to!4!or!whatever!degrees!it!was.!!
•! The!prefabricated!group!got!a!formLthotic,!again!a!brand!I'm!assuming!a!lot!of!you!are!
familiar!with.!It!was!the!market!leader!in!Australia!at!the!time!of!the!study!which!is!
why!it!was!used.!
 •! And!the!placebo!group!was!a!very!soft!extraordinary!soft!EVA,!that!I!could!role!up!in!
my!hand.!But!it!was!heat!moulded!to!the!cast!so!it!was!made!to!look!like!an!orthotic.!
So!very!thoroughly!done.!
•! But!the!results!were!at!3,6!&!9!months!no!difference!between!custom!made!and!preL
made.!
•! By!12!months!the!control!group!had!caught!up,!so!again!orthotics!worked.!This!is!not!
evidence!that!orthotics!don't!work,!the!placebo!group!caught!up!at!12!months.!But!at!
3,6&9!months!the!orthotic!groups!were!doing!better.!I!just!want!you!to!look!at!the!
bottom!point!there,!using!the!'foot!health!status!questionnaire’,!there!were!30!points!
of!improvement!on!the!pain!scale!and!15!points!on!the!function!subscale.!Typical!kind!
of!results!in!this!study.!File!those!numbers!away!because!we!will!be!coming!back!to!
them.!
•! Now!there's!been!other!studies!that!have!looked!at!custom!made!versus!preLmade!to!
the!point!where!a!number!of!years!ago!a!systematic!review!was!done.!
!!
Slide!46!(Prefab!v!Custom):!
•! And!a!metaLanalysis!of!all!the!evidence.!And!that!concluded,!based!on!all!the!evidence!
available!at!that!time,!that!there!was!no!difference!between!custom!made!and!
prefabricated!orthotics,!and!practitioners!could!use!either.!!
•! When!you!do!a!systematic!review.!
!!
Slide!47!(but…):!
•! And/or!a!metaLanalysis!you!have!inclusion!criteria;!where!the!subjects!randomised!
properly,!where!the!people!doing!the!assessing!the!outcomes!blinded!etc.!
•! I!would!like!to!suggest!another!criteria,!that!the!foot!orthotics!used!in!the!study!were!
of!the!type!and!protocol!typically!and!commonly!used!in!clinical!practice.!And!if!you!
start!applying!that!to!the!studies!we!used!in!this!metaLanalysis,!you!would!have!to!say!
no!to!most!of!them.!
•! Again!we!could!debate!this.!Even!if!we!look!at!Karl's!study,!the!custom!made!were!like!
an!average!prescription!for!everyone.!Like!to!me!a!custom!made!device!has!a!heel!rise!
if!the!calf!muscles!are!tight,!it!has!a!firstLray!cut!out!if!the!function!hallux!limitus,!it!has!
a!groove!if!the!plantar!fascia!is!prominent.!That's!what!a!true!custom!made!device!is,!
that!wasn't!done!in!this!study.!
•! If!supination!resistance!is!high,!you!would!use!a!more!rigid!material!or!invert!the!rearL
foot!more.!That!is!what!a!true!custom!made!device!is.!And!that!so!fairly!generic!
custom!made!device!was!no!different!to!a!fairly!generic!prefabricated.!Now!you!could!
have!made!those!modifications!to!the!prefabricated.!
•! So!I!would!like!to!suggest!that!I!don't!we!really!don’t!have!any!good!evidence!of!the!
difference!between!custom!made!and!preLmade.!
•! There!is!no!difference!between!a!custom!moulded!device!and!a!prefabricated!device.!
•! Now!I'm!not!saying!that!if!a!custom!prescribed!with!all!those!extra!things!was!done!
and!compared!to!a!prefabricated!there!will!be!no!difference,!there!may!or!may!not!be.!
But!again!I!don't!think!we!know,!and!I!think!people!have!unfortunately!jumped!to!
wrong!conclusions!based!on!their!limited!understanding!of!what!a!true!custom!made!
orthoses!is.!
•! We're!obviously!going!to!revisit!this!in!a!lot!of!other!modules.!
!!
Slide!48!(effects!of!3!retail!foot!inserts!on!plantar!fasciitis):!!
•! But!to!complicate!it,!and!this!study!was!a!very!big!eye!opener!for!me!and!this!was!one!
where!I!got!funding!from!the!UK!for,!to!test!3!devices!that!you!can!buy!at!the!chemist!
or!the!pharmacy!over!the!counter.!!
•! The!middle!one!there!is!the!orthoLheel!from!a!Vasyli!product,!which!was!the!Vasyli!
product.!
•! The!black!one!there!is!boots!the!chemist.!
•! And!the!one!in!the!brown!paper!bag!was!the!Scholls!product.!It!was!commercially!
sensitive!at!the!time!so!that’s!why!the!photo!shows!it!in!a!brown!paper!bag.!
•! But!in!this!study!we!took!60!people!with!plantar!fasciitis!and!randomised!them!to!one!
of!those!3!devices.!
•! Now!these!are!3!devices!that!I!will!never!use!clinically.!I!could!flatten!every!single!one!
of!them!with!my!little!finger.!So!if!I!could!flatten!that!with!my!little!finger,!imagine!
what!someone!who!is!overLweight!with!plantar!fasciitis!does!to!these!devices.!I!mean!
they!are!useless,!theoretically,!I!wouldn't!use!them.!
•! We!randomised!them,!60!people!randomised!to!1!of!these!3!devices.!
!!
Slide!49!(results):!
•! To!our!utter!amazement,!all!of!them!got!better!except!for!3.!
•! And!on!a!visual!analogue!pain!scale,!when!we!asked!them!how!much!betterLer!are!
you?!The!mean!was!40%.!So!that!was!a!40%!reduction!in!symptoms!at!4!weeks.!Which!
when!you!look!at!a!lot!of!other!planta!fasciitis!studies!40%!reduction!in!pain!at!4!
weeks!is!pretty!damn!good.!
•! Using!the!more!validated!Foot!Health!Status!Questionnaire!you!can!see!20L30!point!
improvements,!very!similar!to!what!Karl!Landorf!got!in!his!study.!!
•! So!you!really!start!to!scratch!your!head,!what!on!earth!is!going!on?!We've!got!issues!
where!custom!made!versus!preLmade,!but!then!we've!got!these!simple!devices!
actually!fixing!people.!
!!
Slide!50!(What!do!we!do!with!this!information?):!
•! We!can’t!ignore!this!we've!got!to!try!and!work!out!what!is!going!on.!
!!
Slide!51!(problem!cont.):!
•! So!again!I!won't!go!through!this!problem!slide!again,!except!to!show!studies!showing!
different!types!of!orthoses!certainly!showing!mixed!results.!
•! What!about!the!relationship!between!clinical!outcomes!and!this!change!in!rearLfoot!
motion?!
!!
Slide!52!(rearLfoot!motion!changes!and!clinical!outcomes):!
•! Earlier!I!showed!you!that!group!of!studies!that!measure!kinematics!in!the!lab,!then!I!
showed!you!the!studies!that!show!they!get!better,!patients!get!better!symptoms!
improve.!
•! NoLone!had!ever!done!a!study!of!combining!the!two.!And!that's!what!we!set!out!to!do.!
•! !In!this!study!we!took!people!with!symptoms,!they!weren't!our!patients,!they!were!
given!a!range!of!different!types!of!foot!orthoses,!other!clinicians!made!those!kinds!of!
decisions.!We!got!them!after!they!got!their!orthotic.!!
!!
Slide!53!(changes!in!rearLfoot!motion!patter!and!foot!orthoses!outcomes):!
•! !So!what!we!did,!we!measured!them!at!baseline!and!4!weeks!using!the!Foot!Health!
Status!Questionnaire,!so!we!were!measuring!their!changes!in!symptoms!over!that!4L
week!period.!
•! We!specifically!stuck!to!people!who!had!foot!symptoms!that!we!could!have!considered!
related!to!excessive!pronation.!And!then!we!measured!changes!in!the!frontal!plane!
motion!of!the!rearLfoot!with!and!without!foot!orthoses.!
•! And!what!we!wanted!to!do!was!to!correlate!that!range!in!motion!to!that!change!in!
symptoms.!
•! So!for!arguments!sake!if!the!foot!orthoses!did!change!rearLfoot!motion!are!they!the!
ones!that!do!better?!
•! And!if!the!foot!orthoses!didn't!change!rearLfoot!motion!are!they!the!ones!that!don't!
get!better!or!don't!respond!as!well?!
•! The!was!the!hypothesis.!We!had!to!reject!that!it!did!not!matter.!
!!
Slide!54!(correlation!between!outcome!and!rearLfoot!motion!changes):!
•! I!won't!go!into!the!details!of!what!we!did,!I'll!link!below!to!the!study.!
•! There!was!no!correlation.!It!didn't!matter!whether!we!changed!rearLfoot!posture,!
alignment,!motion!or!not.!They!got!betterLer!or!not.!It!was!all!over!the!place.!
•! So!again!you!scratch!your!head,!what!on!earth!is!going!on!here?!
•! But!we!can't!ignore!this.!We!published!this!study!in!2007,!so!quite!some!time!ago.!So!
we!can't!ignore!this!information!and!hope!it!goes!away.!
!!
Slide!55!(problem!cont.)!
•! So!hopefully!you!can!see!these!are!the!problems!I!have!been!wrestling!with!for!quite!
some!time.!
•! Then!we!have!studies!like!this!one,!this!is!from!Dorsi!Williams.!
!!
Slide!56!(effect!of!inverted!orthotic!on!rearLfoot!mechanics):!
•! This!was!an!extraordinary!unique!study!from!a!whole!lot!of!perspectives.!
•! These!were!a!group!of!runners!who!were!given!a!standard!root!type!orthosis!that!
didn't!work.!
•! So!rather!then!give!up!on!orthotics!and!do!something!else.!They!were!then!given!a!
Blake!inverted!type!foot!orthoses!and!it!did!work.!
•! Now!they!are!obviously!a!group!of!runners!who!got!the!root!type!orthoses!that!didn’t!
work,!and!a!group!who!got!the!Blake!inverted!orthoses!and!it!still!didn’t!work.!They!
weren't!included!in!the!study.!
•! Only!those!who!were!included!in!the!study!were!those!were!the!root!type!orthotics,!
the!more!conventional!commonly!used!orthotic!hadn't!worked.!But!the!more!
aggressive!Blake!inverted!type!foot!orthoses!did!work.!
•! Now!in!subsequent!modules!we!will!get!into!the!differences!between!these!devices!in!
detail.!!
•! So!quite!unique.!So!their!key!was!let's!bring!these!people!into!the!lab,!which!is!what!
Dorsi!Williams!did,!and!say!what!it!is!about!that!orthotic!not!working!that!the!orthotic!
that!is!working!doing.!
•! Now!you!can!see!here!this!is!the!kinematics,!so!across!the!top!there:!no!orthotic,!
standard!root!orthotic,!and!inverted!Blake!type!orthotic.!
 •! So!peak!eversion:!7.5,!9.1,!8.7,!statistically!no!difference.!
•! And!again!the!inverted!one!was!the!one!that!worked.!
•! Eversion!excursion!i.e.!from!the!full!everted!to!the!fully!inverted!position,!15,!15,!15!no!
differences!there.!
•! Eversion!velocity!how!fast!the!pronation!happened!or!the!eversion!happened.!242!
degrees!per!second,!215,!225!again!statistically!no!difference.!
•! Yet!the!inverted!orthotic!worked,!but!you!can!see!statistically!it!was!no!different!to!
wearing!no!orthotic.!So!again!scratch!your!head,!what!on!earth!is!going!on?!
!!
Slide!57!(graph):!
•! Just!want!to!take!you!to!this!graph,!and!I!acknowledge!Kevin!Kirby!who!let!me!use!this!
graph.!
•! 0L100%!across!the!bottom!is!the!stance!phase.!That!0!line!in!the!middle!is!calcaneus!
everted.!
•! So!at!0%!you!can!see!the!foot!hitting!the!ground!slightly!inverted,!it!then!pronates!to!0!
to!be!vertical,!continues!to!pronate,!maximum!pronation!occurring!at!midstance.!Then!
the!foot!starts!to!resupinate,!back!to!vertical,!continues!to!resupinate!during!the!
propulsion!phase.!But!you!can!see!the!3!colours!there!of!the!3!different!devices.!No!
difference!yet!the!blue!one!is!the!one!that!worked.!
•! So!again,!what!is!going!on?!Why!is!one!device!working!and!one!device!not!working!
certainly!not!for!changing!that!motion!pattern.!But!also!notice!that!maximum!
pronation!happens!at!50%.!That's!what!I!used!to!teach!to!the!students,!and!I!certainly!
got!taught!that!when!I!was!a!student.!
!!
Slide!58!(graph!part!2)!
•! The!other!unique!thing!about!this!study,!is!that!they!included!the!subject’s!specific!
data.!
•! And!this!is!subject!number!5.!And!its!extraordinary,!you!can!see!subject!number!5's!
maximum!pronation!is!probably!7L8!degrees!of!the!black!solid!line!that's!the!Blake!
inverted!device!that!worked.!So!it!pronated!them!more.!The!bottom!line!there!is!
barefoot!is!maximum!pronation!which!is!probably!about!3L4!degrees,!and!in!the!Root!
maximum!pronation!probably!around!5L6!degrees.!
•! So!the!device!that!worked,!pronated!the!foot!even!more,!then!having!no!orthoses.!A!
very!aggressively!inverted!device!pronating!the!foot!more!fixing!them.!
•! This!is!what!I!was!saying!earlier!how!static!data!showed!that!in!some!people.!Here!is!
some!dynamic!data!showing!it!happened.!
•! Subject!number!12.!This!is!more!like!you!would!expect!to!see.!Maximum!pronation!
without!the!orthoses!7L8!degrees,!then!maximum!pronation!with!the!orthoses!was!
about!4L5!degrees.!But!again!no!difference!between!the!two!devices.!The!black!solid!
line!is!the!one!that!worked.!But!at!least!both!orthoses!did!control!that!foot!and!stop!it!
pronating!more!then!no!orthoses.!
!!
Slide!60!(subject!number!13):!
•! And!in!subject!number!13.!Again!even!more!bazar.!Maximum!pronation!with!the!Root!
type!device,!around!15!degrees,!maximum!pronation!with!the!Blake!inverted!device!
almost!10!degrees,!maximum!pronation!with!barefoot!almost!5!degrees.!
 •! Both!orthoses!pronated!the!foot!more.!Again!one!of!them!a!very!inverted!device!
didn’t!pronate!quite!as!much!as!the!standard!Root!type!device.!
•! So!you!really!have!to!start!scratch!your!head!here,!what!on!earth!is!going!on!here?!
!!
Slide!61!(what!do!we!do!with!this!information?!
•! We!can't!ignore!this!kind!of!data,!and!hope!it!goes!away!just!because!we!don't!want!to!
believe!in!it.!
!!
Slide!62!(Paradox):!
•! So!I!think!we!have!a!paradox!that!has!cause!my!hair!to!fall!out.!
•! A!paradox!is!a!group!of!statements!that!leads!to!a!contradiction!or!a!situation!that!
defies!intuition.!
•! So!this!paradox!is!we!have!been!using!foot!orthoses!to!treat!"overLpronation".!
!!
Slide!63!(the!paradox):!
•! However,!you!want!to!define!it.!But!we!know!for!the!evidence!that!overLpronation!is!
not!or!is!a!very!small!or!weak!factor!in!causing!problems.!And!we!know!when!we!put!a!
foot!orthoses!in!a!shoe!we!may!or!may!not!be!changing!this!overLpronation,!but!we!
know!when!we!try!to!do!it!the!outcome!studies!show!it!makes!people!better.!
•! And!that!to!me!is!the!paradox,!that!is!what!I!have!been!wrestling!with!for!a!very!long!
time.!Trying!to!work!out!what!on!earth!is!going!on.!
!!
Slide!64!(what!about!running!shoes?):!
•! What!about!running!shoes?!Running!shoes!are!traditionally!prescribed!and!made!for!
mild,!moderate,!serve!pronators.!It's!still!probably!the!prevailing!paradime!for!the!
prescription!of!running!shoes.!I!may!not!necessarily!agree!with!it!but!it!is!the!prevailing!
paradime.!I've!just!finished!talking!about!overLpronation!not!really!being!a!problem.!
Then!what's!going!on!with!running!shoes?!
•! Can!we!change!outcomes!if!we!do!it!differently?!
!!
Slide!65!(what!will!solving!the!paradox!achieve?)!
•! Wrestling!with!this!to!me,!the!reason!to!try!and!solve!this!paradox!or!problem,!is!that!
if!we!can!we!hopefully!we!can!do!it!better.!
•! Hopefully!we!get!better!outcomes.!Whatever!we!do!has!to!have!some!consistency!
with!the!evidence.!We!just!can't!dismiss!the!evidence!because!we!don't!like!it!or!it!
doesn't!fit!with!what!we!are!doing.!
•! If!you!have!evidence!that!contradicts!your!world!view,!your!paradime,!your!model,!
your!theory,!you've!got!several!options.!You!really!need!to!find!a!reason!as!to!why!that!
was!fatally!flawed.!And!it!better!be!pretty!compelling.!!
•! I!can!find!a!minor!issue!with!most!studies,!but!is!it!fatal!or!not?!Or!you!can!ignore!it,!
this!what!we!shouldn’t!be!doing.!
•! This!is!what!quakes!do,!sudoLscience!do,!woo,!they!ignore!stuff!that!contradicts!their!
world!view!and!hope!it!goes!away.!
•! What!we!should!be!doing!is!adjusting!our!world!view,!adjusting!our!model,!adjusting!
our!theory,!adjusting!the!paradime!to!incorporate!that!new!evidence.!And!hopefully!
you!can!see!I've!evolved.!I!used!to!believe!pronation!was!a!problem,!I!used!to!preach!it!
 wasn't!a!problem,!I've!know!had!to!come!and!acknowledge!that!it!is!a!problem!but!it!is!
a!very!small!one!and!is!statistically!significant.!
•! So!hopefully!that!gives!you!a!picture!of!where!I've!come!from.!In!the!next!video!we're!
going!to!try!and!solve!this!problem!and!in!subsequent!videos!we!are!going!to!apply!it.!
!!
!!
Links!under!video:!
I!know!I!did!promise!most!modules!are!20L30!minutes;!sorry,!but!this!one!is!59!minutes!–!
the!rest!will!be!shorter!!
Downloads:!
Handout!of!PowerPoint!
External.Links:!
My!blog!post!on!the!nonsensical!understanding!of!‘overpronation’!
Ian!Griffiths!post!on!“Foot!Pronation:!is!the!term!‘Overpronation’!valid?”!
Spurious!Correlations!at!Tyler!Vigen!(slide!11;!for!a!bit!of!fun)!
My!blog!post!on!the!Nielson!et!al!study!‘exploding!the!myth’!(slide!23)!
The!Two!systematic!reviews:!Jasper!et!al!(slide!26)!and!Neal!et!al!(slide!27)!
Systematic!review!of!custom!v!prefabricated!foot!orthotics!(slide!49)!
Full!text!of!Williams!et!al!study!(slide!60)!
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