Physiotherapy to compliment Orthotic (insoles) treatment

History

 

In the 1970's the California college of Paediatric medicine in San Francisco found a way to control dynamic motions of gait (walking) in stance.

What they invented was an Orthotic device or insole.

It became so popular that in the 1990's it became over utilised

Retailers started to dispense what should be a medical device!

 

 

So what are the issues with current practice?

There are many studies of biomechanics with an assumption that alteration of abnormal biomechanics will result in clinical benefit

Typically Physiotherapists assess the area where the pain is and the joints either side of it.

More rarely a Physio may have a look at the whole body including the feet.

Podiatrists are sometime guilty of the opposite in that they look at the feet predominantly less the lower limb and even less likely the pelvis and above.

Think about it!

There is a chance that a neck problem could be caused from a foot postural issue and also vice versa!

If someone had medial knee pain and overpronated in their feet then it would make sense to think the overpronation is causing the medial knee pain but 70% of the population overpronate and clearly 70% of the population don't have medial knee pain! 

A Podiatrist may prescribe an antipronation device to treat the pain. But does it work? what else could it be? Is it even likely that one thing is causing it?

Most running-related injuries are overuse injuries and the causes of these injuries are often multifactorial.

So what else could be going on?

Causes of shin splints: Training methods, Training surfaces, Muscle dysfunction/inflexibility, Shoe design & Biomechanics of running

Lower knee extension strength is significantly associated with higher risk for future patella femoral pain syndrome (Lankhorst 2012)

Another reason could be poor glut strength, endurance and control around the hip joint:


Patella femoral pain: Internal femoral rotation is associated with poor gluteus medius activation, affecting the stability of the pelvis

Facts and figures:

Prolonged pronation increases stress on pronation control mechanisms causing compensation that increases stress on other mechanisms

Excessive Supination causes impaired shock absorption = increased force spikes to damage tissues directly

Pronation of the foot: too much, too long or too late can cause an increase in the dynamic valgus vector force on the patellofemoral joint

Pronated position of the foot compromises joint pressure distribution and joint stability

Semi rigid orthoses reduced shin splints in military conscripts (Larsen et al 2002)

Clinically, comfort is the most important and relevant feature when prescribing foot orthoses (Mndermann et al 2003)

 

So what does this mean?

You need to come at the problem from multiple angle. Think about the following:

 

Footwear:

 

Age of footwear (shelf life of 1 year), usage (300 miles), quality, correct for the individual?

Wearing pattern (not just underneath)

Too big? too small?

1.5 cm from longest toe to end

Width also!

Posture:

Gait:

 

Balance and Proprioception:

 

Single leg balance test:

1 minute: count the number of touch downs with eyes open

(above is a more advanced version standing on a stability cushion)

Functional movement:

 

Dynamic lunge - look for knee control and any foot drag etc.

Crucifix against wall – pelvic tilt

Single leg squat

Hypermobility tests

Hip rotations

Bridging

Superman

Overhead squat
 

Single leg stability
 

Force reduction/production: Landing mechanics

 

Joint & Muscle assessments:

POSTURAL MUSCLE SHORTNESS TEST (PMST)

(Chaitow, 2001)

Leg length:

Significance?                                                                                                                                                                                                                                                               

 

 

3 mm                     Running injury risk                               Subotnick

5 mm                     Spinal compensation                              Friberg

6 mm                     Running injury risk                                Brody

7 mm                     No problem < 7 mm                               Corrigan, Maitland 

9 mm                     Lumbar facet angle changes                  Giles

10 mm                   Low back pain                                       Cyriax

15 mm                   Compensatory scoliosis                         Gibson

20 mm                   LE compensation                                   Vogel

22 mm                   Significant scoliosis                                Papaloannu

40 mm                   Requires surgical correction                   Ingram

So as you can see there is plenty of debate of the amounts. Everyone is different so the truth is it depends!

Podiatry assessment

Physiotherapy assessment

Video Analysis of walking and running

 

 

Conditioning Exercises:

Core stability

Strengthening

Cardiovascular Endurance

Flexibility

Muscular endurance

Proprioception

So as you can see, orthotic devices can be useful in the management of lower limb and spinal conditions but you need to look at the whole picture.

Physiotherapy or orthotics on their own may not be enough

Come at it from as many directions as you need.