Research on Orthotics for Heel, Knee and Lower Back Pain.

Section 1) Heel Pain Studies:

Recently a number of studies have been undertaken to measure the effectiveness of orthotic insoles in patients presenting with heel pain, heel spurs or Plantar Fasciitis. Please see below extracts from three of these studies.

Heel Pain Study I

The American Orthopaedic Foot and Ankle Society (AOFAS) announced today the results of a two-year prospective randomized national study on the treatment of heel pain. The study found inexpensive off-the-shelf shoe inserts to be more effective than plastic custom arch supports in the initial treatment of heel pain (plantar fasciitis). Potentially, this finding could save more than $200 million in health care costs annually.

Heel pain affects over two million Americans annually and is the most common foot problem seen in medical practice. Non-operative care for heel pain provides satisfactory treatment for 90 percent of patients. However, research has not established which initial non-operative care is best. The current study, involving 15 orthopaedic foot and ankle centers, was designed to answer this question.

The investigation, conducted by the AOFAS Heel Pain Study Group, looked at the effectiveness of stretching exercises and orthotic devices in the treatment of heel pain. The researchers examined 236 patients who had no previous treatment for their heel pain and no serious medical problems.

The patients were divided (randomized prospectively) among five treatment groups. One group did only Achilles tendon and plantar fascia stretching exercises. (The plantar fascia is the band of tissue that stretches from the ball of the foot to the heel.) The other four groups used an off-the-shelf orthotic shoe insert along with the stretching exercises. All of the patients were examined by an orthopaedic foot and ankle specialist and asked to fill out an activity and symptom questionnaire. They returned after eight weeks of treatment for a repeat examination and questionnaire.

Seventy-two percent of those who did only Achilles tendon and plantar fascia stretching improved. Ninety-five percent of those who used orthotic insoles improved.

The study clearly demonstrates that a stretching program plus an inexpensive pharmacy-bought orthotic insole is the best and most cost effective treatment for heel pain," said Glenn Pfeffer, M.D., San Francisco, Chairman of the AOFAS Heel Pain Study Group. "These findings will allow patients and the health care system to save hundreds of millions of dollars each year by avoiding the unnecessary prescription of a rigid custom arch support for the initial treatment of heel pain."

Heel Pain Study II

Journal of Orthopaedic & Sports Physical Therapy, Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association.

The Impact of Foot Orthotics on Pain and Disability for Individuals With Plantar Fasciitis

Semirigid foot orthotics may significantly reduce pain experienced during walking, and may reduce more global measures of pain and disability for patients with chronic plantar fasciitis. Our results were obtained within a relatively short period of time for subjects who had experienced chronic symptoms associated with plantar fasciitis, and who had used multiple interventions before using the semirigid foot orthotics provided during the study. Semirigid foot orthotics similar to the ones used in this study may be a cost-effective intervention for plantar fasciitis considering the limited number of clinic visits required to fabricate and adjust the orthotics.

Heel Pain Study III

The Short Term Treatment of Plantar Fasciitis Using Simple “off the shelf “ Foot Orthotics.

Department of Podiatry, Curtin University, Kent Street, Bentley, Perth Western Australia .

Simple off the shelf (pharmacy or website bought) orthotics do have a significant effect on plantar fascia symptoms in this patient group. This finding supports the current literature.

The results suggest that clinical measures of the foot have little or no value as predictors of the level of plantar fasciitis thickness, level of pain, disability or reduced activity seen in the patient. The navicular drop technique is a reliable foot posture evaluation. However, it would appear to have no correlation with any of the variables measured. Flatter feet do not seem to produce thicker plantar fascia, have more pain, cause greater disability or reduce activity. The only factor that seems to be correlated to plantar fascia thickness is the increase in BMI and patient's weight.

Section 2) Knee Pain Studies:

Knee Pain Study I

The Effect of Foot Orthoses on Patellofemoral Pain Syndrome - Amol Saxena, DPM* and Jack Haddad, DPM* - Department of Sports Medicine, Palo Alto Medical Foundation, Palo Alto, CA. Corresponding author: Amol Saxena, DPM, Palo Alto Medical Foundation, 795 El Camino Real, Palo Alto, CA 94301. From The Lower Extremity 5(2): 95-102, 1998. Copyright © 1998. Reprinted with permission from Elsevier and the American College of Foot and Ankle Orthopedics and Medicine.

In a retrospective review of 102 patients treated for chondromalacia patellae and patellofemoral pain syndrome/retropatellar dysplasia (PFPS/RPD), the effectiveness of semiflexible foot orthoses was investigated. The combined disorders were diagnosed in 89.3% of the patients. Subjects were 46 women and 54 men, aged 12 to 87 years (mean, 37.9 years; SD, 15.9), who exhibited excessive forefoot varus or rearfoot varus. The initial screening and clinical diagnosis were based on an examination by an orthopedist. Particular attention was directed to patellar crepitation, patellofemoral malalignment, Q-angle measurements, limitation of range of motion, and knee effusion. Patients were evaluated for the onset and duration of patellofemoral pain and degree of knee joint disease. Semiflexible orthoses for each subject were fabricated, based on a clinical lower extremity biomechanical examination. At their follow-up visit, 76.5% were improved and 2% were asymptomatic, showing a significant decrease in the level of pain with orthoses intervention (chi-square P < .001). Although multiple treatment modalities are used for these patients, the results suggest that the use of semiflexible orthoses is significant in reducing symptoms of PFPS/RPD. (J Am Podiatr Med Assoc 93(4): 264-271, 2003)

Knee Pain Study II

The Role of Foot Orthoses as an Intervention for Patellofemoral Pain
Michael T. Gross, PT, PhD1- Judy L. Foxworth, PT, MS, OCS2

Foot orthoses often are prescribed for patients with patellofemoral pain. The purpose of this clinical commentary is to review the theoretical and research basis that might support this intervention and to provide our own clinical experience in providing foot orthoses for these patients. Literature is reviewed regarding (1) the effects of foot orthoses on pain and function, (2) the relationship between foot and lower-extremity/patellofemoral joint mechanics, (3) the effects of foot orthoses on lower-extremity mechanics, and (4) the effects of foot orthoses on patellofemoral joint position. The literature and our own clinical experience suggest that patients with patellofemoral pain may benefit from foot orthoses if they also demonstrate signs of excessive foot pronation and/or a lower-extremity alignment profile that includes excessive lower-extremity internal rotation during weight bearing and increased Q angle. The mechanism for foot orthoses having a positive effect on pain and function for these patients may include (1) a reduction in internal rotation of the lower extremity; (2) a reduction in Q angle; (3) reduced laterally-directed soft tissue forces from the patellar tendon, the quadriceps tendon, and the iliotibial band; and (4) reduced patellofemoral contact pressures and altered patellofemoral contact pressure mapping.

Foot orthoses may be a valuable adjunct to other intervention strategies for patients who present with the previously stated structural alignment profile. J Orthop Phys Ther 2003;33:661-670.


Section 3) Back Pain Studies:


Back Pain Study I

Orthotic support for low back pain by Dr. Mark N. Charrette

Whenever we stand, walk, or run, the lumbar spine and pelvis balance on the lower extremities. If leg length inequalities, foot asymmetries, or postural misalignments exist, abnormal forces traveling along the closed kinetic chain are likely to interfere with spinal function. [1] Most chronic low back pain is due to some form of musculoskeletal weakness or failure. [2] A major cause of chronic lumbar spine breakdown is microtrauma, which is produced by the following conditions: biomechanical errors; excessive external loads; structural asymmetries; or tissue weaknesses. The source of these conditions, which is often an imbalance/condition in one or both of the feet, must be recognized and treated in order to prevent further breakdown and chronic damage.

Foot conditions:
The feet make up the body's postural foundation. Statistical evidence shows that at birth, most people have perfect feet. By age 20, 80% of humans have developed some type of problem, and by age 40, nearly everyone has some kind of foot condition. Many foot problems eventually contribute to health concerns farther up the kinetic chain, especially generalized back pain conditions. It's in the best interest of both the doctor and patient, therefore, to be able to identify a potential low back problem before it is allowed to affect a patient's health and/or lifestyle.

Support with orthotics:
A major factor in reducing excessive forces on the lumbar spine is frequently overlooked by healthcare professionals: the use of external supports (orthotics, heel lifts) to decrease external forces. The following are commonly seen conditions in which the lower extremity can have a major impact on lumbar spine function. In each of these situations, custom-made orthotics are not only appropriate, they will contribute significantly to a cost-effective treatment outcome. 

If a patient presents with excessive foot pronation and/or arch collapse, a torque force will produce internal rotation stresses to the leg, hip, pelvis, and low back. The result is recurring subluxations and eventual ligament instability affecting the sacroiliac and lumbar spine joints. These forces can be decreased significantly with the use of flexible, custom-made orthotics.

In cases of degenerative changes in the lumbar discs and facets, external heel-strike force may aggravate and perpetuate low back pain. This force is easily reduced with the use of shock-absorbing shoe inserts or orthotics which contain viscoelastic compounds. Symptom reduction is often dramatic.

An anatomical difference in leg length produces strains to the pelvic and low back structures. These strains can cause not only chronic pain, but have also been shown to result in specific degenerative changes.  The use of lifts and orthotics has been shown to reduce these structural strains and bring about significant response. In fact, a 15.5 mm leg length inequality in a patient can be reduced to just 4 mm with the use of a custom-made, flexible orthotic.

Look to the feet:
Getting the answers to a few simple questions (see below) can provide valuable insight into the cause(s) of many of your patients' back pains. When the back acts up, check the feet!

1. Do you stand or walk on hard surfaces for more than 4 hours a day?
2. Do you participate regularly in any physical sport (basketball, baseball, tennis, golf, bowling, etc.)?
3. Are you age 40 or over?
4. Have you ever had a prior injury to your knee, back, or neck?
5. Do your shoes wear unevenly?
6. Do you have joint pain while standing, walking, or running?
7. Is one of your legs shorter than the other?
8. Do you have knock-knees or bow legs?
9. Do you have any obvious foot problems (bunions, corns, flat feet, etc.)?
10. Do your feet "toe out" when you're walking?

If your patient gives an affirmative answer to any of the above, consider him or her a likely candidate for flexible, custom-made orthotics.

1. Keane GP. "Back pain complicated by an associated disability." In: White AH, Anderson R. eds. "Conservative Care of Low Back Pain." Baltimore : Williams & Wilkins, 1991:307.
2. Fulton M. "Lower back pain: new protocols for diagnosis and treatment." Rehab Management 1988; Nov/Dec:39-42.
3. Hammer WI. "Hyperpronation: causes and effects." Chiro Sports Med 1992; 6:97-101.
4. Dananberg HJ, Giuliani M. "Chronic low-back pain and its response to custom-made foot orthoses." J Am Podiatr Med Assoc 1999; 89:109-117.
5. Light LH, et al. "Skeletal transients on heel strike in normal walking with different footwear." J Biomechanics 1980; 13:477-480.
6. Giles LGF, Taylor JR. "Low-back pain associated with leg length inequality." Spine 1981; 6:510-521.
7. Friberg O. "Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality." Spine 1983; 8:643-651.
8. Giles LGF, Taylor JR. "Lumbar spine structural changes associated with leg length inequality." Spine 1982; 7:159-162.
9. Hoffman KS, Hoffman LL. "Effects of adding sacral base leveling to osteopathic manipulative treatment of back pain: a pilot study." JAOA 1994; 94:217-226.
10. Yochum TR, Barry MS. "The short leg" (revised edition). Practical Research Studies 1994; 4(5).
(Dr. Mark N. Charrette is a 1980 summa cum laude graduate of Palmer College of Chiropractic. Over the past 15 years he has lectured extensively on spinal and extremity adjusting throughout the U.S. , Europe , the Far East , and Australia . He received a Bachelor's degree from Illinois State University (summa cum laude) in 1976, where he was an NCAA All-American in 1974. Dr. Charrette is a featured speaker in Foot Levelers' 2003 Spring Seminar Series )

Back Pain Study II

Study Identifies Untreated Foot And Ankle Problems As Major Culprit Of Chronic Lower Back Pain:

Common Podiatry Treatment Promises a Cure for Millions of Sufferers

Washington, DC- A new study released this week in the Journal of the American Podiatric Medical Association reveals untreated foot and ankle problems may be the source of chronic lower back pain for millions of Americans. Furthermore, findings of this groundbreaking study demonstrate that the use of a common treatment for correcting such problems may lead to a cure for many sufferers of this debilitating condition.

The legs and lower back operate as one fluid unit -- unimpeded, normal walking motion exerts minimal, if no, strain on the lower back. According to this two-year study, foot and ankle problems restrict or alter normal walking motion, causing a repetitive strain on the lower back. If ignored, this strain, over time, leads to severe lower back muscle damage and resulting pain.

The study's authors, Dr. Howard J. Dananberg and Dr. Michelle Guiliano, both podiatrists, found the use of custom-made foot orthoses, commonly prescribed shoe inserts, can adjust the patient's damage-causing walk, allowing a more even distribution of weight which restores an unhampered flow of motion.

Over ten million Americans suffer from chronic lower back pain -- millions more have acute recurrent episodes. Seventy percent of those who seek treatment from traditional methods including spinal manipulation, physical therapy, therapeutic injections and surgery experience a recurrence of pain within one year of treatment. The New England Journal of Medicine estimates the cost of treating lower back pain in the tens of billions of dollars in the United States alone.

"This study identifies the nature of a person's walk as a source of chronic lower back pain," states Dr. Dananberg. "It makes perfect sense to focus treatment at the source of the injury. We are hopeful that we can now effectively treat and finally cure the pain of literally millions of people."

Prior to entering the Dananberg/Guiliano study, subjects found traditional methods of treatment unsuccessful. Yet, at the conclusion of the foot orthotics treatment, subjects reported experiencing a sixty-eight percent improvement in pain reduction. In a direct comparison to a study of traditional back pain treatments, using the same scale, Dananberg/Guiliano study participants experienced more than a fifty percent improvement in alleviation of pain, over a much longer duration.

Study methodology:
The amount of pain a patient suffered was measured in the study using a questionnaire called the Quebec Back Pain Disability Scale. The scale measures the severity of pain the patient experiences Through a series of questions, the patient assigns a degree of pain on a scale from one to five, generating a mean pain score. The questionnaire is answered three times; once, at the initial examination, the second time three months after treatment, and the last time twelve to twenty-four months after treatment.