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PROTRACK » Coaching & Training » Expert raises doubt over the value of orthotics

Expert raises doubt over the value of orthotics

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Close Look at Orthotics Raises a Welter of Doubts
By Gina Kolata
The Newy York Times
January 17, 2011


Benno M. Nigg has become a leading researcher on orthotics — those shoe inserts that many athletes use to try to prevent injuries. And what he has found is not very reassuring.

For more than 30 years Dr. Nigg, a professor of biomechanics and co-director of the Human Performance Lab at the University of Calgary in Alberta, has asked how orthotics affect motion, stress on joints and muscle activity.

Do they help or harm athletes who use them? And is the huge orthotics industry — from customized shoe inserts costing hundreds of dollars to over-the-counter ones sold at every drugstore — based on science or on wishful thinking?

His overall conclusion: Shoe inserts or orthotics may be helpful as a short-term solution, preventing injuries in some athletes. But it is not clear how to make inserts that work. The idea that they are supposed to correct mechanical-alignment problems does not hold up.

Joseph Hamill, who studies lower-limb biomechanics at the University of Massachusetts in Amherst, agrees.

“We have found many of the same results,” said Dr. Hamill, professor of kinesiology and the director of the university’s biomechanics laboratory. “I guess the main thing to note is that, as biomechanists, we really do not know how orthotics work.”

Orthotists say Dr. Nigg’s sweeping statement does not take into account the benefits their patients perceive.

The key measure of success, said Jeffrey P. Wensman, director of clinical and technical services at the Orthotics and Prosthetics Center at the University of Michigan, is that patients feel better.

“The vast majority of our patients are happier having them than not,” he said about orthotics that are inserted in shoes.

Seamus Kennedy, president and co-owner of Hersco Ortho Labs in New York, said there was an abundance of evidence — hundreds of published papers — that orthotics can treat and prevent “mechanically induced foot problems,” leading to common injuries like knee pain, shinsplints and pain along the bottom of the foot.

“Orthotics do work,” Mr. Kennedy said. “But choosing the right one requires a great deal of care.”

Yet Scott D. Cummings, president of the American Academy of Orthotists and Prosthetists, says the trade is only now moving toward becoming a science. So far, most of the focus in that direction has been on rigorously assessing orthotics and prosthetics for other conditions, like scoliosis, with less work on shoe orthotics for otherwise healthy athletes.

“Anecdotally, we know what designs work and what designs don’t work” for foot orthotics, said Mr. Cummings, who is an orthotist and prosthetist at Next Step in Manchester, N.H. But when it comes to science and rigorous studies, he added, “comparatively, there isn’t a whole lot of evidence out there.”

Dr. Nigg would agree.

In his studies, he found there was no way to predict the effect of a given orthotic. Consider, for example, an insert that pushes the foot away from a pronated position, or rotated excessively outward. You might think it would have the same effect on everyone who pronates, but it does not.

One person might respond by increasing the stress on the outside of the foot, another on the inside. Another might not respond at all, unconsciously correcting the orthotic’s correction.

“That’s the first problem we have,” Dr. Nigg said. “If you do something to a shoe, different people will react differently.”

The next problem is that there may be little agreement among orthotics makers about what sort of insert to prescribe.

In one study discussed in his new book, “Biomechanics of Sport Shoes,” Dr. Nigg sent a talented distance runner to five certified orthotics makers. Each made a different type of insert to “correct” his pronation.

The athlete wore each set of orthotics for three days and then ran 10 kilometers, about 6 miles. He liked two of the orthotics and ran faster with them than with the other three. But the construction of the two he liked was completely different.

Then what, Dr. Nigg asked in series of studies, do orthotics actually do?

They turn out to have little effect on kinematics — the actual movement of the skeleton during a run. But they can have large effects on muscles and joints, often making muscles work as much as 50 percent harder for the same movement and increasing stress on joints by a similar amount.

As for “corrective” orthotics, he says, they do not correct so much as lead to a reduction in muscle strength.

In one recent review of published papers, Dr. Nigg and his colleagues analyzed studies on orthotics and injury prevention. Nearly all published studies, they report, lacked scientific rigor. For example, they did not include groups that, for comparison, did not receive orthotics. Or they discounted people who dropped out of the study, even though dropouts are often those who are not benefiting from a treatment.

Being generous about studies with design flaws that could overstate effects, Dr. Nigg and his colleagues concluded that custom-made orthotics could help prevent and treat plantar fasciitis, a common injury to a tendon at the bottom of the foot, and stress fractures of the tibia, along the shin. They added, though, that the research was inadequate for them to have confidence in those conclusions.

Dr. Nigg also did his own study with 240 Canadian soldiers. Half of them got inserts and the others, for comparison, did not.

Those who got inserts had a choice of six different types that did different things to foot positioning. Each man chose the insert he found most comfortable and wore it for four months. The men selected five of the six inserts with equal frequency.

The findings were somewhat puzzling: While the group that used inserts had about half as many injuries — defined as pain that kept them from exercising for at least half a day — there was no obvious relation between the insert a soldier chose and his biomechanics without it.

That’s why Dr. Nigg says for now it is difficult to figure out which orthotic will help an individual. The only indication seems to be that a comfortable orthotic might be better than none at all, at least for the activities of people in the military.

So where does this leave people like Jason Stallman, my friend and colleague at The New York Times? Jason has perfectly flat feet — no arch. He got his first pair of orthotics at 12 or 13 and has worn orthotics all the time, for walking and running ever since. About a year ago he decided to try going without them in his everyday life; he still wears them when he runs.

Every medical specialist Jason has seen tried to correct his flat feet, but with little agreement on how to do it.

Every new podiatrist or orthopedist, he told me, would invariably look at his orthotics and say: “Oh, these aren’t any good. The lab I use makes much better ones. Your injury is probably linked to these poor-fitting orthotics.”

So he tried different orthotic styles, different materials, different orthotics labs with every new doctor.

That is a typical story, Dr. Nigg says. In fact, he adds, there is no need to “correct” a flat foot. All Jason needs to do is strengthen his foot and ankle muscles and then try running without orthotics.

Dr. Nigg says he always wondered what was wrong with having flat feet. Arches, he explains, are an evolutionary remnant, needed by primates that gripped trees with their feet.

“Since we don’t do that anymore, we don’t really need an arch,” he wrote in an e-mail. “Why would we? For landing — no need. For the stance phase — no need. For the takeoff phase — no need. Thus a flat foot is not something that is bad per se.”

So why shouldn’t Jason — or anyone, for that matter — just go to a store and buy whatever shoe feels good, without worrying about “correcting” a perceived biomechanical defect?

“That is exactly what you should do,” Dr. Nigg replied.

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ripped

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nitta ripped me off!
refund time

Nittas

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First of all Beno Nigg - leading researching in orthotics, this is debatable aswell in my opinion.
As far as i'm concerned this debate has been on going for 40+ years since M. root first published the 'normal foot criterion' and the use or orthomechanical treatment in lower-limb pathology.

Since then, there is debate as to whether orthomechanical devices are able to place a foot into a 'normal' position (whatever that really is), or even correct pathology had been in debate since due to real lack of valid and reliable evidence. However, there have been many correlations with orthotics being successful in treatment of lower-limb pathology - shin pain/achilles pain/plantar heel pain/even knee knee and lower-back pain.

Some current reseachers believe that the effect of orthotics to reduce abnormal forces that abnormal stresses is what can make them effective. Thus, the orthotic should be designed to reduce an abnormal force - and this means the clinician has to be capable of identifying what this is before creating anything to reduce it....The issue is not that orthoses are ineffective, it is that sometimes they are not designed correctly. In my opinion any treatment regime that reduces a abnormal force to reduce pathology, and does not cause another pathology is an effective treatment regime.

If admin is happy to place a 'junk' post like this onto a running forum (since an article like Beno's comes out almost every year) - perhaps he will feel more comfortable reading the professional debates on this: .
There is plenty of debate for and against most clinical treatment regimes - such as pilates etc aswell....while at the same time there's no 'clinical' evidence that is valid and reliable to proove a 'speedball program in athletics' - but there is some practical evidence...similarly if you want hundreds of clinical success cases of how orthotics have assisted in relieving lower-limb pathology in many of my clients including runners and track athletes I am more than happy to give some examples to 'admin'. Or feel free to sit in one of my functional anatomy and lower-limb injury lectures to the uni students admin.

cheers
nitta

Admin

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Nitta

The article was from the New York Times and I read it via Runners Tribe and I thought it interesting. There was no nasty nor malicious intent.

It's an opinion piece from a respectable newspaper and if it's good enough to be mentioned on Runners Tribe then it's worthwhile appearing here.

[You must be registered and logged in to see this link.] (See articles under "ATHLETIC NEWS UPDATED DAILY")

To suggest it is 'junk' and has no place on athletics forum is ridiculous. It's not for you to say what items appear on this forum. The administrators & moderators have earned that right.

By all means refute the findings - but be very careful bagging the administrator for trying to keep the forum ticking over with articles of interest. A lot of hard work goes into Protrack to ensure there is a constant flow of articles, results and reports and I won't cop a serve from someone because they get miffed over an article I had nothing to do with nor have made a comment on.

Don't shoot the messenger.

Take that as a warning.

PS: I have orthotics...don't wear them as often as I should, but certainly see the benefit of them.

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Nittaz

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Then I look forward to the posting of a borderline identical article each year from another researcher in the field explaining the same phenomenon on orthoses - when it makes it into a runners world magazine.....last years fad was barefoot running by lieberman (funnily enough it ended up being a way of promoting his new barefoot running shoes). I wonder Beno is up to ....

PS: Sorry for having a crack at you youngy, but this topic and debate has been exactly the same since the 1970's.....

Mex

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I found the article a good read. It provides a different point of view on something that a lot of people swear by. I personally don't have any, although it was suggested at one stage when I was a student and could not afford them. I found that a change in the brand and model of shoe worked well for me.

This type of article absolutely has its place on this forum and I would hope that if there was an article on the validity of using a "speed ball program" to enhance your running that it would also find its way onto this site.

Keep digging around 'Admin' to find more articles that we 'may' find interesting to read.

youngy

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Mex wrote:I found the article a good read. It provides a different point of view on something that a lot of people swear by. I personally don't have any, although it was suggested at one stage when I was a student and could not afford them. I found that a change in the brand and model of shoe worked well for me.

This type of article absolutely has its place on this forum and I would hope that if there was an article on the validity of using a "speed ball program" to enhance your running that it would also find its way onto this site.

Keep digging around 'Admin' to find more articles that we 'may' find interesting to read.

Rest assured, Mex, if I found an article questioning the use of speedball, medicine ball or another 'ball' or any other piece of equipment, and it was from a reputable publication, offered by an 'expert' in the field then of course I'd post it here.

With the amount of traffic we're now getting, it's imperative we keep it ticking over with items of interest. Sometimes it can be a slow news day and I'll post something that has an indirect relevance to running. Doesn't mean I agree with it; just thought it interesting enough to be posted.

I also found the article very interesting and thought it relevant as I know many people who use orthotics and have a genuine belief in their benefit. If it hadn't been mentioned on Runners Tribe, I would not have known about it.


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8 Orthotics raise a welter of doubts on Wed Mar 23, 2011 4:58 am

bruceg

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This past weekend I found Happy Feet Massaging Insoles. My feet have been hurting a lot since last July due to a bad buying decision on work boots, so I decided to give the product a test. Heck, I'd already spent close to $200 on other insoles and instep supports that did very little to ease the pain. I immediately put the insoles in my shoes and noticed a difference that night when I took my shoes off and walked bare-footed: much less pain than that morning. After three days with the insoles my feet hurt very little, a big change from the past six months when I began wondering if I'd ever be able to walk without severe pain.
Bruce G. SC

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