Podiatry Arena members do not see these ads

Lets reignite this debate.....

From latest JAPMA:


What say you?

I think that it is again, just the research catching up with common practice. Being in a public clinic with restricted budgets, we use prefabs at a rate of 3 to 1 over customs devices, especially for faciitis. It is good to know that prefabs can in some instances be considered best practice, and the most efficient devices.

__________________
Stephen Tucker
Eastern Health
Podiatry Manager

My location

Hi (nice avatar!),
I can think of two examples where a custom device is more effective than an OTC device.
1. Longevity. To use myself as an example here - I've had my polyprop devices for over 20 years, and worn them continuously. In this case custom devices must be less expensive overall than OTC's.
2. Orthoses design. When I need to prescribe a device for maximum control (deep heelseat, high medial flange, cusioned pushout for navicular) OTC's just don't do the job.

In my practice I see many cases where the patient already has a pair of devices. These are often sold as custom (with a price to match) whereas in reality they should be termed "customised". Generally they incorporate the disadvantages of both custom (expensive) and OTC (limited life).
Cheers,
David

Hi All,
From experience I would tend to agree that over the counter devices or 'simple' custom made orthoses have a significant role to play in the treatment of plantar fasciitis. It is worthwile to consider that orthoses may well be only part of the prescribed therapy for this condition depending on the presenting aetiology.
Also I would not normally go for a custom casted device for a first episode of the condition or if I feel that extrinsic factors such as poor footwear,obesity or overuse have had a major influence.
I tend to suggest to the patient that the orthosis is a temporary measure to assist in the resolution of their symptoms just like they may take an antibiotic for a bacterial infection.

Michael Black
Podiatrist

__________________
Michael Black
Podiatrist
Dundee
Scotland

Dear All,
It might help if we define up front what we think are the specific physical forces at work that are contributing to the plantarfasciitis(P/F). What structures are doing what to which etc.
My 2c worth is that if we think P/F caused by levels of tensile stress that are beyond what the tissue can cope with then we need to relieve/lower the levels of stress in the structure.
Put simply: to have less tensile stress on plantarfascia we can decrease the linear distance between the calc medial tubercle and the prox phal of the hallux where the fascia inserts.
If you look at any two pairs of feet you will see they are not the same, and that to achieve the above result is a three dimensional problem requiring the T-N joint to be elevated from the floor and the 1st met shaft to be plantarflexed from that height above the floor. When you do this you decrease stress on that specific tissue during stance phase and decrease the force required to establish the windlass,(see Craigs stuff).
If you use over the counter devices, OK but only if the shape is suitable for the foot, for my money most OTC devices are not steep enough in the 1st met plantarflexion angle for a lot of feet. But they do clearly work for some.
Regards Phill

Regarding the use of customized orthoses in a RCT.
Before a proper RCT can be performed, you must have some information about the inter-clinician variability regarding the modalities of the intervention(s) studied and the outcome variables. Information about variability of clinical achievements among clinicians is essential for the interpretation of the results. Only when there is a small variation, it is possible to generalize the effect of therapy achieved by one clinician to colleagues.

Notwithstanding the lack of aforementioned information, there are no experimental tested theories of functional mechanisms of foot orthoses. There is no uniformity in the various theories about foot orthoses therapy for a particular condition. More over, clinicians who claim to be a representative of a particular school or theory, give the impression to differ in their manner of working regarding a numerous of aspects, such as physical examination, diagnosis, casting and orthosis construction.

As a clinical researcher, I would advocate a bottom-up approach were at first a more fundamental understanding of the mechanisms underlying foot orthoses therapy is studied. With Dephi-rounds, the available scientific evidence has to be combined with the experience of various professional groups in order to formulate clinical protocols. These protocols should be evaluated in RCT’s and, when effective, finally have to be incorporated in the clinical process.

Cheers .

Nick Guldemond, researcher
Dept. Orthopaedic Surgery
University Hospital Maastricht
P.O. Box 5800
6202 AZ Maastricht
The Netherlands
Phone: +31 (0)43 3875031
Fax: +31 (0)43 3874893

Guldemond

Lets reignite this debate.....

That should put it out.

Luke hawkins

Hi Nick,
I'm not sure about this statement - although we may disagree on some of the finer points it is generally agreed in podiatry that ankle equinus should be addressed with heel-raises, that transverse-plane anomilies should be addressed with medial or lateral posting of the orthosis, that the STJ should work around neutral, and that sagittal plane anomilies are perhaps more important than we originally thought.

Its good to have your contribution though, and no one would disagree with the suggestion that more research is needed into orthoses and their effects.
Cheers,
Davidh

Hej Davidh,

Thank you very much for your reply.
I don't disagree with the fact that there's general agreement or consensus about podiatric treatment for particular conditions.
And I don't rule out that these treatments, which mostly based on empirical observations; personal experience and/or traditional habits, could be beneficial for patients. What matter is, what are the arguments for the choosing a specific intervention? General agreement is one (if there exits any agreement among therapists for the individual patient?), which could be evaluated in a more pragmatic oriented RCT. But could the clinical process underlying the treatment be standardized? Is it known what how much millimeter elevation or posting is needed for effective treatment and is this proportional to the foot size et cetera? In other words, is there a clear algorithm for treatment? Notwithstanding the problem of creating homogeneous group on basis of diagnosis and foot characteristics.
It seems to be a bit unfair to summarize all these prerequisites for proper evaluation. But if we don't take these aspects in consideration, we better don't start a clinical trial: if you don't have an idea about the sources of variation regarding the diagnostic process, the treatment modalities and so on, you end up with results which are not meaningful and that is regrettable for all the work done, especially for the patients. Based on literature and our own work, I think the sources of variation are quite large for various aspects, thereby you need a large number of patients to meet an acceptable study power. So, we first need to work on reducing the amount of variation for all aspects of the clinical process. Research on biomechanical mechanisms of foot orthoses therapy is only one facet.
Each long journey starts with a step.
Cheers !

Nick Guldemond, researcher
Dept. Orthopaedic Surgery
University Hospital Maastricht
P.O. Box 5800
6202 AZ Maastricht
The Netherlands
Phone: +31 (0)43 3875031
Fax: +31 (0)43 3874893

Hi Nick,
The problem (as I see it) seems to be in defining what is a "normal" foot.
The normal foot as we recognise it today is well described in the 1909 (I think that's the date ) and subsequent editions of Grays Anatomy. Now - is this simply a reprint of the original 1850's Grays Anatomy, or was some additional work carried out to make sure that the normal foot was normal, and not merely someone's idea of normal, based on observing, say, 10 cadaver feet? we have no way of knowing, but experience (and a little research carried out on 100 asymptomatic feet - "normals" to simple observation) in the disciplined environment of a Bioengineering Dept suggests to me that the "normal" foot is a rare beast indeed.
The other puzzler for me is fossil evidence. Visit your local University Anth Lab and dig out the femur/tib/fib casts of the fossil skeleton of Homo Erectus (Turkana Boy).
Dated 1.6 million years, but you shouldn't have much difficulty in matching the casts with modern bones (you might have to try a few until you get a good match).
So, Creationist/Evolutionist arguments not withstanding, it would seem to me that we are a) walking around on pretty old lower limb geometry, and b) our idea of a normal foot may be erroneous.
The one constant ( and many of my colleagues will point out, correctly, that this is not that constant either) is that nowadays we ambulate mostly on hard, flat surfaces. Are we treating symptoms caused by normal foot variation having to compensate for hard flat surfaces (just one of the surfaces our lower limb geometry has developed for)?

Until we work through this one I can't see how a clinical trial would be appropriate or useful either.
Regards,
David

Podiatry Today have a story on the paper that this thread started with:

Full story

Hello,

I think that this is an interesting discussion although -from my point of view- i would think that you make an orthotic for 'a biomechanical profile' whether they have a plant. fasciitis or a any other clinical complaint.

That's also the reason (i think) why sometimes custom made insoles work and sometimes they don't???

This is what I think. It is not the foot that is "abnormal" it is the modern environment that causes the natural foot to function abnormally. Constantly trying to adapt to flat level surfaces (and also modern footwear) constantly forces the STJ into pronation and creates abnormal forces within the body. When these forces eventually cause pain, we blame the anatomy of the foot and leg instead of the abnormal environment that they have been trying to cope with. The biomechanical model has served us well but we need to question the assumption that "when a foot and leg function poorly on flat level surfaces, it is the foot and leg that are abnormal".
How did we evolve to be the masters of our planet if we are cursed with defective foot and leg anatomy?
The prevalence of foot and leg dysfuntion in modern society should suggest that there is a common environmental factor rather than that our anatomy is unsuited to normal gait.
The current biomechanical paradigm, while useful, is reductionist and does not consider all the factors that determine biological function.
Changes in musculoskeletal function are ultimately the result of neuromuscular effects. It is muscles that control the movement of joints and nerves that control the firing of muscles. The biomechanical effects of FO's might actually be observations of changes in Neuro-motor function rather than mechanical effects of the devices (otherwise, why can taping have any effect on biomechanical function).
It is the body's reaction to devices rather than the devices themselves that determines their effectiveness.
Craig Payne has demonstrated that FO's can reduce the force required to supinate the STJ and to activate the windlass. Are these reductions in force mechanical consequences of the devices or do they indicate that the muscles controlling the STJ now function more efficiently and with less strain?
FO's can be shown to improve balance. This is a neuromuscular effect.
They can also improve forefoot stability. This could also be a neuromuscular effect.
There is no question that FO's are effective. Perhaps their effectiveness is in helping our feet and leg function more physiologically in an unfamiliar and unphysiological environment?

Charlie Baycroft

What if you had a normal foot and your plantar fascia (or whatever hurt?) Does being abnormal cause pain? Does a foot have to be made "normal" to prevent pain? Defining the normal foot is a problem, but not necessarily one that is related treatment of patients. In the tissue stress approach to treatment you identify the anatomical structure in pain and reduce the stress on it. What is the rationale for needing to know what normal is?

Apologies. In an earlier message I assumed that Karl custom fitted and posted the Formthotics in his study. I have asked and he tells me that he did heat mould them in neutral but did not apply any posts to them. Now I am amazed that they seemed to work as well as they did in comparison to the devices made in the lab. I guess this does justify labelling them "prefab" or custom insoles. Seems unfair to the product to use them this way and compare them to posted devices. Better to use them and ones's expertise to custom mould and adjust them properly, as they are intended to be used.
Charlie Baycroft

Kenva
Yes this is spot on in my opinion.

There's a lot of discussion going on regarding custom v's OTC at the moment.

What is a custom device? the one that fits the foot the best or the one that fits the biomechanical profile the best. I choose the latter. This may mean that an OTC can fit the biomechanical profile just as well as the 'custom' job.
So does this mean the OTC is actually a custom device if it fits the biomechanical profile well enough to resolve pathology. I think one could answer in the affirmative.

Cheers Dave

In my opinion a custom device is one made from measurements and molds of a patient's foot specifically for that patient. An over the counter device is one made from a generic mold. You could make a custom device that has a 3 degree forefoot valgus intrinsic post and a 2mm medial heel skive with and a medial arch height of 25mm, and you can buy an over the counter device with pretty much the same shape. They both match the prescription, but one is over the counter and one is custom. It would be unethical, in my opinion, to charge the custom price for the OTC device even though they look very close to the same. So, in terms of price charged, the OTC device is not custom.

Cheers,

Eric Fuller

Eric

I wasn't talking in terms of cost, just the basic principle that an othosis should be custom in its biomechanical funtion, which could include OTC by that criteria. I would say that any orthosis only approximates the shape of the foot at some point of reference. The orthosis itself can and usually does change the relative dynamic morphology of the foot thru the gait cycle, which may or may not be advantageous to resolution of pathology but may be more attainable, if required, thru the use of a custom othoses.
But if these criteria were satisfied by the OTC orthosis would it then be ethical to make and charge for a custom device. I would say yes both to this question and your question is it ethical to charge the same price for an OTC product and a custom.
There are many advantages, as we all know, for using a custom device besides purely it functionality. These include durability, looking better, fit the shoe better, give the customer more confidence, etc etc.
Then again as long as the customer is well informed before purchase and the podiatrist has used all their skill to give the optimal prescription then if you can sell an OTC product for £500 that's fair play. Selling an OTC product for £500 without the above considerations is unethical I would say.
Personally I usually have more confidence in a custom product and I believe if the therapist, in any dicipline, is confident then so will the customer be and that will improve outcome since they are likely to be more compliant with the full treatment plan.
However what if Howard Danenburgh or Dr Stanley Beekman could save the customer all the time and touble of the custom orthoses route and with one manipulation relieve their pain. One could argue that it would be ethical to charge even more than the podiatrist and their orthoses.
Again as long as the customer is well informed before hand then whatever they decide they are prepared to pay is between them and their health proffesional. There is plenty of choice out there.
Having said that both you and I may not feel comfortable about charging such a high price but for some its just business and they are the ones with a big summer house in the Hamptons.

Cheers Dave

I am a little confused as to what can be classed as a custom made product and a prefabricated orthotic.

I have been prescribing a prefabricated orthotic which I post accordingly and customise to the patient's foot according to results obtained from the biomechical assessment. I am using a prefabricated product made out of 100% EVA which I mould to my patient's foot, apply wedging where it is appropriate, and for longer lasting wear I block the arch. By doing this the product lasts a long time and because EVA is shock absorbing and comes in different densities it becomes easier for my patients to comply.

Now would this still be classed as a pre fab or a custom made??

Personally I think it is easier to modify, adjust and alter a prefab orthotic compared to a cast orthotic.

I went to a Workshop in Sydney held by a company called ICB Medical which was informative in the understanding of lower limb biomechanics but they put alot of emphasis on their pre fab product. I took it as a whole lot of sales talk at first until I applied a few pairs and realised that I can really modify this product to what ever shape I wanted to by moulding and applying the appropriate posts.

I have been doing this for a while and achieving better results and feed back from patients as opposed to using a poly cast orthotic as before. The best thing is that it is cheaper and less time consuming.

Does any one else find this is working for them as well??

The heat moulding of of prefabs are a scam. I am surprised people keep getting sucked in by this. You can NOT alter their shape by heating them and expect that shape to stay. As soon as they are stood on they revert back to the shape based on the thickness of the material.

BTW, I also went to a ICB workshop and thought most of what they taught was over 10 years out of date based on all the current concepts.

I guess it all depends on the prefab your using. If your using 100% EVA to mould to a cast why would you find it inappropriate to mould 100% EVA to the shape of a persons foot in the position you want it.

Also if the read my whole post you would have noted that I do not only mould the orthotic I also put the appropriate postings to create the required orthotic. This includes 'blocking the arch' of the orthotic.

In terms of the 'thickness' of the material it does play some role in its life span and how long it can retain its shape, but it also comes down to density of the material used - EVA does come in different densities and it also comes down to precribing the correct density. I prescribe densities accordingly and have prescribed and moulded an ICB pre fab without blocking the arch and it did retain its shape for a significant amount of time. Once I felt my patient required adjustment I re moulded it and blocked the arch for him. This was all done after he was un happy with the cast orthotic I received from a lab, and after adjustment and modification still wasn't satisfied.

I will also note that I have used many labs in the past and I can guarantee you it was not created to the cast. Most of them never came close to contouring to the cast I sent off. At least with the pre fab I was able to mould it to a cast and it did contour correctly.

I don't know what pre fabs u have been using but I have never had a problem with ICB.

I was sceptical about the lecture at first but I have been practising along the same guidelines as Abbie (the lecturer) for many years and getting great results. With a field like orthotics which is not an exact science I cant see how you could see any lecture as being out dated. You absorb and apply what works best for you and the ICB method of assessment and orthotic fitting has worked well for me over the years so I think I will keep going this way.

I am with Davinci on this one --- prefabs can not have there shape changed by heat moulding and the manufacturers that promote this are being very misleading.

The prefabs that claim to be heat mouldable (eg ICB, Vasyli, etc) are made from EVA or PE (or a combination). The shape of these prefabs depend on thickness of the material in different areas to have their shape. They claim the heat moulding makes them customisable - thats absolute crap.

Think about it --- you heat up one of these and have patient stand on it, then, for eg, you elevate the arch area with your hand while its hot to increase conformity to the arch ... when it cools, then you have changed the shape --- BUT, that change of shape can be reversed with a bit of pressure from a little finger --- so imagine what bodyweight does to it !!!!

Heating the EVA does NOT allow the material to be flattened in some areas and not in others .... a simple experiment will show that you can't do that.

I agree: What ICB teach in their workshops, we stopped teaching the students many many years ago.

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

It appears to me that this shows the gulf between Academics and clinicians. I have also attended an ICB Lower Limb course and found the information to be extremely helpfull in the clinic as the weekend was based on actual proven treatment methods. Since attending I have put this information into practice and found that the anecdotal results were great! Both Davinci and Payne appear to be pushing their own particular loyalties. EVA is being used by the podiatry market all over the world, of course there are some deficiencies but a proper clinician can use the product like ICB as a orthotic blank and modify to achieve the required result.
I have used this product as well as others and completely dissagree with Davinci and Payne comments and as for the content of these courses maybe we should be teaching what ICB and others present on these weekends and maybe would see better results from the professiion.

Where did I say that there was anything wrong with EVA? I use it all the time. I use prefabs a lot. I just said that some manufacturers are perpetuating a myth and people fall for it that you can heat mold prefabs.
Please explain what loyalties I have?? What loyality am I pushing? What loyalities does Davinci have? Do you even know who he is? I can tell you he is not an acdemic so you got that wrong.

But most importantly if you are going to take pot shots, then tell us who you are rather than post anonymously.

Do you want to disclose any ties you have to the company?

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

Interesting comments. I used to heat mold the premade orthotics to the patients foot in the shoe as thats what the infomerical seminar I attended told me I had to do. After a while I realised that you can only change the shape until the patient starts walking on it. For that reason I stopped heating them. Has any research been done on this? It should be easy research to so. I did a "study" on one pair with me as the patient and the heating did not change them.

Regards
Bill

From Chazcheh's point restarting this thread. When does a Preform become a Custom device? Whether heat moulded , applied wedges or increased padding on the Plantar interface surely each adaption made will increase the functionality of the device making it less of a compromise over an off-the-shelf custom device.

Whatever the modification does there come a point where it would have been better to go for a good custom device in the first place?

Kind Rgds
Jamie

First off, there is nothing magical about custom that makes them work better. You create a custom device with a certain shape and this shape may be very close, or close enough, to an OTC device that it does not matter which one you use. At one of the PFOLA conferences (San Francisco) there was a presentation about how 80% of the devices made were very close to a particular shape.

So, I think this comes down to an economics issue. If the OTC device achieves the same result as the custom, which one would you choose. However, if the OTC device takes more time to fit and modify than a custom device then your economics might be changing. Some custom devices need modification as well. Who is paying for your time to modify the device? How often do you have to modify the OTC device as compared to a custom device?

On EVA devices and heat molding. EVA, by its nature is a shank dependent orthosis. A shank dependent orthosis (I first heard Kevin K. use this term) is a device made from a very flexible, but somewhat resistant to compression material that maintains it shape as long as there is complete contact with shank of the shoe that it sits in. Pressure from above will cause the device to deform until pressure from below prevents deformation (Or changes the deformation from bending to compression of the material.) So, heat molding does not change the thickness of the device. So, to make the arch stay higher after you heat mold it into that position you will have to add material into the arch for it to stay in that position. You will also have to pay attention to the variety of shoes that a patient wears becuase shank shape can vary to the point that a shank dependent device that works in one shoe will be useless in another shoe.

Regards,
Eric Fuller

Aren't they the people who caused the profession huge embarrasment when they used to state on their website that their courses where endorsed by the Australian Biomechanics Association? (its gone now). The Australian Biomechanics Association does not exist and the matter was raised within the Australia and NZ Society of Biomechanics (which does exist) about this endorsement to the embarrasment of the podiatry profession as they were linked by the biomechanists to podiatry.

Good question.

Has any one done any research on this??

I hope I don't sound like I have any loyalties to any one or any company but I have used many pre fabs and most of them do not mould. I have to say the ICB pre fab does mould significanly to patients foot.

Again I will note that I do block the arch and add postings accordingly straight after I have prepared my mould. I dont see this any different to moulding eva to a cast and I stand by that point.

There seems to be a lot of critics out there against the moulding of a pre fab orthotic. Some one should really do some research on this.

Now I'm no academic or a super expert to say the least but if there is a study that proves me wrong please show me. I believe what I see and a see change in the orthotic after it has been moulded, and I see better compliance with my patients - AFTER MOULDING AND POSTING.

In regards to Abbie and his assessment.

I know you guys are experts but if a practitioner has clinical experience and has achieved results practicing in a certain way wouldn't you preech what you practice??

I guess I have been assessing and fitting orthotics the same way for a while and achieving greater results than I used to before adopting Abbie's methods. So if this is happening why should any one criticise these methods of practice. It sounds like some people have a personal vendeta against Abbie or the ICB group, thats fine with me but I don't agree with any one who critises a method of treatment that works.

THE ONE THING I HATE ABOUT THIS FORUM IS THAT EVERY ONE THINKS THAT THEY ARE RIGHT AND EVERY ONE ELSE IS WRONG!!!

ESPECIALLY WITH ORTHOTICS - IF IT WORKS - DO IT!!!

A well prescribed and fabricated pair of casted FO's are a pleasure to look at and wear. They are elegant, durable, technical and generally very good value for money. However, there does not appear to be any evidence to support the belief that these devices are necessary for the treatment of the majority of patients.

This debate about custom, prefab and OTC surprises me. It seems that the basic issue is how you define what you consider to be a Foot Orthosis. If it is just something that you put into a shoe then Foot Orthosis, insole and arch support all have the same meaning. I think not!
In my opinion, the term Foot Orthosis should mean a therapeutic device, custom made by a skilled therapist to have a desired effect on foot and leg function for a specific patient.
In this context, the issue is not what material is used but whether or not the device can be shown to have the desired effect on Foot and leg function.
Something that you take out of a bag and put into a shoe is an insole or arch support.
If a skilled clinician modifies such a product by altering the shape in relation to the NSTP and adding wedges and can demonstrate that it has the desired effect on function then it is a Custom Foot Orthosis.

The question is how do you validate the effect of the device? The response to a treatment is determined by the adaptation of the patient's body and all people adapt somewhat differently. The only real way to validate the biomechanical function of a FO, is 3D gait analysis in a hi-tech lab and no-one does this. If you do not validate the effect of the device, how can you claim that it is accurate, correct or superior to something else?

Relief of pain does not validate the functional effect of the device. You can get pain relief from very simple shoe adjustments or even wearing orthotics in the wrong shoes. Prescribing a device from measurements and a cast has not been validated as a means of ensuring that the device will have the desired functional effect. If not validated, are they Foot orthoses or arch supports?

I think we have to be honest and concede that making FO's is a craft and not a science unless we can validate the functional effects of what is made.

The term prefabricated Foot Orthoses is a nonsense. The device is not a FO until it has been customized to the patient and the problem using a clinician's expertise. There are products that are partly fabricated and able to be alteraed and adjusted by the clinician and these can provide very cost-effective and convenient relief of symptoms. So why the bias for the more expensive, harder devices when there is no proof that they are more effective either generally or for a specific patient?

Hard materials do make durable devices but there is no proof that the patient needs the devices after the problem resolves. Most of the problems treated with orthoses resolve spontaneously in time anyway, so orthotics are primarily a short term therapy (as far as the pain is concerned). Putting a durable top cover on a softer device also makes it last a long time, my Formthotics are covered with leather and are 15 years old and still good.

EVA and PE are both Polyolefin plastic foams but have very different properties. EVA is more "rubbery" and has high "memory". It resists being deformed to a new shape unless heat molded under high temperature and pressure.
PE has less "memory" and can be moulded to a new shape at a lower temperature and pressure and RETAIN THAT NEW SHAPE!
PE is much more expensive than PE but was chosen for Formthotics (after testing hundreds of compounds) because it could be remoulded in this way to a new shape.

Most "prefabs" are made by heat compression forming (high temperature and pressure) from a uniformly thick sheet of EVA. This is the same way that other insoles are made. It is a simple and very inexpensive manufacturing technique. If you heat these insoles through, the thin parts will expand and can not be recompressed by foot pressure in the shoe.
Formthotics are milled from a sheet of material and then heat moulded (low temperature and presure). If you heat heat them through the realtive thicknesses of the profile will be retained. They can be re-moulded to a totally new shape by foot pressure in the shoe.
Formthotics are 5 times more expensive than Compressed EVA insoles to manufacture.

I emphasise that the plantar fasciitis study used Formthotics and the results do not necessarily apply to other "premades", especially those of compressed EVA.

In all other medical fields, we use the least expensive and complicated therapies possible and then move to more expensive and "harder" therapies if required. Why is the attitude so different in Podiatry?

Respectfully
Charlie Baycroft