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Dear Colleagues
I frequently read, and also I am informed by my local "Running shoe" shop, that one can not wear orthoses with "motion control"or "anti -pronatory" shoes.
Personally I dont believe in these "one rule for all" statements.
When endeavouring to arrive at a suitable prescription for any orthotic therapy, I always factor in both the orthoses and the shoes.
If for example I am dealing with an indivual with a medially deviated STJ axis or ligametous lax/ hypermobile foot. I quite often will combine a Kirby skive with a deep medial heel cup and advise that they be worn with a specific motion control shoe (personally I recommend Brooks).
I feel that simply putting a device aimed at increasing the supinatory moments across a STJ axis into a neutral shoe, you will not achieve the necessary control and will reduce the effectiveness of the device.
Also in terms of motion control shoes there must be huge variations between brands in terms of the amount of rearfoot control?.

I would appreciate any thoughts or papers you have on this topic .


Many Thanks

Rory

I will just take up this bit: There are huge differences between the motion control ability of "motion control" shoes of different companies. HOWEVER, the problem is that the response to the shoe is very subject specific, in that one model may be good at 'motion control' for one person, but not for another and a different model may be the opposite. In data I have only presented at conferences comparing motion control shoes from different companies we found no differences between them in the parameters we measured. What was notable was the massive standard deviation of the parameters and that they went in different directions with different runners in different shoes .... the challenge now is to determine which is the right direction and what predicts that changes, so that can be better matched to the shoe model.

Given that I have no idea what is going on (based on what I wrote above), I have no idea how your shoeshop guy knows what he is talking about.

__________________
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?

Related threads:
What shoe with what orthotic?
Which kind of running shoes with orthotics?
What do we mean by 'motion control' in running shoes
Other running shoes threads

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Craig
one of the points I was getting at , is the fact that "shoeshop guys" are giving advice about not wearing orthoses with motion control shoes.Does this come from the footwear companies or is it just anecdotal driven by running magazine articles?


Rory

I have no idea where its coming from; there is no rationale for making the statement and AFAIMC, its being made by ill-informed self proclaimed experts

__________________
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?

Rory,

There is a running store near me who subscribe to the 'must wear a neutral with orthoses' theory. Even to a point where they undermine professional opinion. Once following a consultation with a patient I sent them off to get some stability shoes. This store popped her on their treadmill and immediately told her I was wrong and she needed neutral shoes. Result - she lost confidence in me and I never saw her again.

Then a chap came in to see one of our physios as he had been running for decades in stability shoes, and this store advised him to change to neutrals. Within a week he had shin and knee pain. At this point the store received a letter from me, fully explaining his foot morphology, movement patterns and the tissue stress mechanism (naturally I laid it on a bit thick with the jargon!). Unsuprisingly I am yet to receive a reply. I now actively tell my patients to not go to this particular store, and send them to another one with whom I have met personally several times and seem to want to work with me rather than against me.

I agree with Craig - there are many running store employees who consider themselves biomechanically knowledgable (yet still use terms such as 'overpronation'). I would save yourself the time and effort of arguing your point with them and just stop using them. I bet there are plenty of other good stores who will happily look after the tens of patients a week you send their way!

Ian

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I was one of the "Agony Aunt page" consultants for a certain well-known running magazine for several years.

The prevailing attitude then (about ten years ago) was that good running shoes expertly fitted could fix most problems, and custom orthoses were hardly ever necessary.
The magazine actively encouraged this point of view, no doubt influenced by the revenue generated by the lavish running shoe and running shoe-shop advertisements which appeared on just about every other page.

Looks like kind of attitude this may still prevail amongst certain shop staff.

Ian
I had a rather intense ( the sort you dont argue with )young female runner one day, whom I advised to replace her current trainers. She went to a "specialist "running shop who advised her that she needed motion control shoes and that she did not need the TL2100 orthoses I had previously issued her with. She asked the shop assistant if both shoes were identical in terms of the amount of motion control they provided. When he replied that they were, she asked if the shoes had "smart" technology in their heel or midsole since she had a structural limb length inequality.
Needless to say he lost the sale!

Rory

Isn't the footwear- orthoses thing a lot like the 'chicken or egg' thing.
Feel free to rip me to pieces, but until Payne & co's results are assessed and published, doesn't the footwear "come" first in that it can completely 'destroy' the desired effects of the orthoses?
(I don't doubt this has been dealt with before in this forum in a much more eloquent? manner)
mark c

Mark,
as i said at the start of this thread

I am not trying to champion orthoses over shoes. In fact one of my pet hates is the belief that orthoses are a stand alone ,cure all, form of therapy.

I was just enquiring if there is any rational behind the orthoses means neutral shoes statement.

Rory

Hi Rory,
This seems a bit contradictory to me and forgive me if I go a bit off topic for a moment but what if they go to buy these specific Brooks shoes and they are uncomfortable? What if they find all brooks shoes uncomfortable?
As a running shop employee (and pod student), I get a lot of referrals for "brooks only" and "asics only" which I think has a little less to do with clinical judgement and more to do with product image and poor knowledge of alternatives.

I'm interested in your perspective on this matter.

I do however agree that putting people in neutral shoes based on a "cancelling out" or "accumulative" concept of support is a widespread and ignorant misconception.

Aidan

Try this one on the running shoe guys- what if the runner is already in a pair of Brooks beasts etc and is still getting problems with their tib post. for example? Or at the other extreme what if the runner is in neutral shoes but is still getting peroneal tendonitis?

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Aidan
I bow to your superior knowledge regarding footwear. The reason I recommend Brooks is based purely on personal experience. I would point out that it is merely a recommendation and not an "only Brooks" order. I do in fact send patients to a particular shop where the guys are big into their running and their shoes ( and not influenced by financial "kick backs" based on sales of particular brands).I get them fit whatever brand suits best. Where we fall out is over the orthoses/neutral shoe debate.

Rory

Sorry Rory, it wasn't my intention to imply this

Yes! This is definately an issue of concern which is rife in the sports shoe industry.

Today at uni our tutor organised a trip to a local shoe store. The idea was to build a relationship with the business where the students can learn about all the different shoes availlable, their features and how the fitting process works but also to provide the staff with a bit more insight as to what we do as podiatrists.
Ideally "shoe shop guys" should be an outlet of initial screening and referral rather than the pod hating headstrong staff who undermine you to the patients you have so kindly referred to their business.
Perhaps organising a continued education night would help?

And before all the people in my year jump on to let everyone know I didnt go on this trip - I had a good excuse. I had clinic and was treating

Gentlemen,

I am in a similar position to Aidan, in that I'm a pod student who works in a running shoe store. (actually we are a multi sports store and I spend most of my time between ski boots and running shoes).

From my experience the blanket "put orthoses wearers into neutral shoes," has come from the running shoe brand tech reps. This was more the case when I stared in the store 8 years ago, the tech guys seem to have pulled there necks in on this one recently.

We are lucky in that we have a good relationship with local podiatrists (we now have a clinic in our store) and by working together I am sure we get better outcomes for our customers and their patients.

I have also experienced an almost anti-podiatry message being put forward by some suppliers, not shoe brands but others concerned with selling "supportive insoles." This will no doubt rub off on some sales staff in certain stores, thankfully not ours!

As an aside I do worry that the running footwear industry has become so obsessed with 'support' that the (imo) equally important fit of the shoe can sometimes be forgotten.

Regards
Euan

Try this for a curve ball:

What do you think a motion control shoe does to post tib function? Would you assume it decreases it?

A project just completed in our dept (not mine; watch this space for details) showed that motion control shoes had NO effect on post tib EMG parameters; in some subjects the post tib had to work a lot harder than it did barefoot or in plain canvas shoes.

__________________
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?

If the shoe is uncomfortable, don't wear it.
If the shoe is not apropriate for the use, don't wear it.

If the shoe is comfortable, and is designed for the activity type, buy whatever you want. The red ones, the blue ones, the expensive ones, the cheaper ones, the new model, the previous model... what ever 'makes you happy'.

The customer ultimately decides anyway - despite the "baffle-with-bull****" marketing out there.

Patients need to invest time, not money in footwear selection, because after all , they're all US$5 shoes anyway...

The retailing of shoes is just like the retailing of ice-cream - buy what you like and you'll most likely stay happy...

This 'retail medicine' approach being given by many of the footwear stores is just trouble for the customer / patient

Cheers,

Paul Dowie

Rory and Colleagues:

Interesting thread. Since I have been following the running shoe industry ever since I got my first pair of running shoes over 35 years ago (Adidas Italia), maybe I can shed some light on this subject that is very dear to my heart (and to the feet and lower extremities of my runner-patients).

First of all, no one has mentioned the weight of the runner, which should very much go into what running shoe is recommended for the runner. A runner with a significantly medially deviated subtalar joint (STJ) axis and posterior tibial tendinitis that weighs 110 pounds may do quite well in a light stability shoe with an over-the-counter (OTC) foot orthosis whereas the 200 pound runner with the same foot type and same symptoms may require a motion control shoe and a highly modified custom foot orthosis to optimize the STJ supination moments from both the orthosis and shoe. Neutral shoes for heavier runners typically aren't a good idea, whether they have foot orthoses in them or not, since they will tend to be too soft and the runner will bottom out the midsole during the first half of support phase of running. Heavy runners need a firmer midsole to optimize the shock absorption from the shoe and may get too little shock absorption from a softer, lower durometer shoe midsole since the midsole will bottom out much like low stiffness springs on a truck axle will harshen the ride of the truck going over larger bumps.

Second, in general, if I am making an orthosis for a pronation-related problem in the runner, I will give advise them to get a shoe with more cushioning than what I would have recommended for them if they didn't have an orthosis. For example, if the runner would normally be in a motion-control shoe without an orthosis, I may have them try a stability shoe with the orthosis inside the shoe. If the runner would normally be in a stability shoe without an orthosis, I may have them try a light stability or neutral shoe with the orthosis inside the shoe. Clinically, this tends to work out quite well probably because the orthosis "robs" some of the shock absorption characteristics from the shoe midsole. By having the shoe provide some more cushion, the runner becomes more comfortable and is able to still become asymptomatic.

Third, one must be careful about the contact phase STJ pronation moment that can occur from running in shoes with a relatively high durometer lateral midsole or with an increased lateral sole flare in the heel. Lateral sole flares and high durometer lateral midsoles in the heel or forefoot will tend to increase the external STJ pronation moment during contact phase of running in heel strikers which may exacerbate some pronation-related pathologies such as posterior tibial tendinitis or medial tibial stress syndrome.

Fourth, the ability (i.e. running speed) of the runner will play a role in the shoes I recommend. Faster runners (those that train between 5-6:30/mile pace) with more stable feet generally do quite well with lighter weight neutral or light stability shoes. Whereas, slower runners (those that train over 8:00/mile) that are just out to run 10-20 miles a week, typically do better in more stable shoes that are more "clunky" since these runners have more tendency toward mechanically-induced problems in their feet and lower extremities and may requre a more supportive, heavier shoe.

It is just plain stupid for a podiatrist to only recommend one style of shoe or one brand of running shoe to a runner since shoe fit is highly individual from one person to another and from one style of shoe to another. I provide my runners with a list of running shoes that is extremely helpful for them and allows them to have an idea of a few types of shoes that may might work well for them. It is best to develop a good working relationship with the best running shoe store in your community so that you can educate them and they can educate you if you truly desire to be THE running podiatrist in your community.

Hope this helps.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
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Kevin
Thank you for this valuable insight. It answers a lot of my queries regarding this subject. I always factor in the weight of runner, but the point you raise regarding the the construction of the lateral midsole is something I must confess I have not considered.

Craig
I wonder if the lateral midsole construction actually contributes to increased tibialis posterior activity?

Regards

Rory

I believe that there is some running shoe research that shows that increased lateral sole flare increases initial rearfoot pronation velocity (i.e. just after heel contact). Doubt there is any that shows increased posterior tibial (PT) activity since it is nearly impossible to isolate the PT muscle with an EMG, especially while running.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

I was going to ask Craig about the research he mentioned for this very reason. How did they isolate PT, Craig?

__________________
Science is the antidote to the poison of enthusiasm and superstition

My location

Ultrasound guided EMG needle insertion and electrical stimulation to confirm.

__________________
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?

Nice work. So the fibres adjacent to the needle were either firing at the same rate or harder, but we can't be sure about the muscle as a whole- right? Cool study though. And their explanation for this observation was...... Robbins-Gouwe hypothesis?

__________________
Science is the antidote to the poison of enthusiasm and superstition

My location

Nigg's classic study on lateral flares could explain this. If the canvass shoe was much narrower than the runner then prediction would be that the narrower shoe would have less Post tib activity. However, did they measure a dual density midsole shoe versus a non dual density midsole shoe?

How did they measure " a lot harder"?

Regards,

Eric

Craig:

Do you know of any other studies that have used similar techniques in quantifying EMG activity of the posterior tibial muscle? Sounds like a great study!

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

I am not one to speak with any authority on the project - will let the investigators do that when its published; but they measured a whole range of EMG parameters: peak amplitude; RMS; timing of onset/off; etc ... in a number of muscles.
One of investigators is doing his PhD on this with orthotics ... there was one study using similar methodology with running shoes (but with only 5 subjects) that did show a reduction in PT activity .... watch this space.

__________________
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?

The boys came to the party.... This just got published:
Effect of foot posture, foot orthoses and footwear on lower limb muscle activity during walking and running: A systematic review
George S. Murley, Karl B. Landorf, Hylton B. Menz, Adam R. Bird
Gait & Posture (in press)

__________________
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?

Craig:

Josh Burns should get together with these other fine researchers to study the tonic peroneal activity seen in cavus feet with laterally deviated subtalar joint axes. This seems like an area that has never been studied before and would certainly add to our knowledge base as to the cause of peroneal tendinopathy/peroneal muscle fatigue often seen in these types of feet. Just a suggestion that I thought you might want to pass on to your Australian research colleagues.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Kevin ,Craig,Simon and other contributors

Many thanks for responding to my initial thread. Your responses as ever are not only very informative but thought provoking. On the down side, I often feel that with podiatric biomechanics, The more I read, the less I feel I know. However I never cease to be intrigued.

Regards

Rory

Every time we run one of our Clinical Biomechanics Boot Camps on campus, I always kick off with a presentation on "what I have learnt since the last one" ... it always runs to at least 3-4 slides of dot points. I also look back at some of my older Boot Camp powerpoints and sometimes say to myself "OMG! did I really say that?!!!"

__________________
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?