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Patients with a cavus or high-arched foot frequently experience foot pain, which can lead to significant limitation in function. Custom foot orthoses are widely prescribed to treat cavus foot pain. However, no clear guidelines for their construction exist, and there is limited evidence of their efficacy. In a randomized, single-blind, sham-controlled trial, the effect of custom foot orthoses on foot pain, function, quality of life, and plantar pressure loading in people with a cavus foot type was investigated. One hundred fifty-four participants with chronic musculoskeletal foot pain and bilateral cavus feet were randomly assigned to a treatment group receiving custom foot orthoses (n = 75) or to a control group receiving simple sham insoles (n = 79). At 3 months, 99% of the participants provided follow-up data using the Foot Health Status Questionnaire. Foot pain scores improved more with custom foot orthoses than with the control (difference, 8.3 points; 95% confidence interval [CI], 1.2 to 15.3 points; P = .022). Function scores also improved more with custom foot orthoses than with the control (difference, 9.5 points; 95% CI, 2.9 to 16.1 points; P = .005). Quality-of-life data favored custom foot orthoses, although differences reached statistical significance only for physical functioning (difference, 7.0 points; 95% CI, 1.9 to 12.1 points; P = .008). Plantar pressure improved considerably more with custom foot orthoses than with the control for all regions of the foot (difference, –3.0 N · s/cm2; 95% CI, –3.7 to –2.4 N · s/cm2; P < .001). In conclusion, custom foot orthoses are more effective than a control for the treatment of cavus foot pain and its associated limitation in function. (J Am Podiatr Med Assoc 96(3): 205–211, 2006)
Awesome job Josh and coworkers!!!! I will immediately add your extremely valuable research to my lecture titled "Foot Orthoses: Theory and Research Evidence for Their Biomechanical Effects".
Congratulations on your continuing work to improve the research evidence supporting the use of custom foot orthoses for certain pathological conditions of the foot and lower extremity.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Mark,
The full details of the rationale and materials used to fabricate the orthotic device are in the paper. In brief:
* Neutral suspension plater cast
* 20% medial soft-tissue arch expansion
* 3mm polypropylene shell (CADCAM produced)
* F/ft width - lateral border of foot to bisection of 1st MPJ
* Length at distal edge was proximal to MPJ's
* Lateral half-only extrinsic heel post
* 12mm heel cup height
* Full length 3mm Poron top cover
* 6mm lateral heel expansion (mainly due to the thickness of the poron)
Mark
eva 350. Thats a pretty hard device for for a rigid cavus foot isn't it? I would have thought that a 350 eva device would have even less 'give'(for want of a better word) than say a 4mm polypropylene device. I find that eva 270 with extra lateral arch support works really well. Amfit devices seem to capture the cavus foot effectively.
OBJECTIVE:: People who have extremely high arched feet are subject to substantial foot pain, despite a lack of obvious pathology. Customized foot orthoses improve pain and function and reduce foot pressure, but their specificity is unclear. This study sought to identify predictive variables for improvement and to determine whether changes in foot pressure were correlated to changes in pain and function.
DESIGN:: Retrospective analysis of data from a randomized controlled clinical trial. SETTING:: Clinical movement analysis laboratory, School of Physiotherapy, University of Sydney. PARTICIPANTS:: Subjects with painful, idiopathic pes cavus. INTERVENTIONS:: Sixty-six subjects received customized foot orthoses; sixty-seven subjects were allocated a sham intervention.
MAIN OUTCOME MEASURES:: Foot pressure data, location and intensity of pain, Foot Posture Index values, and anthropometric and quality of life variables.
RESULTS:: No relationship between change in foot pressure and change in symptoms was found in either group. No individual characteristics were linked to improvement. Subjects who improved most had substantial pain, lowest function scores, and lowest scores for quality of life variables at entry. There was a possible link, in the orthosis group, between improvement and pain confined to the rear-foot region.
CONCLUSIONS:: The mechanisms by which orthotic intervention is effective in improving pain and function in painful, idiopathic pes cavus remain unclear and equivocal. A strong placebo effect may be in place, or perhaps relatively small changes in foot pressure, even those brought about by a flexible insole with limited shock-absorbing properties, is enough to achieve a clinically meaningful change in symptoms.
Dear bfox@atp-usa.com,
From my orginal paper "For the control group, casts were made of both feet using the same technique as for the treatment group. However, they were not used to fabricate the intervention. Instead the control group were given ‘sham’ insoles made simply from flat, non supportive 3-mm latex foam, a material shown to be the least effective at reducing pressure".
Topcover was Kashmeer® and bottom cover was Agotex®.
Joshua,
Have you done any studies using what have become known as "Pre-Engineered" Orthotics? These are not your typical"Dr Scholls"over the counter, 3-dimensional insoles. These are well designed, accomodative insoles with both arch and metatarsal support molded in. These are currently being used by footcare providers as a first step intervention before going to a true custom orthotic. Would appreciate your comments. Bob
Joshua,
Have you done any studies using what have become known as "Pre-Engineered" Orthotics? These are not your typical"Dr Scholls"over the counter, 3-dimensional insoles. These are well designed, accomodative insoles with both arch and metatarsal support molded in. These are currently being used by footcare providers as a first step intervention before going to a true custom orthotic. Would appreciate your comments. Bob
Hello Bob,
Not exactly sure what you mean by "Pre-Engineered" Orthotics, but if you are referring to the type you sell (http://www.prothotics.com/contact.htm), no I have not performed any studies on this type.
Kind regards
Joshua
BACKGROUND: People with pes cavus frequently suffer foot pain, which can lead to significant disability. Despite anecdotal reports, rigorous scientific investigation of this condition and how best to manage it is lacking. OBJECTIVES: To assess the effects of interventions for the prevention and treatment of pes cavus. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Register (April 2007), MEDLINE (January 1966 to April 2007), EMBASE (January 1980 to April 2007), CINAHL (January 1982 to April 2007), AMED (January 1985 to April 2007), all EBM Reviews (January 1991 to April 2007), SPORTdiscuss (January 1830 to April 2007) and reference lists of articles. We also contacted known experts in the field to identify additional published or unpublished data. SELECTION CRITERIA: We included all randomised and quasi-randomised controlled trials of interventions for the treatment of pes cavus. We also included trials aimed at preventing or correcting the cavus foot deformity. DATA COLLECTION AND ANALYSIS: Two authors independently selected papers, assessed trial quality and extracted data.
MAIN RESULTS: Only one trial (custom-made foot orthoses) fully met the inclusion criteria. Two additional cross-over trials (off-the-shelf foot orthoses and footwear) were also included. Both studies assessed secondary biomechanical outcomes less than three-months after randomisation. Data used in the three studies could not be pooled due to heterogeneity of diagnostic groups and outcome measures. The one trial that fully met the inclusion criteria investigated the treatment of cavus foot pain in 154 adults over a three month period. The trial showed a significant reduction in the level of foot pain, measured using the validated 100-point Foot Health Status Questionnaire, with custom-made foot orthoses versus sham orthoses (WMD 10.90; 95% CI 3.21 to 18.59). Furthermore, a significant improvement in foot function measured with the same questionnaire was reported with custom-made foot orthoses (WMD 11.00; 95% CI 3.35 to 18.65). There was also an increase in physical functioning of the Medical Outcomes Short Form - 36 (WMD 9.50; 95% CI 4.07 to 14.93). There was no difference in reported adverse events following the allocation of custom-made (9%) or sham foot orthoses (15%) (RR 0.61; 95% CI 0.26 to 1.48).
AUTHORS' CONCLUSIONS: In one randomised controlled trial, custom-made foot orthoses were significantly more beneficial than sham orthoses for treating chronic musculoskeletal foot pain associated with pes cavus in a variety of clinical populations. There is no evidence for any other type of intervention for the treatment or prevention of foot pain in people with a cavus foot type
Congratulations on a job well done. You and your colleagues should be proud of the exciting and ground breaking research of yours that has recently been published on the cavus foot. Your work deeply satisfies me and gives me renewed hope for the continued excellence of podiatric research in both the near and distant future. Your clinically relevant research should also serve as an inspiration to all podiatric researchers around this small world of ours. Please continue with your most valuable research.
Quote:
American Podiatric Medical Association News
2007 Stickel Award Winner Announced
The winner of the 2007 William J. Stickel Award for Research in Podiatric Medicine is “Effective Orthotic Therapy for the Painful Cavus Foot: A Randomized Controlled Trial” by Joshua Burns, PhD; Jack Crosbie, PhD; Robert Ouvrier, MD; and Adrienne Hunt, PhD. The paper was published in the May/June 2006 issue of Journal of the American Podiatric Medical Association (JAPMA).
In 2006, the format for the competition for the William J. Stickel Award for Research in Podiatric Medicine was modified. Formerly a prospective process, with papers submitted specifically for award consideration, the award is now retrospective, with papers published in the Journal in the preceding calendar year being eligible. In the past, Gold, Silver, and Bronze Awards were normally given for the top three papers submitted; in the revised format, a single award is given for the best original research paper published in the Journal in the preceding calendar year.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Podiatrist & NHMRC Australian Clinical Research Fellow
Institute for Neuromuscular Research, The Children's Hospital at Westmead
Discipline of Paediatrics and Child Health, Faculty of Medicine, The University of Sydney, Australia
Email: joshuab2@chw.edu.au
Acute effect of orthoses on foot orientation and perceived comfort in individuals with pes cavus during standing
Mansour Eslami, Clarice Tanak, Sébastien Hinse, Mehrdad Anbarian and Paul Allard The Foot Volume 19, Issue 1, March 2009, Pages 1-6
Quote:
Background
Changes in foot orientation due to orthoses and the relationship with perceived comfort are still unclear in pes cavus. The purpose of this study was to determine the acute changes of fore-foot angles due to the use of custom-made orthoses and their relationship with perceived comfort during standing.
Methods
Two photographs were taken using a color-coded camera-based system from the posterior and medial views of 20 subjects with bilateral pes cavus under barefoot and with orthoses conditions during standing. Djian–Annonier, calcaneal inclination, 1st metatarsal declination and rearfoot angles were measured and perceived comfort in the forefoot, midfoot and rearfoot was estimated using an adapted Visual Analogue Scale-type questionnaire.
Results
In comparison with the barefoot condition, orthoses increased significantly the 1st metatarsal declination angle by 1.9° (p < 0.01), and the Djian–Annonier angle by 1.1° (p = 0.02). The calcaneal inclination angle decreased significantly by an average of 3.0° (p < 0.01). Wearing orthoses significantly improved perceived comfort in forefoot, midfoot and rearfoot when compared to barefoot condition (p < 0.01). A significant correlation was observed between variation of calcaneal inclination angle and the perceived comfort at the midfoot (r = −0.44; p = 0.04).
Conclusion
Flattening of foot arch and improvement of midfoot perceived comfort in pes cavus could be attributed to the reduction of the calcaneal inclination angle in the sagittal plane by using orthoses during standing.
Dynamic plantar loading index: Understanding the benefit of custom foot orthoses for painful pes cavus
Bijan Najafi, Elizabeth Barnica, James S. Wrobel, Joshua Burns Journal of Biomechanics; Available online 17 April 2012
Quote:
The purpose of this study was to evaluate a new method showing how custom foot orthoses (CFO) improve dynamics of plantar loading. The method is based on the probability distribution of peak pressure time series and is quantified using the Regression Factor (RF). RF is a least square regression slope between the experimentally observed plantar pressure magnitude probability distribution and a modeled Gaussian shape. Plantar pressure data from a randomized controlled trial of 154 participants with painful Pes Cavus were retrospectively re-analyzed. The participants were randomized to an active treatment group given CFO or a control group given sham orthoses. The location of 2nd Peak pressure as a percentage of stance time (PLoc2) and its magnitude (PM2) was also calculated. In addition, plantar pressure data were collected on 23 healthy volunteers with normal foot alignment and no foot pain. Results demonstrated Pes Cavus had a significantly lower RF than healthy participants (0.30 v. 0.51; p<10−7). PM2 was reduced in both active and control groups. However, RF and the PLoc2 were only changed in the active group (p<0.005) without any significant change in the control group (p>0.5). This study suggests that painful Pes Cavus alters the shape of probability distribution of plantar loading during walking and CFO are an effective therapeutic solution that can significantly improve it. Further use of the RF index and 2nd peak pressure location as an outcome measure for treatment of foot and ankle deformities is suggested.
Foot orthoses and the cavus foot
Linear Mode
