In posture (the distribution of body mass with respect to gravity), the lowermost joints in the musculoskeletal system are of fundamental significance.
These include both the feet and ankles, which support the entirety of the musculoskeletal system and the sacral base buttressing the vertebral spine. There are four elements that are capable of reducing more than two-thirds of common pain occurrences:
- Manual manipulation to reduce somatic dysfunction,
- Foot orthotics to optimize the amplitude of the arches of the feet as well as vertically aligning the ankle,
- A heel lift to level the sacral base, and
- A set of therapeutic postures designed to minimize the restrictions of peripheral soft tissue reflective of the earlier posture.1
Most often in musculoskeletal pain, there is no objective evidence of trauma or disease. Rather, one must consider mechanical stress as a contributing factor—the stress often brought on by spinal lesions and improper posture.2-4 In light of the points stated above, the activity of the foot and its management merit further consideration.
A successful solution
Foot orthotic devices have been found to successfully modify selected aspects of lower extremity mechanics and enhance foot stability, as seen in the support phase of gait. The hypothesis was that the use of orthotics would relieve excessive strain on the ankle ligaments and reduce postural sway.
Indeed, recent investigations have demonstrated that custom-fit orthotics may restrict undesirable motion of the foot and ankle, enhancing joint mechanoreceptors to detect perturbations and providing structural support for detecting and controlling postural sway in ankle- injured subjects.5
A more thorough and recent systematic review concluded that foot orthotics increased activation of the tibialis anterior and peroneus longus and might have altered lower limb and back muscle activation.
Changes in electromyographic (EMG) activation were reported as well, although standards for reporting these were found wanting when confidence intervals were calculated.6,7 Attenuations of the gain of the gastrocnemius H-reflex when subjects balance on a stable surface shifting to an unstable surface have been positively correlated with perceptions of the comfort of foot orthotics.8
The effectiveness of custom-fit foot orthotics in alleviating back, foot, ankle, and leg pain in addition to promoting ankle stability is attested to by the findings of 33 randomized and unrandomized clinical trials, case series, and case studies involving 2,674 patients suffering from foot and lower limb pain, juvenile idiopathic arthritis, rheumatoid arthritis, plantar fasciitis, cavus (high arch pain), inversion ankle sprain, Morton’s neuroma, Hallux valgus, and patellofemoral pain..9-39
In some instances orthotics are used in combination with other conservative, noninvasive therapies, often involving spinal manipulation.9,12-42
Better in combination
Regarding the relationship of back pain to foot orthotics, six studies involving 211 patients suggest that pain and disability scales associated with low back pain resolve with the use of orthotics; in fact, one case series reports that the application of orthotics produces a twofold extension of the duration of improvements produced by traditional back pain treatment.10
Of even greater significance is the finding that lumbar disk rupture can occur as the result of a low force repeatedly applied over a long period of time, particularly stress that is applied by rotation and lateral bending.43
One study related this to the utility of foot orthotics by explaining how the pivotal activity of shifting one’s weight from behind,over, and then in front of the weight- bearing foot in normal gait activity requires that the center of mass revolve around the foot as though it were the rim of a wheel. To allow this to occur, a series of three “rockers” (the round underside of the calcaneus, the ankle joint, and the metatarsophalangeal joints) exist within the foot.44
A failure of any of these sites to allow this revolution (called sagittal phase motion) in a timely fashion can cause a sagittal plane blockage that tends to extend the hip such that the psoas muscle has difficulty in lifting a leg not already moving forward before entering the swing phase of gait.45
Because patients often display low-back pain symptoms at the sacroiliac joint on the same side as the sagittal plane blockage, and because the aforementioned studies have shown orthotics to improve the course of back pain, it is easy to see how custom-made orthotics may encourage the weight-bearing foot to revolve properly around its axis and thus allow the hip to avoid the sagittal plane blockage that can lead to some forms of back pain.10-12
The fact that a shoe orthotic that improves both pain and disability contains a spongy polymer to assist in the toe-off portion of gait is consistent with this model.42
A kind of reflexology
There may be mechanisms in addition to the biomechanical model that describe how other parts of the body might be affected by foot orthotics. The nerve impulse or automatic somatic integration theory takes advantage of the fact that feet are conspicuously sensitive to pressure, stretch, and movement.
Indeed, feet play a central role in reflexology—the technique of applying pressure to the reflex areas of the feet or hands to produce a state of deep relaxation and to stimulate healing throughout the body.46
Accordingly, it has been suggested that pressure applied to the feet during reflexology compresses cellular receptors, opening ionic channels in the plasma membrane that triggers local action potentials and conveys messages to the spinal cord and brain. The result is the processing of these signals to produce motor output to the muscles and organs.47
A broader analysis of these principles is reflected in the acupressure and acupuncture literature.
Enter the adjustment
A major question lying ahead that needs to be resolved by further research is whether custom-made orthotics can prolong the beneficial effects seen with chiropractic adjustments. Multiple maintenance care studies relating to spinal manipulation, for instance, have shown that disability or both pain and disability scores of low-back pain patients regress to baseline levels after 9 to 10 months if intervening chiropractic adjustments are not administered each month following the first series of treatments terminating at one month.
With more research to be conducted, there remains an impressive body of literature supporting the clinical utility of using foot orthotics—not only for the relief of back pain, but possibly also creating additional beneficial effects throughout the body.
Depending on the validity of reflexology, the suggestion could be made to the effect that stimulation of the foot through the proper use of custom made orthotics, recognized by the brain, could result in salutary effects through resulting motor-neuron transmissions to the muscles and organs.
Simply demonstrating that orthotics can reduce the number of interventions (pharmacologic as well as nonpharmacologic) needed to produce a sustained relief from back pain would be immeasurably valuable.
Anthony Rosner , PhD, is a champion of interdisciplinary research methodology in the health sciences, having previously served as director of research and education at the Foundation for Chiropractic Education and Research. He was designated Humanitarian of the Year in 2000 by the American Chiropractic Association and holds an honorary degree from the National University of Health Sciences. He obtained his PhD from Harvard in medical sciences and biochemistry. He can be contacted at firstname.lastname@example.org.
1 Irwin RE. The origin and relief of common pain. Journal of Back and Musculoskeletal Rehabilitation 1998;11(2):89-130.
2 Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. The Spine Journal. 2008;8:213-225.
3 Chiropractic Research In Christensen MG, Kollasch MW, Hyland JK [Eds]. (2010). Practice Analysis of Chiropractors 2010. (pp. 13-30). Greeley, CO: National Board of Chiropractic Examiners.
4 Oakley RA, Harrison DD, Harrison DE, Haas JW. Evidence-based protocol for structural rehabilitation of the spinal posture: Review of clinical biomechanics of posture (CBP) publications. Journal of the Canadian Chiropractic Association. 2005;49(4):270-296.
5 Meeker WC, Mootz RD, Haldeman S. Back to basics: The state of chiropractic research. Topics in Clinical Chiropractic. 2002;9(1):1-13.
6 Mundermann A, Nigg BM, Humble RN, Stefanyshyn DJ. Orthotic comfort is related to kinematics, kinetics, and EMG in recreational runners. Medicine & Science in Sports & Exercise. 2003;35(10):1710-19.
7 Murley GS, Landorf KB, Menz HB, Bird AR. Effect of foot posture, foot orthoses and footwear on lower limb muscle activity during walking and running: A systematic review. Gait and Posture. 2009;29(2):172-187.
8 Burke JR. Effects of footwear comfort perception on the neuromuscular control of balance. International Journal of Neuroscience. 2012;122(4):209-20.
9 Zhang J. Chiropractic adjustments and orthotics reduced symptoms for standing workers. Journal of Chiropractic Medicine. 2005;4(4):177-181.
10 Dananberg HJ, Guiliano M. Chronic low-back pain and its response to custom-made foot orthoses. Journal of the American Podiatric Medical Association. 1999;89(3):109-117.
11 Ferrari R. Responsiveness of the short-form 36 and Oswestry disability questionnaire in chronic nonspecific low back and lower limb pain treated with customized foot orthotics. Journal of Manipulative and Physiological Therapeutics. 2007;30(6):456-458.
12 Mattson RM. Resolution of chronic back, leg and ankle pain following chiropractic intervention and the use of orthotics. Journal of Vertebral Subluxation Research. 2008;March 20:1-4.
13 Trotter LC, Pierrynowski MR. The short-term effectiveness of full-contact custom-made foot orthoses and prefabricated shoe inserts on lower-extremity musculoskeletal pain: A randomized clinical trial. Journal of the American Podiatric Medical Association. 2008;98(5):357-363.
14 Trotter LC, Pierrynowski MR. Changes in gait economy between full-contact custom-made foot orthoses and prefabricated inserts in patients with musculoskeletal pain: A randomized clinical trial. Journal of the American Podiatric Medical Association. 2008;98(6):429-435.
15 Kauziaric N. [The use of foot orthoses in school children with foot problems due to sports and other physical activities] Primjena ortopediskih ulozaka u djece s tegobama stopala kod sportskih I drugih tjelesnih aktivnosti. Acta Medica Croatica. 2007;61 Supp 1;15-17.
16 Landsman A, Defronzo D, Anderson J, Roukis T. Scientific assessment of over-the-counter foot orthoses to determine their effects on pain, balance, and foot deformities. Journal of the American Podiatric Medical Association. 2009;99(3):206-215.
17 Michaud T, Fowler S. Superficial peroneal nerve entrapment resulting from a congenital plantar flexed first ray: A case report. Journal of the Neuromusculoskeletal System. 1995;3(1):27-35.
18 Hawke F, Burns J, Radford JA, du Toit V. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Systematic Reviews. 2008;3:CD006801.
19 Jannik M, van Dijk H, Ijzerman M, et al. Effectiveness of custom-made orthopaedic shoes in the reduction of foot pain and pressure in patients with degenerative disorders of the foot. Foot and Ankle International. 2006;27(11):974-979.
20 Powell M, Seid M, Szer IS. Efficacy of custom foot orthotics in improving pain and functional status in children with juvenile idiopathic arthritis: A randomized trial. Journal of Rheumatology. 2005;32(5):943-950.
21 Mejjad O, Vittecoq O, Pouplin S, et al. Foot orthotics decrease pain but do not improve gait in rheumatoid arthritis patients. Joint Bone Spine. 2004;71(6):542-545.
22 Hodge MC, Bach TM, Carter GM. Novel Award First Prize Paper: Orthotic management of plantar pressure and pain in rheumatoid arthritis. Clinical Biomechanics [Bristol, Avon]. 1999;14(8):567-575.
23 Kaviak Y, Uygur F, Korkmaz C, Bek N. Outcome of orthoses intervention in the rheumatoid foot. Foot and Ankle International. 2003;24(6):494-499.
24 Dimou ES, Brantingham JW, Wood T. A randomized, controlled trial (with blinded observer) of chiropractic manipulation and Achilles stretching vs orthotics for the treatment of plantar fasciitis. Journal of the American Chiropractic Association. 2004;41(9):32-42.
25 Rome K, Gray J, Stewart F, Hannant SC, Callaghan D, Hubble J. Evaluating the clinical effectiveness and cost-effectiveness of foot orthoses in the treatment of plantar heel pain: A feasibility study. Journal of the American Podiatric Medical Association. 2004;94(3):229-238.
26 Roos E, Engstrom M, Soderberg B. Foot orthoses for the treatment of plantar fasciitis. Foot and Ankle International. 2006;27(8):606-611.
27 Gross MT, Byers JM, Krafft JL, Lackey EJ, Melton KM. The impact of custom semirigid foot orthotics on pain and disability for individuals with plantar fasciitis. Journal of Orthopedic Sports and Physical Therapy. 2002;32(4):149-157.
28 Brantingham JW, Snyder WR, Dishman RW, et al. Plantar fasciitis. Chiropractic Technique. 1992;4(3):75-82.
29 Seligman DA, Dawson DR. Customized heel pads and soft orthotics to treat heel pain and plantar fasciitis. Archives of Physical Medicine and Rehabilitation. 2003;84(10):1564-1567.
30 Burns J, Crosbie J, Ouvrier R, Hunt A. Effective orthotic therapy for the painful cavus foot: A randomized controlled trial. Journal of the American Podiatric Medical Association. 2006;96(3):205-211.
31 Orteza JC, Vogelbach WD, Denegar CR. The effect of molded and unmolded orthotics on balance and pain while jogging following inversion ankle sprain. Journal of Athletic Training. 1992;27(1):80-84.
32 Brantingham J, Snyder R, Michaud T. Morton’s neuroma. Journal of Manipulative and Physiological Therapeutics. 1991;14(5):317-322.
33 Jeon MY, Jeong HC, Jeong MS, et al. Effects of taping therapy on the deformed angle of the foot and pain in hallux valgus patients. Taehan Kanho Hakoe Chi. 2004;34(5):685-692.
34 Bizzini M, Childs JD, Piva SR, Delitto A. Systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome. Journal of Orthopaedic and Sports Physical Therapy. 2003;33(1):4-20.
35 Barton CJ, Munteanu SE, Menz HB, Crossley KM. The efficacy of foot orthoses in the treatment of individuals with patellofemoral pain syndrome: A systematic review. Sports Medicine. 2010;40(5):377-395.
36 Collins N, Crossley K, Beller E, et al. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: Randomised clinical trial. BMJ. 2008;337:a1735.
37 Johnston LB, Gross MT. Effects of foot orthoses on quality of life for individuals with patellofemoral pain syndrome. Journal of Orthopedic Sports and Physical Therapy. 2004;34(8):440-448.
38 Eng JJ, Pierrynowski MR. Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome. Physical Therapy. 1993;73(2):62-68.
39 Lowry CD, Cleland JA, Dyke K. Management of patients with patellofemoral pain syndrome using a multimodal approach: Case series. Journal of Orthopaedic and Sports Physical Therapy. 2008;38(11):691-702.
40 Cambron JA, Duarte M, Dexheimer J, Solecki T. Shoe orthotics for the treatment of chronic low back pain: A randomized controlled pilot study. Journal of Manipulative and Physiological Therapeutics. 2011;34(4):254-260.
41 Rosner AL, Conable KM, Endemann T. Influence of foot orthotics upon duration of effects of spinal manipulation in chronic back pain patients: A randomized clinical trial. Journal of Manipulative Physiological Therapeutics. 2014;37(2):124-140.
42 Cambron JA, Dexheimer JM, Duarte M, Freels S. Shoe orthotics for the treatment of chronic low back pain: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2017;98(9):1752-1762.
43 Farfan HF, Cossette J, Robertson GH, Wells RV, Kraus H. The effects of torsion on the lumbar intervertebral joints: the role of torsion in the production of disc degeneration. Journal of Bone and Joint Surgery. 1970;52(3):468-497.
44 Perry J. (1992). Gait Analysis: Normal and Pathologic Function. Thorofare, NJ: Slack.
45 Dananberg HJ. (1999). Sagittal plane biomechanics. In Subotnick SI [Editor]. Sports Medicine of the Lower Extremity, 2nd Edition. (pg. 137). New York, NY: Churchill Livingstone.
46 Crane B. (1997). Reflexology: The Definitive Practitioner’s Manual. Rockport, MA: Element.
47 Tiran D, Chummun H. The physiological basis of reflexology and its use as a potential diagnostic tool. Complementary Theories in Clinical Practice. 2005;11(10):58-64.
48 Descarreaux M. Blouin J-S, Drolet M, Papadimitrious S, Teasdale N. Efficacy of preventive spinal manipulation for chronic low back pain and related disabilities: A preliminary study. Journal of Manipulative and Physiological Therapeutics. 2004;27(8):509-514.
49 Senna MK, Machaly SA. Does maintained spinal manipulation therapy for chronic non-specific low back pain result in better long-term outcome? Spine. 2011;36(18):1427-1437.