Heel pain can last a great deal longer than people imagine: in one cohort, 80.5% of patients were still symptomatic at 1 year and 50% at 5 years. Before stacking up insoles or postural corrections, the cause of the pain has to be confirmed first.
If foot pain, trouble walking or a question about insoles is dragging on, Noria Health Hub can arrange a full check-up or a second medical opinion in Brussels, with a report within 24 h, coordinate your care where needed across more than 40 medical pathways in 48 h, then, if your medical condition allows, arrange surgery within 7 days.
Custom-made or off-the-shelf insoles, differences that are often small
Let us start with the result that structures everything else. In every review consulted, across every time horizon, the custom-made insole does no better than the prefabricated one.
| What is measured | The result |
|---|---|
| Effect of orthoses on heel pain, meta-analysis of 19 trials, 1,660 participants | A significant effect only between 7 and 12 weeks, with an effect size of 0.27, moderate quality |
| The same effect short term, 0 to 6 weeks, and long term, 13 to 52 weeks | No demonstrated effect |
| Custom-made against prefabricated | No difference, at any time point |
| Reference 3-arm trial, 136 participants | About 8 points out of 100 of gain at 3 months for the 2 insole types, and no difference at all at 12 months |
The authors of the meta-analysis write themselves that it is uncertain whether this change is clinically important. We shall not put it any more strongly than they do.
On patellofemoral pain syndrome, the Cochrane review finds an advantage of orthoses over simple insoles at 6 weeks, with a risk ratio for improvement of 1.48, a benefit that had gone by 1 year. It also finds more minor adverse effects, rubbing and blisters, with a risk ratio of 1.87. And it finds no advantage of orthoses over physiotherapy.
Prevention, a benefit demonstrated in one precise indication
There is one solid result, and it is narrow. A meta-analysis of 18 trials, overwhelmingly in military populations, measures a reduction in stress fractures with a risk ratio of 0.59, and in injuries overall with a ratio of 0.72.
The same meta-analysis measures the effect of plain cushioning insoles, with no correction. All injuries, risk ratio 0.92, not significant. Stress fractures, 1.15, not significant. Cushioning on its own prevents nothing. The gap between those 2 lines is the only serious argument in favour of an orthosis for prevention, and it concerns only populations carrying a high and imposed training load.
Plantar fasciitis, recovery can be far slower than you are told
One reads everywhere that 80 to 90% of plantar fasciitis resolves on its own within 6 to 12 months. We found no primary source for that figure, and the best longitudinal data available says the opposite.
| What is measured, cohort of 174 patients followed a mean of 9.7 years | The result |
|---|---|
| Still symptomatic at 1 year | 80.5% |
| Still symptomatic at 5 years | 50.0% |
| Still symptomatic at 10 years | 45.6% |
| Mean duration of symptoms in those who recovered | 725 days, about 2 years |
| Prognostic value of the heel spur | None, p of 0.88 |
The last line deserves to be known. A heel spur visible on a radiograph has no prognostic value, and neither does the thickness of the fascia. It is not the image that decides how things will go.
On treatments, precision is needed. In the Cochrane review of 39 trials and 2,492 adults, corticosteroid injections have a short-term effect of 6.38 points out of 100, that is, below the threshold for a clinically important difference set by the authors, and no effect at all between 1 and 6 months. Among the 699 patients injected in those trials, there were 2 fascia ruptures and 3 infections.
On shockwave therapy, a recent double-blind placebo-controlled trial of 200 patients, all fitted with insoles and given advice, measures at 6 months a difference of 0.02 points out of 10 in favour of shockwave, in other words nothing. Plenty of impressive figures circulate about this technique, but they are before and after variations, not comparisons against placebo.
Posturology, a reproducibility problem before effectiveness is even discussed
This paragraph will displease, and we are writing it anyway. The problem with posturology is not first of all its effectiveness, it is the reproducibility of its measurement. If 2 examiners do not find the same thing in the same patient, no conclusion can follow.
| What is measured | The result |
|---|---|
| Agreement between 2 examiners on visual postural assessment, 28 clinicians, 36 subjects | Kappa coefficient of 0.16, described as poor |
| Agreement of the same examiner with himself | Kappa of 0.50, described as fair |
| Reliability of stabilometry on its best parameter, 30 healthy subjects | Standard error of measurement of 19.2% |
| Link between dental occlusion and posture, review of 21 posturographic studies | 2 studies out of 21 find a difference between groups |
Note that this is agreement between assessors. The 28 clinicians in that study were chiropractors, physiotherapists, rheumatologists, rehabilitation physicians and orthopaedic surgeons, in other words trained professionals.
On so-called proprioceptive or postural insoles, the systematic review available covers 12 controlled trials whose methodological quality is rated 3 or 4 out of 10, and its outcome measures are laboratory sway measurements, neither pain nor function. We found no good quality randomised trial showing a clinical effect, and we found no official position from any French-speaking health authority on the subject. We are flagging that rather than filling the gap.
Leg length inequality, the measurement itself can vary
About 90% of the population has an anatomical inequality in lower limb length, averaging 5.21 millimetres. About 14.8% exceed 10 millimetres.
Here is the problem. Between-observer variance of tape measure methods is about 1 centimetre, judged unacceptable for a clinical decision by the very authors who measured it. The measurement error is therefore about 2 times larger than the average inequality it claims to correct. The only reliable reference method is a weight-bearing full body radiograph.
Flat foot in children, most cases settle without treatment
| What is measured, 835 children aged 3 to 6, three-dimensional laser scanning | The result |
|---|---|
| Flexible flat foot | 44% |
| Pathological flat foot | Under 1% |
| Change with age | 54% at age 3, 24% at age 6 |
| Share of children wearing arch supports | 10% |
| The authors’ own conclusion | More than 90% of the treatments under way were unnecessary |
Flat foot in children is, in the vast majority of cases, a normal stage of development that corrects itself. It is probably the best documented over-treatment in the whole of podiatry.
In adults, a prospective cohort of 196 athletes and 227 injury episodes concludes that flat foot is not a risk factor for any lower limb injury, and that the routine preventive use of orthoses in athletes with flat feet is therefore probably not justified. Another cohort, in military cadets, finds a discordant result, and we are reporting it rather than picking the one that suits us.
The diabetic foot, prevention whose importance is well established
Everything above describes a field where the evidence is weak. There is one major exception, and it is the one that justifies the very existence of medical podiatry.
| What is measured | The result |
|---|---|
| People developing a diabetic foot ulcer each year worldwide | About 18.6 million |
| Lifetime risk in a person with diabetes | Up to 34% |
| Share of patients with an ulcer who will undergo a lower limb amputation | About 20% |
| Mortality at 5 years after an ulcer, and after a major amputation | About 30%, and over 70% |
| Ulcer recurrence | 42% at 1 year, 58% at 3 years, 65% at 5 years |
Mortality at 5 years after a diabetic foot ulcer is of the same order as that of several cancers. It is a figure almost nobody knows, including among the people directly concerned.
And on this ground, prevention has figures. Therapeutic footwear reduces ulcer incidence from 25.4% to 13.3%, a risk ratio of 0.49. Self-monitoring of skin temperature with offloading of hot spots reduces it from 30.8% to 18.7%, a risk ratio of 0.51. And care by a multidisciplinary team reduces major amputations from 4.4% to 3.2%, an odds ratio of 0.40.
The international guideline stratifies screening into 4 risk categories, from an annual examination where there is no loss of sensation and no peripheral arterial disease, through to an examination every 1 to 3 months where there is a history of ulcer or amputation. It is the only podiatric screening whose usefulness comes with figures.
Running shoes, shoe type does not simply predict injury risk
The idea that you should choose your shoe according to the shape of your arch has been tested by 2 military randomised trials totalling about 4,000 recruits.
| The trial | The result |
|---|---|
| 2,676 recruits, shoe assigned by arch type against the same shoe for everyone | Hazard ratio of 1.11 in men and 1.20 in women, not significant |
| 1,411 recruits, same protocol | Hazard ratio of 1.01 in men and 0.88 in women, not significant |
| What these trials identify as the actual risk factors | Low aerobic fitness and smoking |
| Effect of pronation, prospective cohort of 1,854 feet, 326,803 kilometres | No significant difference, pronating runners in fact having slightly fewer injuries |
Four independent studies, 2 of them randomised trials, find no effect. On this precise point, the question is closed.
A trial of 553 runners looking at heel-to-toe drop reaches the same overall verdict, with no significant difference. It adds one interesting result, the same shoe protects occasional runners and penalises regular ones. What counts is not the shoe, it is the training load of the person wearing it.
What the studies do not allow us to claim
We will not promise that a custom-made insole is worth more than a prefabricated one, because no study shows it. Nothing entitles us to write that a postural analysis guides treatment, because 2 trained examiners do not agree about the same person. And you will not read here that a child’s flat foot has to be fitted with a device, because more than 9 treatments out of 10 are judged unnecessary by the authors of the reference study.
What we will say is that a diabetic foot is screened, stratified and monitored, with amputation reduction figures that exist. And that heel pain which drags on deserves to be taken seriously, not because a treatment will make it disappear quickly, but because its real duration is a great deal longer than what people are told.
In practice, if this concerns you
You set out your problem, your symptoms or your question. Reports, test results and images already available can be studied before you arrive, so that the pathway is prepared. The aim is not to run every possible test, but to select those that can genuinely help confirm a hypothesis, rule out a risk or guide the decision. The results are then brought together and the next steps organised. Follow-up is coordinated from there.
Have my gait or my feet assessed
Need a medical opinion quickly? For a concern that does not call for emergency services, you can ask to speak to a doctor at any time through Noria Health Hub. This on-demand medical consultation is billed separately from the work-up pathway.
Further reading
The companion articles.
A” rel=”noopener” target=”_blank”>https://noriahealth.com/blog/a-spine-mri-does-not-tell-you-the-pain/”>A spine MRI does not tell you the pain
Pain” rel=”noopener” target=”_blank”>https://noriahealth.com/blog/pain-that-waits-what-the-literature-measures/”>Pain that waits, what the literature measures
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