The question posed in the article is basically the following: “Are shoe inserts (foot orthotics) effective in the prevention and treatment of injuries among athletes?”’
Why is this impossibly broad? This question encompasses dozens of musculoskeletal, neurologic, and degenerative conditions involving scores of scientific studies. It would have been better for the article to define its scope more narrowly—e.g., foot injuries, lower limb injuries, or low back pain— and look at the evidence more carefully.
Gazing through the prism of a single scientist’s work, the article presents an interesting narrative about the difficulties of performing biomechanical and clinical research in this area. And it endorses a skeptical attitude in interpreting the claims of proponents in this multi-billion dollar industry.
However, the answer to the main question is fundamentally unsatisfying—and “soft” from an evidence perspective: “Shoe inserts may be helpful as a short-term solution, preventing injuries in some athletes,” according to the New York Times.
This is a soft statement because almost any prevention method or treatment will help somebody over the short-term some of the time. And this permissive conclusion will certainly not deter athletes from seeking out orthotics for dozens of conditions on the premise that they might work.
However, this broad-brush conclusion doesn’t adequately characterize the evidence regarding shoe inserts. That evidence cleaves a little more neatly than this article implies.
By conventional medical standards (well-designed clinical trials) there is no conclusive evidence that shoe inserts are effective in the prevention and treatment of the majority of athletic injuries.
There are a few conditions for which there is preliminary evidence that shoe inserts may offer modest preventive or therapeutic benefits.
But importantly, and never mentioned in this article, there are also conditions in which the effectiveness of shoe inserts has been tested and disproven.
There is credible evidence, for example, that shoe inserts do not prevent low back pain. If scientists are going to go to the trouble of performing demanding research, it is important that journalists report those results. (See Sahar et al., 2009).
Sahar T et al., Insoles for prevention and treatment of low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group, Spine, 2009; 34(9): 924-933.
The role of shoe inserts in the prevention and treatment of athletic injuries remains one of the most controversial topics in sports medicine, orthopedics and podiatry.
Musculoskeletal pain is a universal complaint in the general population and prompts tens of millions of physician visits every year. The idea of relieving and preventing pain and dysfunction with a simple insole or insert is beguiling.
The aging of the general population—and the rising tide of weight gain and obesity—are colliding to create a growth industry for orthotics.
Shoe inserts—including inexpensive off-the-shelf products and costly custom-made orthotics— are widely prescribed and used in the prevention and treatment of foot problems, knee and hip pain, shin splints, low back pain and many other musculoskeletal conditions.
Yet after several decades of research the benefit of shoe inserts for most injuries and conditions remains uncertain. And it is not clear if the billions of dollars spent on shoe inserts translates into the wholesale alleviation of pain and dysfunction—or just the wholesale transfer of dollars.
It would have been useful to discuss the relative costs of off-the-shelf and custom shoe inserts. The former are generally less than $50 while the latter can run into many hundreds of dollars. The article mentions the expensive price-tag of custom-made orthotics. It didn’t, however, discuss the overall costs of off-the-shelf shoe inserts, which have to be replaced with regularity.
The article offered a brief characterization of the magnitude of benefits related to orthotics among soldiers in one study. But in general the article did not adequately frame the potential benefits of shoe inserts. For instance, in the review that reported a benefit for orthotics in the prevention and treatment of plantar fasciitis and tibial stress fractures, how impressive was that benefit?
This article focused largely on the potential upside of shoe inserts—and didn’t explicitly address potential harms from the use of orthotics. It mentioned that inserts could increase muscle work requirements but didn’t discuss the significance of this point in terms of pain and function.
Some of the potential harms— such as exacerbating injury risk and/or pain and dysfunction—are obvious. There are more subtle harms as well, such as creating the expectation among athletes that they cannot safely exercise, perform normal daily activities, and work without the aid of an orthotic.
It would be difficult if not impossible for a journalist to evaluate the evidence on such a broad topic. And the article didn’t adequately characterize the evidence regarding shoe inserts in the prevention or treatment of most common athletic injuries.
It cited a single published review on orthotics and injury prevention for lower leg injuries, but didn’t discuss other reviews of the evidence.
There was no suggestion of disease mongering. In fact, the article rebutted the need for orthotics in the correction of mechanical/alignment problems and in the management of asymptomatic abnormalities such as flat feet.
The article did present the views of several independent sources. However, the article did not address or identify potential financial conflicts among the contributors beyond identifying their organizations or institutions. Both biomechanical research and footwear research rely heavily on industry funding, which may skew the views of researchers. So this is an important issue. And we can’t give a satisfactory score for half a loaf.
The article did not discuss alternatives to orthotics for athletes. Yet there are many other preventive and therapeutic strategies such as flexibility and strength training, proprioceptive work, and attention to technique which may offer superior benefits to simple insoles and inserts.
The article focused mainly on orthotics compared to no intervention. This might be appropriate for prevention, but a symptomatic patient would also be considering other physical treatments and interventions.
Both off-the-shelf and custom shoe inserts are widely available. This doesn’t merit discussion.
The shoe inserts described in this study are widely available and are not particularly novel in concept or design. The article did not “hype” particular orthotics because of innovative characteristics or qualities.
The article did not appear to rely on a press release.