The STAP-study: The (cost) effectiveness of custom made orthotic insoles in the treatment for plantar fasciopathy in general practice and sports medicine: design of a randomized controlled trial

Can we predict which patients with plantar heel pain are more likely to benefit from insoles? A secondary exploratory analysis of a randomized controlled trial

Background

Plantar heel pain (PHP) is a common cause of foot complaints, for which treatment with custom-made insoles is frequently applied. So far few studies have investigated patient characteristics that predict response to these treatments. The aim of this secondary exploratory analysis was twofold; firstly, to identify patient characteristics that predict prognosis in patients with PHP treated with insoles, and secondly to identify characteristics that might interact with treatment with insoles.

Methods

Data from a randomized trial in which participants received either custom insoles (N = 70) or sham insoles (N = 69) were used. At baseline, information was collected on demographics, foot symptoms, foot and ankle range of motion, navicular drop, presence of neuropathic pain, physical activity and other illnesses in the last 12 months. The primary outcome of this study was the Foot Function Index score (FFI) at 26 weeks. Multivariable linear regression models were generated to identify patients characteristics that predict the outcome for each type of intervention (i.e. insoles and GP-led usual care).

Results

We found two variables associated with a better function score at 26 weeks in patients treated with insoles, female sex (β − 9.59 95%CI -17.87; − 1.31) and a lower FFI score at baseline (β 0.56 95%CI 0.30; 0.82). Explorative analyses in patients treated with insoles showed no significant interaction effects between the type of insole (custom-made versus sham) and any of the potential predictive factors.

Conclusion

When communicating about the effect of insoles for PHP clinicians should take sex and the amount of pain and disability at first presentation into account. Women and people with better foot function scores at baseline (according to FFI) might respond better to treatment with insoles in terms of foot function.

Trial registration

Trial registration: NTR5346.

Cost-effectiveness of custom-made insoles versus usual care in patients with plantar heel pain in primary care: cost-effectiveness analysis of a randomised controlled trial

OBJECTIVES

To evaluate the cost-effectiveness of custom-made insoles compared with general practitioner (GP)-led usual care after 26 weeks of follow-up in individuals with plantar heel pain (PHP) from a societal perspective.

DESIGN

Cost-effectiveness analysis of a double-blinded randomised controlled trial.

SETTING

General practice in the Netherlands.

PARTICIPANTS

116 participants with PHP for at least 2 weeks, aged 18-65 years and presenting to the GP.

INTERVENTIONS

Participants were randomised to GP-led usual care (n=46) or referral to a podiatrist for treatment with a custom-made insole (n=70). Participant randomised to a sham insole (n=69) were excluded from this analysis.

PRIMARY AND SECONDARY OUTCOMES

Outcomes comprised pain during rest and activity, and quality of life. Costs included healthcare and lost productivity costs. Statistical uncertainty was estimated using bootstrapping and presented using cost-effectiveness acceptability curves.

RESULTS

Participants in the custom-made insole group experienced statistically significant more pain during activity at 26 weeks than participants in the usual care group (overall effect 1.06; 95% CI 0.36 to 1.75). There were no significant differences between groups in other outcomes. Total societal costs in the custom-made insole group were non-significantly higher than in the usual care group (mean difference €376; 95% CI -€1775 to €2038). The intervention with custom-made insoles was dominated by usual care by the GP (ie, more expensive and less effective) for pain during activity and quality of life outcomes. For the outcome pain at rest, the intervention was more expensive and more effective than usual care. However, the maximum probability of cost-effectiveness was only 0.59 at very high ceiling ratios.

CONCLUSIONS

These findings show that that custom-made insoles are not cost-effective in comparison with GP-led usual care. Clinicians should be reserved in prescribing custom-made insoles for PHP as a primary intervention.

TRIAL REGISTRATION NUMBER

NTR5346.

Comparison between customised foot orthoses and insole combined with the use of extracorporeal shock wave therapy in plantar fasciitis, medium-term follow-up results: A randomised controlled trial

OBJECTIVE

To determine the clinical results of custom-made foot orthoses versus placebo flat cushioning insoles combined with an extracorporeal shock wave therapy on pain and foot functionality in patients with plantar fasciitis.

DESIGN AND SETTING

A randomised controlled clinical trial with follow-up at six months. Faculty of Podiatry and Centre Clinical private of Physiotherapy, Seville, Spain.

SUBJECTS AND INTERVENTIONS

Patients with plantar fasciitis were randomly assigned to either group A (n = 42), which received custom-made foot orthoses, or group B (n = 41), which received placebo insoles. All the participants received active extracorporeal shock wave therapy including stretching exercises. Recruitment period was from Mach 2019 to July 2020.

MAIN MEASUREMENTS

The main outcome was foot pain, measured by visual analogue scale and the secondary outcome measures were recorded by Roles and Maudsley scores respectively, at the beginning and at one week, one month and six months.

RESULTS

Eighty-eight patients were assessed for eligibility. Eighty-three patients were recruited and randomised. This study showed significant differences between both groups according to the visual analogue scale. In control group, the difference was at baseline (P 0.01) and, in the experimental group was at the one- and six-month follow-up (P 0.001). The mean (SD) visual analogue scale at baseline were Control group 6.31 (1.69) and Experimental group 5.27 (1.64); and at six months were 7.52 (3.40) and 3.29 (4.26), respectively. The custom-made foot orthosis was perceived as 'good' (85%) and 'excellent' (97.5%) at medium-long term.

CONCLUSION

Wearing a custom-made foot orthosis leads to a improvement in patients with plantar fasciitis; it reduced foot pain and improved foot functionality.

Custom insoles versus sham and GP-led usual care in patients with plantar heel pain: results of the STAP-study - a randomised controlled trial

OBJECTIVES

To compare custom-made insoles to sham insoles and general practice (GP)-led usual care in terms of pain at rest and during activity at 12 weeks follow-up in individuals with plantar heel pain.

METHODS

In this randomised clinical trial 185 patients aged 18 to 65 years, with a clinical diagnosis of plantar heel pain for at least 2 weeks, but no longer than 2 years were recruited. Patients were randomly allocated into three groups: (1) GP-led treatment, plus an information booklet with exercises (usual care; n=46), (2) referral to a podiatrist for treatment with a custom-made insole plus an information booklet with exercises (custom-made insole; n=70) and (3) referral to a podiatrist and treatment with a sham insole plus an information booklet with exercises (sham insole; n=69). As well as the primary outcome of pain severity (11-point Numerical Rating Scale) we used the Foot Function Index (0 to 100) as a secondary outcome.

RESULTS

Of 185 randomised participants, 176 completed the 12-week follow-up. There was no difference in pain or function between the insole and the sham groups at 12 weeks. Participants in the GP-led usual care group reported less pain during activity at 12 weeks, (mean difference (MD) 0.94, 95% CI 0.23 to 1.65), less first step pain (MD 1.48, 95% CI 0.65 to 2.31), better function (MD 7.37, 95% CI 1.27 to 13.46) and higher recovery rates (RR 0.48, 95% CI 0.24 to 0.96) compared with participants in the custom insole group.

CONCLUSIONS

Referral to a podiatrist for a custom-made insole does not lead to a better outcome compared to sham insoles or compared to GP-led usual care.

TRIAL REGISTRATION NUMBER

NTR5346.

Does Flexible Flatfoot Require Treatment?: Plantar Pressure Effects of Wearing Over-the-Counter Insoles when Walking on a Level Surface and Up and Down Stairs in Adults with Flexible Flatfoot

BACKGROUND

Orthotic insole is a popular physiotherapy for flatfoot. However, the effects and whether flexible flatfoot needs orthotic insole treatment are not clear, and how the plantar pressure changes while walking up and down stairs has not been studied. Therefore, this study observed the plantar pressures of different walking conditions to find the answers.

METHODS

Fifteen adults with flexible flatfoot and 15 adults with normal foot were examined while walking on a level surface and while walking up and down 10- and 20-cm stairs before treatment. The maximum force and the arch index were acquired with a force plate system. Participants with flexible flatfoot were instructed to wear the orthotic insoles for 3 months, and plantar pressures were measured again after treatment. The repeated measure was performed to analyze the data.

RESULTS

The maximum force and the arch index of flatfoot after treatment were significantly decreased under different walking conditions (P < .01). When walking down 10- and 20-cm stairs, the plantar data of normal foot and flatfoot were significantly increased (P < .05).

CONCLUSIONS

Orthotic insoles could effectively improve the plantar pressure of flatfoot under different walking conditions. In addition, the arches of normal foot and flatfoot were obviously influenced when walking down stairs. It is, therefore, necessary to wear orthotic insoles for flexible flatfoot to prevent further deformation.

Effect of 3D Printing Individualized Ankle-Foot Orthosis on Plantar Biomechanics and Pain in Patients with Plantar Fasciitis: A Randomized Controlled Trial

BACKGROUND Traditional ankle-foot orthoses (AFOs) are not effective in treating plantar fasciitis, while customized 3-dimensional (3D) printed ankle-foot orthoses are effective in treating many ankle-foot diseases. This study investigated the effects of customized 3D printed AFOs on biomechanics and comfort of the plantar foot in plantar fasciitis. MATERIAL AND METHODS Sixty patients with bilateral plantar fasciitis aged 31-60 years participated in this study. At week 0, patients were randomly assigned into 2 groups: the control group consisting of those wearing separate shoes with prefabricated AFOs; and the experimental group consisting of those wearing a separate shoe and customized 3D-printed AFO. The Footscan® system recorded maximum pressure, maximum strength, and contact area of patients' hallux, toes 2-5, first to fifth metatarsal, midfoot, lateral heel, and midfoot heel at weeks 0 and 8. Patients used visual analogue scale scores at weeks 0 and 8 to assess overall comfort of foot orthosis, to determine the credibility and comfort of both orthopedic insole conditions. RESULTS At week 0, in the experimental group, peak pressure in the hallux and first metatarsal area was significantly higher than the control group (P<0.05), while mid-heel and lateral heel peak pressures were significantly lower than the control group (P<0.05). After 8 weeks, all groups reported more comfort compared with the same group in week 0 (P<0.05). The comfort scores reported by the experimental group were significantly lower than those of the control group (P<0.05). CONCLUSIONS This study supports the efficiency of customized 3D printing AFO for reducing damage associated with plantar lesions and improving comfort in patients with plantar fasciitis compared with prefabricated AFO. Customized AFO is useful in the treatment of plantar fasciitis compared with prefabricated AFOs.

Comparison of extracorporeal shock wave therapy with custom foot orthotics in plantar fasciitis treatment: A prospective randomized one-year follow-up study

PURPOSE

Plantar fasciitis (PF) is characterized by the degeneration of the plantar fascia, leading to heel pain. We aimed to investigate the effectiveness of extracorporeal shock wave therapy (ESWT) and custom foot orthotics (CFO).

METHOD

The study was planned as a prospective randomized controlled study. In total, 83 patients were evaluated. The patients were divided into two groups: patients treated with ESWT (group I, n=40) and patients treated with CFO (group II, n=43). Visual analogue scale (VAS) was used to evaluate pain in the morning, evening, at rest and while walking. Foot Function Index (FFI) was used to evaluate foot functions, and Foot Health Status Questionnaire (FHSQ) was used to evaluate foot health.

RESULTS

Both group I and group II achieved significant improvements in our evaluation parameters (morning and evening pain) at 4, 12 and 24 weeks compared with their baseline values (P<0.001), and significant improvement observed in the group II continued at 48 weeks (P<0.05); however, there was no significant difference in some parameters in the group I after treatment compared with their baseline values (P>0.05).

CONCLUSION

Both treatment ESWT and CFO can use interchangebably. Neither method was superior in treating plantar fasciitis.

Plantar fasciopathy: A current concepts review

Plantar fasciopathy is very prevalent, affecting one in ten people in their lifetime.

Around 90% of cases will resolve within 12 months with conservative treatment.

Gastrocnemius tightness has been associated with dorsiflexion stiffness of the ankle and plantar fascia injury.

The use of eccentric calf stretching with additional stretches for the fascia is possibly the non-operative treatment of choice for chronic plantar fasciopathy.

Medial open release of approximately the medial third of the fascia and release of the first branch of the lateral plantar nerve has been the most accepted surgical treatment for years.

Isolated proximal medial gastrocnemius release has been reported for refractory plantar fasciopathy with excellent results and none of the complications of plantar fasciotomy.

Cite this article: EFORT Open Rev 2018;3:485-493. DOI: 10.1302/2058-5241.3.170080.

Plantar pressure differences among adults with mild flexible flatfoot, severe flexible flatfoot and normal foot when walking on level surface, walking upstairs and downstairs

[Purpose] This study observed the plantar pressure between flexible flatfoot and normal foot on different walking conditions to find out if flexible flatfoot needs the treatment and how the plantar pressure change while walking upstairs and downstairs. [Subjects and Methods] Fifteen adults with mild flexible flatfoot, fifteen adults with severe flexible flatfoot and fifteen adults with normal foot were examined while walking on a level surface, walking up and down 10 cm and 20 cm stairs. The max force and the arch index were acquired using the RSscan system. The repeated measures ANOVA was performed to analyze the data. [Results] Compared with normal foot, both max force and arch index of severe flatfoot were significantly increased on different walking conditions. When walking down 10 cm and 20 cm stairs, the plantar data of both normal foot and flatfoot were significantly increased. [Conclusion] The plantar pressure of severe flexible flatfoot were significantly larger than that of normal foot on different walking conditions. In addition, the arches of both normal foot and flatfoot were obviously deformed when walking downstairs. It is therefore necessary to be treated for severe flexible flatfoot to prevent further deformation.