Effectiveness of orthotic shoe inserts in the
long-distance
runner
MICHAEL L. GROSS,* MD, LANCE B. DAVLIN, MD, AND PHILIP M. EVANSKI, MD From the
Orthopaedic and Sports Medicine Associates, Emerson,
ABSTRACT
New Jersey
extremity.5,12
Recent estimates place the number of recreain the United States at close to 30 million.’ According to most reports, approximately 60% of these runners will experience an injury that will necessitate limitation of their activities.3° 9,14~ ls Common disorders sustained by participants in running programs include shin splints, patellofemoral disorders, Achilles tendinitis, plantar fasciitis, and stress fractures.3~ 4~ s, lo, ~s, ~s Injuries occurring in long-distance runners may be related to the tremendous demands made on their lower extremities. Up to 250% of body weight is absorbed by the musculoskeletal system at heel strike. 13,15 This process takes place between 800 and 2000 times per mile while running.4, 13 Injuries resulting from these factors often fall into the category of &dquo;overuse syndromes.&dquo; An underlying structural deficit of the lower extremities may magnify the effects of overuse.1,10 Injured runners frequently present with biomechanical abnormalities, such as hyperpronated feet, malalignment, cavus feet, and limb length discrepancies.3~4 In terms of injury pathogenesis, these may be considered intrinsic factors. Training errors and poor running surfaces3-5, 9,10,15 have also been cited as causes of running injuries. Traditional therapy for problems experienced by runners, including the limitation or alteration of activity, 5,7,10,15 is aimed at modification of these extrinsic factors. However, this approach is tional
Five hundred questionnaires were distributed to longdistance runners who had used, or who were using orthotic shoe inserts for symptomatic relief of lower extremity complaints. Three hundred forty-seven (69.4%) responded (males, 71%; females, 29%). The mean age of the respondents was 36 years (range, 15 to 61). The average distance run per week was 39.6 miles (range, 5 to 98). The mean duration for use of the orthotic inserts was 23 months (range, 1 to 96). The predominant (63%) type of orthotic device used was flexible. The presumed diagnoses in the population studied were excessive pronation (31.1 %), leg length discrepancy (13.5%), patellofemoral disorders (12.6%), plantar fasciitis (20.7%), Achilles tendinitis (18.5%), shin splints (7.2%), and miscellaneous (4.9%). Of the runners responding, 262 (75.5%) reported complete resolution or great improvement of their symptoms. Results of treatment with orthotic shoe inserts were independent of the diagnosis or the runner’s level of participation. A high degree of overall satisfaction was demonstrated by the finding that 90% of the runners continued to use the orthotic devices even after resolution of their symptoms. Orthotic shoe inserts were most effective in the treatment of symptoms arising from biomechanical abnormalities, such as excessive pronation or leg length discrepancy. Along with other conservative measures, orthotic shoe inserts may allow the athlete to continue participation in running and avoid other treatment modalities that are more costly and time consuming, and therefore less acceptable to them.
runners
poorly accepted by
most
runners.
Adjuncts
to treatment
have included modification of training techniques, the use of nonsteroidal antiinflammatory medications, and hot or cold compresses.10, 15 Even with strict adherence to these measures, a significant number of athletes experience treatment failures and undergo further repeated diagnostic or
therapeutic procedures. In an attempt to modify intrinsic factors, an increasing number of orthopaedists treating long-distance runners are using orthotic shoe inserts as part of their regimen. Orthotic shoe inserts reduce symptoms by correcting abnormal lower extremity biomechanics. This is accomplished either by realigning the foot or by a direct cushioning effect. The objective of this study was to: 1) assess the effectiveness of
The recent growth in popularity of recreational running has resulted in an increase in associated injuries to the lower *
Address
to’ Michael L. Gross, MD, Medicine Associates, 440 Old Hook Road, Emerson,
correspondence and repnnt requests
Orthopaedic and Sports NJ 07675
409
410
orthotic shoe inserts in the distance runner, 2) identify those disorders most amenable to treatment with orthoses, and 3) determine the relationship between level of participation and effectiveness of treatment.
MATERIALS AND METHODS Five hundred questionnaires were distributed to participants in events sanctioned by the New York Road Runners Club, and to members of the organization who were presently using, or had previously used, orthotic shoe inserts. Questionnaires were distributed over a period of 3 months. Included with the survey was a self-addressed, prepaid, return envelope. Participants were informed that the data would be available to them at the end of the study. Respondents were asked to list their age, sex, and distance run per week. Data recorded pertaining to the type of orthotic device included: material of composition, type (rigid, semirigid, flexible) and source. The runners were asked to provide the presenting indication for use of the insert, as well as their presumed diagnosis, if known. The duration of use of the insert was recorded, and whether the runner was still using or had discontinued its use. Finally, the runners were asked to provide a subjective rating of their response to treatment with orthotic shoe inserts. Statistical analysis was performed using the chi square test. Of the 500 questionnaires distributed, 347 (69.4%) were returned. These 347 runners who had used or who were using orthotic shoe inserts comprised the primary study group. There were 245 (71% ) men and 102 (29%) women. The average age of the group was 36 years (range, 15 to 61) and the average distance run each week was 39.6 miles (range, 5 to 89). The mean length of time for use of orthotic inserts was 23 months (range, 1 to 96). Of the types of inserts used, 218 (63%) were flexible, 80 (23%) were semirigid, and 49 (14% ) were rigid.
RESULTS runners treated with orthotic shoe inserts, 107 (30.8%) reported complete resolution of symptoms, 155 (44.7%) reported great improvement, 55 (15.8%) runners had slight improvement, 26 (7.5%) felt that they experienced no change in their symptoms, and 4 (1.2%) felt that their complaints increased while using the inserts. Unexpectedly, 46 (13.25%) of the runners surveyed developed a new problem while using the insert (Fig. 1). The complaints that led to use of the orthotic shoe insert included knee pain, 164 (47.3%); foot pain, 116 (33.4%); ankle pain, 50 (14.4%); shin pain, 49 (14.1% ); hip pain, 29 (8.4%); and other miscellaneous complaints, 21 (6.1% ). Miscellaneous complaints were defined as those appearing in
Of the 347
less than 5% of the surveys. Several respondents had more than one complaint, accounting for 429 complaints in 347
respondents. The presenting diagnosis was recorded by 222 of the runners surveyed. Of these, 20 patients had two diagnoses,
1. The effectiveness of orthotic shoe inserts in distance runners (N 347).
Figure
long-
=
Figure 2. The percent of runners with complete relief or great improvement by presenting diagnosis. 242 diagnoses in 222 patients. The most common indication for treatment with orthotic inserts was excessive pronation. This was the presumed diagnosis in 69 (31.1%) runners, followed by plantar fasciitis in 46 (20.7%), Achilles tendinitis in 41 (18.5%), leg length discrepancy in 30 (13.5%), patellofemoral disorders in 28 (12.6%), and shin splints in 16 (7.2%). There were 12 (4.9%) miscellaneous
making
diagnoses reported. The orthoses provided a high level of symptomatic relief in all of the diagnostic categories (Fig. 2). In each diagnostic category the distribution of results
was similar (Table 1). Athletes with the presumed diagnosis of shin splints did not improve as much as runners with other diagnoses, but this difference was not statistically significant. Only 34 (68.8%) of patients with shin splints noted complete relief or great improvement in their symptoms. The percentage of runners experiencing a complete cure or great improvement in symptoms did not vary significantly at different levels of participation. The majority of runners experienced relief of their symptoms using orthotic inserts at all levels. The number of runners who had complete resolution or great improvement is shown as a function of miles per week in Figure 3. There was a strong association between good treatment
411 TABLE 1
Benefit of orthotic shoe insert
Q
Data collected from 230
according to diagnosis’
diagnoses in
222
runners.
Figure 3. The percent of runners with complete cure or great improvement versus miles run per week. results and continued orthotic insert use. Of the 347 runners responding, 280 were still using their inserts at the time of the survey. In this group of 280 runners, there were 238 (85%) who had good results from their treatment with inserts. Conversely, of the 262 overall runners with good results, 238 (90.8%) continued their use of orthotic devices even after resolution of symptoms.
DISCUSSION Our study finding was that orthotic shoe inserts were very effective in providing symptomatic relief in the long distance runner. Seventy-six percent (262) of the runners reported a complete cure or great improvement; this result is similar to other reports in the literature .6,1, &dquo; Treatment with orthoses was effective independent of presumed diagnosis. This does not necessarily imply that orthotic inserts will solve all types of lower extremity complaints. Running injuries are usually the result of alterations in kinetic and kinematic factors. These alterations vary in size and degree. Different combinations will produce different injuries in different individuals. A properly fashioned orthotic device addresses the specific factors present in the user. The results of this study reveal that when the correct orthotic device is used, symptomatic relief is obtained in the majority of cases. Many recent studies have identified the multiple variables
related to the production of running injuries. Training factors, anatomical variations, shoe wear, and running surfaces have all been implicated as contributing factors in the etiology of injuries. 3-5,9,10,15 Lysholm and Wiklander14 distinguished between the intrinsic and extrinsic factors related to running injuries and noted their varying importance. More than likely, a combination of factors, with the relative contribution of each factor varying in different individuals, is responsible for runners’ injuries. The use of orthotic shoe inserts in the treatment of running injuries is an attempt to J temper the effect of the intrinsic factors.3 Long-distance running places great demands on the musculoskeletal system. 11 High loads are produced&dquo; &dquo; over many repetitions4,13 for an extended period of time. Biomechanical deficits may magnify this process by limiting the runners’ ability to accommodate to these demands.4, 7,10 Alteration in shoe wear, training technique, or running surfaces may be the final factor that overloads the compensatory mechanisms of the runner.15, 17 The purpose of orthotic shoe inserts may be to modify the load and anatomical variables,3~5 thereby increasing the threshold for the effects of extrinsic variables. Several studies have clearly shown that lower extremity mechanics can be modified by the use of orthotic shoe inserts.2 13,18 James et al. 10 demonstrated that the pronation measured in an injured foot with an orthotic insert approaches that of a normal foot without inserts. Orthotic shoe inserts can align an unbalanced foot and obtain a neutral position by controlling subtalar motion. This action has been shown effective for relief of symptomatic lower extrem7 ity pain in runners.6, Nigg et al.16 studied the effects of four viscoelastic inserts as compared to conventional insoles in 14 asymptomatic male subjects. They were unable to demonstrate statistically significant differences in the variables describing vertical impact forces or kinematics for shoes with viscoelastic inserts or controls. Symptomatic subjects, or those with underlying lower extremity abnormalities, were not included in this study. The present study was undertaken to provide a clinical investigation of the use and effectiveness of orthotic shoe inserts. The use of a survey and its distribution at racing events introduces a possible selection bias. Runners unable to continue running due to treatment failure would not be included in the patient sample. It is unknown how many runners fall into this group. However, the range and distribution of complaints experienced by the runners in the present study is similar to that reported for runners in general, which supports the validity of the data.8,10,19 The effectiveness of treatment with orthotic shoe inserts was independent of level of participation among the runners in this study. The 50% success rate in the lowest mileage group was not statistically significant from the other groups because of the relatively small sample size of this group; the confidence interval for 4/8 50% in this group is 15.7% to 84%, which reflects the small sample size. It has been suggested that injuries stemming from biomechanical defi=
412
frequent in runners at lower levels of participation. 3,4Significant structural abnormalities will prevent runners from progressing to a more advanced level. Most of the anatomical alterations encountered in the present study were probably not of a severe enough nature to limit achievement if properly treated. This cannot be confirmed since we cits
are more
did not examine the patients ourselves. In part, orthotic shoe inserts achieve their result through the modification of minor biomechanical deficits. This action may allow the runner to achieve a higher level of participation, than would be possible if he/she remained untreated or was treated with other methods. This may explain why so many of the runners continued to use their orthotic devices after their symptoms had resolved.
It was disappointing that 85 (24.5%) of patients had slight, improvement, or increased symptoms and 46 (13.3%) of the runners developed new lower extremity complaints while using a shoe insert. In a previous study of orthoses, Dugan and D’Ambrosia8 found that 50% of their unsatisfactory results were the result of poorly fitting orthoses. That study, as well as others, have noted little success in treating symptoms of a cavus foot with orthotic shoe inserts.3,6-8 As noted, a limitation of surveys of this type is that we did not have the benefit of first-hand examination of the runners or their orthotic inserts. Therefore, we had to rely on their report for a presenting diagnosis and quality of orthotic device. The possibility remains that these patients were not diagnosed correctly by their treating physician or that their insert was not well made. Possibly, the underlying etiology responsible for the complaints in these patients who did not respond well to treatment was one not amenable to orthotic treatment, such as the cavus foot. Interestingly, a large number of these patients (42) also continued to use their devices, despite their subjective dissatisfaction with the results. Treatment of runners is often difficult because of their competitive nature. Treatment regimens that include either restriction or modification of activity are often unacceptable and are met with noncompliance. Jacobs and Berson9 demonstrated that one of the most significant factors leading to success of treatment in this group is patient compliance. In the present study 90% of the runners with good results continued to use their inserts even after resolution of their complaints. This indicates a high level of compliance. Shoe orthoses allow the runner to continue to maintain his current level of activity and, therefore, are well accepted by this no
for the long-distance runner who is in need of conservative therapy.
CONCLUSIONS Orthotic shoe inserts
distance
found to be very effective in
runner.
ACKNOWLEDGMENT The authors thank Dr. Fred Dorey for his contribution to the preparation of the statistical analysis for this study.
REFERENCES 1 Adelaar RS. The
practical biomechanics of running. Am J Sports
Med 14:
497-500,1986 2 Bates BT, Osternig LR, Mason B, et al: Foot orthotic devices to modify selected aspects of lower extremity mechanics Am J Sports Med 7 338342,1979
Techniques in the evaluation and treatment of the injured . 541-558, 1982 Orthop Clin North Am 13 4. Brody DM Running injuries Clin Symposia 32 2-36, 1980 5. Clancy GC: Runners’ injuries Am J Sports Med 8. 137-144, 1980 6 D’Ambrosia RD. Orthotic devices in running injuries Clin Sports Med 4
3 Brody
DM.
runner
611-618,1985 7 D’Ambrosia R, Drez D. Prevention and Treatment of Running Injuries. Thorofare, NJ, CB Slack, Inc, 1982, pp 1-189 8. Dugan RC, D’Ambrosia RD. The effects of orthotics in the treatment of selected running injuries. Proceedings of the Sixteenth Annual Meeting of the Amencan Orthopaedic Foot and Ankle Society. Foot Ankle 6 313, 1986 9 Jacobs SJ, Berson BL: Injuries to runners: A study of entrants to a 10,000 meter race. Am J Sports Med 14 151-155,1986 10. James SL, Bates BT, Osternig LR: injuries to runners. Am J Sports Med 6 40-50,1978 11. James SL, Brubaker CE: Biomechanics of running Orthop Clin North Am
4. 605-615,1973 12. Lutter LD: Cavus foot in runners. Foot Ankle 1. 255-228, 1981 13. Lutter LD Foot-related knee problems in the long distance runner. Foot Ankle 1 : 14.
population.
15
Runners who used shoe orthoses were, in general, quite result. Shoe inserts proved to be an effective treatment for a variety of symptom complexes experienced by running athletes. They are most effective for the correction of the underlying biomechanical abnormalities. Well-made orthotic shoe inserts can be a useful adjunct
16
pleased with their
were
providing symptomatic relief of lower extremity complaints in a large group of long-distance runners. Inserts adjust the biomechanical variables associated with running injuries. Successful treatment with orthotic shoe inserts is dependent on correct diagnosis and a properly fitted insert. The beneficial effect was independent of the class of runner. When used correctly, orthotic shoe inserts are beneficial for a broad range of disorders experienced by long-distance runners. Treatment with orthotic shoe inserts is well-accepted by runners and, therefore, meets with high rates of compliance. The use of orthotic shoe inserts, in conjunction with other conservative modalities of therapy, is a worthwhile treatment method for lower extremity complaints in the long-
17
18
19
112-116, 1980
Lysholm J,
Wikiander J
injuries
in runners
AmJ
Sports
Med 15: 168-
171, 1987 : 190Mann RA, Baxter DE, Lutter LD Running symposium Foot Ankle 1 244, 1981 Nigg BM, Herzog W, Read LJ. Effect of viscoelastic shoe insoles on vertical : 70-76,1988 impact forces in heel-toe running. Am J Sports Med 16 Schuster RO Root types and the influence of the environment on the foot of the long distance runner Ann NY Acad Sci 301. 881-887, 1977 Scranton PE, Pedegania LR, Whitesel JP: Alterations in support phase : 6-10, 1982 forces using supporting devices Am J Sports Med 10 Sheehan GA An overview of overuse syndromes in distance runners Ann NY Acad Sci 301 877-880,1977
long-distance
runner
MICHAEL L. GROSS,* MD, LANCE B. DAVLIN, MD, AND PHILIP M. EVANSKI, MD From the
Orthopaedic and Sports Medicine Associates, Emerson,
ABSTRACT
New Jersey
extremity.5,12
Recent estimates place the number of recreain the United States at close to 30 million.’ According to most reports, approximately 60% of these runners will experience an injury that will necessitate limitation of their activities.3° 9,14~ ls Common disorders sustained by participants in running programs include shin splints, patellofemoral disorders, Achilles tendinitis, plantar fasciitis, and stress fractures.3~ 4~ s, lo, ~s, ~s Injuries occurring in long-distance runners may be related to the tremendous demands made on their lower extremities. Up to 250% of body weight is absorbed by the musculoskeletal system at heel strike. 13,15 This process takes place between 800 and 2000 times per mile while running.4, 13 Injuries resulting from these factors often fall into the category of &dquo;overuse syndromes.&dquo; An underlying structural deficit of the lower extremities may magnify the effects of overuse.1,10 Injured runners frequently present with biomechanical abnormalities, such as hyperpronated feet, malalignment, cavus feet, and limb length discrepancies.3~4 In terms of injury pathogenesis, these may be considered intrinsic factors. Training errors and poor running surfaces3-5, 9,10,15 have also been cited as causes of running injuries. Traditional therapy for problems experienced by runners, including the limitation or alteration of activity, 5,7,10,15 is aimed at modification of these extrinsic factors. However, this approach is tional
Five hundred questionnaires were distributed to longdistance runners who had used, or who were using orthotic shoe inserts for symptomatic relief of lower extremity complaints. Three hundred forty-seven (69.4%) responded (males, 71%; females, 29%). The mean age of the respondents was 36 years (range, 15 to 61). The average distance run per week was 39.6 miles (range, 5 to 98). The mean duration for use of the orthotic inserts was 23 months (range, 1 to 96). The predominant (63%) type of orthotic device used was flexible. The presumed diagnoses in the population studied were excessive pronation (31.1 %), leg length discrepancy (13.5%), patellofemoral disorders (12.6%), plantar fasciitis (20.7%), Achilles tendinitis (18.5%), shin splints (7.2%), and miscellaneous (4.9%). Of the runners responding, 262 (75.5%) reported complete resolution or great improvement of their symptoms. Results of treatment with orthotic shoe inserts were independent of the diagnosis or the runner’s level of participation. A high degree of overall satisfaction was demonstrated by the finding that 90% of the runners continued to use the orthotic devices even after resolution of their symptoms. Orthotic shoe inserts were most effective in the treatment of symptoms arising from biomechanical abnormalities, such as excessive pronation or leg length discrepancy. Along with other conservative measures, orthotic shoe inserts may allow the athlete to continue participation in running and avoid other treatment modalities that are more costly and time consuming, and therefore less acceptable to them.
runners
poorly accepted by
most
runners.
Adjuncts
to treatment
have included modification of training techniques, the use of nonsteroidal antiinflammatory medications, and hot or cold compresses.10, 15 Even with strict adherence to these measures, a significant number of athletes experience treatment failures and undergo further repeated diagnostic or
therapeutic procedures. In an attempt to modify intrinsic factors, an increasing number of orthopaedists treating long-distance runners are using orthotic shoe inserts as part of their regimen. Orthotic shoe inserts reduce symptoms by correcting abnormal lower extremity biomechanics. This is accomplished either by realigning the foot or by a direct cushioning effect. The objective of this study was to: 1) assess the effectiveness of
The recent growth in popularity of recreational running has resulted in an increase in associated injuries to the lower *
Address
to’ Michael L. Gross, MD, Medicine Associates, 440 Old Hook Road, Emerson,
correspondence and repnnt requests
Orthopaedic and Sports NJ 07675
409
410
orthotic shoe inserts in the distance runner, 2) identify those disorders most amenable to treatment with orthoses, and 3) determine the relationship between level of participation and effectiveness of treatment.
MATERIALS AND METHODS Five hundred questionnaires were distributed to participants in events sanctioned by the New York Road Runners Club, and to members of the organization who were presently using, or had previously used, orthotic shoe inserts. Questionnaires were distributed over a period of 3 months. Included with the survey was a self-addressed, prepaid, return envelope. Participants were informed that the data would be available to them at the end of the study. Respondents were asked to list their age, sex, and distance run per week. Data recorded pertaining to the type of orthotic device included: material of composition, type (rigid, semirigid, flexible) and source. The runners were asked to provide the presenting indication for use of the insert, as well as their presumed diagnosis, if known. The duration of use of the insert was recorded, and whether the runner was still using or had discontinued its use. Finally, the runners were asked to provide a subjective rating of their response to treatment with orthotic shoe inserts. Statistical analysis was performed using the chi square test. Of the 500 questionnaires distributed, 347 (69.4%) were returned. These 347 runners who had used or who were using orthotic shoe inserts comprised the primary study group. There were 245 (71% ) men and 102 (29%) women. The average age of the group was 36 years (range, 15 to 61) and the average distance run each week was 39.6 miles (range, 5 to 89). The mean length of time for use of orthotic inserts was 23 months (range, 1 to 96). Of the types of inserts used, 218 (63%) were flexible, 80 (23%) were semirigid, and 49 (14% ) were rigid.
RESULTS runners treated with orthotic shoe inserts, 107 (30.8%) reported complete resolution of symptoms, 155 (44.7%) reported great improvement, 55 (15.8%) runners had slight improvement, 26 (7.5%) felt that they experienced no change in their symptoms, and 4 (1.2%) felt that their complaints increased while using the inserts. Unexpectedly, 46 (13.25%) of the runners surveyed developed a new problem while using the insert (Fig. 1). The complaints that led to use of the orthotic shoe insert included knee pain, 164 (47.3%); foot pain, 116 (33.4%); ankle pain, 50 (14.4%); shin pain, 49 (14.1% ); hip pain, 29 (8.4%); and other miscellaneous complaints, 21 (6.1% ). Miscellaneous complaints were defined as those appearing in
Of the 347
less than 5% of the surveys. Several respondents had more than one complaint, accounting for 429 complaints in 347
respondents. The presenting diagnosis was recorded by 222 of the runners surveyed. Of these, 20 patients had two diagnoses,
1. The effectiveness of orthotic shoe inserts in distance runners (N 347).
Figure
long-
=
Figure 2. The percent of runners with complete relief or great improvement by presenting diagnosis. 242 diagnoses in 222 patients. The most common indication for treatment with orthotic inserts was excessive pronation. This was the presumed diagnosis in 69 (31.1%) runners, followed by plantar fasciitis in 46 (20.7%), Achilles tendinitis in 41 (18.5%), leg length discrepancy in 30 (13.5%), patellofemoral disorders in 28 (12.6%), and shin splints in 16 (7.2%). There were 12 (4.9%) miscellaneous
making
diagnoses reported. The orthoses provided a high level of symptomatic relief in all of the diagnostic categories (Fig. 2). In each diagnostic category the distribution of results
was similar (Table 1). Athletes with the presumed diagnosis of shin splints did not improve as much as runners with other diagnoses, but this difference was not statistically significant. Only 34 (68.8%) of patients with shin splints noted complete relief or great improvement in their symptoms. The percentage of runners experiencing a complete cure or great improvement in symptoms did not vary significantly at different levels of participation. The majority of runners experienced relief of their symptoms using orthotic inserts at all levels. The number of runners who had complete resolution or great improvement is shown as a function of miles per week in Figure 3. There was a strong association between good treatment
411 TABLE 1
Benefit of orthotic shoe insert
Q
Data collected from 230
according to diagnosis’
diagnoses in
222
runners.
Figure 3. The percent of runners with complete cure or great improvement versus miles run per week. results and continued orthotic insert use. Of the 347 runners responding, 280 were still using their inserts at the time of the survey. In this group of 280 runners, there were 238 (85%) who had good results from their treatment with inserts. Conversely, of the 262 overall runners with good results, 238 (90.8%) continued their use of orthotic devices even after resolution of symptoms.
DISCUSSION Our study finding was that orthotic shoe inserts were very effective in providing symptomatic relief in the long distance runner. Seventy-six percent (262) of the runners reported a complete cure or great improvement; this result is similar to other reports in the literature .6,1, &dquo; Treatment with orthoses was effective independent of presumed diagnosis. This does not necessarily imply that orthotic inserts will solve all types of lower extremity complaints. Running injuries are usually the result of alterations in kinetic and kinematic factors. These alterations vary in size and degree. Different combinations will produce different injuries in different individuals. A properly fashioned orthotic device addresses the specific factors present in the user. The results of this study reveal that when the correct orthotic device is used, symptomatic relief is obtained in the majority of cases. Many recent studies have identified the multiple variables
related to the production of running injuries. Training factors, anatomical variations, shoe wear, and running surfaces have all been implicated as contributing factors in the etiology of injuries. 3-5,9,10,15 Lysholm and Wiklander14 distinguished between the intrinsic and extrinsic factors related to running injuries and noted their varying importance. More than likely, a combination of factors, with the relative contribution of each factor varying in different individuals, is responsible for runners’ injuries. The use of orthotic shoe inserts in the treatment of running injuries is an attempt to J temper the effect of the intrinsic factors.3 Long-distance running places great demands on the musculoskeletal system. 11 High loads are produced&dquo; &dquo; over many repetitions4,13 for an extended period of time. Biomechanical deficits may magnify this process by limiting the runners’ ability to accommodate to these demands.4, 7,10 Alteration in shoe wear, training technique, or running surfaces may be the final factor that overloads the compensatory mechanisms of the runner.15, 17 The purpose of orthotic shoe inserts may be to modify the load and anatomical variables,3~5 thereby increasing the threshold for the effects of extrinsic variables. Several studies have clearly shown that lower extremity mechanics can be modified by the use of orthotic shoe inserts.2 13,18 James et al. 10 demonstrated that the pronation measured in an injured foot with an orthotic insert approaches that of a normal foot without inserts. Orthotic shoe inserts can align an unbalanced foot and obtain a neutral position by controlling subtalar motion. This action has been shown effective for relief of symptomatic lower extrem7 ity pain in runners.6, Nigg et al.16 studied the effects of four viscoelastic inserts as compared to conventional insoles in 14 asymptomatic male subjects. They were unable to demonstrate statistically significant differences in the variables describing vertical impact forces or kinematics for shoes with viscoelastic inserts or controls. Symptomatic subjects, or those with underlying lower extremity abnormalities, were not included in this study. The present study was undertaken to provide a clinical investigation of the use and effectiveness of orthotic shoe inserts. The use of a survey and its distribution at racing events introduces a possible selection bias. Runners unable to continue running due to treatment failure would not be included in the patient sample. It is unknown how many runners fall into this group. However, the range and distribution of complaints experienced by the runners in the present study is similar to that reported for runners in general, which supports the validity of the data.8,10,19 The effectiveness of treatment with orthotic shoe inserts was independent of level of participation among the runners in this study. The 50% success rate in the lowest mileage group was not statistically significant from the other groups because of the relatively small sample size of this group; the confidence interval for 4/8 50% in this group is 15.7% to 84%, which reflects the small sample size. It has been suggested that injuries stemming from biomechanical defi=
412
frequent in runners at lower levels of participation. 3,4Significant structural abnormalities will prevent runners from progressing to a more advanced level. Most of the anatomical alterations encountered in the present study were probably not of a severe enough nature to limit achievement if properly treated. This cannot be confirmed since we cits
are more
did not examine the patients ourselves. In part, orthotic shoe inserts achieve their result through the modification of minor biomechanical deficits. This action may allow the runner to achieve a higher level of participation, than would be possible if he/she remained untreated or was treated with other methods. This may explain why so many of the runners continued to use their orthotic devices after their symptoms had resolved.
It was disappointing that 85 (24.5%) of patients had slight, improvement, or increased symptoms and 46 (13.3%) of the runners developed new lower extremity complaints while using a shoe insert. In a previous study of orthoses, Dugan and D’Ambrosia8 found that 50% of their unsatisfactory results were the result of poorly fitting orthoses. That study, as well as others, have noted little success in treating symptoms of a cavus foot with orthotic shoe inserts.3,6-8 As noted, a limitation of surveys of this type is that we did not have the benefit of first-hand examination of the runners or their orthotic inserts. Therefore, we had to rely on their report for a presenting diagnosis and quality of orthotic device. The possibility remains that these patients were not diagnosed correctly by their treating physician or that their insert was not well made. Possibly, the underlying etiology responsible for the complaints in these patients who did not respond well to treatment was one not amenable to orthotic treatment, such as the cavus foot. Interestingly, a large number of these patients (42) also continued to use their devices, despite their subjective dissatisfaction with the results. Treatment of runners is often difficult because of their competitive nature. Treatment regimens that include either restriction or modification of activity are often unacceptable and are met with noncompliance. Jacobs and Berson9 demonstrated that one of the most significant factors leading to success of treatment in this group is patient compliance. In the present study 90% of the runners with good results continued to use their inserts even after resolution of their complaints. This indicates a high level of compliance. Shoe orthoses allow the runner to continue to maintain his current level of activity and, therefore, are well accepted by this no
for the long-distance runner who is in need of conservative therapy.
CONCLUSIONS Orthotic shoe inserts
distance
found to be very effective in
runner.
ACKNOWLEDGMENT The authors thank Dr. Fred Dorey for his contribution to the preparation of the statistical analysis for this study.
REFERENCES 1 Adelaar RS. The
practical biomechanics of running. Am J Sports
Med 14:
497-500,1986 2 Bates BT, Osternig LR, Mason B, et al: Foot orthotic devices to modify selected aspects of lower extremity mechanics Am J Sports Med 7 338342,1979
Techniques in the evaluation and treatment of the injured . 541-558, 1982 Orthop Clin North Am 13 4. Brody DM Running injuries Clin Symposia 32 2-36, 1980 5. Clancy GC: Runners’ injuries Am J Sports Med 8. 137-144, 1980 6 D’Ambrosia RD. Orthotic devices in running injuries Clin Sports Med 4
3 Brody
DM.
runner
611-618,1985 7 D’Ambrosia R, Drez D. Prevention and Treatment of Running Injuries. Thorofare, NJ, CB Slack, Inc, 1982, pp 1-189 8. Dugan RC, D’Ambrosia RD. The effects of orthotics in the treatment of selected running injuries. Proceedings of the Sixteenth Annual Meeting of the Amencan Orthopaedic Foot and Ankle Society. Foot Ankle 6 313, 1986 9 Jacobs SJ, Berson BL: Injuries to runners: A study of entrants to a 10,000 meter race. Am J Sports Med 14 151-155,1986 10. James SL, Bates BT, Osternig LR: injuries to runners. Am J Sports Med 6 40-50,1978 11. James SL, Brubaker CE: Biomechanics of running Orthop Clin North Am
4. 605-615,1973 12. Lutter LD: Cavus foot in runners. Foot Ankle 1. 255-228, 1981 13. Lutter LD Foot-related knee problems in the long distance runner. Foot Ankle 1 : 14.
population.
15
Runners who used shoe orthoses were, in general, quite result. Shoe inserts proved to be an effective treatment for a variety of symptom complexes experienced by running athletes. They are most effective for the correction of the underlying biomechanical abnormalities. Well-made orthotic shoe inserts can be a useful adjunct
16
pleased with their
were
providing symptomatic relief of lower extremity complaints in a large group of long-distance runners. Inserts adjust the biomechanical variables associated with running injuries. Successful treatment with orthotic shoe inserts is dependent on correct diagnosis and a properly fitted insert. The beneficial effect was independent of the class of runner. When used correctly, orthotic shoe inserts are beneficial for a broad range of disorders experienced by long-distance runners. Treatment with orthotic shoe inserts is well-accepted by runners and, therefore, meets with high rates of compliance. The use of orthotic shoe inserts, in conjunction with other conservative modalities of therapy, is a worthwhile treatment method for lower extremity complaints in the long-
17
18
19
112-116, 1980
Lysholm J,
Wikiander J
injuries
in runners
AmJ
Sports
Med 15: 168-
171, 1987 : 190Mann RA, Baxter DE, Lutter LD Running symposium Foot Ankle 1 244, 1981 Nigg BM, Herzog W, Read LJ. Effect of viscoelastic shoe insoles on vertical : 70-76,1988 impact forces in heel-toe running. Am J Sports Med 16 Schuster RO Root types and the influence of the environment on the foot of the long distance runner Ann NY Acad Sci 301. 881-887, 1977 Scranton PE, Pedegania LR, Whitesel JP: Alterations in support phase : 6-10, 1982 forces using supporting devices Am J Sports Med 10 Sheehan GA An overview of overuse syndromes in distance runners Ann NY Acad Sci 301 877-880,1977
