Foot Orthotics for Golf

What do you do with a golfer and the need for foot orthotics? Golf involves a lot of walking, so they need a reasonably firm or rigid pair of foot orthotics to control the foot during that activity (assuming that foot orthotics are indicated). The crucial part of the golf game is the swing. The swing stance involves a reasonable amount of inversion and eversion of teh foot to be done efficiently. How much does a rigid orthotic with a rearfoot post interfere with that motion and affect that efficient golf swing? Foot orthotics for golf are going to have to be a compromise. It is surprising how often this issue comes up on some golfing forums for discussion.

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The Cluffy Wedge

The Cluffy Wedge has been getting a bit of attention lately. It was original trademarked by Dr James Clough as a mean to dorsiflex the hallux to help functional hallux limitus. It was first written about in JAPMA. The concept is based on preloading the hallux to get it to load earlier in the stance phase. The biggest effect of this is to bring the windlass mechanism on sooner as it hold the hallux in a slightly dorsiflexed position. While the Cluffy Wedge can be purchased as an orthotic add-on or shoe insert, many people just fabricate their own. The Cluffy Wedge is being marketed through a number of different channels. Podiatry TV has a number of videos on the Cluffy Wedge.

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Foot Orthotics and Cycling

Cycling represents interesting challenges for podiatric management of problems. First the cycling bike needs to be set up properly to ensure efficient biomechanics and power generation for cycling fast. Any mechanical problem that needs foot orthotics are going to be difficult as there is not a lot of room in the shoe for cycling foot orthotics. Also there is no “swing phase” in the cycling “gait” as there is when walking and running. This can result in a type of plantar forefoot neuropathy due to the constant weight bearing (this is also seen in gyms on equipment like the cross trainers in which there is a constant stance phase). A lot of these issues is discussed amongst cyclists on cycling forums and Podiatry Arena has had a few discussions on cycling.

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Chilblains

Chilblains or pernio are interesting when it comes to the textbooks. You hardly see chilblains mentioned. They are really common in the colder climates. I can only assume that the editors of a lot of the text books do not live in climates where chilblains are common?

The biggest misconception I see about chilblains is that they are caused by the cold. They are not really caused by cold, but are caused by the too rapid warming of the foot after they get cold and circulation has not responded adequately to that warming. They are also not caused by poor circulation, they are caused by how the cold responds to the changes in temperature, so the volume of the circulation is not an issue.

Why are chilblains more common in females? - it is either a footwear thing and that causes pressure on the toes that causes changes to the circulatory response; or it’s a hormone thing as a lot of the female hormones do affect the circulatory responses.

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Foot orthoses or gait retraining for patellofemoral pain?

Its long been held that excessive foot pronation causes the tibia to rotate excessively internally causing a misalignment of the patella and results in patellofemoral pain syndrome or anterior knee pain in runners. Therefore, based on this you use foot orthotics to correct the foot pronation to treat the problem. Two reasonably well conducted RCT’s shows that foot orthotics are successful at that.

However:
1. Almost the cross sectional and prospective evidence shows that foot pronation is not associated with patellofemoral pain (despite the fact that foot orthotics been shown to help).
2. Even though the foot and tibia are coupled, the research as to which is the driving force, shows that it is tibial internal and external rotation that drive foot pronation and supination. It is not foot motion that drives leg motion, it is the other way around (see this discussion). This is so counter-intuitive to what podiatrists, in general, have believed.
3. More and more physiotherapists are using proximal control exercises and gait retraining to treat patellofemoral pain without the use of foot orthotics, and the evidence shows that this is just as effective as foot orthotics in treating this problem.

What is going on? Is it proximal or distal that the problem is coming from? Should we really be using foot orthotics is the problem is proximal? Should physiotherapists be using proximal control exercises if the problem is distal?

I have been in a couple of conference debates with physiotherapists at both a physiotherapy and a podiatry conference. I have learnt a lot through that and I genuinely do believe that the solution to patellofemoral pain syndrome is proximal control exercises. However, I also believe that this proximal control will not work if the ankle inversion moment (or supination resistance) is above a certain threshold (which will probably vary from individual to individual). For example, if the ankle inversion moment is low (i.e. supination resistance is low), then the proximal control exercise should work easy to help and they may not even need foot orthotics. However, if the ankle inversion moment is high (i.e. supination resistance is high), then it does not matter what you do proximally, it’s not going to work as the foot won’t move. So, therefore the role of foot orthotic in patellofemoral pain could be to reduce the ankle inversion moment to below a certain threshold, so the proximal control can work. This theory makes sense to me and is consistent with the most recent evidence.

For more see:
Foot Orthoses for Knee Pain
Foot orthoses and patellofemoral pain syndrome
Foot pronation and knee pain
Does the tibia drive the foot or does the foot drive the tibia?

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