• MSK conditions affect 14.9 million people symptoms of pain, stiffness, limited movement, and disability affecting QOL and independence.

  • Key contributor to multi-morbidity.

  • Ageing population, rising obesity physical activity levels will increase people with MSK conditions

  • NHS spends over £5 billion annually in treating MSK conditions

  • Musculoskeletal Health: A 5 year strategic framework for prevention across the lifecourse (PHE, 2019)

MSK and Public Health

  • MSK non-communicable conditions affect bones, joints, muscles

  • greatest cause of disability in England

  • grouped as inflammatory conditions such as rheumatoid arthritis,

  • conditions of MSK pain such as osteoarthritis of the hip, knee, neck and back pain, and osteoporosis and fragility fractures.

  • 20% population consult GP about an MSK condition each year (PHE, 2019)

MSK and the Foot

  • Heel pain

  • Forefoot pain

  • 1st MPJ pain

  • Inflammatory joint conditions

MSK and the Foot

MSK Pain and Podiatry

Pain and Podiatry

Heel Pain

Plantar Faciitis

  • Plantar fasciitis is a condition in which there is persistent pain associated with chronic degenerative and reparative processes affecting the origin of the plantar fascia and surrounding peri-fascial surfaces. (NICE 2014).

  • Accounts for 80% of heel pains. likely hood of getting 10%(life time prevalance).

  • Therefore, if not sure more than likely to be plantar fasciitis

  • Patients with chronic plantar fasciitis have a thickened plantar fascia,(McMillan et al.2009)

  • MR is good to highlight pathological change 4.5mm or thicker denotes plantar fasciitis.

Plantar fascia rupture

  • Not common,more liable to occur with steroid injection. Loss of medial arch profile. May be partial/complete.
Plantar Fascia Rupture

Tendinous Lesions

  • Flexor hallucis longus,flexor digitorum longus; Tendinitis, tenosynovitis.

  • Swelling, tenderness with posterior medial heel pain.

  • Treatment

    • rest
    • physio
    • NSAIDs.
    • Ultra sound/MRI imaging.
    • Foot Orthotics

Foot Orthotics


  • Change how and where forces are applied to the foot
    • Take the job of some of the structures in the foot that are commonly affected by pain
    • Can change the position and motion of the foot in walking and running (Nester et al, 2014)

  • External forces applied to foot from:
    • Ground reaction force
      • Relates to surface, shoes, insole, hosiery

  • Internal forces applied to foot from:
    • Muscle/tendons
    • Ligaments
    • Bone (joint contact forces)

  • The orthosis will be designed to change the external force applied to the foot in order to reduce the stress experienced by internal (painful) structures

Heel Pain Treatment

  • Stretching of plantar fascia is a common feature of treatment for plantar heel pain/ fasciitis (NICE 2014)

  • Systematic review (Landorf 2015) identified 12 interventions for management of heel pain. *weak, inconsistent evidence for stretching

  • Sweeting (2011) stretching interventions varied significantly between studies but combined plantar fascia and calf stretched of benefit.

  • Footwear difficulties for people with plantar heel pain Sulivan (2015)

  • Systematic review and meta analysis foot orthoses for plantar heel pain, Whittaker (2018)

  • Customised devices are more effective than sham orthoses for improvement of function in plantar heel pain. McCormick (2013)

  • Custom devices for plantar heel pain improve first step pain, Bishop (2018)

  • Customised foot orthoses may be equally effective as prefabricated orthoses at reducing pain or improving function in people with plantar heel pain, Ring (2014).

Inflammatory joint disease & treatment with foot orthotics

  • Foot orthoses may be prescribed for people with inflammatory joint diseases

  • Rheumatoid Arthritis and Osteoarthritis

  • Current debates and evidence on

  • Prefabricated V custom (Gallagher 2018) Chapman (2016)

  • Systematic reviews Hennessey & (Woodburn 2002)

  • Biomechanics and orthoses in RA, Woodburn (2003)Turner (2008)

Forefoot Pain

Forces and the Forefoot

  • External forces are applied to the foot during weight bearing tasks – at varied sites and varied directions.

  • Internal forces from the rest of the body are applied to the foot

  • Passive tissues (capsule, ligaments) come under increasing/decreasing tension

  • Active tissues (muscle/tendon) act in response to sensory information (from passive and active tissues and plantar surface)

Demands on Foot during loading

  • Compliance (absorb energy, “shock” and adapt to surfaces)

  • Stiffness (allow loads to be applied to the ground)

  • Sensory feedback (provide data on loads to assist management of balance and movement during tasks)

Anatomy 1st MPJ


  • Subjective
    • Inflammation and pain
    • Dull or sharp
    • Swelling
    • Medial sesamoid
    • Limited 1stMPJ movement

  • Objective
    • PAC test
    • Passive axial compression

Sesamoids - Other Pathologies

  • Aetiology

    • Traumatic
    • Degenerative (OA RA Gout)
    • Sport
    • Footwear
  • DD:

    • Bipartite
    • Hallux valgus (Panchani 2016)
    • Tenosynovitis / Bursitis
    • Scan if suspect

Morton’s Plantar digital neuritis

  • Subjective:

    • Parasthesia,
    • tenderness on direct palpation,
    • pain on weight bearing,
    • relieved by rest.
    • Demographics,
    • footwear,
    • activity
  • Objective:

    • Pastides (2012) compared clinical and radiological. - Mulder’s click sensitivity
      • 98% U/S sensitivity
      • 90% MRI sensitivity 88%
Morton's Plantar digital neuritis


  • Differential diagnosis?

  • Pressure relieving forefoot pads, Lee (2014)

  • Process evaluation of pod treatment of forefoot pain Van der Zwaard (2013)

Hallux Limitus

  • Subjective:

    • Pain,
  • Objective:

    • reduced ROM,
    • passive,
    • active,
    • resisted,
    • loaded,
    • dynamic X- Ray.
  • Functional Hallux Limitus (Payne 2002) Hubscher Manoeuvre test, not good indicator of limited 1st MPJ dorsiflexion (Gatt 2014)

  • Welsh (2010) foot orthoses for 1st MPJ pain

  • Halstead (2005) relationship between hallux dorsiflexion and heel eversion

Hallux Limitus

Foot Orthotics: Issues for debate

Footwear vs Foot Orthotic

  • Patients attend with pain
  • Expectations
  • Footwear
  • Muntenau et al (2015) RCT orthoses Achilles tendinopathy
  • Williams & Nester (2010) Role of Footwear

Orthotics are just arch supports…

  • Explore the extensive range of possible design features
  • Orthotic prescription – one size does not fit all.
  • Chapman et al (2016) OA and off the shelf and “sham” orthoses


  • Pes planus, flat foot, pronation Children adults
  • normal development
  • Phethean & Nester (2012)
  • Morrison et al (2013)
  • Re-normalise pronation

Custom Made

  • Professional Terminology
  • Patient expectations
  • Commercial developments
  • Hennesey et al (2012) custom made FO for people with RA
  • Prescription & method

Critical appraisal of foot orthotics

  • A number of criticisms have been made and difficulties encountered when researching the effects of foot orthoses. These are due to the variable nature of:

    • the patient profile,

    • individual orthotic prescription,

    • manufacture of the device, and

    • measurement of the outcome.

Orthotics - Patient Perspective

  • Despite development of evidence that orthotics have a therapeutic benefit there is still a lack of robust scientific evidence to support the use of foot orthoses.

  • Despite the significant shortfall of evidence in orthotic care both practitioners and patients strongly defend the clinical benefits of orthotic therapies in reducing pain associated with a wide range of muscular skeletal pathologies

Conclusion - Foot Orthotics

  • There is still insufficient numbers of good quality RCT’S to evaluate the clinical effectiveness of orthotics.

  • Hence, systematic and critical review of the provision and efficacy of foot orthoses remains an essential goal within professional practise so that practitioners can demonstrate a body of evidence supports the clinical decision made.

  • Convential trends in the range of orthotics provision in the health service are being challenged due a range of factors including to economic need, professional development and time management.

  • Service evaluations are required to assess the clinical value of treatment interventions.

Evidence Summary

  • Williams, A., & Nester, C. (2010). Footwear and foot orthoses. Edinburgh: Churchill Livingstone. S.C. Morrison et al. / Research in Developmental Disabilities 34 (2013) 3197–3201 3201

  • Munteanu S, Landorf K ,Menz H, Cook J, Pizzari T, Scott L , (2015) Effectiveness of customised foot orthoses in the treatment of Achilles tendinopathy: a randomised controlled trial. British Journal of sports medicine 49 989-994 doi:10.1136/bjsports-2014-093845

  • Phethean J and Nester C. (2012) The Influence of body weight, body mass index and gender on plantar pressures: Results of a cross-sectional study of healthy children. Gait & Posture 36:287-2901111

  • Morrison S Ferrari J Smillie S (2013) Assessment of gait characteristics and orthotic management in children with Developmental Coordination Disorder: Preliminary findings to inform multidisciplinary care Research in Developmental Disabilities 34 3197–3201

  • Chapman G Halstead J Redmond AC (2016) Comparability of off the shelf foot orthoses in the redistribution of forces in midfoot osteoarthritis patients. Gait and Posture 49 235-240

  • Hennessey K Woodburn J Steultjens M Custom Foot Orthoses for Rheumatoid Arthritis: A Systematic Review Arthitis care and research 64 3 311-320

  • McMillan AM , Landorf KB , Barrett JT , et al . Diagnostic imaging for chronic plantar heel pain: a systematic review and meta-analysis. J Foot Ankle Res 2009; 2: 32. doi:10.11861757-1146-2-32

  • Woodburn J, Barker S, Helliwell PS. A randomized controlled trial of foot orthoses in rheumatoid arthritis. Journal Rheumatol. 2002;29:1377–83

  • Turner DE, Helliwell PS, Siegel KL, Woodburn J. Biomechanics of the foot in rheumatoid arthritis: identifying abnormal function and the factors associated with localised disease ‘impact. Clin Biomech. 2008;23:93–100.

  • Woodburn J, Helliwell PS, Barker S. Changes in 3D joint kinematics support the continuous use of orthoses in the management of painful rearfoot deformity in rheumatoid arthritis. J Rheumatol. 2003;30:2356–64.

  • Nester, C.J., Jarvis, H., Bowden, P.D., Jones, R.K., Lui, A. (2014) Movement of the human foot in 100 pain free individuals aged 18-45. Implications for understanding normal foot function. Journal of foot and ankle research. 7:51.

  • Bishop, C., Thewlis, D., & Hillier, S. (2018). Custom foot orthoses improve first-step pain in individuals with unilateral plantar fasciopathy: A pragmatic randomised controlled trial. BMC Musculoskeletal Disorders, 19 doi:

  • Gallagher, K. S., Godwin, J., Hendry, G. J., Steultjens, M., & Woodburn, J. (2018). A protocol for a randomised controlled trial of prefabricated versus customised foot orthoses for people with rheumatoid arthritis: The FOCOS RA trial foot orthoses – customised v off-the-shelf in rheumatoid arthritis]. Journal of Foot and Ankle Research, 11 doi:

  • McCormick, C. J., Bonanno, D. R., & Landorf, K. B. (2013). The effect of customised and sham foot orthoses on plantar pressures. Journal of Foot and Ankle Research, 6, 19. doi:

  • Lee, P. Y., Landorf, K. B., Bonanno, D. R., & Menz, H. B. (2014). Comparison of the pressure-relieving properties of various types of forefoot pads in older people with forefoot pain. Journal of Foot and Ankle Research, 7, 18. doi:

  • van der Zwaard, B.,C., Swagerman, W. J. C., Vanwanseele, B., Gorter, K. J., van der Horst, H.,E., & Elders, P. J. M. (2013). Process evaluation of podiatric treatment of patients with forefoot pain. Journal of Foot and Ankle Research, 6, 32. doi:

  • Welsh, B. J., Redmond, A. C., Chockalingam, N., & Keenan, A. (2010). A case-series study to explore the efficacy of foot orthoses in treating first metatarsophalangeal joint pain. Journal of Foot and Ankle Research, 3, 17. doi:

  • Halstead J, Turner DE, Redmond AC:The relationship between halluxdorsiflexion and ankle joint complex frontal plane kinematics: apreliminary study.Clin Biomech (Bristol, Avon)2005,20(5):526-531.

  • Landorf KB Menz H (2008) Plantar heel pain and fasciitis BMJ Clinical evidence Landorf, K.B. (2015) Plantar heel pain and plantar fasciitis. BMJ Clinical Evidence. NICE (2015) Clinical Knowledge Summaries Plantar Faciitis.

  • Whiattaker G, et al ( 2017) Foot orthoses for plantar heel pain: a systematic review and meta-analysis a-analysis [accessed Oct 10 2019].

  • Ring, K. Ottter, S. (2014) Clinical efficacy and cost effectiveness of bespoke and prefabricated orthoses for plantar heel pain. Musculoskeletal Care •

  • Sulivan J et al (2015) Determinants of footwear difficulties in people with plantar heel pain. Journal of Foot and Ankle Research

  • Whittaker G (2015) Corticosteriod injections compared to foot orthoses for plantar heel pain: protocol for the SOOTHE heel pain randomised trial Journal of Foot and Ankle Research • Sweeting D (2011) The effectiveness of manual stretching in the treatment of plantar heel pain : a systematic review Journal of Foot and Ankle Research 4:19

  • Whittaker, G. A., Munteanu, S. E., Menz, H. B., Tan, J. M., Rabusin, C. L., & Landorf, K. B. (2018). Foot orthoses for plantar heel pain: A systematic review and meta-analysis. British Journal of Sports Medicine, 52(5), 322. doi: