Joint Pain: Scams, Lies, and Exaggerations, Part 3

As an orthopedic nurse practitioner I see a constant stream of joint pain complaints. They stem from a variety of sources: injury, age-related changes, lifestyle issues, and autoimmune disorders. Patients will often Google their problems and/or their symptoms, and like most medical issues you can find truth on the Internet, but it is never easy or quick. A lot of what I do with patients is teaching, with a good deal of that time spent addressing long-standing myths or marketing scams. This post is part of an ongoing series about orthopedic problems, scams, and myths. Part 1 focused on the myths and quackery surrounding pain in weight-bearing joints. Part 2 focused on one of the most pervasive forms of orthopedic pain: back and neck pain. Part 3 will focus on feet.

Let's take a look at some of the common advice surrounding the health of the human foot.

Your foot is a complicated structure that is often taken for granted. Numerically, one quarter of the body's bones are in the feet, with 26 bones, 33 articulating joints, and hundreds of tendons and ligaments. It is an orthopedically complicated structure made more complicated by its function. The foot has to balance all of our body's weight across all these relatively small joints while we walk, run, climb, or stand. It has to be accommodating to a wide variety of surfaces. It is not hard to be impressed by many body functions, but the human foot is a big part of what makes us uniquely human. It is an integral part of our ability to walk upright and use tools, providing us the flexibility to evolve our intelligence.

Like other weight-bearing joints, injuries to the foot are are common and its fine balance can often become limited and painful. Treatment for such a complex structure is often complicated; and like the other topics I have covered in this series, foot pain is ripe for scams and myths.

According to the Framingham Foot Study, approximately 19 percent of men and 25 percent of women have significant foot pain on most days of the week, which often limits their ability to function. Studies of different foot types have shown that the foot's structure affects its ability to pronate correctly and follow the normal pattern of motion needed during the gait cycle. But, while foot structure and shape likely play an important role in injury, gait mechanics play an equally important role and these two clinical parameters must be assessed together.

In addition, research suggests that age may be a risk factor, as longitudinal arch height declines somewhat with age, and the frequency of forefoot injury in older patients suggests that the same phenomena occurs in the transverse arch. Internal and external factors such as weight and lifestyle play a role. Despite common misconceptions by the public, there is no good data indicating that any type of flooring plays any direct role in foot pain more than any other. And while footwear does affect our feet, its benefit is very non-specific and rife with unproven marketing. This is similar to the marketing surrounding bedding for back pain. The key theme to understand about your feet is that pain and dysfunction are multi-factoral and there is no single answer. Any solution that claims to fix all foot problems should make you very skeptical.

Home Remedies

Although it's not a specific medical ailment, foot pain, for whatever reason, has a large number of "home remedies." Most of these home remedies involve a warm or cold foot bath with an additive. Additives are too numerous to list in this post, here's a smattering:

vinegar
Epsom salt
cayenne pepper
sage
clove oil
asparagus
a host of additives called euphemistically "essential oils"

They all suffer from the same issue: a complete lack of any credible evidence. Sure, you can find reams of in vitro or anecdotal studies that claim benefit for any of these additives in a non-specific way, but there are no well-controlled studies. The proponents don't even test to see if the additives perform any better than a regular, unadulterated foot bath. There is no compelling reason to believe any of these claims. Certainly it is plausible that if you add cayenne pepper to your water you will notice a reaction. That doesn't mean that it equates a medical benefit. It can give you a really painful couple of hours if you overdo it, but there is no reason to believe that it's helping your feet any more than plain old hot water. And it's equally unreasonable to expect that one untested additive will be better than any other. These additives are probably no more dangerous than they are effective, though there might be a risk of discomfort, allergic reaction, or contact dermatitis. In my opinion, foot baths are fine for relaxation, but additives are unnecessary and may present some risks.

Shoe Inserts
Should we all be "Gellin," as one commonly marketed shoe insert suggests? The effectiveness of insoles is actually very difficult to assess. There are a wide variety of available shoe inserts, including orthopedically prescribed custom orthotics, over-the-counter versions, and a host of gimmicky inserts from a variety of sources, including shoe stores to outdoor outfitters. The actual research is very sparse in this area, even for the prescribed orthotics. Some studies persuasively demonstrate that they do work for some conditions, but we don't really know why. Americans spend $4.7 billion annually on foot orthotics of one type or another. Is this money well spent?

The definition of what constitutes an orthotic is contentious and there is no consensus opinion, even in podiatry. Response to the treatment is very individual. There is growing concern that orthotics can make foot problems worse long term. Dr. Michael Nirenberg, a podiatrist in Crown Point, Indiana, was quoted in a 2011 article in the Canadian Medical Association Journal, saying:

"When you brace the foot, that may alter the function of the foot for the better, but in doing so it negates the need for many of the muscles in the foot to do anything. Common sense tells us that if you don’t use a muscle, it’s going to weaken."

Similar to all medical treatment, there is always a price to be paid and no treatment is risk free. I suspect that the downside of orthotics has more to do with continued age-related changes than muscular weakening, especially since the foot's relative musculature is nominal compared to the bone, joints, ligaments and tendons.

Beyond a possible detriment there are issues of individuality. Even if a person has the same problem (e.g. plantar fasciitis) at similar age, weight, sex, and activity level, they may need very different appliances. Additionally, those prostheses may not work at all for one person, and wonderfully for another. Even the term "orthotic" is an indeterminate and broad description. Gel inserts from the drugstore are just as much orthotics as custom-made prescription inserts from a doctor. The over-the-counter pair likely costs only a few dollars, while the prescriptive may cost hundreds, and there is no guarantee that the expensive insert will work any better than the cheap one.

Bottom line: you can't choose the right insert by stepping on a foot pressure machine at the drugstore and there is no surefire orthotic for any problem, even when they are prescribed by a doctor.

Acupressure
Acupressure is often used as a foot pain treatment. Its theological basis is similar to acupuncture, with magical "meridians" of "energy" and such. I have a short exploration of this treatment in Part 2 of this series. Acupressure has less research than acupuncture and is based upon an implausible, pre-scientific idea that violates all that we know about physiology, chemistry, and anatomy. There is no evidence that it is in any way effective for the host of problems it is claimed to treat. Still, it is a type of foot massage, which has subjective benefit for foot pain. This is probably its only benefit. In my opinion if you want a foot massage, get one, but dump the rigmarole surrounding this treatment.

Footwear

Similar to Part 2 of my seriesâ€"in which I discussed bedding marketing for back and neck problemsâ€"specialized footwear has the same paucity of evidence to support its assertions for pain reduction. Footwear has tons of marketing: everything from pump sneakers to barefoot running shoes to muscle-toning sneakers, with no shortage of promises. Some claims lack plausibility, others are reasonable. Price markups don't typically follow effectiveness, and there is no compelling reason to believe that $30 running shoes are therapeutically different from those priced at $300.

An example of this is barefoot running shoes. Skeptoid episode #185 covers the benefits of barefoot running verses conventional running shoes. The episode no longer is up to date with the current research, but Brian's findings still hold true. The data showing a lower injury risk for any running shoe is contradictory. The key factor for benefit in barefoot running seems to be that barefoot runners develop better mechanics. That seems to be factor that leads to less injuries. The problem lies in the causality. Do barefoot runners run with better mechanics because they are barefoot or are runners with better mechanics able to run barefoot? The answers are still unclear. One thing is apparent in the recent literature: running barefoot has the same incidence of foot injuries unless you improve your mechanics.

Many clinicians and runners believe that selecting the shoe best suited to the runner’s foot type prevents injury; however, this concept is not well supported by the literature. Studies of recruits in the United States Marine Corps and Air Force undergoing basic training found that assigning shoes to recruits based on foot type did not significantly reduce injury rates. In addition, a systematic review found insufficient evidence to support the prescription of running shoes based upon foot type. The results of a subsequent trial suggest that the level of cushioning may not affect injury rates. In this trial, 247 recreational runners were randomly assigned to wear running shoes that differed only in midsole hardness, for five months, and reported their running volume and all running-related injuries. No significant difference was noted in injury rates between the two groups. One crossover randomized trial found that some popular, neutral-cushioned running shoes reduced plantar pressures in the cavus foot, hypothetically reducing injury risk. But further study is needed to determine if this is so.

Regardless of the shoe type used, several studies of the shock-absorption properties of running shoes have shown that new shoes lose up to half their cushioning after 250 to 500 running miles. Therefore, most sports medicine practitioners counsel runners to change their shoes every 350 to 500 miles.

For runners, the balance of the evidence is as follows: athletes should select a running shoe that feels extremely comfortable and is well-suited to their foot structure (e.g. high arch). Barefoot running, while it may help to improve the biomechanics of some runners, probably only benefits those who already have good running biomechanics, and should be limited to softer surfaces. Many running clinics are seeing an increase in metatarsal stress fractures in individuals new to barefoot running. And while this, and evidence favoring better running mechanics form, are useful for runners, there is no evidence supporting any particular footwear for everyday casual wear. All other footwear types have little or no research. Basically there are no individual or systematic reviews that indicate any form of footwear is beneficial over any other. Footwear manufacturers can pretty much claim any benefit that they want, but there are limits.

In 2012, Skechers had to settle a $40 million class action lawsuit after they got in trouble for making misleading and unsupported marketing claims about their toning shoes and they were required to remove their claims that you could lose weight without exercise. Lawyers have alleged that the shoes can cause injuries. There is no actual research yet, just speculation based upon data tracking of consumer complaints, which is far from showing a causal relationship for hip injuries. In my opinion any shoe that radically changes how you walk could result in injury. That said, I am skeptical that toning shoes could result in any direct injury to the hip by wearing them without falling. The balance of all orthopedic research shows little benefit in treating foot mechanic discrepancies to reduce weight-bearing joint injuries and it seems implausible that mechanical changes alone can cause serious injuries.

Bottom line for footwear: there is no one type that is good for everyone and no one type that is more harmful than another. There is one glaring exception, though: high heels. Calluses, bunions, and corns are foot problems found almost exclusively in people wearing high heels. Yes, I know you look good in them. Just be aware that there is a price that you pay for it.

My personal advice for your feet: you should get your feet measured regularly to adjust for the age of your feet. Foot baths are just foot baths, not medical treatments. People with medical problems such as diabetes have special needs that require podiatric care. For the average person with recurrent foot pain don't go to the Nike outlet store for adviceâ€"see a podiatric specialist. Custom-made shoes, and other expensive footwear, are dramatically more expensive and really have no known benefit. Always be suspicious of expensive shoes and inserts. Ask pointed questions about necessity of orthotics and discuss long-term issues with a doctor. Grabbing the most expensive shoe off the shelf is no guarantee of superior quality or benefit. Finally, stay away from fad advertising that promotes implausible-sounding, unsupported recommendations.

Joint pain, backaches, headaches, foot painâ€"we all get them. If anyone is offering simple solutions to complex problems you have good reason to be skeptical. Talk to your doctor; if he/she thinks you need to see a specialist then do so. Please don't just Google it and self treat. You're wasting your time, money, and maybe doing something dangerous.

Take a minute and support Skeptoid. The money doesn’t go to me, but instead goes to keep Skeptoid running as a resource of science and skepticism. Remember: all donations and gifts to Skeptoid Media, Inc. are tax deductible under section 501(c)(3) of the Internal Revenue Code (sections 170, 2055, 2106, 2522).

You can follow me at Twitter @steveproacnp for a daily dose of skeptical nursing. Please check out the completion of the series Occ: The Skeptical Caveman, which I helped produce with the guys at The Skeptics Guide To the Universe.

Disclaimer: This post is my personal opinion, it is not a substitute for medical care. It is for informational purposes only. The information on Skeptoid blog is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. This post does not reflect the opinion of my partners, professional affiliates, or academic affiliations. I have no financial conflicts of interest to disclose.