A Case For Orthotics?

running orthotics for painIt’s been well over a year since I’ve discussed orthotics. Orthotics, just like stretching, is an emotional and somewhat controversial topic because so many believe in their effectiveness for injury treatment and prevention. Others, such as myself, feel as though they either create, provoke, or hide a true problem. In my article, “Are Orthotics Ever Really Necessary?” I discuss how orthotics are never truly fixing any problem. They support, rather than correct, dysfunction. They also dampen your senses as your feet are no longer allowed to move as unrestricted as they should. Your sense of body position (proprioception), and sensory feedback from your feet to your nervous system (kinesthetic sense), are dampened.

Yes, often they diminish and even eliminate pain, which is why so many claim they are successful. Perhaps you’ve had success with orthotics, or not; or maybe you make hundreds or thousands of pairs of orthotics a year for your patients as some doctors who (unhappily) contact me have. Either way, I have decided to look through the eyes of these people, and try to see what they see. Okay, it’s really just one eye – the other is going to look away.

Case Number One: Orthotics Relieve or Eliminate Pain

orthotic-foot-pain

Like a slipper.

Pain is the number one reason someone is going to receive a pair of orthotics, most often from a podiatrist or chiropractor. Although most orthotic wearers suffer from foot pain (such as plantar fasciitis), others are using them for knee, hip, or even back pain. Do they help with pain? If they’re made correctly then yes – absolutely. There are many different types of orthotics as well as ways orthotics are made today so some of this success is going to be dependent on the skill and knowledge of the prescriber. Also, other therapies employed at the time the orthotics are prescribed often help with symptoms. Some prescribers, such as chiropractors, may adjust the bones of the ankle and foot before fitting the patient for an orthotic. This of course can also lead to greater success as the foot is in a more balanced and corrected state before support is rendered.

Though orthotics can be very effective in removing pain, (and I’m all for pain removal), this support-system method of treatment often is simply masking the symptoms and not addressing the problem. Say you have plantar fasciitis, for example. The fascia running along the bottom of your foot is too tight, torn, or even degenerated, and it’s causing pain. Your foot is not moving correctly and most often this is from a problem (weakness) in the tibialis posterior muscle. The main arch of the foot is not supported correctly, proper pronation and supination of the foot is not occurring, and the fascia is working too hard to stabilize the foot. The orthotic will often help stabilize the foot, but it will not correct the problem because it can not correct the weakness of the tibialis posterior. Just as if your wrist hurts because of a problem in the forearm, bracing your wrist is not going to correct your forearm. Masking the pain is not a correction, though this is often the answer in many types of medicine which looks for a quick and easy solution to a symptom. Orthotics for pain and dysfunction are like aspirin in your footwear.

Sure there are plenty of studies to say orthotics are “effective”. Unfortunately most of them are very short-term studies and they only look at one parameter for success – the removal of pain. They don’t ask or understand that although the [foot] pain may be reduced or eliminated, there is now pain in the knee, back, or perhaps shoulder from the new, different, and altered mechanics.

Let’s look at a few of the studies which support (haha) the use of orthotics.

1.      Saxena & Haddad found that of 102 patients with patellofemoral pain syndrome, 76.5% improved and 2% were pain-free. 2% is not a huge success, and the 76.5% is left for interpretation as to what is “improved”. There were also other treatments used in this study and the age range was huge – 12 to 87 years old.

2.      Shih et al found that a wedged insole was useful for preventing or reducing painful knee or foot symptoms in runners with a pronated foot. This study was only one 60-minute test and it’s unclear what a “pronated” foot is. After all, pronation is normal.

3.      Gross et al report great success with orthotics in several symptoms, and this study is often cited by orthotic proponents. However, the study was a questionnaire given to 500 runners (262 responded). That’s not really a study, and as mentioned, it is only asking about the symptoms they were given the orthotic for.

4.      Chang et al found that running injuries were related to training duration and use of orthotics. But just like above it was a questionnaire study of over 1000 runners (893 responded) and there is no indication between the training and orthotics.

5.      Gross et al, (not the same as previous), found a 75% reduction in disability rating and a 66% reduction in pain with plantar fasciitis. There were only fifteen subjects, they looked at their 100 meter walk times (not very far) and the orthotics were only worn for 12-17 days.

Case Number Two: Orthotics Improve Joint Mechanics

stability training

If this tree was an orthotic I’d be super stable.

So do orthotics simply support dysfunction as I have stated previously or do they actually correct dysfunction? Well, that answer depends partly on what you interpret healthy joint mechanics to be. One study notes less strain in the foot with orthotics and a possible prevention for a stress injury to the second metatarsal (Meardon et al, 2009). The caveat emptor here though is that the subjects couldn’t really say too much regarding what they were feeling since they were all dead. The eight cadaver specimens were mounted to a dynamic gait simulator to be analyzed.

Controlling “undesirable motion” is a term touted by orthotic advocates often. They say there is instability in a joint and it must be controlled, thus improving joint mechanics and reducing or eliminating pain. Sure instability isn’t a good thing in a joint, but how do you correct instability by stabilizing a joint with any device? You don’t. You stabilize a joint by correcting the faulty mechanics which are resulting in the unstable area. Actually, one of the best ways to train stability is with instability. This is why balance exercises are so good for stability.

You’re not going to improve stability very much standing on both legs on a flat surface, even if you are barefoot. I like to train stability while barefoot on a thin, uneven log – it’s so unstable; look out joint mechanics! So when a study says that orthotics may “enhance joint mechanoreceptors to detect perturbations” (Guskiewicz and Perrin, 1996), I say that they actually negatively alter these mechanoreceptors. Mechanoreceptors, by the way, are sensory receptors that respond to mechanical stimuli, such as pressure. You want as much healthy sensory stimuli getting to your brain as possible. This is what awakens and vitalizes your nervous system and is accomplished by interacting with your environment.

But there is a fine line between too much and not enough sensory stimulation as well as the source it comes from. So many people are in such sensory overload already from excessive lifestyle stresses that they can’t even walk barefoot because the added mechanoreceptor information and kinesthetic sense excite their nervous system too much, too fast.  So they dampen this system with either conventional footwear or orthotics, and they feel better for it. But dampening the mechanoreceptor activity because of too much other external sensory “noise” is not the way to correct the problem. It’s not much different than calming your nervous system with alcohol at the end of a long, hard day. (Now I can get attacked by linking orthotic use to alcoholism.)

Speaking of movement, orthotics can have such negative effects too. Flexible arch supports have been shown to increase knee varus torque (Franz et al, 2008), and influence medial tibial stress syndrome (Hubbard et al, 2009). So it’s not always good, even when you’re in bad shape.

orthotics: neck brace for foot

Most would never wear this without any other intervention.

So yes, for those in a state of overall health distress, there may be improved joint mechanics as well as improved nervous system function with an orthotic compared to without. Even though I never use orthotics as I have other methods for treating such problems, I understand how they can so easily be the “go-to” treatment. If that’s the case, however, then function and health still needs to be addressed. These patients need to have their health and movement problems addressed and properly rehabilitated. They need to learn how to move well again, and not be dependent on their orthotics for so long, as often they are told to wear them for their entire life. The success of the orthotics will eventually run its course. So have a plan to wean out of those braces, (see “Lose Your Shoes“), so you can move with strength, stability, and grace in any environment.

                                                                        

Saxena and Haddad. The effect of foot orthoses on patellofemoral pain syndrome. J Am Podiatr Med Assoc. 2003 Jul-Aug;93(4):264-71.

Shih YF, Wen YK, Chen WY. Application of wedged foot orthosis effectively reduces pain in runners with pronated foot: a randomized clinical study. Clin Rehabil. 2011 Oct;25(10):913-23

Gross ML, Davlin LB, Evanski PM. Effectiveness of orthotic shoe inserts in the long-distance runner. Am J Sports Med. 1991 Jul-Aug;19(4):409-12.
 
Chang WL, Shih YF, Chen WY. Running injuries and associated factors in participants of ING Taipei Marathon. Phys Ther Sport. 2012 Aug;13(3):170-4.

Gross MT, Byers JM, Krafft JL, Lackey EJ, Melton KM. The impact of custom semirigid foot orthotics on pain and disability for individuals with plantar fasciitis. J Ortho Sp Phys Ther, 32:149-157, 2002.

Meardon SA, Edwards B, Ward E, Derrick TR.. Effects of custom and semi-custom foot orthotics on second metatarsal bone strain during dynamic gait simulation. Foot Ankle Int. 2009 Oct;30(10):998-1004.

Guskiewicz and Perrin. Effect of orthotics on postural sway following inversion ankle sprain. J Orthop Sports Phys Ther. 1996 May;23(5):326-31.

Franz JR, Dicharry J, Riley PO, Jackson K, Wilder RP, Kerrigan DC. The influence of arch supports on knee torques relevant to knee osteoarthritis. Med Sci Sports Exerc. 2008 May;40(5):913-7.

Hubbard TJ, Carpenter EM, Cordova ML. Contributing factors to medial tibial stress syndrome: a prospective investigation. Med Sci Sports Exerc. 2009 Mar;41(3):490-6.

Comments

  1. Very well written article. Thanks!

  2. Hi Doc, I’m a post-menopausal, 51 y.o. woman. In the past year or so, I’ve noticed my balance has severely worsened. On your advice, I stopped using supportive footwear for my physical activities. Then I stopped taking the anti-depressant I was on because it was causing dizziness and I thought maybe was causing the balance problem, too. Maybe it will take being off the meds longer to see imporovement. I don’t have a log to walk on, so I wonder what is the next best way of improving my balance? I work out on a rebounder some, which should help.
    Also, is there some medical problem that could cause the poor balance?
    Thank you.

  3. I am curious to know if the use of aids such as Dr. Morton’s recommended toe pad for Morton’s toe are in the same category as orthotics. I have done foot strengthening exercises and while it does make my feet stronger, I don’t see it realigning my hereditary condition. Is it not necessary in cases such as this one to have the metatarsals aligned and balanced in order for the foot to function correctly? FYI, I have Morton’s toe on both feet. Thanks for the help!

    • If everything is working correctly in your foot (primarily the muscles) then it doesn’t matter what hereditary condition you have, for the most part. Sure there are always exceptions. Any device which is used to modify biomechanics in your shoe is considered an “orthotic”.

  4. Jeffrey Berkowitz says:

    Hello Sockdoc, You discussed that stretching is not good for you because it weakens the muscles. Does that mean that yoga is not good for you since yoga is basically going into a pose and holding it, which would be stretching your muscles? Also, after I play golf my left quad and hamstring muscles get tight so I stretch them. When I do not stretch my legs after I play my legs get stiff that day and the next. Do you feel that stretching my legs after golf is not necessary and that my legs will be fine and will recuperate in a few days without stretching?

  5. Hi soc doc i am a teenager with Gynecomastia. I eat paleo and get good sleep but is there any other things i can do to get rid of it? I know for teens it usually goes away but any tips would help. Thanks!

  6. What do you think about an orthotic that corrects leg length discrepancy? One of my legs is significantly shorter (it is a verified anatomic problem, I can’t remember if it was in the femur or tibia though) than the other and I was having a great deal of back pain and leg pain when running – when I got the orthotics with the lift a few years ago, I have never had this problem again.

  7. Stacey says:

    Thank you for your insight! I am a Pilates instructor and have been trying to convince my clients to get rid of their orthotics and overly rigid shoes. Recently, a male client was complaining of foot pain (numbness, nerve tingling and pain) and was convinced the problem was in his foot. The doc told him the ligaments in his foot were “stressed” and gave him an orthotic. The pain continued so I thought we were try some rolling and myofascial release techniques to see if we could get a better idea of what was going on. As soon as he applied pressure to the peroneus/soleus the foot lit up. He ditched the orthotics right then and has been working on releasing the fascia in his lower legs. Having another voice in my corner has been helpful – thanks!!

  8. Katherine says:

    Hello, I just stumbled across your website. I think a lot of what you say about orthotics makes sense. I totally agree they are overprescribed and that most people can do without them, if they work to strengthen their feet and correct their stance isntead. However, I feel uncertain about the way you categorically dismiss them. I have severe bunions (my big toe on each foot is so out of alignment it crosses over my second toe) and my feet have been this way since highschool – and it is at least partially hereditary. In the past few years I’ve started running outdoor fitness classes and we do lots of foot strengthening and balance exercises – my feet and arches are much stronger than they used to be – and if I am very conscious about it I can stand in my house barefoot (or sockfoot) and keep my arches up and my knees aligned for maybe.. 30 minutes. However it requires incredible effort and consciousness, because of the way my big toe joint is shaped and how flat my feet are- and eventually I get achy and tired. I’ve had orthotics since I was 18 years old (33 now) and I wear them inside and outside and they have literally changed my life – As a teenager I used to hate standing, hate walking, get knee pain biking and running…. and now all is well. I wonder if you might consider that in some cases, particularly if people’s bones have actually moved out of alignment as mine have, that orthotics may be a good solution…?

  9. Hi Steve! I’m a great follower of yours, I’m a physiotherapy student and I really hate what they teach me. This is my last degree’s year, but i want to keep studying. I write you to help me about what would you recommend me to study after this degree? I mean like another degree, a master… I’m interested in sport’s injury prevention and treatment. Thanks

    PD: Sorry for the Grammar! I’m from Spain.

    • Hi Pau, usually the ideal thing to do is study and learn on your own during/after you get your official degree. There are many great courses out there and people and books to learn from but I don’t know of any ideal “natural sports injury treatment & prevention” degree.

  10. Hello
    I’ve read your posts on orthotics as I sit in my bed unable to get up. I’ve started wearing orthotics three weeks ago and yesterday I wore the ‘sport shoe’ ones all day. Today I’m bed ridden and my spine hurts all over.
    I like your approach and wish I read about this earlier! I live in toronto, do you know anyone here who utilizes your methods? Please write me back urgently.
    Many thanks

  11. Suzanne pope says:

    Hi
    Great website thanks . Do you have any info on sore hips during and after running. I am currently having pressure point therapy and acupuncture. It has been two months since I got injured and the trips to the Chiro and physio haven’t helped.
    Thanks
    Suzanne

  12. frankie rodriguez says:

    Hi Doc,
    I’ve been eating primal/paleo for a few months now.No complaints at all. I live a very holistic lifestyle. I see my Chiropractor 2x a week,get acupuncture 2x a week as well.I stay away from all the processed junk foods.The few concerns that i do have are my heel spurs and knee pain.I want to get out of my z-coils but need some help.Is it possible to slowly transition into a shoe like a Vivobarefeet shoe with the addition of wearing Correct Toes?Along with trigger point therapy.Thanks

  13. Frankie Rodriguez says:

    Ok Doc, what do you think?I think I’m going to keep my Z-coils and slowy work into a Vivobarefoot shoe.Possibly something like the Neo Trail M.Going to go at this with full force and determination.I will continue to do the Trigger Point therapy with my Acupuncturist.And i will listen to my body.I, like the countless many have grown tired and frustrated with aching knees,heel spurs,and PF.Time to get going.Do the Vivibarefoot shoes run small?

    • The Vivobarefoot shoes don’t run like other sizes. I wear a 41 in the trail Breatho, and a 42 in the Evo and dress shoes. In my Inov8 shoes I wear a size 9.5 – which does not equate to a 41-42.

  14. Nike Free 5.0 good starter shoe for walking on concrete and asphault?

  15. Hello,
    After botched bilateral bunion and hammertoe surgeries that injured my 2nd metatarsal joints, I developed bilateral 2 nd space neuromas, which are very painful. I was wearing 927 new balance sneakers for support all the time and tried orthotics that were not helpful. Couple of weeks ago I was in such pain that I took off my sneakers and started to walk barefoot. I was surprised that I felt much less pain without “support”. I searched ” walking barefoot with neuroma” and found your site.
    I already had 4 surgeries and just cannot go through neuroma surgeries as the success rate for this is low.
    Can I cure my neuromas by walking barefoot and what shoes do I have to wear outside?

    Thank you.

  16. so what would you reccomend as an alternative to orthotics since they are so bad? i have very flat feet.thx.

  17. Hello,

    I just heard about this web site, and this was the first article I’ve read… you perfectly described my situation!!! At age 10, an Army doctor put me in orthodics because my feet were “flat” Over the years, I’d occasionally have foot pain or leg issues, and a podiatrist would adapt or add to the orthodics to miraculously reduce my pain… but then I’d have another issue 5-10 years later that would also be “cured”. At age 51, my podiatrist told me my feet were so weak and collapsed that I should not even risk going to the bathroom at night without the orthodics.

    I then shifted to running in “barefoot” minimalist running slippers, and within 6 months, I was out of my orthodics! I pulled a muscle in my big toe from running too much too soon, and my new podiatrist said that I had the strongest feet they’d ever seen! My knee pain from old injuries has gone away, my arch is back (still low, but at least I have a footprint that looks like a foot instead of a pancake!), my hip pain is less, and I finally ran a marathon without much pain or recovery. As a massage therapist who work with runners, I now warn everyone that support makes you weak.

  18. Over the past few years I have taken up trail/ultra running. I ran my first 50K last October and went just fine. A few weeks after the race I had pain in my left foot – thought it was a stress fracture. Rested for 2 months and felt fine. Started training again this year and pain came back. Finally went to a podiatrist today and in fact it is not a stress fracture, its irritation of a nerve and/or tendon on the top of my foot. I have very high arches and he’s recommended orthotics. As I see it, there isn’t much I can do naturally to do away with my high arches, which according to the doctor is the reason for the pain. In my case are orthotics the only answer?

    Any suggestions appreciated!

    Thanks!

  19. cate davis says:

    After running(shuffling) for about a year, only 10-12 miles a week, did a few 10ks along the way, had problem with metatarsal tendons. x-ray showed no fracture. stayed off for several months wearing a metatarsal pad on my foot. Was planning on looking into orthotics, however, after reading your articles I’m wondering about going minimalist. It seems counter-intuitive to the lay person, but your articles are persuasive. your thoughts? I’d like to get back to running eventually. Thanks!

  20. stefani says:

    Very informative article. Wondering if you could give advice on my situation. In a nutshell: I was a barefoot kid and gymnast for most of my life. Recently got into hiking but realized I can go no farther than six miles without having excrutiating pain in my arches. Regular shoes make my arches, shins, calves and knees hurt. I have been wearing Vibrams for a year and they have eliminated all the pain except for my arches. M y arches are very high, my feet are very wide. The problem seems to be coming from having pressure (velcro, shoe laces) In even the smallest amount pushing down on my feet. Is there anything you know of that I could try to fix this?

  21. Sharee Chapman says:

    Thanks for your informative article. I was advised to wear orthodics by a representative at Good Feet given I had pain in my left knee. Wearing the orthodics improved the pain; however, about two or three months into wearing them, I felt major pain/stain in my right calf. I’ve been a long distance walker for years and couldn’t walk one or two blocks without needing to stop. My D.O. says it’s the orthodics and not to wear them, or if I do, to wear a much softer one. After cranial sacral treatments, the condition has improved. I went back to Good Feet to see if they could redeem some of my investment (substantial)–they tell me I need to be refitted for orthodics. Just to explore all avenues, I temporarily (for two hours) wore the orthodics they suggested. The pain came back almost immediately. Does this sound familiar to you–should I stay off orthodics completely even though they did initially help the left knee pain. Thanks!

  22. Hi Doc, I agree with your thoughts on barefoot running, orthotics and stretching. I also have a 19 month old daughter who wears soft soled shoes as much as possible. However, I have noticed that her right foot rolls in substantially while her left foot is “normal”. Do you have any advice as to what is happening or what (if anything) needs to be done?

  23. Hello Sock Doc,

    Interesting articles on your site. For the past 5-years I have had foot pain in my right forefoot. I use to be a student athlete in high school and undergrad. I did cross country and I was a hurdler in track & field. My right forefoot began to ache while working in a warehouse and lifting heavy items on a concrete floor. I transferred positions from the warehouse to an inside office position. I thought that the pain would go away overtime since I was no longer lifting heavy items. Unfortunately the pain did not, and increased when I started grad school (heavy backpack and walking long distances.) I was diagnosed by one podiatrist as having a neuroma. That podiatrist wanted to cut the nerve to kill the pain. I saw a second podiatrist, who said that cutting the nerve was not a good idea, I assume because the underlying problem would still be there. The second podiatrist did a metatarsal osteotomy on my second and third metatarsals, which gave them an artificial arch instead of being flat.

    After the swelling subsided, I had both feet casted for orthotics. My arch areas feel fine but I could feel a lot more pressure on the balls of my feet. After several months of wearing them, I started to develop pain on the ball of my right foot. After an x-ray and MRI, my podiatrist stated that I had sesamoiditis. He gave me a steroid shot, and the ball of my foot has felt better, but feels like it could use another shot. He had my orthotics adjusted, but I have yet to wear them. I am afraid that the orthotics are the cause of the sesamoiditis, and I honestly do not want the full force of the pain to return.

    Also, my podiatrist blames my past as a student athlete for part of the pain in my right foot. I have also stopped working out because of the pain.

    I do have low arches, and I tend to underpronate, I wear out the heel and outside of my shoes.

    What are your thoughts? Should I just walk around in racing flats?