Readers often tell me that they think they “might need orthotics,” but they rarely know more than that. The idea is based on an uncertain hunch that something wrong with the way they walk and run can be fixed with just the right kind of support under their feet — which is all the fanciest orthoses amount to. Custom foot orthoses, custom orthopedic footwear, or orthopedic shoe modifications can be invaluable in the right circumstances … but those circumstances tends to be quite specific, technical and often medical.1 Meanwhile, there are many unscrupulous and shoddy suppliers of these products, and the science is complex and incomplete. It is hard for consumers to determine whether they actually need any of these products, or where to get an expert prescription and a quality product.
Fortunately, there are some more reliable sources for these products and services: Certified Pedorthists (C.Ped) and Certified Orthotists (CO) are the professionals that I particularly recommend. Unfortunately, most consumers are unfamiliar with these professionals, why they are the best choices, or where to find them… and many therapists won’t refer, because they want to sell you orthotics themselves.
We train for many years and we take our jobs very seriously. It’s great to see support for pedorthists, and recognition of the difference between podiatrists and pedorthists. I have a problem with a professional who is allowed to diagnose, prescribe, and dispense within a 15-minute appointment. Prescribers are not providers for a reason!
— T.Moffitt, C.Ped. (C) Certified Pedorthist, Edmonton, Canada
The entire question of orthotics can be answered reasonably well by keeping your expectations pretty low — there’s just only so much that foot support can do for most people — and by consulting pedorthists and orthotists instead of nearly anyone else. That’s the short story. But on this website we delve into these things …
Foot, ankle, knee and hip biomechanics are extremely complex. Gait analysis is an art as well as a science. In my opinion, non-specialists cannot navigate this maze successfully with every patient, and orthotics should never be prescribed without a thorough examination — at least a half hour, and more if the case is complex.
Yet across North America — and I’ve seen it myself here in Vancouver — you can find lab-coated charlatans hawking corrective shoe inserts in shopping malls, using flashy displays and entertaining technology to “assess” or “scan” your feet with lasers or infravision … anything at all that will distract you from their lack of skill and knowledge.
Unfortunately, many orthotics sold to consumers may not be worth more the clay the mold was made from — even when a professional appears to be expert about feet, the effectiveness of orthotics prescribed or manufactured by anyone but pedorthists and orthotists is questionable. Only pedorthists are trained in both gait analysis, lower body anatomy and biomechanics and the actual fabrication of custom foot orthoses.2 All other professionals are obliged to order orthotics from an external supplier.
For instance, most physical therapists or chiropractors selling orthotics will usually asks a client to step in some special foam in a box, fill out a form specifying features of the insert, and then ship the foam off to a manufacturer who sends back some shoe inserts. Like lasers at the mall, this procedure may create the illusion of a “customized” product, but in reality not much is being done except making a piece of plastic that fits your foot: and none of the common methods even create an accurate fit!3 Let alone one that is corrective or therapeutic in any way. Such “prescriptions” are extremely common practice, but wiser and more ethical practitioners wisely shun them. This massage therapist described to me how she refused the sales pitch:
A few years ago I had a phone call from a company that was trying to sell me a franchise to sell and fit orthotics. Apparently I could make very good money doing this. I’m a massage therapist and I think I have a better-than-average knowledge of feet and gait, but I do not consider myself qualified to fit and sell orthotics. No fear, the company representative said they would send someone to train me — for half a day! The sales person seemed to be astonished that I turned down this wonderful opportunity. I prefer to refer my clients to a person who is qualified to do this work.
Good for her. But many professionals jump at this dodgy chance to make more money.
It’s a common misconception that orthotics provided by a podiatrist — a foot doctor — are necessarily of good quality. Unfortunately, the credentials of a podiatrist do not guarantee quality orthotics. They may well be, but many probably are not, as suggested by this rather chilling story from Dr. Michael “America’s Podiatrist” Nirenberg:
A middle-aged woman arrived at my office last week complaining of heel pain and carrying a bag of custom-made foot orthotics (orthotics are custom made arch supports that are fabricated from a mold of the patient’s feet). Each orthotic this woman had with her was expertly fabricated by a different podiatrist and yet none of them had come close to alleviating her heel pain. At first I thought maybe these podiatrists didn’t know what they were doing. But, when I learned their names, I knew this woman had seen competent, skilled and reputable physicians.
I asked myself “how could this be?” More interestingly, no two sets of orthotics were even remotely alike. Further, given that nearly all podiatrists learn similar principles of biomechanics, shouldn’t orthotics for a given patient be the same regardless which podiatrist makes them?
Dr. Michael Nirenberg, in his review of a book by Dr. Benno Nigg, Biomechanics of Sport Shoes: The Disturbing Truth About Running Shoes, Inserts and Foot Orthotics
A podiatrist is a full physician, but specializing in foot problems. In Canada and the US, his or her expertise is primarily concerned with foot pathology and corrective surgery, and does not always extend to include expert gait analysis and physical assessment of biomechanical dysfunction of the lower limb as a whole. Obviously some podiatrists cultivate an interest in this, and there are some prominent experts in the field who have really gone this direction, but they are not obliged to do so.
You could say that it’s not in their job description.
As a point of interest, most podiatrists outside of North America, are probably a different matter — and I have a large international readership, so this is a worthwhile clarification! Dr. Mark Heard, in Australia, agrees with my assessment that most North American “Pods” are surgery focussed, but explains that other Pods around the world are more focussed on biomechanics:
Undergraduate training around the world doesn’t go so far as the US in surgical training. It’s an option in other countries, but greater training is required. So most Pods here tend to be more biomechanically focussed, and more interested in a holistic approach to musculoskeletal health. We have the option of surgery, but it requires considerable post graduate training. My own training allows me to undertake superficial surgery (i.e. for ingrown toenails, removal of warts etc), but that only makes up a small amount of my practice.
Dr. Mark Heard, Podiatrist D.App.Sci, M.A.Pod.A., from personal correspondence
In any case, even a podiatrist skilled in the prescription of custom foot orthoses is still obliged to have them manufactured by someone else. For this reason, many podiatrists prefer to refer their patients to certified pedorthists.
The supply dramatically exceeds the real demand. However, there are four common conditions that pedorthists treat, and for which orthotics have the most potential to help:
Other potentially treatable conditions include patellofemoral knee pain, shin splints, achilles tendonitis, and bunions, as well as numerous systemic pathologies that (like diabetes) affect the function of the lower limbs.
The repetitive strain injuries are common and difficult, and they are probably the main thing that gets most people wondering if they need some orthotics. This is generally based on the flawed notion that RSIs are caused by flawed biomechanics.
While biomechanics may be a factor, the main problem with most repetitive strain injuries is, strangely enough, repetitive strain — that is, your parts would be in trouble even if you were biomechanically flawless. There may also be much more exotic factors, like the genetics of healing mechanisms, that may trump everything else — that is, some people will get Achilles tendinitis if they so much as go for a walk, whereas others can run marathons for decades without trouble. These sorts of things are all explored in great detail in my free repetitive strain injury tutorial. All I want to get across here is that it is clearly not just a case of “fix those biomechanics!” It’s much harder to know if RSIs can really be treated with orthotics than you probably thought.
But it gets worse. A great deal has to fall into place before orthotics can actually work. Even if you do have a biomechanical glitch at the heart of your RSI:
That all adds up to a long shot. And yet orthotics may still be worth trying — particularly if you do have a fairly obvious biomechanical problem. Good orthotics are a reasonably good way of trying to “tinker” with any gait or postural dysfunction that may have contributed to your pain in the first place. For instance, unusually high arches are a plausible factor runner’s knee.4
Orthotics certainly seemed to be a good option for me. I have an obvious biomechanical problem in my right foot,5 It’s just the sort of biomechanical bogeyman you might be tempted to blame for my own nasty history IT band syndrome. Surely that gimpy turned-out leg made me more vulnerable to IT band syndrome?
No, not as far as I’ve ever been able to tell: my own IT band syndrome was always quite symmetrical, never much better or worse on either side, with or without orthotics.
But it was worth trying. The orthotics did help my chronic low-grade plantar fasciitis in that foot, and the experiment was fairly cheap (compared to, say, a year of chiropractic adjustments) and safe. So why not? If you have foot or leg or knee pain, by all means seek the opinion of a certified pedorthist. Even if orthotics are not likely to help, he or she may recommend a shoe type that may be more appropriate for you — a factor that is often overlooked.
Sadly no, probably not, and for all the same reasons that they aren’t exactly a magic treatment bullet. You should definitely be skeptical of any sales pitch for orthotics or custom shoes if you have no particular problem to solve. Many orthoses are sold with the promise that they will prevent injury. Even if prevention is not the main reason for the prescription, it is often thrown in as a bonus reason to buy. But it has been tested, and it does not work well at all.
In 2010, researchers assigned running shoes based on the plantar shape of the foot for Marines going through basic training.6 One group of several hundred — a large experiment — was provided with motion control, stability, or cushioned shoes for plantar shapes “indicative of low, medium or high arches.” A comparison group got a “stability shoe” that was not customized for plantar shape. Injuries during the 12 weeks of training were analyzed. The disappointing conclusion?
…assigning shoes based on the shape of the plantar foot surface had little influence on injuries.
What “Big Ortho” doesn’t want you to know! Naturally there is some possibility that more precise prescription could produce a different result. However, the kinds of orthotics tested here are certainly strongly representative of how and why most orthotics are prescribed.
An example of a possible exception is OESH shoes…
The idea of most high-tech shoes is to make life better for the average foot. They aren’t customized, so they have to work based on general principles that apply to most feet, most of the time. While orthotics and custom shoes are generally intended to “correct” something, mass-produced running and walking shoes have the more modest goal of simple shock absorption. The benefit of this mostly boils down to injury prevention — if they can’t reduce painful problems, what’s the point? The hope has produced mostly gimmicky, expensive shoes that have had little or no significant benefit for consumers.7 I’ll provide one good example and one poor one.
The most promising example I know of is OESH Shoes, the creation of Dr. Casey Kerrigan, who left a promising career in biomechanics research to found a shoe company. It turns out that the goal isn’t so much to “absorb shock” as to change your gait by simulating a springier surface:
We all bought into the idea that foam, gel, air filled bladders, and the latest “shock absorbers” cushioned our joints and reduced pressures on them. But now you know why that doesn’t work. Impact is not when injury occurs, so cushioning it doesn’t do us any good. In fact, cushioning impact seems to do more harm than good — one of the reasons why I found that cushioning ends up increasing the peak pressures on joints.
So rather than “absorbing shock” at heel strike, Dr. Kerrigan designed a shoe that literally puts a spring in your step — little carbon-fiber springboards — and more spring in the shoe means less spring and bending in the joints.8 The benefits are far from proven, but it is a sound and science-inspired principle (and interesting). There’s a respectable chance that Dr. Kerrigan’s shoes actually do reduce injury-causing forces more than other shoes, since that was the whole point of a design inspired by years of research. That’s more than we can say of any other shoe that I know of.
For an example of a much less promising shoe idea, I submit exhibit B: minimalist running shoes, the ones that look like feet, like Vibram FiveFingers. This is a fad, based on speculation about our “natural” ability to run shoeless. It is unlikely to prove to be a big injury preventer. For detailed (and quite snarky) analysis of that hot topic, see my article, Does barefoot running prevent injuries? A dive into the science so far of barefoot or minimalist “natural” running.
Orthotics are not risk-free. The risk is not large, and so not much needs to be said about it. However, good or bad, they can be difficult for a body to adjust to, disrupting fine-tuned postural adaptations and forcing awkward new ones.
I had a pair of hiking boots that I really wanted to love: beautiful, expensive boots that seemed to fit perfectly, and so sturdy. It was liking wearing cozy tanks! But they also consistently made my right foot ache about 20 minutes into every hike in a way that no other boot or shoe ever had before, or ever has since. Those hiking boots consistently made my right foot ache about 20 minutes into every hike in a way that no other boot or shoe ever had before, or ever has since. I kept those boots for years, trying them hopefully each hiking season. The pain was as as reliable as sunrise. Who can say what it was about those boots? What subtle interaction with my body? Nearly impossible to diagnose, I imagine. It was trivial but inevitable.
I’ve seen numerous examples over the years where orthotics seemed to have this kind of effect — just a temporary wrench in the works. In the worst cases, people simply ditched the orthotics and the problem was solved.
I think every pair of orthotics is a minor gamble with some potential to help … or do what those boots did.
To wrap up, let’s get back to the subject of pedorthists: the professionals you should seek out if you’re still wondering if you “might need orthotics.”
Certified pedorthists must have a relevant degree, spend at least three years in apprenticeship, and then pass demanding exams. That entire period of work experience is devoted to the lower limb, and to the ankle and foot in particular. There are even more advanced professional designations for pedorthists as well.
“The Pedorthic profession in Canada is moving in a great positive direction with integrity, attracting only University educated individuals to become certified pedorthists,” says Paul Rauhala of OKAPED in Canada’s Okanagan Valley. That training translates into an impressive experience for the patient: I have been a patient at OKAPED in the past, and was blown away by the thoroughness and technical expertise of their assessment, which included slow motion video. My own limited training in orthopedic assessment gave me just enough knowledge to realize how much more Mr. Rauhala knows about it than I ever will — in the leg, anyway!
C.Peds and COs are not the only sources for good orthotics, but I think they are the most likely to work out. If any other health care professional wants to sell you orthotics, please ask them to refer you to a certified pedorthist instead.
Or find one yourself! In Canada, go to the website for the Pedorthic Association of Canada. In the United States, the Board for Certification in Pedorthics. You can easily Google similar associations in other countries — wherever pedorthists are practicing, they will have an association, a website, and practitioner information.
Saturday, 1 June, 2013 — Added a good quote about inconsistency in the prescription of orthotics.
Wednesday, July 4, 2012 — Added valuable new reference to Telfer et al.
Tuesday, 13 March, 2012 — General editing and significant expansion.
Foot orthotics are made from basic measurements and captured images of the foot (plaster casting, foam box impressions, or three-dimensional computer images). None of these techniques is very accurate (<80%), especially with the peak arch height. Skilled 3D computer imaging may be the most accurate. Basic measurement is particularly inaccurate.BACK TO TEXT
Terrific short myth-busting interview with a running, shoe and biomechanics expert — who is (delightfully) a bit cranky about “so many wrong ideas out there.” It’s all too rare to see this kind of sanity-inducing, hype-reducing talk on this topic.From the article, quoting biomechanics expert Benno Nigg:
Nigg has noted that running injuries have not changed over the years despite the massive development of the running-shoe industry. Unlike others, he hasn't jumped to the conclusion that shoes are bad, or that barefoot or minimalist-running or forefoot-striking is the answer. Instead, looking at the same data, Nigg concludes: Okay, apparently shoes aren't a big part of the equation.BACK TO TEXT