What you need to know
Prescription orthotic devices are shoe inserts that are fabricated to precisely control the biomechanics of the feet.
Many people have arches that flatten out excessively (called “pronation”) whereby the ankles roll in towards each other.
This is due to faulty foot structure that one has had all their life.
The bones of the foot actually collapse and it’s not due to weakness, but rather abnormal positioning of the forefoot and rearfoot. Our feet should push us off the ground and function as a “rigid lever” for propulsion.
Some people have the opposite problem of a rigid high arched foot that needs to be biomechanically rebalanced.
Indications for the use of orthotics
Many foot problems are a direct result of abnormal bone structure. Hence “overuse syndromes” can develop as a result of repetitive strain with the thousands of foot strikes that we experience with normal walking.
Some of these common problems that orthotics can address are:
heel pain (heel spur syndrome)
arch pain or fatigue (plantar fasciitis)
pain at the ball of the foot (callouses or capsulitis)
pinched nerves (neuromas )
large toe joint problems (bunions)
mid foot symptoms (periostitis)
ankle instability or fatigue
lower leg muscle strain (shin splints)
some knee problems (such as “runner’s knee” / patello femoral syndrome.)
sometimes back problems can be related to abnormal foot mechanics.
When the foot bones collapse, then the lower leg internally rotates, which can affect the knees or even the back.
How orthotics work:
First you need a proper foot examination
A podiatrist will do a foot examination and look at your bone structure and foot function. (A biomechanical evaluation). Symptoms and medical conditions are considered and areas of pressure are evaluated. Often there are callouses, or areas of hard skin which is a protective mechanism by the body to protect the bones from excessive forces. Callouses can become painful with walking, however a podiatrist can painlessly remove them in order to provide you with immediate relief.
Part of the examination includes evaluating muscle and tendon function, joint ranges of motion, strength and flexibility etc. At the same time a dermatological evaluation and vascular examination is usually performed.
As part of the overall examination, your medical history is considered along with signs and symptoms.
The key to success with treatment with orthotics is in the “casting” technique.
There are many providers of orthotics that “hope for the best” since their techniques are often based on guess-work. People sell “orthotics” at trade shows, or those with minimal training on the foot will often sell orthotics that may be a little helpful by supporting the foot somewhat, but are often not all that precise.
Many individuals will have you step on a pressure pad or take a foam impression of your feet, but this doesn’t capture the foot in a corrected position. Hence the orthotics often don’t do enough to control abnormal biomechanics.
For example: You may have a high arch to your feet when you’re sitting (non weight bearing), but when you stand up the arches collapse. If you were to step on a pressure pad, then that would capture your feet in a deviated position (with collapsed arches). Hence proper correction can’t be achieved.
The resultant orthotics may feel comfortable at first (or not), but often symptoms persist as the foot still functions abnormally.
Better: a podiatrist usually will take a plaster cast of the feet non weight bearing in a corrected “neutral subtalar joint position”. (This is the joint under the ankle joint that allows the foot to roll in).
By capturing this exact position and shape of the foot, the resultant orthotics can then maintain this stable foot position when you are walking or standing.
Newer technology: we’re now using a non weight bearing 3D laser scanner which creates a virtual cast of the foot in it’s corrected position. This is replacing the previously preferred gold standard of a plaster casting technique, is less messy and some say more accurate.
Types of orthotics.
This is determined by the practitioner based on the needs or requirements of the individual and the types of activities they are doing. In my practice we’ll often use a “universal” type of orthotic that will work in most shoes. It would have to be fairly thin, very supportive, yet having some degree of flexibility and cushioning. An orthotic does not have to be the full length of the shoe. Many providers of orthotics use a full length device which can be bulky and cumbersome and will often only fit running shoes.
A “3/4 length” orthotic is often all you need. Once you go up on the ball of the foot, the orthotic has already done its work in repositioning your foot, so the forefoot extensions are usually not needed.
What about sports?
The all purpose orthotics that we prescribe will go right on top of the existing insoles of your running shoes, so that you don’t have to take out the shoe insoles. Most running shoes insoles readily bottom out in the arch area so your feet won’t be overcorrected if the orthotic goes on top of the insole. (Test: you can take the insole out of your running shoe and press down on the arch area and you’ll see how it flattens right down). The orthotics that we prescribe will have some flexibility to them so the impact forces of sports will be accomodated.
Special sports considerations:
Some long distance runners require maximum cushioning and support in which case an orthotic can be designed with maximum shock absorption and is designed to be full length and bulkier in which case in will only work in a sports shoe where by the insole would be removed and replaced with the custom orthotic.
Women’s dress shoes and orthotics.
Of course women love to wear dress shoes, but still need some biomechanical correction in which case most orthotics won’t work in their footwear.
The laboratory that we use has come up with a patented design for ladies’ dress shoe orthotics. They are made to be quite thin, yet supportive, flexible and well cushioned and will fit in flats, slip on, chunky heels and some other high heeled shoes. (Usually up to about 2" heels.) If women are going to wear 4” or 5" heels, then no orthotic will help as the biomechanics of walking are so skewed. Helpful: alternate shoes and wear more comfortable, lower heels most of the time and use the really high shoes on limited occasions.
Best of both worlds:
Some women have orthotics specifically for dress shoes, and a separate pair for sports shoes.
What about sandals?
In the summer, Ontarians love to wear sandals. The problem is the feet collapse readily in most sandals and overuse syndromes can result.
Many of the orthotics that we design can go easily into most sandals with the use of simple velcro stickers that we can dispense
Children and orthotics – are they even required?
Often in my practice, I’ll see children 5 or 6 years old with very pronated feet. You can see their ankles rolling in towards each other. Many pediatricians will refer children with pronated feet to my practice. However there are still some doctors who say not to worry as they’ll “outgrow it”. (They don’t as adults with pronated feet had the same foot structure as a child).
If left untreated, then children with pronated feet will often go on to develop the problems that plague adults. These develop as “overuse syndromes” as time goes on..
How orthotics affect children:
By repositioning the foot structure, the orthotics allow the feet to function ideally in their stable “neutral postion”. As children grow, then “functional adaptation” takes place. Meaning: the tendons and muscles of the foot function within their normal ranges of motion, and as the feet grow, these structures maintain their corrected position. Example: there is a tendon that attaches to the medial side of the foot ( about half way between the heel and big toe) and it acts to pull up the arch. When the foot flattens this tendon becomes lax and inefficient. With the continued use of orthotics, the tendon strengthens and functions as it was meant to.
Children grow fast!
The laboratory we use for orthotics has an “outgrowth policy” whereby if a child has a big growth spurt and outgrows their orthotics within a year (up to the age of 13), then they are replaced at no charge. We will do new biomechanical measurements and casting as a courtesy as well.
Often however children can actually grow one or two shoe sizes and the orthotics still work well. In most cases, orthotics are good for about one or two shoe size changes which often translates to about 2-2 ½ years with children.
What about orthotic failures?
Many patients have had the experience with orthotics that have failed or have been uncomfortable. Often they present to my office and when I examine their feet and the orthotics, it becomes apparent that the devices often did not match their neutral or corrected foot position. Usually this is because the casting methodology was something other than a plaster cast or laser scan.
Sometimes the orthotics are just too bulky and in some cases they may be too rigid or create excessive pressure on some areas.
Our philosophy with orthotics
Orthotics should be comfortable and accurate. Usually patients can wear them all day right away and they should feel good.
They are some instances whereby we need to make small adjustments or modifications to orthotics in order to improve their comfort.
Nothing is guaranteed in medicine. We do know what works and what doesn’t when it comes to orthotic prescriptions.
We tell our patients that if they are not happy with their orthotics then we are happy to make any modifications to them as required and occasionally we’ll need to have the lab make completely different orthotics for a patient and change the materials or degrees of correction etc.. There are no fees for these adjustments or replacements.
If all else fails and patients are not happy with their orthotics, then we’ll be happy to refund the fee for the orthotics 100%.
Many providers of orthotics do not offer a refund as they feel they have done their work and “it is one of those things”.
However, I feel confident in knowing that we can help and that orthotics can be comfortable and corrective so we’re happy to offer this refund guaranty.
Over the counter orthotics
Many stores sell “orthotics”. They are relatively cheap and come as a set size.
Why then are podiatrists so successful in prescribing orthotics that cost almost six hundred dollars? Answer: a precisely prescribed orthotic that is designed to match exactly to a patient’s foot will offer more comfort and better biomechanical control. Often this is exactly what a patient needs.
However, sometimes a store bought device is better than nothing and affords some degree of support.
Of course cost may be a consideration. Many people have extended health insurance that covers a good part of the costs of orthotics. Others are willing to spend a lot of money for orthotics that will work well and last for years as their health is important enough to them thatcosts are secondary.