Many runners have been prescribed orthotics at some point in their running career. This may be as simple as a suggestion for an off-the-shelf “supportive” insert, or as intricate as a custom device made specifically for the foot of an individual. As a runner, you are probably familiar with orthotics. If not, they are basically supportive insoles designed to change the mechanics of the foot, ankle, knee, and hip when running or walking. The prescription of orthotics usually comes from a physician, podiatrist, or physical therapist, some of whom make their own for patients.
While commonplace in the treatment of running-related injuries 10-15 years ago, orthotics have become a bit of a relic today, and for good reason. As our understanding of running mechanics and injury has progressed, we’ve learned that, in most cases, orthotics did not do patients any favors. Let’s take a closer look and the evolution of “best practice” as the evidence has been gathered.
Before going to medical school, I worked in a running shop. My undergraduate research focused on rear foot motion in runners, so I had a particular interest in this topic. We spent time fitting runners to shoes based on their arch height and sometimes even watching them run briefly on a treadmill. The cutting-edge knowledge of the day told us that runners with a lower arch and over-pronation of their heel would require a very supportive, “motion control” shoe. Those with higher arches and less pronation (or even supination) should be placed in a cushioned shoe. Matching the foot and the foot mechanics to the right shoe would control the movement of the foot, which would correct the mechanics of the ankle, knee, and hip. If we could get them in the right shoe, and perhaps the right insole or orthotic, we could help them alleviate their pain. Of course, this is a bit oversimplified, but I’m sure some of this will sound familiar to many readers.
Most problematic was the runner with a low arch and excessive pronation in their gait. We thought that a supportive, even custom, orthotic would hold the foot in the proper position through the stride and allow the rest of the leg to function optimally. It makes sense at first, but it’s just not that simple. As this theory was tested in study after study, it didn’t hold up. At best we got mixed results, and mixed results are about as reliable as a coin flip. So sports medicine had to go back to the drawing board.
The question we should have been asking was, “Why does this runner’s foot have this shape, and why does it move the way it does?”. As with most things in medicine, a forced fix was not the answer.
The barefoot running movement ushered in a new way of thinking about gait and biomechanics. Admittedly, there were many problems with barefoot running and its implementation on a broad scale, but that was the pendulum swinging. We’re starting to see it settle back in the middle, having learned lessons from both extremes. Barefoot running taught us the importance of learning to run correctly. Proper form can be neither forced nor assumed, but it can be taught.
So, where do we stand now? What have we learned about orthotics for runners? Here’s a useful analogy I often share with patients. If you were to come to my office with a broken ankle, we would put you in a cast. But that’s not the fix! We don’t just cast your ankle, throw up our hands, and “voila!” you’re better! The cast serves the short-term purpose of helping you through an injury, and then it is removed. Orthotics should be considered in the same light. If your degree of pain and injury is such that you are unable to move well and cannot even complete rehabilitative exercises, an orthotic can be a great short-term aid to help you through the healing process. However, I still see patients who have been prescribed orthotics and are wearing them years later! In 99% of cases, that is unwarranted and a sign of very poor treatment, in my opinion. Often, the reason I see them in my office, is that they are now having different pains when running. The orthotic may have altered their foot and ankle mechanics, but no one fixed the underlying problem. The imbalance and weakness persists, poor movement is still their norm, but the stress has shifted to a different body part.
Instead of asking how we can restrict movement at the foot and ankle, I think we should be looking at runners to see how we can fix the movement dysfunction and help them attain a strong, resilient gait pattern. Placing a runner in an orthotic is not a treatment success. Instead, the goal should be to transition patients out of their orthotics to pain-free running with improved mechanics. Sports Medicine literature demonstrates that orthotics are, in rare cases, an appropriate short-term aid. In extremely rare cases of actual anatomic deformity, they can be a long-term necessity. Both of these scenarios should be the uncommon exception to the rule, but there are still practices that put most of their runners into orthotics. The vast majority of their use is unwarranted, likely counterproductive in the long-term, and often quite expensive.
That last point is an important one and a reason that I think some practitioners stick to an outdated treatment. Orthotics are a money maker! I don’t believe that these folks consciously prescribe a treatment they know to be ineffective. Rather, I think there is an unconscious bias toward a profitable treatment which they’ve used for years. In medicine, the evolution of care often requires us to admit that we may not have provided the best treatment to our patients in the past. That’s hard to do, but it’s essential that we remain open to new evidence and knowledge.
Rather than holding strong to an outdated or ineffective treatment, runners should take stake in their care and seek out a professional who can help them address the underlying problem. Your practitioner should watch you move, identify the dysfunction, and have a plan for you to address it in a manner which encourages you to improves your gait. Occasionally, orthotics play a short-term role, but the goal should be to work with that practitioner to get you out of them as quickly as possible. Your body is designed to move well. When that’s not happening, the addition of a rigid support is not the answer. Take the time to address the true problem, and you’ll be able to enjoy many years of pain-free running.