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  • Sam Fischer

THE SKINNY ON CUSTOM ORTHOTICS.....

So your feet hurt. Maybe your knees hurt. Maybe your hips or lower back hurts and someone mentioned getting custom orthotics to "fix" your "alignment." You should be skeptical of this, especially if someone is trying to charge you $700 plus for a pair. What I'd like to discuss in this post:


- Pronation vs supination?

- What are custom orthotics and how do they "fix" your "alignment?"

- 3/4 length vs full length......what gives?

- How are they made (traditionally)? And what is wrong with this model?

- What are their success rates?

- So Sam....what do I do about my feet that hurt?


Now, you may also be thinking to yourself. "Well what do you know about orthotics, aren't you just a physical therapist?" Excellent question. Let me give you a brief synopsis of my background. Prior to PT school I was a pedorthist. I had advanced training in orthotic fabrication techniques, shoe modification and shoe construction. I was the guy the podiatrist would send your casts off to, in order to have your expensive orthotics made. But not just me, they go through the hands of a multitude of people before you get the finished product. I also had the privilege of learning under some of the leading human biomechanics professors in the nation and have fabricated orthotics for professional athletes, weekend warriors as well as for people that have experienced amputations from diabetes or trauma. This was all prior to PT school. Couple rehab experience as a PT and it gives me an interesting vantage point about orthotics and the research behind them. Now.... let us get into the nitty-gritty. (I'd like to mention that everything from here on out is based on research, it is not my opinion. There are items here that are not 100% for everyone, there are always exceptions to these rules based on the individual person orthotics are made for.)


PRONATION VS SUPINATION?


Pronation is simply a term describing a tri-planar motion in the foot. Supination is the opposite of that motion. Despite what people say....Pronation is NOT BAD!!!!!! It is essential for proper loading of your legs and hips so you can walk, run, jump, etc. Without it, you'd be in rough shape. More important is how far you pronate, when you pronate, and if you can supinate out of your pronation. It is funny.....your forearms also pronate and supinate, but no one uses scare tactics up there when it comes to pain.


WHAT ARE CUSTOM ORTHOTICS AND HOW TO THEY "ALIGN" THINGS?


Well plainly put, custom orthotics are products that are molded from your feet in one way or another and are 100% custom to your individualized needs. More often than not they are made from durable polypropylene or polyethylene hard plastic material that will last approximately five lifetimes if it was tossed into a landfill. I've seen some offices mold pre-fabricated orthotics to individual's feet and try to pass those off as custom. Those are NOT custom. These are customized over the counter inserts. I am by no means saying these are bad or wrong, just not true custom orthotics. It would be the same as if you took a "insert brand" insert and added a heel lift or a met pad. Customized, not custom. Orthotics do NOT align things. Maybe in a world where you strickly stand stationary, they can help align things but the second you start walking alignment gets thrown out the window. Now we need to focus on function and movement. If your clinician isn't focused on movement the inserts probably aren't going work as well as you'd like them to.


3/4 LENGTH vs FULL LENGTH......WHAT GIVES?


Well, ideally we would only see full length inserts. Your foot in motion spends about 1/3 of the time during heel strike phase, 1/3 during mid stance or foot flat, and 1/3 during push off. So what if you have heel pain, but it's being caused by a big toe issue (another whole topic entirely) and you have been given a 3/4 length orthotic. During pushoff the orthotic is floating in the air in your shoe while your big toe or forefoot is on the ground causing problems and not being helped in the least the insert. This will not help your problem at all. You just spend $700 for 2/3 of a product that isn't going to address your particular problem. Some 3/4 length orthotics are sneaky and covered with a cushy full length foam. These are still only helping the back of your foot, they just are nicer in the shoe because they won't slide around.


HOW ARE THEY MADE (TRADITIONALLY)? AND WHAT IS WRONG WITH THIS MODEL?


Othotics are traditionally made from a plaster cast or foot impression in a foam box. Your foot is placed in "neutral" during the casting process. These are almost exclusively done non-weight bearing or in a seated position. These negative casts are then sent out to a lab where a positive mold of your foot is made from more plaster. Once the positive mold is made it goes through a chain of people to manually smooth out the mold, melt on a piece of plastic, smooth that out and cut to size. Then they add canted posting material in the back and a top cover if needed. These are then boxed up and mailed back to you. The whole process might go through 4-10 different hands prior to yours. Plus there is the chance of the cast getting smooshed in transit to the facility. There are a lot of places for errors. So what is wrong with this method? Well, nothing really.....so long as you plan on using your orthotics only while you are non-weight bearing floating around in space or sitting down. At a very basic level, these methods don't account for fat pad flattening on your heel, the fact that your foot is larger standing than laying down due to gravity and joint mobility. They don't account for ground reaction force or the fact the rear foot "neutral" laying down is completely different than rear foot neutral when you stand up. They don't account for leg position. Basically they are really good at capturing the contour of your arch, but have minimal consideration for how your foot needs to function with everything up-chain. This may sound like I'm bashing these type of inserts......that is because I am. Don't get me wrong, some people find great relief from these types of orthotics. You may even be one of them, and that is great, however, you are in the minority. There are BETTER methods to making orthotics? If you are interested in learning about them give me a ring. Don't worry, I don't make them currently so I won't try to sell you anything.


WHAT ARE THE SUCCESS RATES?


Not great! In fact, there are a multitude of well-performed randomized controlled research studies that show that custom orthotics do NOT outperform over the counter inserts for heel and arch pain. Meta-analysis studies have shown that you will likely do better with a customized over the counter insert rather than going full custom. There are certainly instances where custom orthotics are needed, but for many people, an adjusted over the counter version will do just fine.


SO SAM, WHAT DO I DO ABOUT MY FEET THAT HURT?


Great question. It very much depends on your specific scenario. Often an inexpensive change can make a world of a difference. Getting the right shoe to match your foot function/shape can often bring you immense pain relief. If you have questions about orthotics, foot pain or shoe selection please call the clinic or shoot me a message and I'd be happy to discuss things with you.





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