By: Kelly Akers, PT

Orthotic intervention has been greatly studied over the last 25 years.  In very simple terms an orthotic is an insert placed in a shoe to help address standing foot structure.  It is generally accepted that custom foot orthotics are an effective treatment for some knee pain, plantar fasciitis and a variety of other overuse injuries.  However, in recent years, a more minimalist approach to footwear has become popular.  The minimalist approach basically puts less emphasis on orthotics and uses shoes with very limited support, such as the popular Vibram five finger shoe.  Because of the shift in the academic research arena and the retail industry to the minimalist approach this raises the question, “when is it appropriate to recommend orthotics to a patient?”

In the pediatric population it is important to consider whether or not the child is reaching their developmental milestones within the appropriate timeframe.  In many instances developmental delay has nothing to do with foot alignment but in a small subset of children this can be a contributing factor. In this group of children a comprehensive evaluation of foot structure and lower extremity alignment is imperative.  Great benefits can be achieved with addressing standing foot structure using orthotics because correcting the abnormality at the foot and ankle then restores normal gait mechanics and allows for increases in activity tolerance.

In the athletic population two different scenarios will lead us to look into the possibility of orthotics.  The first example would be the athlete who is not having foot or lower leg pain but its determined that he/she has a deviation from normal foot alignment that is decreasing speed and efficiency with running.  Recent research has shown that an appropriate custom orthotic can improve endurance running performance up to 12%. Often there is not a pair of shoes that will accommodate these deviations and orthotics can be very helpful. 

The second example would be the athlete who is frequently and without explanation suffering from recurrent overuse injuries.  In many of these cases abnormal foot alignment can be to blame due to the increased stress placed on structures that are not designed or accustomed to the increased workload.  Orthotic management can create improved foot alignment, improved running efficiency, and decreased pain by simply decreasing the burden on overworked structures. In both of these different examples it is important to investigate the least invasive combination of orthotics and footwear that will decrease energy expenditure and pain while also increasing efficiency and comfort with foot strike.   It is important to note, however, that many alignment deformities do not cause pain or decreased efficiency with activity.  If the athlete is able to maintain the proper strength and dynamic control of the foot/ankle, and appropriately progresses the time and intensity of their training, they may participate in years of athletic endeavors with no problem.

In the case of an acute injury, an orthotic may be used in conjunction with mechanical treatment to achieve pain relief.  This practice is utilized in an effort to immobilize or reduce the level of strain on the injured structure.  This allows for healing and strengthening of the injured structure with plans to remove the orthotic when enough healing has taken place to withstand the stresses of normal footwear.

In writing this article it was my goal to not only outline the benefits of orthotics but also the appropriate uses in individual patients.  It cannot however be understated the importance of treatment of the underlying problem in conjunction with an orthotic device to achieve optimum results.  Orthotics need to be used as an adjunct to treatment by a trained professional.  It is not appropriate to simply put an orthotic in a shoe and hope for the best.  This frequently leads to dissatisfaction and ultimately can lead to more problems.  For this reason I suggest treatment by a trained medical professional to address the cause of pain either in the foot, knees, hips, or spine.  This evaluative process ensures that the most appropriate and cost efficient treatment is being utilized and delivered.  It can also eliminate the dependency and hassle of orthotics for those patients who are no longer realizing any benefit from the orthotic they were given in the past.