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Are foot orthotics a permanent fix for an injury, or are they masking and underlying weakness?


Check out Dr. Stephen Gangemi’s thoughts on orthotics!
Originally posted on http://naturalrunningcenter.com/2013/04/29/sock-docs-view-orthotics/

Sock Doc’s View on orthotics: Don’t leave home wearing them.
By. Dr. Stephen Gangemi

It’s been well over a year since I’ve discussed orthotics.

Orthotics, just like stretching, is an emotional and somewhat controversial topic because so many believe in their effectiveness for injury treatment and prevention. Others, such as myself, feel as though they either create, provoke, or hide a true problem. In an earlier article, “Are Orthotics Ever Really Necessary?” I discuss how orthotics are never truly fixing any problem. They support, rather than correct, dysfunction. They also dampen your senses as your feet are no longer allowed to move as unrestricted as they should. Your sense of body position (proprioception), and sensory feedback from your feet to your nervous system (kinesthetic sense), are dampened.

Yes, often they diminish and even eliminate pain, which is why so many claim they are successful. Perhaps you’ve had success with orthotics, or not; or maybe you are in the foot/footwear business and make hundreds or thousands of pairs of orthotics a year for your patients as some doctors who (unhappily) contact me have. Either way, I have decided to look through the eyes of these pro-orthotics people, and try to see what they see. Okay, it’s really just one Sock Doc eye; the other is certainly going to look away.

Argument Number One: Orthotics Relieve or Eliminate Pain
Pain is the number one reason someone is going to receive a pair of orthotics, most often from a podiatrist or chiropractor. Although most orthotic wearers suffer from foot pain (such as plantar fasciitis), others are using them for knee, hip, or even back pain. Do they help with pain? If they’re made correctly then yes – absolutely. There are many different types of orthotics as well as ways orthotics are made today so some of this success is going to be dependent on the skill and knowledge of the prescriber. Also, other therapies employed at the time the orthotics are prescribed often help with symptoms. Some prescribers, such as chiropractors, may adjust the bones of the ankle and foot before fitting the patient for an orthotic. This of course can also lead to greater success as the foot is in a more balanced and corrected state before support is rendered.

Though orthotics can be very effective in removing pain, (and I’m all for pain removal), this support-system method of treatment often is simply masking the symptoms and not addressing the problem. Say you have plantar fasciitis, for example. The fascia running along the bottom of your foot is too tight, torn, or even degenerated, and it’s causing pain. Your foot is not moving correctly and most often this is from a problem (weakness) in the tibialis posterior muscle. The main arch of the foot is not supported correctly, proper pronation and supination of the foot is not occurring, and the fascia is working too hard to stabilize the foot. The orthotic will often help stabilize the foot, but it will not correct the problem because it can not correct the weakness of the tibialis posterior. Just as if your wrist hurts because of a problem in the forearm, bracing your wrist is not going to correct your forearm. Masking the pain is not a correction, though this is often the answer in many types of medicine which looks for a quick and easy solution to a symptom. Orthotics for pain and dysfunction are like aspirin in your footwear.

Sure there are plenty of studies to say orthotics are “effective”. Unfortunately most of them are very short-term studies and they only look at one parameter for success – the removal of pain. They don’t ask or understand that although the [foot] pain may be reduced or eliminated, there is now pain in the knee, back, or perhaps shoulder from the new, different, and altered mechanics.

Let’s look at a few of the studies which support (haha) the use of orthotics.
1. Saxena & Haddad found that of 102 patients with patellofemoral pain syndrome, 76.5% improved and 2% were pain-free. 2% is not a huge success, and the 76.5% is left for interpretation as to what is “improved”. There were also other treatments used in this study and the age range was huge – 12 to 87 years old.
2. Shih et al found that a wedged insole was useful for preventing or reducing painful knee or foot symptoms in runners with a pronated foot. This study was only one 60-minute test and it’s unclear what a “pronated” foot is. After all, pronation is normal.
3. Gross et al report great success with orthotics in several symptoms, and this study is often cited by orthotic proponents. However, the study was a questionnaire given to 500 runners (262 responded). That’s not really a study, and as mentioned, it is only asking about the symptoms they were given the orthotic for.
4. Chang et al found that running injuries were related to training duration and use of orthotics. But just like above it was a questionnaire study of over 1000 runners (893 responded) and there is no indication between the training and orthotics.
5. Gross et al, (not the same as previous), found a 75% reduction in disability rating and a 66% reduction in pain with plantar fasciitis. There were only fifteen subjects, they looked at their 100 meter walk times (not very far) and the orthotics were only worn for 12-17 days.

Argument Number Two: Orthotics Improve Joint Mechanics
So do orthotics simply support dysfunction as I have stated previously or do they actually correct dysfunction? Well, that answer depends partly on what you interpret healthy joint mechanics to be. One study notes less strain in the foot with orthotics and a possible prevention for a stress injury to the second metatarsal (Meardon et al, 2009). The big what if here, though, is that the subjects couldn’t really say too much regarding what they were feeling since they were all dead. The eight cadaver specimens were mounted to a dynamic gait simulator to be analyzed.
Controlling “undesirable motion” is a term touted by orthotic advocates often. They say there is instability in a joint and it must be controlled, thus improving joint mechanics and reducing or eliminating pain. Sure instability isn’t a good thing in a joint, but how do you correct instability by stabilizing a joint with any device? You don’t. You stabilize a joint by correcting the faulty mechanics which are resulting in the unstable area. Actually, one of the best ways to train stability is with instability. This is why balance exercises are so good for stability.

You’re not going to improve stability very much standing on both legs on a flat surface, even if you are barefoot. I like to train stability while barefoot on a thin, uneven log — it’s so unstable; look out joint mechanics! So when a study says that orthotics may “enhance joint mechanoreceptors to detect perturbations” (Guskiewicz and Perrin, 1996), I say that they actually negatively alter these mechanoreceptors. Mechanoreceptors, by the way, are sensory receptors that respond to mechanical stimuli, such as pressure. You want as much healthy sensory stimuli getting to your brain as possible. This is what awakens and vitalizes your nervous system and is accomplished by interacting with your environment.

But there is a fine line between too much and not enough sensory stimulation as well as the source it comes from. So many people are in such sensory overload already from excessive lifestyle stresses that they can’t even walk barefoot because the added mechanoreceptor information and kinesthetic sense excite their nervous system too much, too fast. So they dampen this system with either conventional footwear or orthotics, and they feel better for it. But dampening the mechanoreceptor activity because of too much other external sensory “noise” is not the way to correct the problem. It’s not much different than calming your nervous system with alcohol at the end of a long, hard day. (Now I can get attacked by linking orthotic use to alcoholism.)
Speaking of movement, orthotics can have such negative effects too. Flexible arch supports have been shown to increase knee varus torque (Franz et al, 2008), and influence medial tibial stress syndrome (Hubbard et al, 2009). So it’s not always good, even when you’re in bad shape.
So yes, for those in a state of overall health distress, there may be improved joint mechanics as well as improved nervous system function with an orthotic compared to without. Even though I never use orthotics as I have other methods for treating such problems, I understand how they can so easily be the “go-to” treatment. If that’s the case, however, then function and health still needs to be addressed. These patients need to have their health and movement problems addressed and properly rehabilitated. They need to learn how to move well again, and not be dependent on their orthotics for so long, as often they are told to wear them for their entire life. The success of the orthotics will eventually run its course. So have a plan to wean out of those braces, (see my other article “Lose Your Shoes”), so you can move with strength, stability, and grace in any environment.

Studies Cited
Saxena and Haddad. The effect of foot orthoses on patellofemoral pain syndrome. J Am Podiatr Med Assoc. 2003 Jul-Aug;93(4):264-71.
Shih YF, Wen YK, Chen WY. Application of wedged foot orthosis effectively reduces pain in runners with pronated foot: a randomized clinical study. Clin Rehabil. 2011 Oct;25(10):913-23
Gross ML, Davlin LB, Evanski PM. Effectiveness of orthotic shoe inserts in the long-distance runner. Am J Sports Med. 1991 Jul-Aug;19(4):409-12.
Chang WL, Shih YF, Chen WY. Running injuries and associated factors in participants of ING Taipei Marathon. Phys Ther Sport. 2012 Aug;13(3):170-4.
Gross MT, Byers JM, Krafft JL, Lackey EJ, Melton KM. The impact of custom semirigid foot orthotics on pain and disability for individuals with plantar fasciitis. J Ortho Sp Phys Ther, 32:149-157, 2002.
Meardon SA, Edwards B, Ward E, Derrick TR.. Effects of custom and semi-custom foot orthotics on second metatarsal bone strain during dynamic gait simulation. Foot Ankle Int. 2009 Oct;30(10):998-1004.
Guskiewicz and Perrin. Effect of orthotics on postural sway following inversion ankle sprain. J Orthop Sports Phys Ther. 1996 May;23(5):326-31.
Franz JR, Dicharry J, Riley PO, Jackson K, Wilder RP, Kerrigan DC. The influence of arch supports on knee torques relevant to knee osteoarthritis. Med Sci Sports Exerc. 2008 May;40(5):913-7.
Hubbard TJ, Carpenter EM, Cordova ML. Contributing factors to medial tibial stress syndrome: a prospective investigation. Med Sci Sports Exerc. 2009 Mar;41(3):490-6.

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