When are Orthotics Right?

by Mitch Hauschildt, MA, ATC, CSCS

I have been on record as saying over the last couple of years that I only fit about 1/5th of the orthotics that I used to just a few years ago.  This is for a whole host of reasons, but overall, my major reasoning for decreasing the number that I make and fit are as follows:

• Change in approach:  Years ago, I just believed that if they didn’t have good foot structure, than I needed to provide that for them with an orthotic.  What I now know is that if we train stability and motor control appropriately, we can oftentimes teach a person to do it on their own with some time and appropriate training.
• New Taping Techniques:  Over recent years, I have learned some new taping techniques that work well to support the arch.  Tape is cheaper, easier and our athletes like the way the tape fits in their shoes much better than an orthotic.
• Patients Don’t Care for Orthotics:  There are a number of factors that go into a proper orthotic fitting and selection.  If you make them soft and spongy, they are really comfortable, but those don’t typically support the foot all that well and they break down quickly, especially for demanding athletes.  If the orthotic is rigid, it supports the foot well and is durable, but it takes longer to adapt to and many athletes don’t like the way they feel in their shoe.  The other problem is the shoe itself.  Orthotics take up space in a shoe and a lot of people (especially athletes) are sensitive to that feeling, and don’t like them, regardless of whether or not they are the perfect orthotic for their shoe.

So, because of all of the factors, I find myself moving away from orthotic use.  With that being said, there are times when they are absolutely necessary.  When considering orthotic use, I take a lot of things into consideration.  I look at their foot structure of course, their overall build, movement patterns, shoe wear, activity level, strength, stability, and motor control, to name a few factors.  While I don’t believe that there is such a thing as an absolute with the human body, I do tend to create a check list of situations where I do think that it is imperative that I give my patients some extra help in the form of external stability.  Here is a list of those instances:

• Low Tone Patient:  What I mean by this is there are some people who just struggle to have a lot of stability, motor control and strength in general.  I tend to see this with my female patients and the ones who are tall and lanky (especially with long legs).  I also see this with patients who are younger and overweight and non-athletic.  Many of low tone patients will never learn how to create good foot structure on their own because their nervous system just isn’t built to learn new patterns very efficiently after doing it for so long.  These patients typically come to me for knee pain, lower leg pain, or trouble correcting basic lower extremity fundamental movement patterns.
• Pronators and Hip Rotators:  These are the patients that I worry about tearing their ACL.  The most common mechanism of injury for an ACL tear is foot pronation, tibial internal rotation and valgus at the knee.  When I do a foot biomechanical evaluation on a patient and I know that they are involved in a speed and power sport and the already present with a pronated foot, internal rotation and some level of valgus while walking, I’m probably going to put them in some sort of an orthotic as a preventative measure.  This isn’t always true, but if I can block the pronation, I can save some knees, which is a big deal.  Notice that I said that I fit those people who present with all 3 (pronation, rotation, valgus).  I see a lot of pronators who have no other lower extremity dysfunction.  Those people are usually just fine.  I see people who have great foot structure and some valgus.  Again, those people don’t worry me as much.  It is those who are already part of the way to an ACL tear and haven’t even stepped on their field of play that scare me.
• Freshman Inseason Athlete:  Oftentimes when working in college athletics, I will have an athlete come in as a freshman that competes in a fall sport (i.e. volleyball, soccer, etc) that I know we can make a big difference in their stability and movement patterns with some high quality training, but the time of year is just not a good scenario for motor learning to take place.  These athletes are practicing a ton, traveling with their team, trying to adjust to being away from home for the first time, and on a very modified lifting program with them being new and in season.  In the past, I have tried to make strides with them while in season, and it just doesn’t seem to work well.  Their nervous system and stress levels are on overload, so trying to teach their foot how to create stability and structure has not worked well for me.  For these athletes, I have found that using an orthotic during their season to give them some help with the intent of removing them after their season is done and we have the ability to train them appropriately works really well.
• Rearfoot Valgus:  I have found a lot of worthwhile interventions for mid foot and forefoot control, but I find that if someone has a lot of rear foot valgus, more often than not, they will end up with an orthotic.  This is the best way that I have found to counteract this issue.  To me, this is more of a structural issue than a motor control problem.
• Turf Toe:  If you have ever had turf toe, you know that it is very painful and I haven’t had a lot of success with taping turf toe.  I prefer to take a “blank” orthotic with little to no posting or support anywhere else and I glue on either some 1/4″ cork or poron onto the forefoot.  This builds up the entire forefoot.  After that, I grind out everything under the first toe.  This limits the extension of the first toe and allows toes 2-5 to handle much of the load.  As with some of our other interventions, this is really a means to an end.  It allows my athletes to keep competing with limited or no pain while we address the root cause of the pain.
• Flexible Forefoot Valgus:  Some people have an excessive amount of flexibility in their forefoot.  Because of this, when they roll onto their forefoot, their foot collapses into pronation.  Some people can be taught how to stabilize their foot to avoid pronating, but others just never seem to “get it”.  I actually approach this with a Valgus post under the forefoot to essentially bind the foot up and create a mechanical block and it works quite nicely.

Overall, I honestly don’t fit many orthotics at all anymore.  But, there are times where orthotics are necessary and work very well.  Knowing when it is right is the art of what we do as clinicians.  Hopefully this sheds some light on when they are a good fit for the patient.