orthotics

Author: Dr. Marc Mitnick
Reviewed by: Medical Review Board

WHAT ARE CUSTOM ORTHOTICS

It is a custom made device fitted directly to a patient’s feet. It requires a doctor's prescription. Unlike an arch support that anyone can buy in a store, a prescription orthotic is a device that is built for a specific individual and in most cases a specific foot or leg problem.

So if you and your uncle Bill have the same shoe size, his prescription inserts will not fit you, just like your prescription eyeglasses will not fit him.

A prescription insert is used to treat all sorts of foot, leg and even lower back problems. (Orthotics should not be confused with an ankle foot orthosis which is a more complex device used to control the foot, ankle and lower leg generally reserved for more severe musculo-skeletal and neurological problems.)

An abnormally functioning foot can have an adverse affect all the way up to the lower back. Over the years I have put patients in prescription devices for a foot problem only to have them come back and report that their back pain has improved as well.

As just stated prescription orthotics are used to treat abnormally functioning feet, for the purpose of this discussion basically either feet that over flatten when a patient walks (pronation) or feet that do not flatten out at all (supination). Both types of abnormal functioning feet create problems from the feet to the back, however, pronation problems are seen more frequently than supination problems.

To better understand the gait cycle and how orthotics may help, click here.

Prescription orthotics are further divided into two types. One is an accommodative orthotic. This device as the name implies accommodates a problem. For example, if you suffer from very arthritic feet an accommodative orthotic may be built that would better support your feet in an effort to reduce the stress being placed on the arthritic joints and not force the joints to have to go through their full range of motion which is what usually causes pain, since the primary sign of arthritis is the limitation of motion in the affected joint.

The other type of prescription orthotic is known as a functional orthotic. This is a type of orthotic that is built in an effort to change the way the foot functions in the gait cycle, to make up for the deficiencies in an individual's anatomical make-up. This type of orthotic attempts to change the biomechanics of the foot, which in turn may have a positive impact in the skeletal system all the way up to the lower back.

In order to make a prescription orthotic a plaster of paris cast is taken of both feet in their neutral position, the ideal relationship of the feet to the legs. Although there are other methods to take an “impression”, plaster casting is considered the most accurate (also the most messy) way of capturing the feet. These casts are sent to a professional lab where an orthotic is fabricated based on the recommendations of the prescribing doctor.

Prescription orthotics can be made out of a multitude of materials and may have various additions added to them based on the patient’s problem. For example, a patient with a supinated foot, generally exhibits poor shock absorption as his foot hits the ground. This inability of the foot to absorb shock allows the “shock wave” to travel up the leg where is can manifest itself as pain all the way to the lower back. In this case the prescription orthotic may be built out of materials that help absorb shock.

Notice the various types of orthotics that can be prescribed

Listed below are some of the conditions that a prescription orthotic may be used for:

• Heel spurs, plantar fasciitis
• Shin splints
• Ankle instability
• Arthritic conditions of the foot and ankle
• Sesamoiditis
• Diabetic foot protection and partial foot amputations
• Running injuries including runner’s knee
• Forefoot pain such as capsulitis, neuroma, metatarsalgia
• Treatment for mild bunions and hammertoes
• Pediatric problems such as in toeing and out toeing
• Juvenile bunions
• Apophysitis in children
• Adult biomechanical abnormalities

As you can see, there are many uses for an orthotic. Many times the question patients will raise is why can’t they buy an over the counter arch support.

In my office I never say never. BUT, for simple foot problems like a mild ache in the heel something over the counter may do the job. In fact many times patients will come to me having already tried something they bought in the drug store.

There are a number of issues here. First, store bought supports are sold by shoe size, not foot structure. So if you are a size ten shoe and buy a size ten arch support you have to hope that your arch support happens to be the same as your foot structure. There are any number of foot structures in the human anatomy, but you may be the lucky individual whose foot structure matches the arch support. In addition store bought arch supports do not address the weight of the patient. It would stand to reason that a person weighing 250 pounds would have different support needs than someone who weighs 150 pounds.

Although I cannot state that I have seen every arch support sold in drug stores and supermarkets, I can say that I have never seen one that is much better than the arch supports that come in a good pair of sneakers. So an easy rule of thumb might be that if you are having pain in spite of wearing reasonably good sneakers with a built in arch then purchasing a store bought arch support is probably a waste of your time and money.

Next, you have to hope that the arch support is built out of the material best suited to help your foot problem. Many prescription orthotics have padding added and cutouts made in certain parts of the orthotic to accomodate various foot problems. Your problem is that store bought arch supports do not come with any additions for specific foot problems like the prescription orthotics do.

running orthotics

For those of you who suffer from foot, ankle or leg issues associated with running, a different type of orthotic is often necessary. Not only does a sporthotic have to control your particular medical issue, but it has to be designed to withstand the stresses placed upon it by athletic activities. The takeaway here is that a regular orthotic designed for every day shoes, should not be used for sports. This includes both custom and store bought supports.

Next, is the life expectancy of the arch support vs. a prescription orthotic. Although a prescription orthotic is not designed to last forever (even though I have patients still wearing 30 year old orthotics), store bought arch supports generally last anywhere from 3-6 months depending on the patients activity.

Lastly, if you get lucky and your store bought orthotic happens to fit your foot contour and is supportive enough for your weight (not great odds of both those things happening), you have found yourself a partially accommodative orthotic. Yes, it might work for some of the problems an accommodative orthotic is designed for, but what if your problem really requires a functional orthotic? The odds of your store bought orthotic fulfilling that requirement is almost nil.

Does that mean I never recommend store bought arch supports? No, of course not. There will be situations where I suggest a patient try something from a drug store; I usually recommend a store bought arch support if the patient presents with vague symptoms of a potential problem, not quite severe enough to warrant aggressive treatment, but certainly something that should not be ignored. Since most people cannot wear sneakers all day, this is the next best option.

shoes for orthotics

Another consideration for orthotics is the types of shoes you intend to wear them in. Generally speaking men's shoes are not an issue as the cut of a dress shoe is not much different than an athletic shoe. The real problem occurs with women's shoes. Obviously an orthotic designed for a sneaker rarely will fit into a pump or high heel.

The problem is exacerbated by the fact that to get an orthotic into a very dressy shoe it has to be dramatically modified (translated: made much thinner and narrow) and of course this takes away from the effectiveness of the orthotic. It stands to reason that if a women is suffering from a severe foot problem and an orthotic is the answer, it will usually have to be a full functional orthotic which will generally require wearing conservative shoes.

Not sure if prescription orthotics are for you? Click here for the results of a recent study on prescription orthotics.

There are orthotics that are made for women's dress shoes but in most instances I find them to be a waste of time. For the reason stated above, the dress shoe orthotic has to be so modified in order to fit into the dress shoe that its effectiveness is usually minimal to none.

OK, so you finally got your prescription orthotics now what? I generally explain to people that orthotics are like eyeglasses. When you wear them they do what they were intended to do. At the end of the day, if you walk around the house barefoot, all the benefit derived from the orthotic is lost. Wearing orthotics all the time is mandatory, at least initially in treating painful conditions.

REFERENCES

OrthoInfo

American Podiatric Medical Association

Harvard Health