Dear Running Doc,
Last August, I was fitted with orthotics by my physical therapist. After wearing them for 2 months, I developed knee pain that hasn’t gone away. I heard you did say orthotics should not be hard and end in mid-arch. This is what my orthotics look like. Do you think the orthotics are the cause of my knee pain?
-- Jack J., Oceanside, NY.
Thanks, Jack for the question. Orthotics are like a fine Jaguar car. When working well, there is nothing better. When wrong, they will put you in the shop! Yes, your orthotics are wrong for a runner and yes, they are probably the cause of your knee pain by not correcting your biomechanical problem. Running magnifies every biomechanical flaw with each step. Clearly, over 80% of runners that come into my office complaining of lower extremity, foot or back pain, that say they don’t need orthotics because they already have them, have the wrong type. I think it is about time, in this column, I clear up what runners need to know about orthotics.
The first task is defining the term orthotic. The medical community views an orthotic as any device, appliance or apparatus used to support, align, prevent deformities or improve the function of the foot. According to this definition, many devices may be considered orthotics including over the counter arch supports, shoe inlays, shock reducing insoles, heel cushions or cups and even felt or silicone pads. When Sports Physicians speak of orthotics, we mean a VERY SPECIFIC type of foot support. It is important to recognize that ALL types of foot supports have their place, but they must be used properly if they are to prevent injury.
Shoe inlays or shock absorbing insoles are devices placed into the shoe to absorb shock or alter load pattern on certain areas of the foot. Spenco®, PPT® or Scholl’s Pillow Insoles® are examples. They are flat (little or no arch), cut to the length of the shoe, and made of soft, flexible materials. These are best used for a bruised or irritated foot.
Most runners are familiar with the vast array of over the counter arch supportive devices available at the local running shops and pharmacies. These “generic” supports are usually flexible and made to the size of the foot over a common form or “last” with increased support on the inside of the arch. Arch supports act similar to a “truss” by placing bulk under the arch providing a physical barrier to arch collapse. If enough support is placed under the arch, the amount of arch drop or pronation (rolling to the inside as you push off) is reduced. Runners with mild foot deformity who are experiencing foot, lower leg or back problems may benefit by using these ach supports.
The orthotics, the very specific term Sports Physicians use, is reserved for a device that is custom-made by computer scan, casting, or impression of the foot that is then “corrected” so that foot and lower leg alignment is consistently maintained. Casting or scanning should be done laying on a stretcher face down with your feet hanging off the table in the so-called “neutral” position. In this position, measurements are made, and casting material is placed on the foot and removed (Note: If your health professional asks you to step into a box to make a mold…step right out of that office. You are getting a Madam Trousseau’s Wax Museum replica of your foot, T a proper orthotic!). Then those measurements, plus leg length (measured) and observations of gait are added to the formula to make a proper orthotic. I usually make a temporary orthotic made of a body-heat moldable material for the runner to use for 4 weeks minimum to gather more information to put into the permanent device that may last 4-7 years.
The way the orthotic is designed determines its effectiveness. There are two major design factors: length and material. Runners need full length orthotics to control the forefoot. Think about it. Clearly, when you run, you spend 70-80% of the time on the ball of your foot. If running
and pronation is the cause of some pain then if the forefoot is not controlled, then the device is not working 70-80% of the time. Half orthotics that stop mid arch are fine for walking but do nothing significant to correct your problem while running. A flexible material is also important for runners. Hard materials help set up heel bruising long term and are uncomfortable. A leather, full length orthotic will last and be comfortable while correcting you the way you need to be corrected.
Runners ask: How long do I have to wear these things? The answer is simple: As long as you are active. If we superglue orthotics to your foot for 30 years and then they come off, the second they come off, you revert to your inherited foot strike. Unfortunately, there are no good exercises or operations to correct pronation adequately. So, blame your parents for giving you those feet, not your Sports Doctor.
Finally, does everyone need orthotics? Well, if your practitioner is a CPD (“Car Payment Due”) doc, you may get them if you say, “Is my gait correct?” In reality, if you are not broke, I don’t recommend fixing it. Many runners have significant pronation and never have problems. But, if your pain is diagnosed to be caused by your biomechanical flaw, then an orthotic is right for your situation.
I hope this answers all your questions Jack. If you have any more questions please do not hesitate to write.