Readers often tell me that they think they “might need orthotics,” but they rarely know more than that. The idea is usually based on an uncertain hunch that something about the way they walk and run can be fixed with a wedge of just the right shape under their feet — which is all orthoses amount to, even the fanciest ones.
Custom foot orthoses or orthopedic footwear or modifications may be helpful for specific medical situations, but it’s probably only truly reliable for a single condition: painful pes cavus (high arches). Everything else is less certain, even quite obvious and common foot problems like hallux valgus (lateral bulging where the big toe meets the foot). With wise prescription and skilled crafting, many people will be helped, and many will not.
Unfortunately, you can’t count on wise prescription! There are many unscrupulous and shoddy suppliers of these products who will prescribe them for almost any problem — or none! — and the science is complex and incomplete. It is nearly impossible for consumers to know if they actually need any of these products, or where to get an expert prescription and a quality product.
The good news is that there are some more reliable sources for these products and services: Certified Pedorthists (C.Ped) and Certified Orthotists (CO) are the professionals that I recommend. Unfortunately, most consumers have never heard of them and don’t know why they are the best choices, or where to find them … and many therapists won’t refer, because they want to sell you orthotics themselves.
The entire question of orthotics can be answered reasonably well by keeping your expectations pretty low — there’s just only so much that foot support can do for most people — and by consulting mainly pedorthists and orthotists. That’s the short story. But on this website we delve into these things …
We train for many years and we take our jobs very seriously. It’s great to see support for pedorthists, and recognition of the difference between podiatrists and pedorthists. I have a problem with a professional who is allowed to diagnose, prescribe, and dispense within a 15-minute appointment. Prescribers are not providers for a reason!
— T.Moffitt, C.Ped. (C) Certified Pedorthist, Edmonton, Canada
Foot, ankle, knee and hip biomechanics are complex. Extremely complex. It’s not rocket science — it’s actually much harder. And gait analysis is an art as well as a science. In my opinion, non-specialists just cannot possibly navigate this maze successfully with every patient. Orthotics should not be prescribed without a thorough examination — at least a half hour, and more if the case is complex.
Yet across North America — and I’ve seen it myself here in Vancouver — you can find lab-coated charlatans hawking corrective shoe inserts in shopping malls, using flashy displays and entertaining technology to “assess” or “scan” your feet with lasers or infravision … anything at all that will distract you from their lack of skill and real knowledge.
Unfortunately, many orthotics sold to consumers may not be worth more the clay the mold was made from. The effectiveness of orthotics is uncertain no matter who prescribes them, which I’ll get into below. Most “custom” orthotics are mostly just pieces of plastic that fit your foot. Maybe. None of the common methods can even create an accurate fit reliably!Pedorthists and orthotists have the best chance of providing a useful prescription. Only pedorthists are trained in both gait analysis, lower body anatomy and biomechanics and the actual fabrication of custom foot orthoses.All other professionals are obliged to order orthotics from an external supplier.
Most physical therapists or chiropractors selling orthotics usually ask a client to make footprints in foam in a box, fill out a form specifying features of the insert, and then ship the foam off to a manufacturer who sends back some shoe inserts. Like lasers at the mall, these procedures may create the illusion of a “customized” product, but it’s mostly just a piece of plastic that fits your foot. Maybe. None of the common methods can even create an accurate fit reliably! Let alone one that is corrective or therapeutic in any way. Such “prescriptions” are extremely common practice, but wiser and more ethical practitioners wisely shun them. This massage therapist described to me how she refused the sales pitch:
A few years ago I had a phone call from a company that was trying to sell me a franchise to sell and fit orthotics. Apparently I could make very good money doing this. I’m a massage therapist and I think I have a better-than-average knowledge of feet and gait, but I do not consider myself qualified to fit and sell orthotics. No fear, the company representative said they would send someone to train me — for half a day! The sales person seemed to be astonished that I turned down this wonderful opportunity. I prefer to refer my clients to a person who is qualified to do this work.
Good for her. But many professionals jump at this dodgy chance to make more money.
Most consumers assume a foot doctor is a good source of orthotics. Unfortunately, this is far from guaranteed. Many podiatrists are qualified for it, but probably most are not, as suggested by this rather chilling story from Dr. Michael “America’s Podiatrist” Nirenberg:
A middle-aged woman arrived at my office last week complaining of heel pain and carrying a bag of custom-made foot orthotics (orthotics are custom made arch supports that are fabricated from a mold of the patient’s feet). Each orthotic this woman had with her was expertly fabricated by a different podiatrist and yet none of them had come close to alleviating her heel pain. At first I thought maybe these podiatrists didn’t know what they were doing. But, when I learned their names, I knew this woman had seen competent, skilled and reputable physicians.
I asked myself “how could this be?” More interestingly, no two sets of orthotics were even remotely alike. Further, given that nearly all podiatrists learn similar principles of biomechanics, shouldn’t orthotics for a given patient be the same regardless which podiatrist makes them?
Dr. Michael Nirenberg, in his review of a book by Dr. Benno Nigg, Biomechanics of Sport Shoes: The Disturbing Truth About Running Shoes, Inserts and Foot Orthotics
A podiatrist is a full physician, but specializing in foot problems. In Canada and the United States (most familiar to me), his or her expertise is primarily concerned with foot pathology and corrective surgery, and does not always extend to include expert gait analysis and physical assessment of biomechanical dysfunction of the lower limb as a whole. Obviously some podiatrists cultivate an interest in this, and there are some prominent experts in the field who have really gone this direction, but they are not obliged to do so.
You could say that it’s not in their job description.
Most podiatrists outside of North America are probably a different matter.4
In any case, even a podiatrist skilled in the prescription of custom foot orthoses is still obliged to have them manufactured by someone else. For this reason alone, many podiatrists prefer to refer their patients to certified pedorthists.
The supply dramatically exceeds the real demand. However, there are four common conditions that orthotics have the most potential to help:
plantar fasciitis, a common painful inflammation of the sole of the foot, most easily recognized by its tendency to cause pain first thing in the morning
arthritis, which often affects joints of the foot
diabetes, which intereferes with circulation in the feet, requiring custom shoe modifications or custom-built footwear
metatarsalgia, a painful foot disorder that affects the bones and joints at the ball of the foot
Other conditions that might be treatable — but it’s much less clear — include patellofemoral knee pain, shin splints, achilles tendinitis, and bunions, as well as numerous systemic pathologies that (like diabetes) affect the function of the lower limbs.