Orthotics

Orthotics are custom made foot supports. However, it may be better to state what they are not. They are not arch supports. Arch supports are inserts that are pre-manufactured, bought in a store or mail ordered, and require no examination or consideration for one's type of foot structure and how the foot functions. They do not make allowances for leg length, leg rotation, or how the foot/leg/muscle relationship performs. Dr. Rob Roy McGreger, a well-known sports podiatrist from Boston, feels that orthotics are like eyeglasses. If you need a pair, you need your own. You cannot wear someone else's and have them work.

History
How long have orthotics been used? This depends on how we define today's orthotics. In the late 1960's and early 1970's, Dr. Merton Root, a podiatrist from California and founder of today's modern biomechanics, explained how the foot and leg function. He detailed in his publication and lectures the exact mechanism of foot mechanics from heel strike to toe off, and even when the foot and leg swing in the air preparing for another step. He emphasized the relationship of the back part of the foot to the front part, and how the foot functions with the leg to allow movement. The arch of the foot is affected by the relationship of the rearfoot and forefoot. The arch itself is not the key to proper foot mechanics, but is affected only by what the rest of the foot is doing.

During my first year in school we were taught a different theory of balanced foot mechanic's, i.e., foot problems were the result of imbalances or structural bone problems that were to be accommodated with inlays to decrease the pressure on bones. For example, if a person had a callus on the bottom of his foot, an inlay would be made to "float" that increased pressure spot, putting more weight on the surrounding areas. Furthermore, many foot problems were thought to be the direct result of improper shoes. I recall how I was taught that a corn on a small toe was due to poor fitting shoes. While there are some problems caused by shoe pressure, shoes merely aggravate preexisting mechanical or bony problems. In certain areas of the world there are large segments of the population that do not wear shoes at all and still have bunions, corns, calluses, and assorted maladies of the foot. Fortunately, we were also taught Root's Biomechanics. In 1970, Dr. George Sheehan, cardiologist, runner, and noted author, published an article in Runner's World that, according to Gabe Mirkin, M.D., and author of The Sports Medicine Book, revolutionized the treatment of runners' knee and other foot and leg injuries.

Dr. Sheehan discussed the case of a runner with knee problems that failed to respond to two years of standard medical treatment. Orthotics were prescribed by Dr. John Pagliano, podiatrist and marathoner, and within two weeks the runner was without pain. On the other hand, arch supports and inlays have been used for many years. While they might be comfortable and provide some relief, they are not orthotics. Some of the earliest arch supports were made of stainless steel. I know of patients who have needed to have them readjusted every three to four months because they would literally bend them out of shape. This resulted from excessive pressure put on them by abnormal biomechanical factors. These stainless steel devices were true arch supports.

Indications
Surveys of patients who have used orthotics indicate that 80 to 85 percent of the overuse injuries of the lower extremities treated responded to some form of biomechanical control, as well as a well-balanced stretching and strengthening program. Many athletes we see complain of foot, ankle, leg, knee, thigh, and low-back problems. After a careful history and examination, the first thing to be decided is whether the condition is primarily Podiatric or Non-Podiatric in scope. Although most conditions can be the result of abnormal biomechanics, lack of impact shock, or muscular imbalance, there are specific conditions such as nerve root compression, herniated disks of the back, or torn knee cartilage, that must be referred to the appropriate specialist.

Runners seen as patients seem to fall into two categories. The first and by far the largest group are those runners who have tried for several weeks to self-treat themselves for a particular problem without satisfactory relief. They have usually resorted to all types of remedies from aspirin, to over-the-counter arch supports, rest, ice, and advice from fellow runners. The second group of runners are those who have already been treated by a professional, but have not had satisfactory results.

Both the first-time patient and the one who has been seen already are usually not interested in being told to try anti-inflammatories, exercises or rest until they have no symptoms. They have heard about steroid injections, including their possible adverse problems, and usually prefer not to have them. They have tried whirlpools and taping their feet, all without satisfactory results. I strongly feel that no one should have an orthotic prescribed, either temporary or permanent, with out a complete, comprehensive, and thorough history and biomechanical examination. X-rays are also almost always indicated. The x-rays should be weight-bearing rather than non-weight bearing.

It is important to know how one bone relates to another instance. Taking a picture of a foot extended in the air is not of much value in a biomechanical evaluation.

Overuse conditions are commonly associated with proration or rolling inward of the foot. When the foot rolls in the leg rotates inward. Problems associated with this are shin splints, pain on the inside aspect of the knee, inflammation of the inner arch of the foot (plantar fasciitis), heel spurs, bunions, and hammertoes. We also see pain in the central part of the lower back due to

Impact shock problems are seen in supinated foot structures. These are rigid, non-yielding, non-shock absorbing feet associated with irritation of the outside aspect of the heel, outside knee pain, upper leg and back symptoms, ilio tibial band syndrome, and tailor's bunions. This type of foot structure is harder to treat because it is fixed in its position as compared to the flexible, prorating structure which adapts much better to specific orthotic control. Statistically, al most 80 percent of the feet we see are the flexible type verses 20 percent of the non-flexible or rigid type.

Contributing Factors
While foot structure is the major cause of overuse or impact shock, there are other factors that contribute to these problems. The most frequent extra factors are shoes that are excessively worn down. Running on tracks or banked surfaces also affects function. In a previous article, I stated that 90 percent of the population has a leg-length difference. This is often not detected nor treated. Other factors such as stride length and style of running are influences on normal functioning mechanics.

Types of Orthotics
Certain considerations must be given to selecting the best type of orthotic. First is to determine the objective of orthotic therapy. It must be deter mined if we want cushioning, control, accommodation, balance, or any one or combination of all of these factors. In general, the more flexible foot type requires firmer control, and therefore uses more rigid materials. Conversely, the more rigid foot type needs more cushioning with softer materials. Orthotics are classified as flexible semi-flexible, and rigid. They may also be described as balanced or functional, depending on which theory of foot control is used.

There are various forms of soft or flexible orthotics, ranging from felt to rubber-molded fillers and foams. Semi-flexible orthotics are made usually of leather and firmer foam or rubber products. Rigid orthotics are almost always made of thermoplastic materials.

Functional orthotics, those which control over use and impact shock problems, must be constructed precisely to accommodate the findings of a biomechanical examination. The foot and leg must be aligned properly when the cast or impressions are made so the orthotics will truly represent and compensate for the problems causing the pain. Any materials used to make orthotics will be effective if used properly.

Prescribing Orthotics
When a runner is first seen in our office, we rarely prescribe permanent orthotics. If the problem has been determined to be biomechanical in nature, a temporary soft orthotic is constructed which incorporates in it corrections for rearfoot and forefoot variations as well as leg-length differences. The patient is then re-appointed in one to two weeks. During that time we encourage a continuation of running activities as long as there is no secondary injury which mandates rest first. If the reexamination reveals an overall improvement, then permanent orthotics are prescribed. Sometimes the temporary provides improvement only for a few days and then the symptoms return. This is still acceptable because they are used as indicators to determine if orthotics will work. Sometimes we know exactly what the biomechanical cause of the problem is, but cannot control it mechanically. This is due to such external factors as stride length, running style, type of shoes, and even the body's ability to continually adapt to the pressures exerted on it by the orthotics.

Instructions for Use
Permanent orthotics are dispensed to the patient with specific written instructions. These instructions are very important and are gone over thoroughly. A break-in period may be required, and may vary from patient to patient. Standard recommendations state to use them one hour the first day, two hours the second day and so forth. Orthotics can also be worn to tolerance. This means that they may be worn as long as desired unless discomfort develops or the legs or feet become tired. If this happens, the orthotics are removed from the shoes, and not used again until the next day. A frequently asked question is whether to wear orthotics only in running shoes or street shoes too. I feel if the overuse or impact problems occur only because of the increased stress of running, then the orthotics should be worn for that activity solely. Conversely, if there is a general problem that occurs in running and walking, the orthotics should be worn both in running and street shoes.

Orthotics can cause blisters and therefore should be worn with socks. Sometimes it is necessary to cover the orthotic with a top cover such as Spenco to eliminate blister formation. Excessive perspiration can be avoided by lightly dusting foot powder inside the shoe. I have found that spraying feet with underarm spray deodorant with an antiperspirant in it is an easy and inexpensive way to reduce excessive perspiration and subsequent blister formation.

Orthotics must function on a flat surface. The one-piece insole or foam arch-cookie found in running shoes must be removed before the orthotic is placed inside the shoe. Placing it on top of the soft insoles of running shoes will negate the ability of the orthotic to function properly. It is usually not necessary to buy larger shoes when using orthotics. It is best to buy whatever shoe size you normally wear, then remove the insole and insert the orthotics.

Specific Orthotics
There are specific orthotics for specific sports or activities. They are divided into two basic groups: unidirectional and multidirectional.

Unidirectional orthotics are used primarily in long distance running and training. This activity is repetitive, linear, and reproducible. Multidirectional activities such as football, soccer, and dance aerobics, require orthotics that are designed to control the foot not only in a unidirectional fashion, but also in side-to-side and twisting motions. Orthotics come in many designs, colors, materials and with special features. Only a well-trained practitioner can decide which will work best.

Sometimes an orthotic can control foot function too well. While this may seem strange, the foot needs to be able to normally adapt to the weight bearing surface. This adaptation allows for certain amounts of shock absorption to occur. If too much control is exerted, side effects such as outside knee pain, hip and back discomfort, and even ankle sprains may occur. It is far better to provide a little less control with an orthotic than too much. The body seems to adapt much better when given a little leeway of its own.

Abuses
Not everyone needs orthotics. Not everyone who has orthotics should be wearing them. There are some inherent problems with the use of orthotics. If any of the steps taken in the evaluation, construction, or dispensing is incorrect, the patient and doctor may have less than satisfactory results. Some individuals do not function well in the neutral or normal position. They do better in a semipronated or slightly rolled-in position. The cast impression of the foot may not capture the biomechanical problem. These kinds of difficulties are unusual but do occur.

The most frequent orthotic problem that I see is with the patient who already has had an orthotic prescribed and still has pain. In most cases, their "orthotic" is an arch support or has not been prescribed properly. It may be possible with adjustments to these devices to make them work better but new orthotics commonly have to be made.

Another problem area is using orthotics to treat almost every known malady to mankind. As we have found, orthotics help control pain by controlling abnormal biomechanics. They do not cure the common cold! Athletes should be aware of what orthotics can and cannot do. Not every case treated is successful, although some of the results that we have obtained with chronic and disabling problems have been very rewarding.

Summary
Orthotics, or biomechanical support systems are frequently used to treat a variety of overuse and impact shock problems. Their basic concept in alleviating symptoms is to control abnormal motions that occur between the foot and shoe, and the shoe and weight-bearing surface. They act to bring the ground up to the foot, rather than the foot going through abnormal motions to meet the ground. Although constructed from a variety of materials, any material properly used is satisfactory in alleviating overuse problems. An orthotic should control function, be comfortable, and reasonably priced. They may need adjustments on occasion to accommodate alterations or changes in biomechanics. An athlete's expectation must be reasonable, and consistent with the body's ability to respond to control of abnormal biomechanics.

Orthotics add to our ability to treat overuse and impact shock problems; they allow us to run and walk without pain, continue to participate in our favorite activities; and they help prevent problems from recurring.