A reader recently asked me when I would consider using foot orthotics, with his bias being on MDT and the SFMA, both of which do not really give any info on orthotic prescription.
If someone had asked me this question about 8-10 years ago, I would have told them research shows OTC orthotics seem to help just as well and in some cases more than custom orthotics. I used to make "custom" orthotics with the Vasyli brand, where you head them up to make them moldable, have a patient stand on them, and find subtalar neutral. They would then cool and be "customized" for the patient with foot, arch, knee, hip, lumbar pain.... etc.... My goal was to undercut the $400 custom orthotics that are often prescribed by podiatrists.
There is a short answer to this question, do you still a soft neck collar on all of you neck pain patients or have your lower back pain patients wear a back brace ALL of the time? What about custom ones?
In the last 4 years I only prescribed orthotics once out of all the patients I have seen with feet. My goal in screening with the FMS or assessing with the SFMA is to check the patient's minimum competence in stability or mobility in functional patterns and have that guide my treatment.
Points I explain to patients
- arch supports inhibit your natural support, making you dependent on them
- this is what often causes the foot and arch pain when you go cold turkey from enormous maximalist shoes in the winter/spring to flip flops in the summer
- would you wear knee braces all 3/4 of the year, and just take them off in the summer, expecting your knees to be as strong as they need to be?
If someone absolutely needs orthotics for whatever reason, the intent should be that they will eventually wean from them, going from hard, if needed, to softer, to less supportive, and then eventually shoes with little to no support. Have them walk around frequently throughout the day, but going x amount of hours on, and y amount off, eventually increasing off time and decreasing on time. I have not done this in several years, but that is how I used to do it.
A mini case
The last time I actually prescribed orthotics was for a couch to 5K runner with a true 3/4" leg length discrepancy. She just started running that year and had completed 2 5K runs, something she never thought she would be able to do. This is around the time I discovered Irene Davis' running research and modified my own stride lengths and foot strikes so I could run without right knee pain. I tried to do the same instruction that worked for me and several other of my patients. The patient started having medial knee pain. Tibial IR mobilizations helped transiently as well as a self treatment as well as RockTape. Her SLS, SL squat and overall dynamic stability were excellent. Filming her in slow motion saw little to no valgus on the involved side.
I tried taping, general stability work, coaching on symmetry and stride length.... after about 1.5 months, she just pops her orthotics back in. This effectively compensated for her TRUE leg length discrepancy, when structure actually mattered. I may have eventually pursued this further, but she only wears them when running, and not full time anymore.... plus she is my wife, so you can only make so many suggestions after what you initially suggested caused knee pain in the first place. D'OH! This was the only time I have actually "prescribed" orthotics in the past several years. So I cannot say I am diametrically opposed to the viewpoint by most podiatrists and PTs who make custom orthotics, but it's pretty close.
The "other side of the coin" case can be found here, one of my first Case of the Weeks!
Keeping it Eclectic....
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