Orthotics are such a frequent topic among my athlete patients, I wanted to post my thoughts on them. Here goes:
In my opinion, there are four reasons clinicians prescribe orthotics. (There really should only be one reason, and unfortunately, it’s usually the least common):
1) Lazy clinician
2) Greedy clinician
3) Soft tissue problem
4) Structural/postural deformity
Let me expand on that.
1) As physical therapists we are taught to find the biomechanical problem and fix it. But many clinicians don’t look at the body as a whole anymore. The patient comes in with foot pain, a fallen arch, a non-mobile MTP joint, etc., and rather than finding the true problem or weakness that is causing the issue, they use an orthotic to correct the biomechanics of the foot. This will help in the short term but won’t fix the real problem. An expensive, short-term crutch that doesn’t solve the patient’s problem? Seems pretty silly.
2) Think of an orthotic as a bottle of wine at your favorite restaurant. You want to splurge a bit, so you don’t mind the overpricing. Orthotics are marked up by clinicians who have contracts with manufacturers in a similar way as that wine — about 300-400%. Call it what you want… greedy, shady, ambitious? Bottom line, that prescribing clinician stands to gain a wad of cash from your purchase.
An athletic friend of mine recently saw a podiatrist for ankle pain and was told he needed orthotics after a very brief, non-functional evaluation of his foot. My friend refused, told the doc he was having ankle pain, not a problem with his foot, and the podiatrist replied “but we’ve already verified that your insurance covers them, so it won’t cost you anything.” This story is so disheartening to me as a clinician because the real problem was not diagnosed and the clinician was pushing something that wasn’t needed solely for his own gain. Luckily my friend is smart and still declined, got the script he needed to come see me for physical therapy, and is feeling much better. (FYI: his problem was a posterior tibialis strain that was manifesting pain around his malleolus. He didn’t need an orthotic at all). If you’re scratching your head over why this matters since the insurance would’ve covered them in the first place, think about this — unnecessary prescriptions make money for clinicians and drive up health care costs for all of us. If you don’t think this affects your premiums, you’re kidding yourself.
3) Soft tissue problems in the foot can often benefit from the support of that tissue. Foot support can keep the tissue relaxed and relieve some pressure. My issue with orthotic prescription in this scenario is the cost vs. benefit analysis. There is no need to purchase an expensive pair of custom orthotics when an over-the-counter substitute works just as well (in most cases, not all). When I do prescribe orthotics for a patient, I usually recommend Superfeet. I’m not a retailer for them, nor do I make any money off their sales. But I have seen their products work for many patients, for many different problems. Superfeet cost approximately $35 for a pair, and will last anywhere from 6 months to a year, depending on your use and frequency. A good pair of prescription orthotics for an endurance athlete won’t last much longer than a year before they have be replaced either, so you can see the cost analysis here. As an aside, Superfeet also offers a range of products that will work with shoes other than sneakers, so patients can receive the benefit of support whether they’re training or not. (I’m never going to endorse high heels for my female patients, but if you’re gonna do it anyway, at least you can minimize the damage).
4) If you have a leg length discrepancy, or other serious structural problem, custom orthotics can truly help. Depending on the case, I sometimes recommend trying a more rigid Superfeet insole for awhile prior to prescribing custom ones, but this is one scenario where it may be worth it to spring for them. There are many complicating factors to address, and custom orthotics can be the best way to adjust height in one shoe without damaging gait, etc.
Here’s a case study to show my point:
I had a patient with chronic bilateral ITB problems, knee pains, ankle problems, very supinated (rolled out) feet, whose dad is a podiatrist. She had been running (trying anyway) in orthotics for years. They were regularly updated to try to fix each of her pains as they arose. This kind of customization is not possible for most people, but it proves that orthotics can’t fix the underlying problem causing her pain. Despite going to multiple PTs, an orthopedist, and even another podiatrist, she wasn’t getting better. That’s when she came to me. I told her to ditch the orthotics. She wouldn’t. I treated her on and off for almost a year. After we had addressed every muscular imbalance that she had in her body outside of her foot and ankle, she finally got fed up enough to give it a shot. Once she got a more free-motion shoe and we worked on her ankle stability, she started to pronate on her own without the orthotics. They were actually holding her normal motion back. She has been running in normal shoes, without orthotics, for almost a year now — PAIN FREE.
Enough to make you think twice about those orthotics? I hope so!
If you’ve been prescribed orthotics or are wondering if they might be right for you, find a good functional-based practitioner who will evaluate your entire body and see why the foot is doing what it’s doing, and correct it.
Dr. Josh Grahlman
Founder + Athlete Mechanic
Note: This article is based on personal experience and individual patient case study. This is not peer-reviewed, and therefore has not been published or written up for publication. Other clinicians may say their way of prescribing or fitting orthotics is superior, and their patients respond well to them. I hope for the athletes’ sakes, that’s the case. But in my experience, the underlying cause of pain needs more than a pricey insole.