Custom orthotics have been the mainstay of treatment for many foot and ankle pathologies for more than 50 years. Many critics say that orthotics are overkill and that pre-fabricated devices and stretching with strengthening exercises should eliminate the need for orthotics. There is actually good evidence-based literature that confirms that orthotics work for biomechanically induced foot and ankle problems including: plantar fasciitis, metatarsalgia, hallux limitis, adult-acquired flat foot (posterior tibial tendon dysfunction), rheumatoid arthritis, tarsal tunnel syndrome and lateral ankle instability.
Plantar fasciitis is the most common pathology treated with orthotics. And for good reasons! Multiple studies have shown that an orthotic that is designed to prevent midtarsal joint collapse during gait results in 85-89% relief of symptoms. Many studies have compared pre-fabricated devices, heel cups and custom orthotics with mixed results. One study even concluded there was no difference, but if you look at it further, there was no consistency at all in the treatment protocol making its conclusions totally invalid. Overall, the conclusions are that custom functional orthotics should be the gold standard of treating chronic and recurrent plantar fasciitis. All patients with acute and chronic heel pain should be placed in a pre-fabricated device that is replaced with a custom device when available for long-term pain control.
The diagnosis of metatarsalgia includes the symptoms of pain under the metatarsal heads. Differential diagnosis includes Morton’s neuroma, 2nd MPJ capsulitis, stress fractures, arthritis and neuritis; most cases have some degree of mechanical overload. Custom orthotics that off load the metatarsal heads with proximal padding and prevention of midtarsal joint pronation have been shown in every study to consistently decrease pain in the forefoot. Metatarsal padding added to the custom orthotics dramatically increased positive clinical outcomes compared to padding or orthotics alone.
Functional Hallux Limitis
Functional Hallux Limitis is the biomechanical pathology behind hallux valgus, hallux rigidus, hallux pinch callus, and sub-hallux ulcerations. Many studies and discussions have occurred over the years on this subject. Bottom line: Functional hallux limitis is biomechanical and should be treated with orthotics. Structural hallux limitis is ineffectively treated with orthotics and should be a surgical candidate. Functional hallux limitis is due to abnormal foot position and there is ample proof that a functional orthotic can reverse this limitation.
Adult-Acquired Flat Foot (Posterior Tibial Tendon Dysfunction)
The use of the nomenclature of “Adult-acquired Flat foot” acknowledges that a rupture or longitudinal attenuation of the tendon by itself does not lead to the progressive flat foot deformity seen in many older adults. This deformity includes the pathology of the PT tendon, overloading of the spring ligament, the superficial deltoid ligament, and the long and short plantar ligaments and includes the plantar fascia. Orthotics alone cannot reverse this deformity but have been shown to be quite helpful in the delay of the progression of the deformity. Non-operative treatment with orthotics is particularly useful in decreasing pain and disability in poor surgical candidates due to multiple medical problems. Ankle-foot orthotics that control not only midtarsal and subtalar joint motion but also control ankle joint abnormal motion are particularly helpful in severe cases.
More than 2.1 million Americans are affected by rheumatoid arthritis. 36% of these patients present initially with foot pain. Numerous studies have shown orthotics to be quite helpful in controlling pain in these patients. Many studies compared shoes alone, soft accommodative orthotics and firm functional orthotics. Every study shows that a well-made firm custom orthotic decreases pain in RA patients more effectively than their softer counterparts. In fact, when looking at juvenile RA patients, the pain relief was remarkable. All patients with RA should be fitted with custom orthotics to improve their clinical outcomes.
Tarsal Tunnel Syndrome
Tarsal tunnel syndrome is biomechanical in origin. Traction on the posterior tibial nerve and compression of that nerve by the flexor retinaculum or compression of the medial plantar nerve as it perforates the plantar fascia causes the symptoms of TTS. This is caused by excessive subtalar joint pronation in most patients which decrease the longitudinal arch causing increased pressure in the tarsal tunnel. Studies have shown over and over that control of this subtalar joint pronation, preventing rearfoot eversion and increasing the longitudinal arch, provide excellent relief of symptoms in early tarsal tunnel syndrome. Orthotics should be the mainstay of treatment in TTS.
Lateral Ankle Instability
An unstable ankle due to chronic or acute disruption of the lateral ligaments can be effectively controlled with an orthotic device by improving postural control of the patient’s foot. Postural control is the ability to maintain the body’s center of mass over the supportive foot, aka being able to keep your balance. Often, balance or proprioception is lost in chronic ankle instability patients. Many studies have concluded that a functional orthotic reduces postural sway and improves stability, therefore reduces further injury in patients with lateral ankle instability.
Orthotics work! In particular for those conditions that are biomechanical in origin. This conclusion is reinforced by outcome studies and real peer-reviewed scientific evidence based research not just anecdotal evidence.