The Orthotics Debate

I had the pleasure of listening to a lower extremity seminar presented by Dr. Mitch Mally, who is a world renowned speaker and extremities expert, guy is lighting quick too.  Check out a seminar if you get a chance,

Mally Seminars

Dr. Mally discussed how he does not fit a patient for orthotics until he feels that he has corrected the function of the foot, and every patient in his clinic is getting an orthotic.  This is a great way to look at where orthotics fit into the treatment model, but in my opinion not EVERY patient needs an orthotic, probably not even 80% NEED an orthotic.  At least Dr. Mally's approach is a bit more forward thinking than some patients I see that are prescribed an orthotic that is being used as a constant propioceptive reminder to the foot of why it is mal-positioned or dysfunctional, without any actual rehabilitative cue.

In our clinic orthotics are the rarity, and it usually comes down to those patients that have been through the entire treatment and rehabilitation gamut, and finally we need to give them some sort of corrective orthotic to maintain longer lasting results, the key word here being, CORRECTIVE.  What do I mean by corrective?  Dr. Mally's theory is that he is improving the structure and function of the foot through treatment, and when the foot has reached an optimum functioning level, he will then fit an orthotic to 'hold the foot' in this newly improved form.  Again, I think there is merit to this approach, but I think longer lasting results, and in the sports world, higher performance results, are gleaned by instead fully rehabbing the foot/issue to the fullest potential of that patient/situation.

Once we put someone in a rigid orthotic, we offload the intrinsic and sometimes extrinsic muscles that correlate to appropriate function of the feet.  By doing so we dampen the propioceptive abilities of almost 7000 nerve endings that are present in each foot.  The elite athlete relies on every propioceptive and mechanoreceptive fiber they have access to, so by stripping the foot's natural mechanics out of the equation I believe we are not doing what is in the best interest of the athlete/patient.  Again, there are instances that will require an orthotic, large leg length deficiencies, collagen laxity disorders or morphologic/traumatic structural changes, but this is not the norm.

With all the recent hub-ub about the Vibram Five-Fingers case, I guess I'll take a second to discuss the other side of the spectrum.  If a rigid orthotic is detrimental, shouldn't a minimalist shoe be the answer?  Well not exactly, the medium upon which we stride has changed significantly from that of our caveman brethren.  As a species we have moved from dirt and grass to concrete and hardwood, these changes have forced us into the modern footwear we know today.  While Vibram had/has a great idea, the American mantra of 'a little is alright, but more is always better' is what spelled their ultimate demise.  Inactive, overweight and out-of-shape people were looking to the Vibram to cure their foot pain, knee pain and maybe even make them a middle-American ultra runner.  The truth is that we have to protect our Westernized feet to a certain degree, and running a couch to 5K is in a sock of a shoe is probably not ideal for the vast majority of people.  All of that being said, training barefoot (or close to it) is CRUCIAL to improving balance and overall athletic prowess.  Although, care should be taken to provide the right setting and activity for athletes/patients to do so.

So the next time you or one of your patients is fitted for orthotics, ask yourself if everything has been done to get the foot (and the rest of the body) to the highest level of function without adding a supportive treatment to the equation.  I think outcomes can be improved, injury will be prevented and performance is definitely enhanced.

"The foot feels the foot when it feels the ground."

- Buddha

Dr. Beau Beard, DC, MS, CCSP