Readers often tell me that they think they “might need orthotics,” but they rarely know more than that. The idea is based on an uncertain hunch that something about the way they walk and run can be fixed with a wedge of just the right shape under their feet — which is all orthoses amount to, even the fanciest ones.
Custom foot orthoses or orthopedic footwear or modifications can be really helpful … but mostly for specific, technical, and medical reasons.1 Meanwhile, there are many unscrupulous and shoddy suppliers of these products who will prescribe them for almost any problem — or none! — and the science is complex and incomplete. It is nearly impossible for consumers to know if they actually need any of these products, or where to get an expert prescription and a quality product.
The good news is that there are some more reliable sources for these products and services: Certified Pedorthists (C.Ped) and Certified Orthotists (CO) are the professionals that I recommend. Unfortunately, most consumers have never heard of them and don’t know why they are the best choices, or where to find them… and many therapists won’t refer, because they want to sell you orthotics themselves.
The entire question of orthotics can be answered reasonably well by keeping your expectations pretty low — there’s just only so much that foot support can do for most people — and by consulting mainly pedorthists and orthotists. That’s the short story. But on this website we delve into these things …
We train for many years and we take our jobs very seriously. It’s great to see support for pedorthists, and recognition of the difference between podiatrists and pedorthists. I have a problem with a professional who is allowed to diagnose, prescribe, and dispense within a 15-minute appointment. Prescribers are not providers for a reason!
— T.Moffitt, C.Ped. (C) Certified Pedorthist, Edmonton, Canada
Foot, ankle, knee and hip biomechanics are complex. Extremely complex. It’s not rocket science — it’s much harder. And gait analysis is an art as well as a science. In my opinion, non-specialists just cannot possibly navigate this maze successfully with every patient. Orthotics should not be prescribed without a thorough examination — at least a half hour, and more if the case is complex.
Yet across North America — and I’ve seen it myself here in Vancouver — you can find lab-coated charlatans hawking corrective shoe inserts in shopping malls, using flashy displays and entertaining technology to “assess” or “scan” your feet with lasers or infravision … anything at all that will distract you from their lack of skill and real knowledge.
Unfortunately, many orthotics sold to consumers may not be worth more the clay the mold was made from. The effectiveness of orthotics is uncertain no matter who prescribes them, which I’ll get into below. Most “custom” orthotics are mostly just pieces of plastic that fit your foot. Maybe. None of the common methods can even create an accurate fit reliably! Pedorthists and orthotists have the best chance of providing a useful prescription. Only pedorthists are trained in both gait analysis, lower body anatomy and biomechanics and the actual fabrication of custom foot orthoses.2 All other professionals are obliged to order orthotics from an external supplier.
Most physical therapists or chiropractors selling orthotics usually ask a client to make footprints in foam in a box, fill out a form specifying features of the insert, and then ship the foam off to a manufacturer who sends back some shoe inserts. Like lasers at the mall, these procedures may create the illusion of a “customized” product, but it’s mostly just a piece of plastic that fits your foot. Maybe. None of the common methods can even create an accurate fit reliably!3 Let alone one that is corrective or therapeutic in any way. Such “prescriptions” are extremely common practice, but wiser and more ethical practitioners wisely shun them. This massage therapist described to me how she refused the sales pitch:
A few years ago I had a phone call from a company that was trying to sell me a franchise to sell and fit orthotics. Apparently I could make very good money doing this. I’m a massage therapist and I think I have a better-than-average knowledge of feet and gait, but I do not consider myself qualified to fit and sell orthotics. No fear, the company representative said they would send someone to train me — for half a day! The sales person seemed to be astonished that I turned down this wonderful opportunity. I prefer to refer my clients to a person who is qualified to do this work.
Good for her. But many professionals jump at this dodgy chance to make more money.
Most consumers assume a foot doctor is a good source of orthotics. Unfortunately, this is far from guaranteed. Many podiatrists are qualified for it, but probably most are not, as suggested by this rather chilling story from Dr. Michael “America’s Podiatrist” Nirenberg:
A middle-aged woman arrived at my office last week complaining of heel pain and carrying a bag of custom-made foot orthotics (orthotics are custom made arch supports that are fabricated from a mold of the patient’s feet). Each orthotic this woman had with her was expertly fabricated by a different podiatrist and yet none of them had come close to alleviating her heel pain. At first I thought maybe these podiatrists didn’t know what they were doing. But, when I learned their names, I knew this woman had seen competent, skilled and reputable physicians.
I asked myself “how could this be?” More interestingly, no two sets of orthotics were even remotely alike. Further, given that nearly all podiatrists learn similar principles of biomechanics, shouldn’t orthotics for a given patient be the same regardless which podiatrist makes them?
Dr. Michael Nirenberg, in his review of a book by Dr. Benno Nigg, Biomechanics of Sport Shoes: The Disturbing Truth About Running Shoes, Inserts and Foot Orthotics
A podiatrist is a full physician, but specializing in foot problems. In Canada and the United States (most familiar to me), his or her expertise is primarily concerned with foot pathology and corrective surgery, and does not always extend to include expert gait analysis and physical assessment of biomechanical dysfunction of the lower limb as a whole. Obviously some podiatrists cultivate an interest in this, and there are some prominent experts in the field who have really gone this direction, but they are not obliged to do so.
You could say that it’s not in their job description.
Most podiatrists outside of North America are probably a different matter.4
In any case, even a podiatrist skilled in the prescription of custom foot orthoses is still obliged to have them manufactured by someone else. For this reason alone, many podiatrists prefer to refer their patients to certified pedorthists.
The supply dramatically exceeds the real demand. However, there are four common conditions that orthotics have the most potential to help:
Other conditions that might be treatable include patellofemoral knee pain, shin splints, achilles tendonitis, and bunions, as well as numerous systemic pathologies that (like diabetes) affect the function of the lower limbs.
Repetitive strain injuries are common and difficult, and they are probably the main thing that gets most people wondering if they need some orthotics. This is based on the flawed notion that RSIs are caused by flawed biomechanics.
While biomechanics may be a factor, the main problem with most repetitive strain injuries is, strangely enough, repetitive strain — that is, your body parts would likely be feeling the strain even if you were biomechanically flawless.
There can also be much more exotic factors, like the genetics of healing mechanisms, that trump everything else — that is, some people will get Achilles tendinitis if they so much as go for a walk, whereas some people can run marathons for decades without any tendon trouble. These sorts of things are all explored in great detail in my free repetitive strain injury tutorial. All I want to get across here is that treating RSI is definitely not just a case of “fix those biomechanics!” It’s much harder to know if RSIs can really be treated with orthotics than you probably thought.
But it gets even worse.
A lot has to fall into place before orthotics can possibly work. Even if you do have a biomechanical glitch at the heart of your RSI:
If you can’t tick off one of those, the game is up: orthotics aren’t going to work out. It all adds up to a very long shot.
And yet orthotics could still be worth trying — particularly if you do have a fairly obvious biomechanical problem. Good orthotics are a reasonably good way of trying to “tinker” with any gait or postural dysfunction that may have contributed to your pain in the first place. For instance, unusually high arches are a plausible factor in runner’s knee.5
Orthotics certainly seemed to be a good option for me. I have an obvious biomechanical problem in my right foot.6 It’s just the sort of biomechanical bogeyman you might be tempted to blame for my own nasty history with iliotibial band syndrome. Surely that gimpy turned-out leg made me more vulnerable to IT band syndrome?
No, not as far as I’ve ever been able to tell: my own IT band syndrome was always quite symmetrical, never much better or worse on either side, with or without orthotics. And after years of being recovered, I’ve never had a recurrence of IT band syndrome, on either side.
But it was worth trying. The orthotics did help my chronic low-grade plantar fasciitis in that foot, and the experiment was fairly cheap (compared to, say, a year of chiropractic adjustments) and safe. So why not? If you have foot or leg or knee pain, by all means seek the opinion of a certified pedorthist. Even if orthotics are not likely to help, he or she may recommend a shoe type that may be more appropriate for you — a factor that is often overlooked.
Sadly no, probably not, and for all the same reasons that they aren’t exactly a magic treatment bullet. You should definitely be skeptical of any sales pitch for orthotics or custom shoes if you have no particular problem to solve. Many orthoses are sold with the promise that they will prevent injury. Even if prevention is not the main reason for the prescription, it is often thrown in as a bonus reason to buy. But it has been tested, with poor results.
In 2010, researchers assigned running shoes based on the plantar shape of the foot for Marines going through basic training.7 One group of several hundred was provided with motion control, stability, or cushioned shoes for plantar shapes “indicative of low, medium or high arches.” A comparison group got a “stability shoe” that was not customized for plantar shape. Injuries during the 12 weeks of training were analyzed. The disappointing conclusion?
…assigning shoes based on the shape of the plantar foot surface had little influence on injuries.
That seems quite clear, but science is messy: I got a firsthand account from one of the study subjects, explaining that they also spent most of their time in army boots, not their special shoes. That taints the study for me, but there are also other reasons to believe the conclusion. Like the fact that decades of “fancy” runnings shoe has had no apparent impact on injury rates in runners.8
Maybe a more precise prescription could produce a different result, but the kinds of orthotics tested are certainly strongly representative of how and why most orthotics are prescribed.
More expensive running and walking shoes all try to absorb shock in various ways, and then there are also specific designs intended to correct or compensate for common biomechanical issues like pronation. Most of these designs and features are all about injury prevention, and this hope is behind countless gimmicky, expensive shoes with no clear benefit for consumers.9 Running injuries are just as common as they were decades ago, despite all the fancy footwear, and typical “prescriptions” of running shoes — the kind you can get from an “expert” shoe seller — are definitely not evidence-based.10
But there may be some hope for technical shoes. One of the more promising and instructive examples I know of is OESH Shoes, the creation of Dr. Casey Kerrigan, who left a promising career in biomechanics research to make shoes for women. Her goal wasn’t so much to build a shoe that would “absorb shock” as to change gait by simulating running on a springier surface. More spring in the shoe means less spring and bending in the joints.11 This is an interesting and clearly science-inspired shoe. We know that runners are amazingly good at adapting to changes in surface rigidity,12 and a similar spring-sole design was tested in 2017 and found to reduce lower limb muscle forces.13
Whether such shoes actually prevent injury is another matter entirely, and no one knows that yet. But at least it’s a good idea, which is more than we can say for an awful lot of competing products.
For contrast, I submit exhibit B, one of the least promising examples of a special shoe: minimalist running shoes, the ones that look like feet, such as Vibram FiveFingers. The idea here is to remove any form of shock absorption at all and let feet do their job as nature intended, “paleo” running shoes, really just an extra layer of synthetic skin. If humans evolved to be good at distance running — and we probably did14 — why mess with a good thing? This fad has actually been studied enough in the last few years that we more or less know the answer now: it doesn’t prevent running injuries. At best it simply changes the kinds of injuries runners get, and at worst they get hurt more.15 For detailed analysis of this topic, see my article, Does barefoot running prevent injuries?
Or, read more about shock absorption and the risks of running on pavement. The short version: we still don’t actually know if it is risky, and nothing you can put between your feet and the road has yet been shown to reduce whatever modest risks there may be.
Orthotics are not risk-free. The risk is not large, and so not much needs to be said about it. However, good or bad, they can be difficult for a body to adjust to, disrupting fine-tuned postural adaptations and forcing awkward new ones.
I had a pair of hiking boots that I really wanted to love: beautiful, expensive boots that seemed to fit perfectly, and so sturdy. It was liking wearing cozy tanks! But they also consistently made my right foot ache about 20 minutes into every hike in a way that no other boot or shoe ever had before, or ever has since. Those hiking boots consistently made my right foot ache about 20 minutes into every hike in a way that no other boot or shoe ever had before, or ever has since. I kept those boots for years, trying them hopefully each hiking season. The pain was as as reliable as sunrise. Who can say what it was about those boots? What subtle interaction with my body? Nearly impossible to diagnose, I imagine. It was trivial but inevitable.
I’ve seen numerous examples over the years where orthotics seemed to have this kind of effect — just a temporary wrench in the works. In the worst cases, people simply ditched the orthotics and the problem was solved.
I think every pair of orthotics is a minor gamble with some potential to help … or do what those boots did.
To wrap up, let’s get back to the subject of pedorthists: the professionals you should seek out if you’re still wondering if you “might need orthotics.”
Certified pedorthists must have a relevant degree, spend at least three years in apprenticeship, and then pass demanding exams. That entire period of work experience is devoted to the lower limb, and to the ankle and foot in particular. There are even more advanced professional designations for pedorthists as well.
“The Pedorthic profession in Canada is moving in a great positive direction with integrity, attracting only University educated individuals to become certified pedorthists,” says Paul Rauhala of OKAPED in Canada’s Okanagan Valley. That training translates into an impressive experience for the patient: I have been a patient at OKAPED in the past, and was blown away by the thoroughness and technical expertise of their assessment, which included slow motion video. My own limited training in orthopedic assessment gave me just enough knowledge to realize how much more Mr. Rauhala knows about it than I ever will — in the leg, anyway!
C.Peds and COs are not the only sources for good orthotics, but I think they are the most likely to work out. If any other health care professional wants to sell you orthotics, please ask them to refer you to a certified pedorthist instead.
Or find one yourself! In Canada, go to the website for the Pedorthic Association of Canada. In the United States, the Board for Certification in Pedorthics. You can easily Google similar associations in other countries — wherever pedorthists are practicing, they will have an association, a website, and practitioner information.
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
Five updates have been logged for this article since publication (2002). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more
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I log any change to articles that might be of interest to a keen reader. Complete update logging started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.
See the What’s New? page for updates to all recent site updates.
— Miscellaneous improvements to the section about special/technical running and walking shoes.
— Minor clarifications about pedorthist scope of practice.
— Added a good quote about inconsistency in the prescription of orthotics.
— Added valuable new reference to Telfer et al.
— General editing and significant expansion.
Foot orthotics are made from basic measurements and captured images of the foot (plaster casting, foam box impressions, or three-dimensional computer images). None of these techniques is very accurate (<80%), especially with measuring the peak arch height. Skilled 3D computer imaging may be the most accurate. Basic measurement is particularly inaccurate.BACK TO TEXT
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Undergraduate training around the world doesn’t go so far as the US in surgical training. It’s an option in other countries, but greater training is required. So most Pods here tend to be more biomechanically focussed, and more interested in a holistic approach to musculoskeletal health. We have the option of surgery, but it requires considerable post graduate training. My own training allows me to undertake superficial surgery (i.e. for ingrown toenails, removal of warts etc), but that only makes up a small amount of my practice.
Dr. Mark Heard, Podiatrist D.App.Sci, M.A.Pod.A., from personal correspondence
Terrific short myth-busting interview with a running, shoe and biomechanics expert — who is (delightfully) a bit cranky about “so many wrong ideas out there.” It’s all too rare to see this kind of sanity-inducing, hype-reducing talk on this topic.From the article, quoting biomechanics expert Benno Nigg:
Nigg has noted that running injuries have not changed over the years despite the massive development of the running-shoe industry. Unlike others, he hasn't jumped to the conclusion that shoes are bad, or that barefoot or minimalist-running or forefoot-striking is the answer. Instead, looking at the same data, Nigg concludes: Okay, apparently shoes aren't a big part of the equation.BACK TO TEXT
This simple experiment showed that runners adapt to changes in the hardness of the surface they are running on with amazing speed — just a single step — as measured in terms of maintaining the height of their centre of mass. Importantly, this nearly instantaneous adaptation only occurs with an expected change on familiar surfaces, but we are probably pretty quick with unexpected and unfamiliar surface changes as well.BACK TO TEXT
I waited a long time for this one: at last, the first prospective comparison of injury rates in shod versus barefoot running. All research on this topic until now has been unable by design (methodologically inadequate) to answer this question, and so for many years now we’ve endured tedious argument about injury rates based on the wrong kind of data. “Prospective” is what we needed the whole time: following a bunch of initially uninjured runners of both types to see what happens to them.
For this test, 200 experienced runners were studied over the course of a year: 94 wearing shoes, 107 with no shoes or (for about a quarter of their mileage) “true minimalist shoes.” The barefooters had been running that way for at least six months, and more than 18 on average, so they weren’t in that awkward transition phase where injury rates could well be higher.
The results are clear and unsurprising: there was no important difference in injury rates, just the kinds of types of injuries. Each is better in some ways, worse in others. Although the paper emphasizes “fewer overall injuries” for barefoot runners, injury rates are what matters — the number of injuries per 1,000 miles, say — and they were “not statistically different between groups due to significantly less mileage run in the barefoot group.”
But there’s an extremely important caveat, and it does not flatter barefoot running: the barefoot running volume was just 24 kilometres a week, while runners in shoes ran nearly twice as much — 41km — without an increase in injury rate. Although this is all made clear in the paper, it’s strange that it wasn’t more strongly emphasized. As Alex Hutchinson put it for Runner’s World, “The only way the comparison has any relevance is if they’re arguing that barefoot running reduces injuries by preventing you from running as much as you’d like.”
Naturally, a larger, longer study may have different results. But this is an excellent start, and we can now say with high confidence that barefoot running is not a panacea for running injuries.BACK TO TEXT