Prescription shoe inserts
have been used by physicians for over thirty years to provide stabilization and support to feet whose structure and shape cause numerous painful foot conditions. These devices work based on concepts developed by research begun in the 1960s to understand how the foot functions mechanically, and how that function can be altered to treat foot pain. This article discusses how these orthotic devices work, and how they differ from store-bought inserts.
Many cases of foot pain and deformity can be directly linked to variations in one's foot structure from what is considered 'normal'. Typically, these variations are composed of either flat feet or high arches. Of the two, the flat foot type is the most common amongst foot variation in the United States. There are numerous causes for these variations, and nearly all of them are genetic. Whether or not one is flat footed, normal, or high arched has much to do with the shape and position of a joint under the ankle joint called the subtalar joint. This joint is the connection between the bottom bone of the ankle (talus) and the heel bone (calcaneous). This joint allows for the foot to pitch and roll back and fourth, as it flattens and curls inward. These motions are respectively known as pronation and supination. When there is an excessive tendency of the foot to go more towards one direction or the other, pain and foot strain can develop. This is a result of excessive strain (flat feet) or poor shock absorption (high arches). Due to these strains, immediate conditions can develop like plantar fasciitis (heel pain), tendonitis, neuromas (pinched nerves), tarsal tunnel syndrome (similar to carpal tunnel syndrome), and increased sprain tendency. Long-term conditions also develop over time as a result of the abnormal foot structure, including bunions, hammertoes, corns, calluses, and arthritis. The foot is incredibly complex, and individual parts adjust and accommodate to the excessive motion. This adaptation of the rest of the foot can create problems of their own, and contribute further to many of the above listed conditions.
With proper control of the abnormal foot structure, many of the above listed conditions can be controlled, and even prevented. Unfortunately, it is not as simple as placing a wad of padding or mass produced plastic into the arch and assuming the foot's structure will be effectively supported. This technique will do in a pinch, and can help to improve some conditions, including mild heel pain and arch fatigue. High arched feet in particular may benefit from simple store-bought padding as the shock absorbing properties of these products are sufficient to help with many symptoms related to high arches. For exacting control, and especially to control flat feet, a prescription device made of a plaster molding of the foot is the better option, and the only way to slow the progression of certain foot deformities that need exacting structural control. A good analogy is comparing prescription orthotics and store-bought inserts to prescription eyeglasses and drug store brand reading glasses. Sure, one can 'see' better with only the reading glasses up close, but a near sighted person will have no way of correctly seeing a billboard down the road without prescription eyewear. Store bought inserts will help the foot feel better at first, but after awhile 'in the distance' their effectiveness will be minimal. When such store bought inserts are made of hard plastic, foot problems can potentially become much worse. Unlike molded plastic prescription orthotics, hard plastic inserts in stores and insert chains are not made of a mold of the foot, and are simply constructed to meet a general size of foot. Every foot is different, and the hard plastic of these inserts potentially can press into the foot in sensitive areas, leading to eventual discomfort. Because a prescription orthotics is made from a mold of the foot, the hardness of it's plastic (or graphite in some cases) will fit the foot contours exactly, and no discomfort will be felt. The difference lies in how the orthotic mold is created. The traditional cast molding technique (and still the most accurate) involves holding the foot in such a way that the subtalar joint is positioned so that it is neither pronated nor supinated. This is called the neutral position. The ball of the foot is then lined up to be perpendicular with the heel. The cast dries, is removed from the foot, and then is sent to a lab for manufacture. The written prescription for this device is made to reflect any additional changes that must be made to the eventual orthotics based on a foot exam and measurement of various angles. Some people have special foot shapes and joint positions that need a little more modification to the usual orthotic mold, and this is where the expertise of the podiatrist prescribing the orthotics becomes vitally important. There are other molding techniques that can be performed, but many of these techniques have problems with getting an accurate representation of the neutral position of the subtalar joint. Some of these techniques, like foot scanning, rely on computer estimation of the subtalar position. This does take away some error on the part of a person making a physical cast mold of the foot, but it is still a computer estimate that is prone to its own error. Other techniques, like stepping in foam molding in a box, yields a poor subtalar neutral position because this joint can't be easily controlled by a second person doing the molding when one is placing weight on their foot.
Once the mold is made and it is sent to an orthotics lab, the finished orthotic is produced and dispensed to the patient. Although most people can wear these devices all day from the first day, some people with significant foot structural weakness need to gradually break them in, as the foot needs to strengthen and adapt to walking with more support. Over one to three weeks a person needs to gradually wear the orthotics longer and longer each day until the orthotics are completely comfortable. One needs to be aware that using orthotics for many years does not change the foot structure internally to the point that orthotics will be no longer needed, as only reconstructive surgery will change the overall foot structure permanently. This is similar to eyeglasses, of which the use over time will not improve vision. Eyeglasses only correct vision when they are worn, much like orthotics only support feet when they are worn. This will not change over time. However, they are an easy device to move from shoe to shoe, and they should be durable for many years until (and if) the foot structure gradually changes enough that the old prescription is no longer helping. At that point, a new molding may be needed. For most people, this is at least ten years down the road.
Prescription orthotics obtained from a podiatrist are an effective way to control abnormal foot structure that allows numerous foot injuries and deformities to occur. They are not a cure-all, and in some cases simple store bought inserts will do just fine. When properly fabricated and used, an orthotic can prevent or stabilize numerous foot issues, and should be an important tool in the treatment of foot disease.
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