Should I be wearing foot orthotics?
Will they help my joint pain?
You may have asked yourself these questions. I did. After my third knee surgery, I pursued orthotics with my orthopedic surgeon. And, although he didn’t seem convinced they would help, he did write me a prescription, and I soon had custom inserts in my shoes.
Did they help? I’m not sure. I didn’t have any more knee surgeries but did need a hip arthroscope two years later.
Pete Egoscue, founder of the Egoscue Method®, has a strong opinion about orthotics: “Inserts may make the feet seem more comfortable, but they do nothing about the continued stress in the ankles, knees and hips.” This was probably true for me. All I did was put orthotics in my shoes and hope for improvement. I didn’t address the underlying postural misalignments and functional issues that caused the breakdown in my knee in the first place.
Left untreated, these additional imbalances throughout my body--over exaggerated spinal curves, uneven back muscle tension, excessive forward pelvic tilt and twisting, uneven shoulder position, torso and ribcage rotation, jaw misalignment--soon affected my hip. Slipping a piece of foam under my foot without retraining my muscles, nerves, connective tissue and brain couldn’t possibly control my asymmetries and distorted movement patterns. So, not surprisingly, the orthotics didn’t help me avoid further joint deterioration and another surgery.
When I started practicing the Egoscue Method® for pain relief after my hip surgery, I ditched my orthotics. Why not? They didn’t seem to be helping anyway. The Egoscue® philosophy is to build strength and stability of the foot position from the inside out. My therapist advised me not to rely on an external device (orthotic) to improve my position and function. Rather, I needed to retrain the chain of muscles and joints that were causing the foot to be in a poor position. Additionally, I was to do my corrective posture exercises with minimal foot support, i.e. barefoot. I made good progress with this approach but eventually plateaued in my recovery.
Last year, I began attending Postural Restoration Institute (PRI) courses and working with a physical therapist trained in the technique. At the first two courses I attended, the instructors commented about my minimal shoes; noting that they were not appropriate for me. My therapist concurred. So, I soon bought more supportive running shoes that became my daily uniform. Arch inserts were added, and eventually I had custom PRI orthotics made. From orthotics, to toe shoes and barefoot running, and back to orthotics--I’ve come full circle.
How our feet contact the ground creates a chain reaction throughout the body from the foot to the head. This chain-reaction concept was introduced by Gary Gray, PT and founder of Applied Functional Science®. Orthotics, therefore, are used not only to treat symptoms of the foot and lower leg but pains all the way up the body to the neck and jaw. In Gray’s words, “The whole reason to create an environment such as an orthotic for the foot is to enhance the body. [...] Orthotic is a tweak, that’s all it is. It’s a way to change the angle of the ground and change the reaction of the body via the foot via the knee via the hip so the body can actually be more functional.” A foot orthotic changes the way that forces are directed into the joints above. This can reduce strain and pain throughout the body--but only if the orthotic is made correctly and proprioception--your ability to sense how your foot is contacting the ground--is simultaneously improved.
What’s different about my PRI orthotic and why should it work any better than my previous one?
First of all, my PRI orthotic was made with my foot in a neutral, non-weight bearing position. This means my ankle bones--calcaneus and talus--which make up the subtalar joint, along with the surrounding muscles and tendons, were in correct alignment. Please refer to the Wikipedia image below.
The subtalar joint initiates rotational movement of the foot, what is often referred to as pronation (foot rolling inward) and supination (foot rolling outward). By casting the foot in a neutral position to create the PRI orthotic, excessive rotation of the foot is reduced. This is important because rotation around the subtalar joint creates instability in the foot. An orthotic is designed to stabilize the foot, which is dependent on the muscular compression across the subtalar joint. This stabilizing compression can only be generated when the bones and soft tissues are in correct alignment.
According to Paul Coffin, DPM and creator of PRI orthotics, “Most biomechanical experts are in agreement that stability of the foot is created by compression across the joints, and instability of the joints in created by rotational motions around the joints. The appropriate relative position of the bones creates compression across the joints stabilizing the foot.”
When my first orthotic was made my foot was not in a neutral position. I was standing when my previous impressions were taken. Standing on my foot with the influence of gravity and body weight allowed my foot to overpronate and become unstable. Hence, the orthotic, which had been made from a mold in which my foot was overpronated, would not stabilize my foot and improve the function in my joints above. One of the main goals of PRI orthotics is to stop overpronation early, not allowing the foot to roll excessively inward when the foot contacts the ground in walking or running.
When the foot pronates or supinates, alignment between--calcaneus and talus--is lost. When these bones are out of position with each other, the surrounding muscles are also compromised. Lacking a good position, the muscles are unable to compress down and stabilize the subtalar joint between the foot bones, leaving it unstable. Foot instability creates twisting in the lower extremity; as a result, the foot, ankle and knee are no longer in alignment and are no longer going in the same direction. My PRI orthotic holds my foot bones in alignment so the lower leg works as an integrated unit. The position of the lower extremity influences muscle activation patterns during walking (gait).
Coffin puts it this way: “The central nervous system recruits muscles during the gait cycle in a learned pattern. This pattern is dependent upon the function of the lower extremity, and the relative position of the bony structures. The recruitment of muscles will be different in a foot that is excessively pronated throughout the gait cycle than in a foot that is more appropriately aligned.” In other words, when the foot it appropriately aligned, the central nervous system will respond accordingly. That’s the goal!
As an example, when my arch collapses due to overpronation and I don’t sense contact of my big toe to the ground when I take a step, I struggle to engage my big, powerful gluteal and hamstring muscles, and I overuse my calves. However, when I wear my PRI orthotics, my arch is supported and I am able to contact my big toe without overpronating and activate my leg and butt muscles in the appropriate pattern. Yeah - nervous system!
While wearing my minimalist shoes, I had no control over the alignment of my foot bones and was overpronating with each step. I could not find and feel the correct muscles to use for good gait mechanics. Therefore, I developed strong compensations in my movements that took a toll on my knee and hip above. My new PRI orthotics, along with targeted exercises and enhanced sensory awareness of my foot position, have allowed me to become reaquainted with muscles and function long forgotten. The orthotics enabled this progression which wasn’t possible with my prior unsupportive shoes and foot position.
Properly constructed orthotics can be helpful to realign the foot and improve function. Foot orthotics impact the soft tissue and joints in the chain above. Orthotics are most effective when used in combination with corrective exercises that retrain muscle mechanics. Although an orthotic can improve foot position, attention still needs to be paid to how the foot is contacting the orthotic in the shoe. I had been wearing my inserts for several months before it became apparent that I was struggling with some exercises because of my lack of awareness about how my foot was being weighted. I had assumed the orthotic would fix everything and I could disregard my foot mechanics. Wrong! I still needed to be able to feel my heel, big toe and arch (PRI reference centers) while wearing the orthotic. As I found out, I could still cheat and fail to engage the correct muscle patterns by not appropriately feeling important reference centers in my feet during my exercises.
Are my PRI orthotics helping? Yes! I have overcome previous plateaus and continue to feel stronger and move with less pain and greater function. Are PRI orthotics or any type of shoe inserts right for you? Perhaps. Every foot is unique. If you have been suffering with long-term chronic pain and haven’t addressed your foot mechanics, it is something to consider. Work with your local medical provider or find a PRI provider in your area.
Take care of your feet to enjoy pain free activity for years to come!