Orthotics 4 Foot and leg Pain

Because prescription orthotics are custom made to the individual there is an almost endless variety of orthotics that can be fabricated along with an abundance of additions that may be added to the orthotic in order to accomplish a certain goal.

Custom orthotics are divided into two groups. The first is known as an accommodative orthotic. The purpose of an accommodative orthotic is to “accommodate” a particular lower extremity problem and not necessarily try to correct or eliminate a problem. An example might be someone with a very arthritic foot or perhaps a diabetic with very sensitive feet as a result of the disease. In these examples the orthotic would primarily cushion and secondarily support the foot. By cushioning the foot a lot of the pain associated with walking can be alleviated.

These are not the only uses for an accommodative orthotic but it gives you an idea of their purpose.

accommodative orthotics


Accommodative orthotics are made out of a variety of materials ranging from very soft and spongy all the way to a combination of some rigidness in the inside of the orthotic with softer materials on top and bottom to aid in comfort and shock absorption.cork and leather accommodative orthotics

One of the functions of the foot is to absorb shock as we walk from point A to point B. In many individuals this does not occur either due to their inherent foot structure or to disease states that have affected the foot. In these instances an orthotic can make up for this loss of shock absorption. 

The accommodative orthotic does this in two ways. One is in the materials which go into making the orthotics. When the heel hits the ground and then lays flat on the ground in the gait cycle, cushioning materials will aborb some of the excess shock that is created. 

The second way in which an orthotic absorbs shock is the way an orthotic may change the pitch of the heel when it first hits the ground. Rearfoot posting is an addition that is added to the orthotic to allow the heel to hit the ground in a more acceptable position. This new position (differing from the patient’s natural way of hitting the ground) allows the foot to better absorb shock and this absorption of shock can reduce problems not only in the feet but all the way up to the lower back. 

There is a saying in medicine that “structure follows function”. What this means is that if there is an abnormal function in the way the musculo-skeletal system functions, in this case the foot and leg, then the structure (skeletal system) will adapt to it and in adapting to it I mean in an abnormal fashion. So as we age the musculo-skeletal system becomes more rigid in the sense that there is less range of motion in the joints, our muscles are less flexible and the ligaments in our body become more taught.

Any of you reading this who are over the age of fifty, know what I am talking about. It seems it takes us longer to get moving in the morning from the stiffness that develops during the night, or even after being seated for a long period of time. So, along that point, my personal feeling is that most older individuals who require orthotics generally will require accommodative orthotics because they are more “forgiving” than the rigid orthotics we are also going to discuss.

Is there a drawback to accommofative orthotics?  Because of the need to have a lot of cushioning, these devices tend to be on the bulky side compared to the "plastic" orthotics.  That means there will be a limitation in the shoes that people may wear with accommodative shoes.  In general, they will fit very nicely in sneakers after removing the inner sole and will do well in conservative laced shoes.  They will not fit very well in loafers, women's dress flats and certainly not in dress heels.  In this day and age, many orthotics labs are able to make accommodative orthotics that have less bulk to them, but still, it will be difficult to get them into anything but a conservative shoe.  It is also worth mentioning that orthotics in general will only work in shoes with a back to them.  In other words clogs and sandals are not a good shoe choice when wearing orthotics.  Having said that I have seen patients over the years wearing their orthotics in backless shoes.

functional orthotics

The second type of prescription orthotics that we are going to discuss are known as functional orthotics.  This orthotic attempts to solve a foot or leg problem by altering the biomechanics of the foot.  What do we mean by this?  The orthotic, based on the way it is constructed, will alter the gait of the patient in an effort to allow them to walk in a more acceptable gait pattern.  Depending on the medical condition being treated, the altered, more normal walking pattern should alleviate the medical issue.

People that end up in functional orthotics, in broad terms, are those that have feet that either flatten out too much in their gait cycle, or those whose feet have no flattening motion which is also a bad thing.

functional orthoticsSo, a functional orthotic once again essentially brings the ground up to the foot so that the foot can function in a more normal fashion thus eliminating abnormal stresses that would otherwise be placed against the foot, ankle or leg.

Unlike accommodative orthotics, functional orthotics are usually made out of more rigid materials which "force" the foot into a certain position during gait.  Going back to  "structure follows function", wearing rigid orthotics may be an issue with older individuals.  If your feet have been functioning in a certain position all these years, attempting to change that position with an orthotic that has no give to it may end up causing problems.

In an effort to solve the problem of too much rigidity in an orthotic for older individuals, most orthotic labs now offer plastic type orthotics with varying degrees of flexibility to them.  Thus, by using a more forgiving plastic, it is possible to put older individuals in functional orthotics.

Because the plastic shell is much thinner than lets say an accommodative orthotic made out of compressed layers of cork or rubber, the functional orthotic ends up being thinner than the softer orthotics.  The slimmer make-up of the orthotic gives the wearer more flexibility in shoe selection.  This still does not mean high spiked heels but many functional orthotics can be made to fit in men's loafers and women's dress flat and low heel pumps.

sporthotics

The orthotics that you wear in your every day shoes is not necessarily the ones you should be wearing when you participate in sports. Stated the other way, some people only need orthotics when they participate in athletics as you will see as you go through the various conditions for which a person may require an orthotic.

Typically, a sporthotic is much like a functional orthotic in its construction.  Because the main component of the orthotic, the shell, is made of a plastic polymer it will tend to hold up to the rigors of sports, particularly running for which most sporthotics are ultimately made.

functional sporthoticsOne could argue that running is actually fast walking and although that is not totally correct (there is a difference in gait), the stress and impact of running on the feet exaggerates any deficiency in foot biomechanics that a person exhibits.  So a sporthotic obviously attempts to hold the feet in their "neutral" position relative to the leg all the time being able to withstand the pounding that an athlete will place on the orthotics.

This is not to say that accommodative orthotics cannot be used for sports activities as I personally prescribe them to primarily older patients who have foot issues that are better served with accommodation rather than a functional repositioning of their feet.

dressthotics

At some point in time the issue of trying to get an orthotic into a dress shoe is going to come up. Lets face it, there are men and women that have to wear high style shoes on a regular basis. I should also mention it is these high style shoes that can be the source of their foot problems to begin with.

Nevertheless we are faced with the problem of trying to get the foot and an orthotic into a very confined space.  This is no easy task.

So along came dressthotics which as the name implies is an orthotic for dress shoes.  This can be a very effective means to treat some but not all foot conditions.  In these instances it can come down to just how much foot pain the patient is experiencing.  If an orthotic is the treatment the patient wants as opposed to surgery, physical therapy, or medication, then the patient is going to have to make some decision as to the type of shoes they are willing to wear.  I always tell my patients that I prefer to be their podiatrist and not their fashion consultant, but, I am also not a magician and they will have to work with me to solve their foot or leg pain.dressthotics

A dressthotic as the picture shows is a thinner narrower version of a functional orthotic with a lot of the "functional" missing.  Any time you have to thin out and minimize the size of the orthotic to get it to fit in a shoe, you also end up minimizing its effect.  That is why I only recommend dressthotics in certain conditions because in others, I know they will tend to be ineffective.  This is so much the case that in most instances, particularly with women who wear very high style shoes, I will recommend an off the shelf dress orthotic because I do not believe we are giving up much compared to the prescription version and of course they are a lot less expensive.

When talking about dressthotics for women's shoes I mean dress flats and low heeled shoes.  For those women who insist on wearing high spiked heels, there is virtually nothing that can be called a true orthotic and fit into those shoes.  If someone tries to sell you an orthotic for a high spiked heel, if it is a few dollars you have nothing to lose by trying it, but in general they tend to be worthless.


childrens orthotics

I guess you can argue it is never too early to start when it comes to orthotics and so, yes, there are orthotics for children.  It is important to note that all children start out with flat feet, so just because a foot is flat in a very young child it is no reason to put them into orthotics.  Twelve months is the average age for a child to start walking and most of them will exhibit flat feet and will walk with an abductory gait (feet facing outward) to better balance themselves.  This is all normal.  As time passes their gait will straighten out in the vast majority of children. childrens orthotics 

There are however, some children who will continue to exhibit an abnormal gait and an orthotic may be the answer for them.  Children's orthotics can be designed to "force" the foot into a different position in order to allow the child to walk more normal.  This type of orthotic usually is of a prescription nature.

If the pediatrician, podiatrist or orthopediist feels a childs developing feet would benefit from an arch support, for what ever reason, then an off the shelf type is usually a better investment for the simple reason that the child is going to quickly outgrow them and will require a larger pair.

Childrens orthotics are almost always made out of very rigid material in an effort to place the feet in their maximum favorable position.  Unlike older individuals, a child can usually tolerate the rigidity.

ankle foot orthosis (AFO)
Richie Brace

There are some conditions where not only is the issue a problem within the foot, but the ankle as well is involved. The goal of an ankle foot orthotic is to re-balance the foot and to create a better alignment between the foot and the ankle.  Particularly in instances of severe flat foot which over the years has adversely affected the alignment of the ankle relative to the foot, simply trying to raise the arch of the foot will not be enough.

Because the goal is to better align the foot , the ankle, and the foot to the ankle, these devices generally have to be prescription made.  Especially in severe cases of flat foot and resultant ankle arthritis the need for accuracy in the device is paramount in order for the patient to stand any chance of pain relief.

People who end up in an ankle foot orthosis generally have real foot issues and for whatever reason are not surgical candidates.  They do make off the shelf ankle foot orthosis and although I suppose there are some instances where they can be used, people who have chronic foot and ankle issues will tend to do better in a custom made device.

              what if prescription orthotics are not in your budget?

The cost of prescription orthotics may be prohibitive to many people. In this day and age, fewer and fewer insurance companies are covering orthotic therapy.  That leaves you with two other options.  

The first is to buy an arch support in the supermarket or drug store.  The problem here is that most devices sold in these places tend to be very bulky and not very supportive, which for many conditions other than perhaps "tired feet" make them essentially useless.  As you will learn from reading about the various conditions discussed on this site, if you are going to try orthotic therapy to alleviate your problem, adequate support is the primariy goal with cushioning second.

Fortunately a few years ago, orthotic labs around the country realized the problem for those who could not afford, or perhaps did not need a prescription device and solved it by manufacturing medical grade off the shelf orthotics.  These are pre-made devices but unlike store bought arch supports, these orthotics are made out of prescription grade orthotic material, so their primary goal is to support and cushion second.

As I go through the various medical conditions where an orthotic may be beneficial, I will also review the types of orthotics available and whether or not each of them can be helpful.  Yes, you could argue that a prescription orthotic should be helpful for all conditions and you would be right, but, I would argue that there are a number of conditions where a prescription orthotic may not be neccessary.


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MEDICAL GRADE ORTHOTICS

best buy in pre-made orthotics for sneakers, work boot and casual lace shoes

KLM SuperStep Orthotic    

best buy in pre-made orthotics for womens flats, low heel pumps and mens dress shoes

Redithotics 3/4

medical grade off the shelf childrens orthotics because kids outgrow orthotics so quickly

childrens orthotics



Copyright © 2013. All Rights Reserved.Marc Mitnick DPM