Are Custom Running Orthotics Worth the Cost

If you’ve ever been to a podiatrist or a sports medicine doctor because of a running injury, it’s likely that he or she suggested you get a custom shoe insert, or “orthotic,” made to treat or prevent injury. They often come with a hefty price, and the cost is not always covered by insurance.

This week, we’ll take a look at the science behind custom orthotics and whether they are worth the cost.

The pronation paradigm

Custom orthotics have quite the colorful scientific record. They’ve been around for quite some time, so podiatrists have developed a variety of theories on which to base the design of a particular orthotic. For a long time, orthotics were centered around the “pronation” paradigm, which, in short, held that overpronation (an inward rolling of the ankle during the running stride) was the root cause of many running injuries.

To that end, orthotics incorporated a built-up arch and a slanted heel that tilted your foot outward. The idea being that the built-up material would prevent the foot from pronating, and hence prevent or treat injuries related to overpronation. And, in the experience of many podiatrists and sports medicine doctors, they were successful. Runners came in injured, were prescribed a custom orthotic, and recovered.

But there were ruminations of trouble when biomechanics labs attempted to quantify the degree to which a particular feature (say, a slanted heel) on a custom orthotic altered a runner’s gait. Experiments were producing different results, and generally not agreeing with the predictions of the pronation theory. Furthermore, studies of running injuries were not showing a clear connection between pronation and injury.

Differing responses to to same orthotic features

These problems came to a head when Benno Nigg published a now-widely-cited paper in 2001 detailing the evolution of his laboratory’s work on pronation and orthotics.

In it, he detailed a series of studies he carried out which illustrated that individual runners had differing responses to the same orthotic features. So, while a reinforced arch and a slanted heel reduced pronation in some runners, others had little or no change, and some even exhibited increased pronation. Perhaps most interestingly, using bone pins and X-ray imaging, Nigg and his colleagues found that there is little difference in skeletal movement between shoes with standard inserts, shoes with custom inserts, and no shoes at all!1

At the same time, however, several studies were showing a beneficial effect of custom orthotics.

A 1991 survey of 347 runners who used custom orthotics after suffering an injury found that 75% reported complete or near-complete recovery, and 90% continued to use their inserts after recovery.2

A more recent investigation in 2011 similarly found that custom orthotics reduced pain and were well-tolerated among most runners.3 The evidence when it comes to specific injuries is less clear—they might hasten recovery from knee injuries, for example, but the overall recovery rate is similar between runners with knee injuries who receive custom orthotics and those who do not.4

So, is there any way to resolve this dilemma?

Nigg proposes that an individual runner’s body has a “preferred joint motion path,” which the body will always try to follow, regardless of the footwear condition. If an orthotic encourages this preferred path of motion, the body won’t have to work as hard, and muscle activity will decrease. But if an orthotic (or shoe, for that matter) opposes this preferred path of motion, the body will attempt to overcome it by activating muscles more strongly.

So, if a runner’s preferred path of motion at the ankle involves some degree of overpronation and a custom orthotic is opposing that, the body will activate the muscles of the lower leg to reinforce the preferred path of motion. This explains why changes in pronation, for example, are small and nonsystematic when comparing groups of runners using the same custom insert. Under Nigg’s theory, the body will respond to a “good” orthotic by subjectively feeling more comfortable when walking and running in it.1

Testing the individual response theory

Nigg’s theory was put to the test in a 2001 study of military recruits. Instead of giving each recruit a custom-molded orthotic as is typical of this type of study, Nigg and his colleagues provided all 206 recruits with six options, which varied in heel height and cushioning. Each recruit selected the most comfortable insert. Regardless of which shoe insert the recruits chose, they all had a lower incidence of injury during basic training than recruits who were assigned a control insert.5

So, are custom orthodics worth it?

Certainly, there are still some universals when it comes to custom orthotic design.

A runner with chronic pain under his first metatarsal head will almost certainly benefit from a shoe insert which relieves pressure on this area. And fortunately, the field of podiatry is (slowly) moving away from evaluating every foot relative to a “normal” one and instead focusing on the actual cause of tissue stress.

If your doctor does recommend a custom insert, don’t be afraid to try a high-quality over-the-counter orthotic (like SuperFeet or PowerStep insoles) at first, since they aren’t nearly as expensive as a custom orthotic, and at least one study has indicated that they may work just as well as a custom orthotic.6

But the issue of comfort remains your best indicator of whether or not an orthotic is going to work for you. If you have a foot or lower leg injury and decide to give an orthotic a shot, it should feel better, not worse, than running without an orthotic. If an orthotic feels wonky while walking or running, it’s unlikely that it will help prevent future injuries.

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References

1. Nigg, B., The Role of Impact Forces and Foot Pronation: A New Paradigm. Clinical Journal of Sports Medicine 2001, (11), 2-9.
2. Gross, M. L.; Davlin, L. B.; Ebanski, P. M., Effectiveness of orthotic shoe inserts in the long-distance runner. American Journal of Sports Medicine 1991, 19 (4), 409-412.
3. Hirschmüller, A.; Baur, H.; Müller, S.; Helwig, P.; Dickhuth, H.-H.; Mayer, F., Clinical effectiveness of customised sport shoe orthoses for overuse injuries in runners: a randomised controlled study. British Journal of Sports Medicine 2011, 45, 959-965.
4. Collins, N.; Crossley, K.; Beller, E.; Darnell, R.; McPoil, T.; Vicenzino, B., Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. British Journal of Sports Medicine 2009, 43 (3), 163-168.
5. Mündermann, A.; Stefanyshyn, D.; Nigg, B., Relationship between footwear comfort of shoe inserts and anthropometric and sensory factors. Medicine & Science in Sports & Exercise 2001, 33 (11), 1939-1945.
6. Pfeffer, G.; Bacchetti, P.; Deland, J.; Lewis, A.; Anderson, R.; Davis, W.; Alvarez, R.; Brodsky, J.; Cooper, P.; Frey, C.; Herrick, R.; Myerson, M.; Sammarco, J.; Janecki, C.; Ross, S.; Bowman, M.; Smith, R., Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciits. Foot & Ankle International 1999, 20 (4), 214-21.

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14 Responses on “Are Custom Running Orthotics Worth the Cost

  1. I recently made the mistake of allowing a physical therapist to insist on orthotics to help me deal with an Achilles issue (and, in fact, didn’t do well enough to insist that the only possible reason I’d need orthotics is to correct a leg length discrepancy, which probably doesn’t need corrected in the first place). They were horribly uncomfortable from the start, making my Achilles worse (and the PT said he “expected that”?) and causing pain in my IT band. And this was just from walking around in them. There was no way I could bring myself to run in them. And, as you suggest, insurance didn’t cover it. Biggest waste of money I’ve ever spent in regards to running.

    • Thanks for the comment, Greg. I thought of you when I read the part in the article about orthotics needing to be comfortable to work – I am glad you had the foresight not to run in them. Sorry you had such a rough experience with the orthotics and had to pay out of pocket. At least you now know that orthotics aren’t the right approach for you and can avoid them (and any PT or doctor who insists on them) in the future. Hope the achilles is coming along.

    • First off, a LLI or leg length discrepancy is a very common disorder and does in fact create a mechanical distortion of the entire kinetic chain. Think about it…would you run with only one shoe on? Of course not. Why? Because it would create an unlevel pelvis and unnecessary spine and entire body compensations due to the force passage up through the feet and down through the body due to gravity. This would result is the abnormal remodeling of bone and soft tissue over time in accordance with Davis’ Law and Wolff’s Law. With that said, there is only 1 specific way to measure a LLI and that’s via a Fergusons Sacral Base X-Ray. This is an xray taken that allows a measurement to be made of the sacral base. The sacral base is either level or unlevel and if it’s the latter you’ve got a problem, i.e, you’ve got an unlevel pelvis.

      Secondly, unless the 3-D impression of a clients foot is captured in a non-weight bearing position, calibrated to flex specific to each foot’s Gib Test rating and the individuals body weight, it’s useless. Seriously, would you make an impression of your foots deformed posture and then an orthotic to support that deformed position? Of course not. Let’s not forget that the true test of a “custom” orthotic is when the foot is moved through supination that full contact remains. In other words, if you hold your orthotic against your arch as you raise your heel 45 degrees from the ground, unless your orthotic maintains full-contact, it’s useless. Unfortunately most folks confuse a truly custom foot orthotic with a pre-fabricated, made-in-advance, pointless shoe insert instead of one created from an accurate 3-D impression of the client foot that is calibrated to match their weight, foot flexibility, and activity level! Additionally, very few “custom” orthotics are not made completely from scratch, most likely made with generic starter plates, add-on pads and/or arch filler…truly failing to meet the definition of custom.

  2. I had an experience that convinced me my orthotics were very effective. After wearing them for several years, they broke and I thought perhaps they really weren’t necessary, so I ran without them – over a period of a year I suffered a patellar tendon tear an plantar fasciitis. So I got my orthotics replaced and since wearing them again the last 2 years, I’ve had no major problems. I’ve got a fairly large leg length discrepancy but a neutral gate.

    • Thanks for sharing your story, Julia. I am in a similar situation – I have a short achilles and my foot actually “snaps back” after normal pronation, which puts a lot of stress on my calves. I can’t run for more than a few miles with regular shoes, yet I can run 140mpw (yup, that number is right :) with my orthotics in. Just goes to show that there is no “absolute” correct way to run for everyone. We have to be adaptable and listen to our body.

  3. Pingback: There’s a Gaiter in my Post! « run+breathe+be

  4. It’s interesting the differing opinions on this. A year ago I had a severe lisfranc injury involving breaks and dislocation of my midfoot, after getting my cast off I was fitted with orthotics with more support under my metatarsals. At the beginning they made a world of difference with normal walking. Without them my whole foot would ache. I’m now at a point deciding whether I need to continue wearing them or try going without. I wear them exercising and when i stand at work all day. Some people say to keep them and others that they are bad. I guess ill just try and find out! Thanks for the article :)

  5. I had a pair of orthotics customer made in December, not to cure any injury, simply my Physio recommended if I wanted to up my mileage getting a good orthotic would prevent future future injury. After 6 weeks of not running in them just walking I started to run only small distances as prescribed. One month in my ankle started to cause me pain. After being prescribed rest the problem 8 weeks on is still there, plus I now have knee pain. The Physio who got his in house orthotic specialist to design the insert now thinks I need a cortisone in the ankle to get the ankle fit again but I’m now wondering if this ankle pain that won’t go away, plus the knee pain are actually caused by the orthotic so should I can them and just try a period without them, could they actually be the cause. May I add both the Physio and orthotic specialist are very we’ll known in professional sport and treat top class athletes but could it be I’m just not suited to orthotics and my body was fine as it was?

    • I have had a year of pain, with doctors thinking it was gout, x-rays, blood tests, anti inflamatories etc. Because my ankle swelled up a few months after I started using my `custom` made orthotics. 2 chiropodists work at that place but then I compared my other pair I`ve been wearing since 2002 and realized the shape is completely different.

      I am trying to get my money back and very upset that I paid 1000$ for 2 pairs of junk that gave me pain.

      I went back to wearing my 2002 ones and the pain is slowly going away. Therefore I recommend you go back to do what you were doing before the pain appeared and see what happens. A doctor once told me that cortisone injections are bad for me and preferred to treat symptoms in other ways so I would stay away from that.

  6. I had plantar fasciitis in my left foot last year and going to a chiropractor helped get rid of it. Earlier this year I got PF in my right foot. I again went to a chiro and it went away but came back. Only recently can I say that there is no pain while running or afterwards.
    I wanted to know what was causing it. So I went to a podiatrist who recommended I get custom orthotics. They scanned my feet by walking on a rubber mat which produced a pressure point image. The orthotics would be made from this.
    At the same time I saw a chiroprator for a gait analysis. She stated that my problem was weak hips and weak upper butt muscles (not the technical term). She prescribed some exercises for me to do which would strengthen my butt and improve my balance. It has been almost 3 weeks and I can sense the difference. My balance has improved. Still no foot pain.
    The other day my custom orthotics came in. I have worn them the past couple of days. 4 hours then 6 hours. They are not as bad as I had imagined but there is noticeable arch support. They assured me that these would be the perfect platform for my feet to run on.
    After reading your article and others, I am really worried about trying to run in them. Right now everything seems to be going good by using the exercises.
    What to do ? How can I know when to stop using them ? Or should I even try ?

  7. I have ordered a pair of custom arthotics due to getting pain in my hip and groin area in the past 6 months, also all my running shoes wear on the outside after only 120 miles, some of my insoles in my right shoe even have holes in them on the outside, Physichal therapist says my left leg is 10mm longer than my right and that i my left leg isnt straight, interestingly a lot of my problems in the past 12 months have been on my left side. hoping they will be a success.

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