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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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.