Minimalist podiatry and orthotics in running

The most surprising aspect of the running technique coaching work Mark and I have been doing this past year has been the number of runners we see that use orthotics. This strikes me as odd given the furious debate around minimalist running shoes and the trend of moving away from designing shoes that seek to control motion.

In all of this the use of orthotics seems to have escaped notice and flown under the radar. It’s interesting because many of the orthotics we see day-in-day-out do restrict movement of the foot and ankle much more so than your average heavy duty running shoe. For example, a rigid, built up orthotic can often be taking things much further than a Brooks Beast. So is it time to talk about and encourage a minimalist brand of podiatry?

Orthotics the antibiotic of running?

I don’t know the exact proportion of runners using orthotics, but given how often we see them, my gut says the number might be as high as one in six or one in five. That’s a lot of orthotics. I decided to write this article on orthotics in running, because in my opinion orthotics appear to be over-prescribed to runners. This is especially true where runners continue to have injury concerns after wearing orthotics or in fact have new niggles emerge that could be related to orthotic use.

Melbourne Podiatrist Jason Agosta says there are two people on average, per day that present in his practice with problems secondary to using orthotics, and/or have an intolerance to wearing them.

Some things just don’t look right such as runners bursting out of the top of the shoe because the orthotic is too large. More worryingly, some athletes get tipped out so far by orthotics that their weight rests on the lateral edge of the foot. In many cases the orthotics are combined with intractable, motion controlling shoes which unnaturally load the outside of the ankle. Many of these runners unsurprisingly complain of ankle pain.

Runners and coaches need to have enough knowledge to get the best advice they can from a podiatrist and realise that orthotics are one option available amongst a range of measures that could be used to alleviate running injury or pain.

If there was one take-out for runners and coaches who read this articles, it is this: don’t be afraid to get multiple professional opinions on whether you or your athletes need orthotics.

Minimalist podiatry in action

As we’ve discovered there are a number of podiatrists who share views that are not too dissimilar to ours. It has been reassuring that we’ve had a recent clients that have seen a podiatrist and been told that “I can give you orthotics, but they’re not going to help – your problems are coming from further up at the hips.” I can’t stress strongly enough how big an impact poor alignment and stability issues at the hips has on your running. It makes sense right? If your thighs and hips are out of alignment and they rotate excessively inwards, your knees, lower legs and feet will follow.

However, if you have injury concerns then covering all bases is smart, when I first seriously started to look into fixing my running technique I went and saw Jason to tick the box to find out if I needed orthotics. I’d been constantly injured for years so perhaps orthotics could have helped me? Jason sent me away with the simple advice that I didn’t need podiatry and referred me to a running coach.

That was great advice, I’d ticked the podiatry box, and my issues were not caused by abnormal foot and ankle mechanics. This meant I could narrow my focus down to working on better running form, strength training and wearing neutral running shoes. I had received minimalist and very valuable podiatry!

In this article and series

Aside from getting the message out there that it’s ok to ask for a second opinion on your orthotic prescription, there are a few other issues that warrant discussion. As a runner or coach having a bit more information about orthotics is worthwhile, I’ll cover some basics and introductory material in this article and then delve into a few more tricky issues in the coming months as time permits.

Part of the reason for writing this series is to learn more about the topic so I asked two very experienced sports podiatrists Jason Agosta and Stewart Hayes  to help me understand the issues.

This article is my opinion that has been informed by discussions with Jason and Stuart. It should not be considered professional advice.

What is an orthotic?

While orthotics can be made to support or align many parts of the body, this article will concentrate on the familiar kind that are pre-made or custom made to be inserted into your running or everyday shoes. The goal of these devices is generally to support and/or control motion around the foot and ankle.

What are orthotics made of?

Without getting too far into the technical details and names of the materials used, orthotics fall into two main categories rigid and flexible. At the most flexible end of the scale they look a lot like regular running shoe inner soles, but often have an additional built up component made of EVA material not too dissimilar to what you’d find in the cushioning of your average running shoe. In the mid-range, a flexible shell maybe used combined with EVA.

At the hard, rigid end of the scale, the orthotic is a rock hard piece of plastic material that would probably survive a nuclear attack.

Why is the material used important?

As you can imagine, the harder and more built up the orthotic, the less the foot and ankle will be able to move. From discussions with Jason and Stewart I’ve realized that these rock hard orthotics are actually old technology, but until recently Podiatry students have been (and in some cases still are) taught to make and prescribe these as part of their University qualifications. Therefore they are still pretty mainstream and commonly used. The materials are getting better, but not all podiatrists are moving with the times. We have certainly seen many runners with these hard and unfriendly looking devices.

There is a general move away from this type of orthotic for the very good reason that they block the natural motion of the foot which involves some degree of flattening of the arch and pronation to absorb energy and load the feet and calves to provide a springy platform for running. If you run in hard rigid orthotics, getting them reviewed and a second opinion is a good idea. Even if you need some support, a flexible device is likely to be more comfortable and conducive to running with a lighter, springier and stronger stride.

When would you or an athlete you coach need orthotics?

So this is where it gets controversial, as you will get a range of views from different health practitioners (e.g. physiotherapists versus sports doctors) and also very different views within the field of podiatry itself. This is the first clue that you shouldn’t be afraid to ask a lot of questions and shop around for multiple opinions.

I think that orthotics should only be prescribed where there is some kind of physical impediment or injury that cannot be rehabilitated or improved through the use of proactive measures such as strength training. I also believe there is a case for temporary support of an injured area that can be removed once the injury is resolved or another measure such as strength training takes effect.

Jason Agosta says orthotics should only be prescribed where a runner demonstrates a history of excessive motion and/or asymmetry (unevenness between the left and right side of the body) that is related to a history of problems. He also says orthotics should not be prescribed for the aim of achieving symmetry alone.

What follows are some explanations of circumstances where orthotics might be prescribed to a runner.

Abnormal foot mechanics leading to excessive pronation

Probably the most common reason for podiatrists to prescribe orthotics is to control excessive pronation that could be linked to running injuries such as shin splints (MTSS), stress fractures of the tibia (shin bone), runner’s knee and the like.

There are two areas where the waters are very muddy; the first is what is excessive pronation? Pronation is natural and needed, but how much is too much? And secondly if excessive pronation is present – when is it caused by abnormal foot mechanics versus hip weakness that leads to poor alignment and internal rotation of the thigh? The latter being associated with lack of strength and control of the buttocks muscles. I recognize these are two different things, but they appear to be often confused or assumed to be the same issue and treated the same way e.g. through the prescription of orthotics.

The former presents a legitimate cause for additional support, the latter not so much. Orthotics appear to be prescribed in many cases for issues that would be better solved through commencement of strength training and/or pilates that involves developing buttocks strength and practicing control of the hips. This topic is another article in itself as there needs to be more discussion about what excessive pronation actually is and where it might be a problem.

Sydney based Podiatrist Stewart Hayes makes the point that classifying foot types and then making assumptions about foot mechanics (e.g. pronation) is misguided. I covered this last year in relation to shoe fit as did Pete Larson in this  detailed article. Stewart has seen numerous runners with high arches that excessively pronate – the traditional view being flat feet leads to pronation.

Differing leg lengths and injuries

Another area where a device might be warranted is if there is a significant difference in the length of legs. This may be naturally occurring or be the result of old injuries such as broken bones. There are probably some dissenting opinions on this, but we have practical experience in working with one client, who as a young man broke a leg, this has resulted in a difference in leg lengths but also some other mechanical changes. The bottom line, he looks much more sound running in his orthotics than without them.

Flat feet

A lot of runners say they have flat feet and that this is why they have been prescribed orthotics. When I look at their feet I often see that their foot is flatter than mine, because I have a relatively high arch, however their feet are not truly flat. Observing the foot on the ground can be misleading as it will tend to naturally flatten as weight is shifted over the foot.

Stewart Hayes says that very few runners have true flat feet that warrant the intervention of an orthotic. A true flat foot does not have any medial arch when it is lifted off the ground.

Questions you should ask your podiatrist

I asked Jason and Stewart what questions a prospective client and orthotic user should ask their podiatrist during the consultation. Don’t be afraid to ask these and any other questions you want answered.

Jason’s questions:

  • Why are orthotics needed? Must be a good reason related to history.
  • What materials will they be made of?
  • Should I be wearing these short or long term?
  • What shoes should I combine these with?

Stewart’s questions:

  • What is your experience in my condition and chances of success?
  • Will the orthotics be rigid or semi-flexible to work with my foot rather than block its motion?
  • How long with the orthotics last, not just the covers but the structual components of the device?

Conclusion: minimalist podiatry and orthotics?

The purpose of this article is not to cast podiatry as profession in a poor light, as I’ve said we refer clients to a podiatrist on a regular basis. However, from what we have observed it does appear that runners and coaches need to increases their level of knowledge to ensure they get the best possible advice from podiatrists concerning their orthotic use.

Injuries and pain in running are rarely resolved through the application of one solution, but as a coach or runner you need to become a problem solver and seek as much advice as possible – even if the advice is conflicting (and it will be). So while it might be an attractive option to go with an orthotic as a quick fix to your problems it may not be an appropriate solution or might be only part of the solution.

Where I think we are at the moment is represented by this sketch – orthotics prescribed too frequently (orange), the minimalist podiatry vision would be to restrict prescription to the smaller number of cases where intervention is more warranted (blue).

Written by

Thanks to Stewart Hayes and Jason Agosta

Sincere thanks to Stewart and Jason for answering my questions and helping me learn more about the issues associated with orthotic use and running.

Stewart Hayes is based in Sydney and has over 15 years experience as a podiatrist specializing in the area of “Sports Podiatry” (the specialty dealing with biomechanical, sporting & overuse complaints rather than general footcare such as toenails or corns). Stewart has dealt with children, adults, the elderly, workplace injuries, military personnel, social and international level athletes. Previous and current services/memberships: 2006-11 Australian Golf Opens. 2003 Rugby Union World Cup. South Sydney Rabbitohs Rugby League Team.

 

Jason Agosta is based in Melbourne. His past private practice experience has included 12 years of working at Olympic Park Sports Medicine Centre. Jason has continued study in biomechanics and has studied the ‘Effect of running spikes on Achilles tendon load in distance runners’ at Victoria University. His private practice focus is on difficult foot and lower limb problems, effect of footwear on walking and running, and post-operative care. Jason is the podiatrist for Melbourne Storm Rugby League Club, Melbourne Rebels Rugby Union Club, Victorian Bushrangers Cricket and many national track athletes. Jason is the podiatrist on call for the Australian Open Tennis Championship.

8 Responses to Minimalist podiatry and orthotics in running

  1. Stew March 28, 2012 at 2:10 pm #

    JD – your comments somewhat confuse me as I don’t understand your terminology. You mention “heel hallux valgus rotates flattening my feet”, but hallux valgus is basically a bunion and not near your heel.

    As such, I will give some general info that you may find helpful.

    Feet that flatten when you stand up are deemed to be pronated feet and hallux valgus does not flatten feet, but the opposite – pronated feet put an increased amount of force at the 1st MTP joint (big toe joint) resulting in a valgus force = bunion.

    An Arizona Brace or Ankle Foot Orthoses (AFO) may be beneficial, but I cannot say as I do not know enough about your foot shape or mechanics. It is typically used if someone has Tibialis Posterior Dysfunction – I don’t know if you do have this.

    Walking barefoot on grass, sand, rocks, hills, whatever, is fine as that is what we evolved to walk on, not flat, concrete footpaths. It will help with your proprioception – they ability to determine where your body is in space (your proprioceptors allow you to close your eyes and touch your nose with your finger). Knowing what position your foot is in is imperative for walking and stability.

    You mention leg and hip strengthening, which is beneificial as you will start to use bigger muscles to walk, rather than your extremities. Good runners run with their core and major muscle groups like the buttocks – the legs and feet are merely the levers that they throw forward each step, then they repeat it…

    Hope this info helped.

    Stew

  2. JD March 27, 2012 at 3:18 pm #

    My heel hallux valgus rotates flattening my feet. I ordered orthotics and have been recommeneded a arizona brace. though I can still walk barefoot and lift up the arch some what, I was thinking about doing 10-15 mins of barefoot walk on grass to strengthen the feet.

    have you had anyone do anything like this? I am also doing hips, legs strengthening as well.

  3. Stew March 27, 2012 at 2:09 pm #

    1. Heel spurs are not the problem, but the result of the problem. When bones are under stress, they lay down new bone (calcification – it’s how we heal fractures). The plantarfascia (the tough fibrous muscle under the foot) originates at the calcaneous and it can become tight, thus stressing the bone, hence the bone lays down new bone that is pulled into a spur formation by the plantarfascia. Sometimes orthotics are used, but not all the time as even people with good foot mechanics or feet that don’t pronate enough can develop heel spurs.

    2. Depending on which professional you see will determine what they consider to be a significant leg length difference (LLD). Typically, anything under 5mm is insignificant as the body will compensate and adapt for that amount without too much trouble. Any more than that and you can get hips droping, scoliosis, knee angles changing, 1 foot pronating more, etc. You do not have to get back to zero, just the healthy ball park of 0-5mm and you may be ok.

    Overall, as Brian has alluded to, both cases need professional advice as the above comments are generalisations and may not be appropriate for you.

    Good luck,

    Stew

    • Brian March 27, 2012 at 2:13 pm #

      Thanks for chipping in there Stew with those insights, much appreciated. Brian

  4. Michelle March 6, 2012 at 10:37 pm #

    You have mentioned shin splints in this article. I was wondering if you would recommend Orthotics for a heel spur or are there other options?

    • Brian March 6, 2012 at 11:04 pm #

      Hi Michelle, I’ve not had any experience personal or with clients suffering from a heel spurs so I can’t offer any thoughts on that. Best to get it checked out by a professional. Brian

  5. Seattle Runner March 6, 2012 at 4:27 pm #

    So, when mentioning leg length difference. What is considered a difference that causes problems. 1 inceh, 1/2 inch, 2 inches??? Can strengthening the hips compensate enough to not worry about trying to offset the difference?

    • Brian March 6, 2012 at 4:49 pm #

      Thanks for the comment. The best answer I can give is I don’t know. Like most of these things it will depend on the individual and so first step would be to find out if there is a difference, how big it is and assess any impact on your running. I have heard of people getting around the problem by strengthening the hips, but it’s not something I could say would work in all cases. Brian