Orthotics are often prescribed for the painful foot condition called plantar fasciitis, for “flat feet’ or “fallen arches, for high arches and for the pain and structural changes caused by rheumatoid arthritis. They are sometimes also prescribed to deal with knee, hip and back pain - the reasoning being that they will alter, in a useful way the biomechanics of a patient’s walking.
A news article in the Sydney Morning Herald on 31st March, headed "Expensive Orthotics No Better than Sham" took me to a systematic review of twenty high quality studies on orthotics and their impact on plantar heel pain published in the British Sports Journal of Sports Medicine
It appears that you might just as well buy cheap orthotics in a shoe shop as get expensive custom-made ones made for you. But how effective are orthotics anyway? According to the systematic review quoted in the newspaper "There is moderate-quality evidence that foot orthoses are effective at reducing pain in the medium term, however it is uncertain whether this is a clinically important change” And keep in mind that this study was only studying orthotics in the context of heel pain, not a range of other foot conditions.
This newspaper article generated a lot of comments ranging from people for whom orthotics had provided immediate relief from foot pain, to those for whom they had not worked, and those who had discovered another wonder cure, of which my favourite was wearing high heeled cowboy boots for a week. Scientific evidence for any strong effectiveness in most conditions except for rheumatoid arthritis and pes cavus or high arches does not exist. There is however fairly strong evidence of their ineffectiveness in treating low back pain
An Alexander Technique Perspective
I am often asked by clients for my opinion on orthotics and often on my opinion of the orthotics which they are wearing.
I will always ask then a number of questions. Are their orthotics comfortable to wear? Do the orthotics help to relieve any pain? Since they have been wearing orthotics have they got pain in other parts of the body? (This is not all that uncommon as orthotics will alter the biomechanics of walking.) How long have they been wearing their orthotics?
I also look at students standing and walking with and without their orthotics firstly as they normally walk and then as they may walk after the change brought to the overall body coordination in the Alexander technique lesson. At one extreme I have had one man come into my studio hobbling on his orthotics: his feet improved markedly once they were dispensed with. And at the other extreme I have seen a marked and immediate improvement in the overall coordination of a person with rheumatoid arthritis with the orthotics in.
The most common conditions people who have been given orthotics hare is an over-prontated ankle joint or “flat feet”. Pronation is the inward motion of the ankle bone and outward motion of the rest of the foot bones which occurs naturally in walking. Over-pronation occurs when the inward motion of the ankle bone is too much and goes past the healthy point of natural motion. In this case you can see the ankles visibly roll inwards. (See Figure 1 below)
If we look at people in their normal standing, a fair proportion has some degree of excess pronation compared to the ankle being neutral (See Fig 1.) A much smaller proportion of the population have excess supination which I won't talk about in this article. For many of those people, when the ankle is readjusted neutrally their foot arch is somewhat restored and their "flat feet" disappear. However we have a much smaller proportion of the population which have what I would call "true" flat feet where the ligaments and tendons of the feet have been so overstretched as to loose all elasticity.
While the arches are supported by a strong network of ligaments in the feet, the muscles supporting arches of the feet are not primarily in the feet, but are the much larger muscles in the lower leg which help to lift the arches. When these muscles cease to work to support the feet the ligaments of the feet can become over-stretched and weak.
What causes these muscles to cease to work as designed is a whole body dis-coordination, right from the head to the feet – what in the Alexander Technique we describe as “misuse” of the self. Basically the healthy foot is “sprung” by these powerful ligaments and tendons. If we attempt to stand on our hands we notice how heavy our body is, but our feet spring us up from the ground with no feeling of weight and effort.
Figure 2
This underlying postural disorganisation then underlies our movement patterns in walking and running. Look at the runners in Figure 3 We are catching them in just a moment of time, but the differences in style are quite obvious and the way in which the forces are moving through their bodies to their feet means that these forces will work differently through their feet. And for most of them those forces will be putting pressure, and over the longer term. causing pain and injury, if not to their feet, then to other parts of their bodies. Look also at the differences in walking between the child in Figure 4 and the woman in Figure 5, whose heels will strike the ground with considerable force.
Figure 3
Figure 4
Figure 5
Obviously orthotics are not going to significantly change these underlying patterns of walking or running. The muscles which are failing to help to support the arches are being given crutches rather than being encouraged to work. And that encouragement can only come from a proper coordination of the whole body which will indirectly begin to exercise the appropriate muscles, not only for the support of the arches, but also for the support of the whole body.
For people orthotics may “cure” and for others will not “cure” foot pain. But orthotics don’t “cure” the underlying cause of most foot pain. And even if foot pain is “cured” people are still left with their underlying pattern of posture and movement which in the long run is likely to put pressure on a different area of the body – or they may alter the biomechanics enough to throw the body out of balance in a different way.
In my foot workshops and in teaching the Alexander technique more generally we start to identify the patterns of misuse which cause and perpetuate foot dysfunctions and to develop a new and improved pattern of the use of the self which will take pressure, not only off the feet, but off the whole of the rest of the body.
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