I routinely have runners present to our office demanding orthotics for their shoes. Even more common is the request for replacement orthotics. The question is: Should they even be running in an orthotic?
To begin the discussion, runners who do not even have a biomechanical abnormality commonly overutilize orthotics.1,2 Many runners adhere to the false belief that they need to “support” their arches with an orthotic device to protect from the heavy pounding that occurs from running. Others have simply recovered from an overuse injury and have elected to continue running with orthotics.
What runners and physicians need to be aware of is what exactly they are trying to accomplish with an orthotic. We typically prescribe rigid or semi-rigid orthotics to control excessive pronation occurring in the subtalar joint. Even if the patient does not have a true pes planus deformity, a gait examination may demonstrate increased pronation occurring during heel strike and into midstance. This leads the practitioner to recommend an orthotic device.
With all the recent attention on barefoot running and minimalist running shoes, we have also seen the focus on “proper running form.” This seems to be the most important limiting factor in correcting overuse injuries, more so than the actual shoe or orthotic.
The debate now enters a second arena. Do we advocate striking on our midfoot/forefoot or our heels? There is evidence that demonstrates most elite runners who are finishing first and running faster are landing on the forefoot.3,4 While our focus should remain on being healthy and not just winning, we could extrapolate from these runners that they have adopted an efficient and natural way to run.
A recent study published by Lieberman and colleagues demonstrated a significant increase in injury rates amongst collegiate competitive cross country runners who habitually rearfoot strike in comparison to those who forefoot strike.5 The injury rate associated with those who heel strike was comparatively as large when researchers compared this to other factors thought to influence injury rates such as age, prior injury, body mass index, foot type, lumbopelvic strength, arch type, flexibility, Q angle and neuromuscular control.6-10 Numerous studies also demonstrate minimal, if any, significance for the prescriptive use of orthotics or running shoes for running injuries.11-15
Given the observation that both scientific and anecdotal evidence is pointing toward forefoot/midfoot striking, we now must ask ourselves the question: Where do orthotics play a role in running?
One important concept to understand with forefoot or midfoot striking is that we convert the vertical force of striking the ground into rotational force by lowering the heel to the ground. This occurs by pronation of the entire foot first, then with pronation of the subtalar joint just before the heel lifts off the ground to begin its forward momentum. Accordingly, preventing subtalar joint motion with an orthotic device and heel striking is not a relevant issue. We need the motion that is occurring through the entire process of forefoot strike to heel contact and pronation to absorb the shock adequately.
Obviously, more studies need to examine this concept but it poses a very interesting question: Do we really need to control pronation if we have proper running form?
In my practice, when runners bring up the question of what type of shoe they should be wearing, I explain that they first need to “learn how to run.” Then shoegear and orthotics become irrelevant. We also use the same approach with orthotics. As with any treatment protocol, that “treatment” must be justified via sound evidence-based medicine.
If a runner presenting to our office has dealt with any type of overuse injury that is chronic, we stress the importance of learning proper running form and educating the patient on forefoot striking, proper cadence and proper transitioning from the current running form.
If patients are in mid-season training for a marathon or similar distance event, we educate them on proper running form, but advise them that a drastic change in their gait prior to a race could be detrimental if training time is not sufficient. If the patient is heel striking, we can implement an orthotic temporarily but only until the patient can begin transitioning from a forefoot strike pattern and only if symptoms are present due to the overpronation occurring as a result of heel striking.
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