Orthotics — Are They The Answer? Part I.
Over the past half-dozen years, I’ve seen probably twice that number of runners who have sought my help for a particular problem. The conversation usually goes something like this:
“What can I do for you?”
“I need orthotics.”
“Are you injured?”
“Are you having pain when you run?”
“Then why do you need orthotics?”
“Because I pronate.”
“How do you know that?”
“My friend told me.”
“How does he know that?”
“He says when I run that I have flat feet.”
“But you have no pain.”
Usually at this point I tell the patient it was a pleasure meeting him/her, thank him for stopping by to see me, and tell her that since my basic philosophy is “If it ain’t broke, don’t fix it,” I really cannot see any reason for her to throw away her money. And, as I strongly believe that education is the most important part of physical therapy, I explain why he should not concern himself with this “problem” unless he develops an injury which causes pain. Perhaps I can save you an unnecessary visit by explaining it here.
After training errors, the most frequently cited cause of running injuries is biomechanical abnormalities. Essentially all this means in this context is that the movement patterns seen in running deviate in some way from those which are considered to be normal. The movement most frequently cited in both the medical and lay literature as responsible for most running injuries is — pronation. Actually, the modifier “excessive” or “over-” usually precedes this term, but unfortunately most people seem to ignore this, incorrectly believing that pronation of any kind is detrimental and must be treated.
The truth of the matter is that pronation is a normal, essential component of human locomotion. Before I explain why this is so, let’s first make sure everyone understands what we’re talking about here. First, place your right foot on the floor. Without lifting your heel or toes, roll your foot toward the outside so that only the right side of your foot is in contact with the floor. (The left side – the arch – should be in the air now.) This motion is supination. Now roll in the opposite way so that the arch is flattened and the outer portion of your foot is off the ground. This is pronation.
In so-called “normal” gait, when your foot (the heel, actually) first makes contact with the ground it is in a slight degree of supination. As you bring the rest of the foot down, you pronate until you are at a position known as mid-stance, when your lower leg is directly perpendicular to the ground. As you go past this point, your foot reverses direction and supinates. This pronation then, is not only normal, but also essential for several reasons, two of which I’ll mention here. First, when your foot pronates, it serves to “unlock” the many joints in the foot, allowing it to adapt to uneven surfaces. This is an evolutionary development our ancestors found helpful since Nike wasn’t around yet to protect them. Second, pronation, as we have seen, is a rolling motion, which helps us absorb shock when we land. Picture a Hollywood stuntman taking a fall from a horse. You know how he goes into a shoulder roll rather than landing flat on his back? That’s sort of what pronation does for us. (Best I could do…)
Hopefully, you’re not too confused at this point and thinking you have to become an equestrian to prevent a running injury. The question becomes, then, If pronation is normal, why do we hear about it so much in relation to injuries? The answer has to do with the degree of pronation, whether it is too much or too little, too soon or too late in the stance phase of gait. Basically, it all comes down to the “timing” and it is crucial because the motion in the foot is directly translated upwards through the entire lower extremity and pelvis, affecting all sorts of muscles, tendons, ligaments, bones, etc.
As many of you are aware, orthotics are designed to control this pronation movement so that it stays within the confines of what is considered normal. So, it at least makes sense that if you pronate abnormally in some way, orthotics would be the answer, right? Life would be so nice if things were that simple but unfortunately, of course, it’s not.
The fact is, abnormal pronation is not a disease unto itself. It is a symptom of an underlying problem, a sign that something is not right structurally somewhere. That “somewhere” can be anywhere from the low back down to the toes. Simply stated, abnormal pronation is a compensation for a deficiency elsewhere. It may be related to bone structure or muscle length or strength, but it’s always the result of something else.
A common cause is an abnormality in the structure of the foot itself in terms of bone position. When this is present, the foot must sometimes travel further than normal to compensate, to allow the entire heel and ball of the foot to reach the ground. In these cases, orthotics most often are the answer, since the only alternative would be to surgically reposition the bones, a rather drastic course of treatment. So because we can’t alter the structure of the foot, what we are doing by using orthotics is essentially changing the position of the “ground” so that the foot doesn’t have to pronate excessively to function.
But abnormal pronation can also be the result of other structural faults from above the foot. Sometimes these are skeletal abnormalities, but more often the problem relates to muscle imbalances. In these cases, orthotics are rarely, if ever, helpful and next month, in Part II, we’ll finish this complicated explanation of why orthotics are only sometimes appropriate and at other times a waste of money.