One Size Does Not Fit All
Nearly 20 years ago, not long after I started practicing as a physical therapist, I attended a seminar entitled, “When the Foot Hits the Ground, Everything Changes.” The course was essentially advocating for the use of foot orthotics to treat just about every possible lower extremity, gait-related injury.
Because I had some knowledge and experience in this area prior to taking this course, I was suspicious of this “one-size-fits-all” philosophy; I became even more skeptical when I realized that the seminar was sponsored by a major company that makes orthotics.
Make no mistake – as I’ve stated here in previous articles (Articles #3 and 4), foot orthotics can be a valuable tool for treating many injuries, from runner’s knee to shin splints to hip bursitis to … well, just about anything that can be a consequence of too much pronation of the foot. But – and this is a big but – orthotics will only be of help when the excessive pronation is the result of abnormal foot structure. In cases where the foot pronates too much because of muscle imbalances or weaknesses elsewhere in the lower extremity (most often the hip), orthotic devices are much less likely to be effective and, in my experience, can sometimes cause problems if prescribed in such instances.
If there is one condition for which orthotics seems to be prescribed almost automatically, it would have to be plantar fasciitis. Perhaps because it is an injury so clearly associated with overpronation and involves the foot itself, it must seem logical that a device designed to control motion in the foot would be the most effective treatment. But as I’ve argued before (Article #13), this is not always the case.
Overpronation of the foot can and is often caused by factors originating higher up the biomechanical chain. Inflexibility of the calf muscles can be one reason for compensatory pronation in the foot, and when I first wrote about this condition a decade ago, I would have said it was the primary cause. Now, however, I tend to look a bit higher up for the key underlying source of these faulty movement patterns.
The most obvious of these patterns is excessive medial, or internal, rotation at the hip joint. This motion translates all the way down the lower limb to the ankle joint, which forces the foot into an excessive pronatory movement. Another less obvious cause can be a short or stiff iliotibial band (ITB), which can laterally rotate the lower leg, turning the foot outward. Such a change can alter the center of gravity in relation to the foot, causing increased pronation as well.
The bottom line is that the “one-size-fits-all” approach doesn’t work for anything, whether it pertains to shoe style, training regimen, or orthotic inserts for injuries related to foot overpronation. The smart runner should ask questions and ask for all options before accepting a pat solution to a complex problem.