We get this question a LOT in our profession. Much like every other question in our industry, the answer is not so straightforward. I’ve been working as a physical therapist for 25 years and have been casting orthotics for 20 years and I still don’t have the exact answer to this question! However, I have learned a great deal regarding this topic over time, and I’m here to share it with all of you.
First let me start out by saying that I truly don’t believe everyone needs orthotics. Sometimes it is a matter of wearing the correct shoe or supplementing with the correct exercise. That being said, by the time someone comes to see a physical therapist with a significant gait abnormality, it can be very challenging to fix it through manual therapy and exercise. We start walking around age 1, the arches in our feet finish developing around age 10, and it usually isn’t until age 30, 40, or 50 that we start thinking we are walking funny. That’s potentially 20, 30, 40 YEARS of an established motor program that needs to be reset. Now, I said “challenging” to fix it…. not impossible.
The way we decide if someone truly needs orthotics is if all our other avenues fail. As movement experts, we use external support as a last resort. We first assess your posture from head to toe. We look for things like scoliosis, leg length discrepancies, hip dysfunction, ankle restrictions, big toe mobility, balance issues and strength. We use manual therapy techniques like joint mobilizations, dry needling, taping, and myofascial release to improve quality of gait movement. We emphasize strength throughout core, hips, knees, ankles and feet to ensure proper motor control.
Depending on what the issue is, we typically can identify if someone is a good candidate for orthotics after 8-10 sessions of physical therapy. That usually equates to around 6-8 weeks of care. If we don’t see a significant change in gait AND you, as the patient, don’t report an improvement with our strategies, we dive into the orthotic discussion.
From my personal experience, casting orthotics is the best way to go for the most custom design. There should be a non-weight-bearing foot assessment, a weight-bearing static assessment and a barefoot gait assessment. We know that not everyone should walk exactly the same way, but there are certain aspects of gait that should be apparent in every gait cycle. For example, the ability of the rearfoot (heel) to move through neutral should be present, but some patients will move through 10 degrees of motion whereas others may move through 3. That may sound like gibberish to you, but I share it with you so you can understand that not all gaits are created equal, but they serve their purpose to allow us to walk! Ultimately, I believe the orthotic should support the way your body wants to walk and not necessarily CHANGE it - an assessment we would make in our physical therapy visits. Custom orthotics can be quite the investment and there are semi-custom options that are available and help determine if a full custom option is worth it. These are typically heat-moldable but less durable. The BEST news: Altitude can help you with any of your orthotic needs!
So, to answer the question of “how do I know if I need orthotics?”.... the answer is to come see us! We can ensure a thorough evaluation and attempt all other options of exercise and manual therapy prior to making the orthotic decision. Like I said in the beginning of this post: not everyone needs orthotics. Let us help you figure it out!
Bob Cranny, PT, Owner
There has to be something like over 1 million different types of shoes out there, right? How do you know which shoe is best for you? The answer to that question is one that we hear in physical therapy school a lot….. IT DEPENDS!!! **also note that these are my professional opinions and I have no affiliations or relationships with any particular shoe brands**
There are always going to be fads and trends when it comes to footwear. For example, the finger toes, the barefoot running shoe, the Skecher ShapeUPs, the HOKAS, the skater shoe, Converse, AirJordans, Asics, Nikes, and the list goes on and on. This blog is meant to cover shoe selection generically and finish with the burning question I get from aging runners - Should I switch to HOKAS (or cushioned shoes)??
When it comes to shoewear, there are a lot of things to consider. Are you running? What type of surface are you running on? How often do you run? How far do you run? Are you walking? Where do you walk mostly? Are you in any foot pain? Do you have any pain with walking? Do you wear gym shoes all day? Do you wear high heels for work? Do you wear sandals in the summertime? It’s quite the specialty to pick the perfect shoe for someone and we almost never get it right the first time…
When you come to physical therapy and ask the question, “but which shoes are best for me?” your physical therapist will start asking the above questions. They’ll also follow it with a gait or running analysis in addition to a movement screen. They’ll check the range of motion of your low back, hips, knees, ankles, and the tiny joints in your feet. The most important thing about selecting a shoe is finding one that will SUPPORT your current and preferred movement pattern versus attempting to CORRECT it. In my 7 years of working with runners and hikers in Colorado, I have only once ever recommended a MOTION CONTROL shoe for a patient. More frequently, we are able to address motor control deficiencies before relying on an external source, like a shoe, to correct any gait or running deviations.
Now, to address the most recent fad or trend in shoewear, I’m going to talk a little bit about HOKAS or shoes that have a lot of cushion. I took two intensive running courses over the past 7 years and they presented similar information regarding the theory behind HOKAS. The idea is that the significant cushion will reduce shock absorption through the rest of the body. The reason I write THEORY is that this is almost impossible to prove with the current technology (at least at the time I’m writing this blog). There are studies that show ground reaction forces when wearing HOKAS and when BAREFOOT. Ground reaction forces are a measurement of how hard you stomp on the ground. This measure has an equal and opposite force through your body. Ultimately, the study found that there was no change in the magnitude of your ground reaction force. Where the study is limited is showing WHERE the ground reaction force is being absorbed. Hence, THEORY. With that great of a cushion, the assumption is a large amount of that force is being absorbed by the shoe and not your joints.
So, I always get the question from the aging runner - should I switch to HOKAS? And just as I started this blog, the answer is - IT DEPENDS! If I watch you run, jump, hop and I can see you have a difficult time with absorption through musculature and joints, I may recommend the HOKA-type shoe. But if I think it’s something that you can train and work up to, I would go down that path first. In my opinion, the downside of HOKAS is that the cushion significantly increases the distance between the sensors in your feet and the ground. Basically, your entire lower kinetic chain takes longer to process any feedback from the ground and this can often lead to ankle sprains, falls, and other injuries.
I also mentioned in the beginning of the blog that selecting the perfect shoe is incredibly challenging and that we almost never get it right the first time. There are so many factors in addition to what I’ve already discussed from a physical therapy standpoint. We need to take into consideration cost, cosmetics, comfort, durability, fit, and ease of getting them on and off. I may very well pick a shoe that I think is perfect for you, you’ll test it out and absolutely hate it! This is where your shoe history is incredibly helpful. I often find that whatever shoe you used to wear all the time is likely the correct shoe for you - we just may need to adjust your motor control for efficient muscle firing during walking or running.
And if we simply cannot find the right shoe for you, that’s when we start considering orthotics. The question of “how do I know if I need orthotics?”.... Well, that’ll be for another blog post :)
Lisa Corken, PT, DPT
Bob Cranny, PT