Author: Dr. Stephen Gangemi
The prescription and use of orthotics is a hot topic. Some physicians don’t appreciate that fact that I think orthotics are expensive pieces of carbon graphite, neoprene, and other material that most often serve as a disservice to the patient. My stance on orthotics is such due to how I evaluate, treat, and manage patients. It is a 100 percent holistic approach. I see professional athletes – dancers, runners, hockey and soccer players – and professional people – CEOs, attorneys, medical doctors, accountants. These patients have injuries of all kinds – foot, hand, back, neck, etc. And I deal with just about any ailment you can imagine from the common cold to an infection such as Lyme disease, hormonal problems, digestive disturbances, sleep issues. That is not to say that I don’t see patients who are taking medications – but I’m working with them (and their prescribing medical physicians) to lower and hopefully eliminate their drugs, which is often a very obtainable goal as health becomes restored.
Using an orthotic is not natural, so it is not part of my practice to prescribe such devices. While I have had to refer patients for surgery or to their medical doctor for a necessary medication such as an antibiotic to overcome illness or perhaps save their life, I have never had to refer a patient to receive an orthotic, and yes, I have seen plenty of extreme cases of foot pain and gait imbalances. With no disrespect to those who treat their patients with orthotics and with no arrogance I feel confident saying that based off my education, experience, and understanding of the human body (not just the foot), that those who wear orthotics are suffering compromised health and those who prescribe them are not restoring their patient’s health to its fullest potential.
An orthotic is a support device meant to either control motion or change foot function, and therefore the function of other areas of the body. It’s not natural and unless all other means have been exhausted, (which they rarely have), then reconsidering orthotic use should be a priority. Orthotics may serve a very temporary purpose to help a person overcome acute pain and discomfort, but anything more than short term “emergency” use will only harm the wearer. Yes, they support some dysfunction somewhere – whether it is in the foot itself, the gait, or some other imbalance anywhere in the body.
A healthy person does not need an orthotic. Orthotics alter the somatosensory system in the body, which is how various stimuli is received and transmitted through the nervous system to the brain. This is a major part of one’s proprioception (body position), along with one’s vision, inner ear mechanism, and other important reflexes. Actually, any footwear alters one’s proprioception to some degree, which is why going barefoot as much as possible is a great way to help balance, foot strength, and overall health.
“Custom” orthotics, as well as heel lifts and other footwear devices negatively affect proprioception and foot health more than most footwear because they support muscles, tendons, and ligaments in such a way that they don’t have the need to function as they normally should. Essentially, the feet become weaker and weaker, and soon it spreads to other areas of the body including the nervous system. Then the orthotic user has to rely on other aspects of proprioception such as vision, because their feet are in such disarray. Put this common situation in an elderly individual that often already has poor vision and you’ve got an unstable person who will soon fall, break a hip, and die soon after. That’s a sad, common occurrence.
Are there exceptions outside the very temporary use? Yes, but they are rare. Orthotic use is a sensitive subject especially since many physicians rely heavily on them to treat patients as well as their own financial security. If orthotics are their major tool to help a patient deal with pain or walk properly then I completely understand that they are going to fight hard about their necessity. Currently the only patient who I treat who actually benefits from an orthotic suffers from post-polio syndrome. Her left leg is approximately three inches shorter than her right. So she walks with a lift throughout her entire footwear and this benefits her; she’s been wearing it for decades. I also treat another woman who suffered a different childhood disease which resulted in her left leg being approximately two inches shorter than her right. She came to me because of hip pain and fatigue when walking. The orthotic in her shorter leg not only helped her gait but also diminished her pain to about 50 percent for the many years she was using it. Eventually, over a period of four to five visits, her muscle imbalances were corrected by using various manual medicine techniques such as trigger point therapy, muscle reflex points, and nutritional therapies, so the orthotic only made things worse and she removed it entirely. Obviously this was a big step for her as she had worn it for over twenty years and because of the leg length discrepancy. Of course I was not able to make her leg lengths equal but by helping her muscles adapt to the way her body currently is, she was able to be pain free for the first time in her life and without an orthotic or supportive device of any type.
Dr. Phil Maffetone discusses and demonstrates proper muscle testing procedures in his book, Complementary Sports Medicine. Chiropractors, physical therapists, personal trainers, and most medical doctors are taught some form of muscle testing during their education. Unfortunately, it is often not taught properly and when the therapist does learn to correctly test a muscle, they often don’t know what to do with the information they receive from the test. My office is in close proximity to both Duke and the University of North Carolina and I see physical therapists and personal trainers who have graduated from these schools who quickly realize that their muscle testing education was not up to standard. After all, an inhibited muscle (one that is “weak”) cannot become facilitated (“strengthened”) by exercise, which is what most are taught. I discuss this a bit more in Stop Stretching. Muscle imbalances occur due to nervous system dysfunction which can be the result of injury, pain, nutritional imbalances, organ dysfunctions, and other health issues, including general stress. Muscle imbalances in the foot will cause local foot imbalances and this leads to a physician often considering and using an orthotic to correct this imbalance. Orthotics can (when applied correctly) facilitate muscles; I see this in my office when evaluating a patient with many muscle imbalances and their orthotic was properly made – it helps. But the problem is that the continued use of the orthotic doesn’t allow the body to heal and correct those imbalances and the orthotic is not addressing why the imbalances are there in the first place. Remove the orthotic – the imbalance presents itself again. That is not healthy.
Take a common muscle dysfunction of the tibialis posterior muscle. This muscle supports the main arch of the foot and is responsible for proper pronation and overall foot stability. In one individual the tibialis posterior might be inhibited because of a local injury to the muscle, which itself can be a result of too much walking or running in improper footwear. When this muscle is injured, symptoms like plantar fasciitis and shin splints can be the result, leading one to perhaps resort to orthotics. As I show in my videos of the respective subjects, these injuries can often be treated very successfully in other, more natural, ways.
A gait disturbance is another very common reason for a person to have muscular imbalances and joint dysfunctions leading them to seek out help and orthotics. I recently saw a patient who was wearing orthotics because he had plantar fasciitis symptoms several months ago. Those symptoms were gone (the orthotics helped him recover quicker), but now he had some shoulder pain when playing tennis. I had to correct several muscular imbalances in his injured shoulder using the manual medicine therapies which I utilize in my office, but interestingly, I had to correct even more in the foot that had the plantar fasciitis issue months ago. The foot problem still existed and was causing a gait disturbance, but the orthotics were essentially hiding this imbalance and causing further compensations elsewhere in his body. The patient removed the orthotics and both the shoulder injury and the foot dysfunction quickly improved.
In another person that tibialis posterior might be failing because they are under so much dietary stress (eating too many refined carbohydrates, for example), and that is causing inhibition of the muscle. Excess carbohydrates are known to cause inflammation throughout the body, and this inflammation can impact muscles of the foot, too, resulting in foot pain and diagnoses such as tendonitis, bursitis, or plantar fasciitis. This is another common occurrence I see in orthotic-wearers. Their diets are often horrendous. They are often consuming high levels of sugar and other refined foods, diet drinks (Splenda and Nutrasweet), trans fats, and too many vegetable fats from corn, soy, and safflower oils. They’re an inflammatory nightmare and their joints, muscles, and health are all suffering. So they need support, and one way is through orthotics. Once they clean up their diet, they can ditch the orthotics too.
One can see, whatever the case, an orthotic is not the ideal treatment – addressing the root cause is. Figuring out that root cause and working through it can sometimes take a very long time, an hour if not much longer, which is not something most physicians have the time, energy, or ability to do either physically or mentally. So many have to resort to orthotics. And for those who practice this way and get a person walking, moving, and out of pain then that is entirely fine. But again, it is treating the symptom, not the cause, and it is not addressing the patient’s overall health. The use of the orthotic will hopefully be temporary to truly benefit the patient.
Orthotics will always support a dysfunction. If they were supporting function then they would not be necessary because function would be restored in the first place. I don’t quite understand the term “functional orthotic.” There is nothing functional about controlling motion. If an imbalance “appears” to be restored with an orthotic, it is only that – an appearance. Yes, I know that’s not something any physician wants to hear and I got some flack for that statement after speaking to a several hundred chiropractors at a conference, but I can’t think of any exceptions. Feel free to kindly comment if you have an exception (I’ve received some nasty ones from a couple docs whose livelihood is based off prescribing orthotics). Even in my one patient with post-polio syndrome, we both fully realize that we are supporting her dysfunction with the orthotic. For most all patients though, function can be restored, even if they have tremendous foot pain. It may take time as they wean out of their orthotics, as it would transitioning from a traditional shoe to a minimalist shoe, but as overall health is restored, so is foot health. Some other devices, like Ray McClanahan’s “Correct Toes” are great products to use for feet that have suffered structural misalignments due to years of poor foot health and improper footwear (not really an orthotic).
As you can see, there is not necessarily any specific exception for using an orthotic; it is all very individualized. Even what some might consider an extreme need for an orthotic, perhaps isn’t so. Treating an individual fully is a lost art. Sure, all physicians want to say that they treat everybody differently and every case is unique. But how many physicians evaluate the entire body every time? In other words, how many evaluate the state of an individual’s hormones, diet, exercise regime, and entire musculoskeletal system when investigating any major problem, let alone a foot dysfunction? How many examine the integrity of all the joints in every limb, and their relationship to the present foot ailment? I’d say very, very few. It takes a lot of time, a thorough understanding of the entire body, and proper evaluation skills – many of which require proper muscle testing and other challenge parameters, which is a skill acquired over years, and one that is not regularly taught in any school of medicine – conventional or “alternative.” The many “specialists” in the field of medicine typically fail to see the whole picture of a patient, including the ones who prescribe insurance-covered foot orthotics. This is the concept of what I like to refer to as systems health care – the inter-relationship between everything in the body and how every organ, muscle, bone, movement, etc. is related to each other in some fashion. In other words, poor health results in poor foot health which results in the appearance to need orthotics. What comes to mind is that marijuana commercial from the 80s. This is your foot (egg). This is your foot in orthotics (egg on frying pan).
Photo credit: zingersb