Sports Injuries and Foot Orthotics: Prevention and Recovery

Up to 70% of runners will experience an injury in a given year. This can lead to significant missed running time among bother amateur and professional runners. Foot orthotics represent one tool which may help reduce the risk of injury. And, should injury occur, they may also assist with the patient’s recovery. In this article, we’ll briefly review the available literature, and attempt to draw conclusions as to the efficacy of orthotic devices in sports injury prevention

This is a guest post from Pedorthotic Association of Canada looking to increase awareness of foot orthotics among athletes.

The Basics

Foot orthotics, commonly referred to as shoe inserts, are used for a number of purposes including:

Arch support
Correction of overpronation and oversupination
Treatment of lower limb injuries like plantar fasciitis
Improving athletic performance

Loosely, we’ll focus on injury prevention and recovery. As such, we’ll discuss the correction of overpronation and oversupination (both of which can promote and exacerbate injury), and the treatment of various lower limb injuries.

It should be noted that there are a number of ways in which a pedorthist can modify footwear. In this article, we focus on one such area – foot orthoses, or simply, orthotics. Orthotics can be procured in 3 ways – prefabricated, semi-custom, and custom. Custom orthotics can be designed using foam box impressions, plaster casts, and 3D imaging.

Image 1. Example of semi-custom insole with various inserts in the background.

Challenges

The study of orthotics presents a number of challenges. There are 3 ways of procuring orthotics, and a further 3 ways of designing custom orthotics. This means studies of one type of orthotic may reveal little to nothing about another kind of orthotic.

Research can be challenging due to the complexity of the foot, with dozens of joints, bones, and muscles that all work in concert during exercise and sport. Each person’s ‘normal’ and thus pathology is different in subtle but important ways. For this reason, there is no one-size-fits-all orthotic. Studies show that different podiatrists, orthotic specialists and pedorthists will prescribe completely different orthotics for the same patient. Additionally, the effect of the same orthotic on different patients with the same condition (such as overpronation) can vary widely.

All of this makes the effect of foot orthotics incredibly difficult to study. And though there’s evidence that orthotics work (which we’ll discuss in later sections), there’s also ample evidence that they may not work to correct mechanical-alignment problems.

The Placebo Effect

Studies are further complicated by the placebo effect. To paraphrase comedian Mitch Hedburg: “Dr. Scholl is a doctor, which means he spent nine years in med school. It took him nine years to learn that cushions make shoes comfortable.”

This is not, by any means, to disparage the study of foot orthotics or the work pedorthists do. Rather, it’s to point out that cushioning the sole of the shoe can lead patients to feel less pain and more comfort, regardless of whether or not the orthotic device was specially designed.

In fact, Munteanu et al found that both customized foot orthoses (CFOs) and sham orthotics showed the exact same effectiveness in treating mid-portion Achilles tendinopathy. That is to say an over the counter, generic orthotic was equally as effective as a custom one (Munteanu 2015).

As we’ll discuss, there’s some evidence among a few studies that foot orthoses can help patients prevent injuries and, should injuries occur, recover from them. We hope to see more rigorous studies in the coming years as the understanding of orthotics improves.

Image 2 and 3. Examples of over the counter orthotics

Oversupination & Overpronation

Both overpronation (which results in flat footedness) and oversupination (which results in high arches and a skinny footprint) can promote and magnify a variety of injuries such as plantar fasciopathy, achilles tendinopathy and stress injuries. As such, correcting overpronation and oversupination may help prevent sports injuries.

MacLean et al found orthotics lead to significantly decreased maximum values in rearfoot eversion angle, rearfoot eversion velocity and internal ankle inversion moment. Eversion angle is the term for the foot collapsing inwards, which causes the foot to flatten. Eversion velocity has an impact on foot injuries – by slowing eversion velocity, orthotics may be able to reduce the chance of injury. This study was conducted on participants who were not prone to overpronation. As such, the impact may be greater on people with overpronation, we simply don’t know.

There are too few studies on oversupination to give an accurate assessment here. Anecdotally, however, pedorthotists have found orthotics can help correct oversupination.

Custom and Semi-Custom Orthoses

Custom orthotics are designed and made to match the individual foot and biomechanics. Although they are theoretically superior (the literature isn’t entirely clear), they are much more expensive to produce. A pair of custom orthotics can range from $100 to $400. For this reason, semi-custom orthoses have become popular. Semi-custom orthoses have more specific molds and landmarks than a generic over-the-counter insert. For this reason and decreased cost, they are likely a good compromise between custom foot orthotics (CFO) and your basic shoe insert.

Patients with overpronation may wonder whether it’s worth the extra time and expense required to get CFOs when semi-custom foot orthoses (SCFOs) are available. Davis et al showed that CFOs tended towards being more effective at correcting the degree of eversion than SCFOs (Davis 2008). However, the difference in the degree of eversion between CFOs, SCFOs, and wearing shoes with no orthotics was not statistically significant.

The study did find that CFOs and SCFOs both reduced eversion velocity in a statistically significant way. Comfort was also studied, and while CFOs were considered significantly more comfortable than SCFOs in the foot arch, differences in comfort elsewhere were statistically insignificant. This suggests the main advantage of CFOs over SCFOs in helping pronation issues lies in foot arch comfort.

Injury Recovery

Hume et al found that semi-rigid custom orthotics have “a moderate to large effect on treating and preventing plantar fasciitis and posterior tibial stress fractures, and small to moderate effects in treating patellofemoral pain syndrome” (Hume 208). This same review found that “further research with randomized controlled trials is needed to establish the clinical utility of a variety of FOs for the treatment and prevention of various lower limb injuries.” For this reason, we postulate that foot orthotics likely help with injury recovery, but the degree of benefit and which disease states respond to this treatment requires further clarification.

Conclusion

We have a plethora of anecdotal evidence that orthotics help patients reduce pain, and prevent and recover from injuries. These outcomes are important, despite the fact that there is a general lack of objective, research based evidence. The limited research that we do have, however, mostly supports our anecdotal understanding. Though we don’t entirely understand the biomechanics of foot orthotics, the evidence does point to their ability to reduce the risk of injury and aid in recovery.

– More Foot/Toe Pain from Sports Medicine Review: https://www.sportsmedreview.com/by-joint/foot/

References

Munteanu SE, Scott LA, Bonanno DR, et alEffectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trialBritish Journal of Sports Medicine 2015;49:989-994.
MacLean C, Davis IM, Hamill J. Influence of a custom foot orthotic intervention on lower extremity dynamics in healthy runners. Clin Biomech (Bristol, Avon). 2006 Jul;21(6):623-30.
Davis IS, Zifchock RA, Deleo AT. A comparison of rearfoot motion control and comfort between custom and semicustom foot orthotic devices. J Am Podiatr Med Assoc. 2008 Sep-Oct;98(5):394-403. doi: 10.7547/0980394. PMID: 18820043.
Hume P, Hopkins W, Rome K, Maulder P, Coyle G, Nigg B. Effectiveness of foot orthoses for treatment and prevention of lower limb injuries : a review. Sports Med. 2008;38(9):759-79.