Foot Orthotics – Are They Worth the $?

I’m often asked about orthotics and the questions usually involve two basic issues:

     1.  Do orthotics really work?

     2. Why are orthotics so expensive?

I find it ironic that most people asking these questions own orthotics.  If they are wearing orthotics and they have to ask if they work, it must mean the orthotics are not doing their job.  No one seems to ask such questions about contact lenses or glasses.  If they’re wearing contacts and they question their effectiveness, the contacts probably aren’t the right lenses for that person.

Orthotics are no different.

As for the price, in many cases I think orthotics are grossly over-priced.  Sure there is tons of science and detail installed into a properly fitted pair of orthotics but there is little reason why someone needs to charged $600 for any shoe insert that isn’t covered in gold and diamonds!

I’m a fan of orthotics if fitted properly….for the right reasons and for the right price.  Approximately 40% of my athletes presently wear orthotics.  I owe a great deal of my knowledge about the lower kinetic chain and orthotics to David Tiberio, professor and friend from one of my alma maters, the University of Connecticut.  He’s a brilliant physical therapist and I appreciate him sharing his amazing insight with me over the past 25+ years.

What is an orthotic?

An orthotic is a specifically designed shoe insert which is custom-made to correct a biomechanical abnormality by correcting the poor alignment and enhancing the body’s ability to move.

How Do Orthotics Work?

As I tell my pro football players: “Orthotics bring the ground up to the foot.”  The foot is the base of support of the entire body and it starts the movement pattern when the foot is in contact with the ground during standing, walking or running.

If you were to put a smaller wheel on the front left side of your car, the car will still be driveable and get you to where you want to go.  It will be slower, it will be harder to drive, other parts of the car will be stressed more, the other tires will wear-out faster and the appearance of your car will change.  Poor foot alignment is no different.

To get that car alignment corrected without changing the tire, it can be done two ways.  1.  The car can be driven without the front left tire ever touching the road – not likely to happen or  2. The road can be brought up to the tire as if that tire was now riding on the curb.  This is a simple example of how an orthotic functions.

The Benefits of Orthotics

There are many reasons why orthotics are used.  Those reasons include leg length discrepancy, plantar fasciitis, heel pain, ankle sprains, tendonitis, arch pain, shin splints, foot pain, stress fractures, low back pain, muscle pain/injury, neuromas, bursitis, and sciatica. The influence of an orthotic, as with the base of support of any structure, can reach from the bottom to the top of that structure.

There is much discussion related to the best manner to create the orthotic and it goes well beyond the scope of this sports medicine blog posting.  Weight bearing status, casting, laser, standing, sitting, laying prone, hard orthotics, half-length, orthotic material, where to stabilize the arch,…etc. are just some of the factors related to orthotics.

The Truth About “Perfect Alignment”

The mechanics of the human body are amazing and a big reason why I love doing what I do as an athletic trainer and physical therapist in the NFL.  Every joint in the body has a three-dimensional movement pattern.  Unlike the hinges on your door that moves in only one plane of motion, the human body joints have what is called accessory movements.  These are subtle movements of a joint are necessary for full range of motions to occur.

I like to restore “proper alignment” because there is no such thing as “perfect alignment”.  This normal three-dimensional movement means that an orthotic must bring the ground up to the foot to allow for this normal movement pattern to happen naturally.  In other words, orthotics allow the body to do its job by moving naturally without pain.

I tell my players that the only time they will have bilateral symmetry on the football field is during the National Anthem.  It’s true.  Think about it: the field is never level and they are always changing direction throughout the game.

The A Factor

As for the athletes (A) themselves, one leg is usually longer than the other, injuries change joint motions over the years, flexibilities vary from side to side, the wear pattern of the shoe alters the mechanics of the foot, muscle weakness alters the running sequence and their joint laxity/arthritis changes how that athlete moves.

In other words, the athlete himself isn’t moving the same on both sides of the body.  With this being said, the theory of an orthotic is to help balance the manner in which an athlete moves on both sides of their body.

Back to Orthotics….

Now that we got all the kinesiology and body mechanics out-of-the-way, let’s get back to the orthotics themselves.  I emphasize to my athletes that a properly fitted pair of orthotics should fit like your favorite pair of blue jeans.  They “just fit right”.  No two pair of favorite jeans are the same.  The same is true for orthotics.  A well-fitted orthotic should have no hot spots, no pressure points, no uneasy feeling when they are worn and the athlete should almost forget that they are there.

Think about it this way:  if your orthotics are doing their job properly, the foot and the entire body above it is positioned to do its job.  Those previously noted movements can now happen with ease.  It’s like tucking that napkin under the leg of the wobbly table.  Now the table is both level and stable to do its job of being a table.

Getting the proper orthotic to meet your needs is the key.  The most important factor related to the orthotic is what YOU, the athlete, feel and think.  Speak up and give your medical team the necessary feedback to adjust your orthotics so they “just fit right”.  Don’t forget that it’s your feet and your money!

 

Sprained Ankle Management

Sprained Ankle Management

Year over year, ankle sprains are the most common lower extremity injury in all of sports.  From a minor “tweak” to a high ankle sprain, the range of symptoms and corresponding limitations vary greatly.  Ankle sprains are challenging due to the ankle joint’s inherent vulnerability years after the sprain and ligament instability that is common after a significant injury.

The term “sprain” refers to an injury that involves ligament damage.  Ligaments connect bones to bones, while tendons connect muscles to bones.  Ligaments help stabilize joints and are embedded within capsules surrounding most joints in the body.  The ligaments in a “normal” ankle provide static stability to lower leg and hindfoot bones.

A ligament sprain can be as simple as a minor stretch or as complex as a complete disruption or tearing of the ligament fibers that provide joint stability.

Lateral Ankle Sprain

When a lateral ankle sprain, commonly referred to as an inversion sprain, occurs, the majority of the ligament damage occurs along the lateral or outside part of the ankle joint.  This includes the following ligaments:

1.  Anterior Talofibular Ligament (ATF) – located in front of the outer distal Fibula (shin) bone

2.  Calcaneofibular Ligament – connects the fibula (shin) to the heel bone

3.  Posterior Talofibular Ligament (PTF) – located behind the outer distal Fibula (shin) bone

High Ankle Sprain

We often read about elite athletes who have an ankle sprain that sidelines them for 2-6 weeks.  This sparks immediate questions about why anyone would miss so much time with “just” a sprain (rather a more serious-sounding injury, like a break).  In most cases, this athlete has suffered a high ankle sprain, one of the most frustrating and difficult injuries to overcome.  Recovery is even more difficult when the athlete plays (what I refer to as) a “stop-and-go sport” that involves quick changes in direction.

With a high ankle sprain or interosseous ankle sprain, most damage is found in the anterior ankle and distal shin area.  These structures include:

1. Interosseous Membrane – located between the two distal shin bones

2. Anterior Distal Tibiofibular Ligament – located at the front of the two distal shin bones, just above the ankle joint

Ankle sprains cause damage to surrounding bones, tendons, capsules and joint surfaces, but the most serious ones can lead to a rupture of lateral and anterior ankle ligamentous structures, including the capsule.  Ankle joint dislocations and fractures can also occur, which I personally suffered as a collegiate athlete and had to endure two surgeries and four months of rehabilitation.

Signs and Symptoms of a Lateral Ankle Sprain

The signs and symptoms of a lateral ankle sprain vary based upon the grade or significance of the ligament damage.  Sprained ankles are graded from one to three depending on their laxity, or looseness of the ligaments.

Grade 1 Lateral Ankle Sprain:

  • Mild pain
  • Mild joint stiffness when walking or running
  • Minor stretching of the lateral ankle ligaments
  • Minimal joint instability with a firm end-feel or tautness of the ligaments when stressed
  • Minimal swelling around the bone on the outside of the ankle

Grade 2 Lateral Ankle Sprain:

  • Moderate stretching and tearing of the lateral ankle ligaments
  • Moderate joint instability with a firm end-feel or tautness of the ligaments when stressed
  • Moderate swelling on the outside, front and back of the ankle
  • Moderate bruising of the lateral ankle and mid-foot
  • Moderate-to-severe pain and difficulty walking
  • Significant stiffness of the ankle and mid-foot

Grade 3 Lateral Ankle Sprain:

  • Complete tearing of the lateral ankle ligaments
  • Significant joint instability with a soft end-feel or tautness of the ligaments when stressed
  • Significant pain
  • Significant swelling throughout the outside, front and back of the ankle and mid-foot
  • Significant bruising of the lateral ankle and mid-foot

Treating a Lateral Ankle Sprain

  • Rest the distal leg with Ice, Compression and Elevation (RICE).
  • Leverage the power of ice as a valuable tool for a fast recovery.  Placing ice bags on the outside and inside of the ankle joint for 15 minutes each day is a good way to reduce pain and swelling.  The best way to aggressively treat the entire ankle/foot/distal shin area is to immerse it in an ice bucket for 10 minutes.  Placing a rubber glove or insulated sock over only the toes will make this significantly more tolerable.
  • Depending on the grade of the sprain, adhere to weight-bearing limitations.  Utilize a walking boot and/or crutches to help gradually reduce symptoms while still allowing for normal activities of daily living (ADLs).
  • Gradually perform range-of-motion (ROM) activities with elevation.  Use only upward (dorsi flexion) and downward (plantar flexion) directions to avoid stretching any damaged ligaments located on the outer ankle joint.
  • Use compression to control swelling and pain in the ankle joint and surrounding tissue when performing weight-bearing activities.  Mixing compression with rest is also helpful for acute sprains.
  • Massage the arch, ankle joint, Achilles and calf to help reduce swelling and enhance blood flow to the injured tissue.
  • Ride a bike using compression, which can be started early on.
  • When the swelling is 50% improved, perform strengthening exercises with manual resistance.  Start with upward (dorsi flexion) and outward (eversion) movements while avoiding inward (inversion) stretches, as inversion motion is the typical injury mechanism that causes ligament damage in the outer ankle.
  • Use a slant board to aid in stretching the calf and posterior ankle joint as it becomes more comfortable.  Include calf-strengthening heel raises when tolerable.
  • As you prepare for your return to sport, perform balance activities, which are great exercises during the final stages of treatment. 
  • Begin sport-specific activities when back to 75% strength and if swelling does not significantly increase with activity.
  • Call on a certified athletic trainer to tape your ankle joint, a smart way to minimize the chance of re-injury.

Questions a Pro Athlete Would Ask

Here’s what smart pro athletes would ask their sports medicine specialist to ensure a fast and safe return to their beloved game or sport:

1. Is my ankle sprain classified as Grade 1, 2 or 3?

2. Is an X-ray required to rule out a fracture?

3. What do I need to accomplish in rehab to safely return to my sport?

4. Should I have my ankle joints taped or braced when I return to my sport?

Sports Medicine Tips for a Sprained Ankle

Avoid a Bum Ankle – Trust me: A chronically loose ankle can ruin your confidence and your game.  Without proper treatment, ankle sprains can result in a “bum ankle” that rolls over while performing simple actions such as walking across the yard or stepping off a curb.  Prioritize treatment to tighten affected ligaments and prevent becoming a “bum” down the road.

Flexible Calves and Achilles Are Key – Partnered with loose calves and Achilles, your ankle will enjoy great range of motion and function normally.

Compression is Your Friend – Employing compression on the ankle joint and distal calves will help maintain congruity of the lower leg long after the sprain has healed.

Get Back to Basics – Other than Michael Jordon, none of us were born with sneakers on our feet.  Bust out of those tight shoes and spend more time barefoot to strengthen your arches, foot muscles and ankle ligaments.