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Supportive Footwear + Orthotics? Let's Review The Evidence

This week I read a review of a research article from the Journal of the American Podiatric Medical Association 2014; 104(2): 211-220.  Special thanks to the Research Review Service ( and article reviewer Dr. Daniel Avrahami for writing a great review of a much talked about phenomenon in sports medicine these days.  The article focused on the theoretical basis for which running related injuries (RRIs) occur.  For my purposes, I hypothesize the same discussion should occur for all weight-bearing activities (walking, sports, running).

For all intents and purposes, the basis behind this debate is simple: Injuries occur in runners.  And, for that matter, injuries occur in everyone (runner or not) due to the biomechanics of our feet and gait pattern (walking or running).  The debate is about how to prevent or decrease the injuries.

As explained in the review article, the theories for running related injuries (RRIs) are broken down into two categories:

  1. The “Running Shoe Theory” (RST)
  2. “Barefoot Running Theory” (BRT)

The Running Shoe Theory for running (and I suggest for all walking/weight-bearing) injuries hypothesizes that the shoe itself contributes to the injuries because of the very features it believes prevents said injuries.  The “shoe” (and, in my opinion, the added “orthotic”) is designed to reduce the forces causing tissue overload and improve the function of the foot to prevent excessive forces due to bad form.  The shoe (and/or orthotic) boasts a rigid heel counter to control motion at the subtalar joint with pronation control and an elevated cushioned heel.  Does evidence prove this prevents injury?  No.

Do the features of the shoe protect us from the high forces and/or frequency of the forces?  Or, should we just fix our form by increasing stride length, enhancing muscle control, cadence, and altering our foot-strike pattern (less heel strike; more mid-foot or forefoot strike)?  Regardless of cushioning, evidence suggests we have the same forces affecting our feet.  Theoretically, this is because the cushioning itself may cause more harm than good by diminishing proprioception and providing the runner with a false sense of security against high-impact forces.  When we run without cushion, we adjust for the lack of cushion by protecting against high forces by adjusting our form (as explained in the “Barefoot Running Theory”).

What about the dreaded overpronation?  What impact does overpronation at the subtalar joint have on RRIs?  Pronation control shoes or orthotics reduce the overpronation, but do they reduce injury?  Evidence suggests no.

Well, what about the “Barefoot Running Theory” (BRT)?  This theory is based on the hypothesis that supportive shoes lead to atrophy of the intrinsic foot musculature, diminished somatosensation (sensory feedback between peripheral and central nervous system), and abnormal gait (shoes cause heel strike, while barefoot promotes natural form that is more mid-foot or forefoot striking patterns, higher cadence, decreased stride length).

However, RRIs still occur with barefoot runners too.  Despite the theoretical model that suggests BRT improves gait patterns, and reduces injuries, neither is proven by the current evidence.

So, the bottom line is that there is no evidence that either theory is correct.

So, what should you do?

Should you buy the most supportive, clunky footwear available?  Or, run around in barefeet?  Should you rely on the shoe manufacturer’s motion control shoes, or upgrade to a custom orthotic? Should you wear supportive shoes sometimes, and other times go barefoot?  Should you use orthotics, but also train your feet to develop intrinsic muscles?

Really, we don’t know …. yet.

So, we still must take an individualized approach to whether or not you use supportive footwear, orthotics, or whether you go for the barefoot shoe?

If you and I have spoken about the role your foot plays in your biomechanical aches and pains, you know that I take the individualized approach.  For those with obvious gait pattern “problems” (overpronation, flat feet) AND gait-pattern related aches and pains (plantar fasciitis, bunions, metatarsalgia, to name a few), I do recommend supportive footwear and orthotics; Especially with a history of relief when wearing these devices.  However, if you have symptoms and no gait pattern dysfunction, I’ll often stick to treatment methods to get you better (laser, Graston Technique, etc.).  But, if you do have gait pattern problems and NO symptoms, should you wear supportive footwear and/or orthotics for “preventative” reasons?  I don’t know.  Lately I’ve been taking the wait and see approach.

If you’re one of my orthotic patients and have had relief, ignore the absence of evidence and continue to do what works for you.  I do.

If you’re having foot, knee, or another pain and wondering if orthotics can help, come in for a visit.  Let’s talk about it.

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