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Give OTC orthotic soles a test run before going custom.

SAN FRANCISCO -- There's no truth to the old wives' tale that a person can become dependent on orthotic insoles, and at a conference on sports medicine sponsored by the University of California, San Francisco, Dr. Anthony Luke maintained that orthotics can be very useful in correcting certain foot problems.

"Do you want to wear more comfortable shoes, or do you want to wear crummy shoes? Because that's really all you are doing," said Dr. Luke of the department of orthopaedic surgery at the university. "You're putting an insert in. You're not doing surgery on [patients], and you're not taping it to their foot for the rest of their lives. I don't know how you necessarily become dependent, [although] I certainly run into people who really love their orthotics and never want to go without them."

It's by no means certain, however, that $400 custom-made orthotics are substantially better than over-the-counter types available in every shoe store.

The primary purpose of orthotics is to improve the efficiency of a person's gait by helping to control excessive or unwanted motion.

It's also possible to use them to relieve the weight load on sensitive areas of the foot. If a patient has metatarsal pain, for example, pads can be added to the orthotic to decrease pressure on the painful area.

To determine whether a runner would benefit from orthotics, the first step is to examine the foot when it's not bearing weight and when it's in the "subtalar neutral" position--neither pronated nor supinated.

Many methods for determining "subtalar neutral" have been proposed, and there's controversy in the literature about which is best. Dr. Luke has the patient lie prone on the examining table and lifts the patient's foot by the fifth metatarsal. He then places his other hand on the opposite side of the ankle and rocks the foot back and forth, causing the calcaneus and the talus to invert and evert. The aim is to "find that position where the talus is no longer banging into my fingers. That's going to be subtalar neutral," he said.

Next, he looks at the Achilles' tendon and the angle of the calcaneus. A heel that is turned inward indicates a heel varus, and suggests that the patient has trouble unlocking the midfoot. Conversely, if the heel is valgus, the patient is starting off in a bad position, and it is no wonder they're pronating.

Orthotics can be customized to correct specific problems. For example, they can include a lift if there's a discrepancy in leg length. And they can have posts added in areas that need special support to achieve a subtalar neutral position.

A number of different materials can be used to construct orthotics, but Dr. Luke is suspicious of especially rigid materials. "It's kind of like running on a very hard surface," he said. "And I've run into people who have had problems [with such orthotics]."

But before he prescribes custom orthotics, Dr. Luke suggests to his patients that they try an over-the-counter pair. There's little compelling evidence that custom orthotics are significantly better than over-the-counter ones, and custom orthotics are as much as 10 times more expensive.

If nothing else, the cheaper orthotics can be used as testers, and although the correction with an over-the-counter version may not be perfect, the patient is likely to experience at least some improvement if an orthotic insole is what he or she needs.

An easy way of testing whether an orthotic is doing its job is to have the patient take it out of the shoe and stand on it. Compare the patient's stance in the orthotic to the stance when he or she is standing on the floor.

If the device corrects a patient's pronation (for example) in the static position, there's a good chance it will correct the pronation in motion.

On the other hand, if the orthotic insole does not correct the patient's stance in the static position, then it probably would not be useful for that patient in motion.


San Francisco Bureau
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Title Annotation:Sports Medicine; Over-the-counter (OTC) drugs
Author:Finn, Robert
Publication:Internal Medicine News
Geographic Code:1USA
Date:May 15, 2007
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