Orthotics or insoles: What they are, how they work and their cost
What is an orthotic?
An orthotic can be a life-improving medical device. They are small, lightweight and comfortable devices that sit inside your shoes to take pressure away from your sore spots. Also known as orthosis and sometimes called innersoles, orthotics are a part of a podiatrists tool kit to treat a variety of foot, ankle and lower leg problems.
Orthotics can be used to optimise loads on the foot and ankle to treat injury and build strength and capacity to tolerate load. What orthotics are not, however, are a brace, something that weakens the foot, or a panacea that cures all ails. Orthotics can be beneficial to a wide variety of foot and ankle issues and even more so when they form part of an overall management plan alongside exercise and education.
History of orthotics
Orthotics have been around for nearly as long as shoes. It seems that as soon as we decided to pop something protective on our bare, hairy feet we had ideas about making our feet more efficient and more comfortable.
While the idea of orthotics has been around for a long time, it's in the last 30 years we've seen rapid increases and changes in how orthotics are used.
With modern 3D laser scanning, 3D printing and lightweight material orthotics are now able to be both comfortable and effective, whilst not weighing down distance runners or those with muscle weakness. For example, after a stroke, there may be significant muscle weakness and motor control loss. In the past, an orthotic would need to be bulky and heavy to provide extra support. These days they can be made lighter and faster with a quick turnaround time.
With the materials podiatrists use to make orthotics changing over the years the lifespan of orthotics has changed as well. Old style orthotics made from cork and leather tend to wear much faster than lightweight carbon fibre, 3D printed nylon and soft EVA materials.
Podiatrist and orthotics
Podiatrists are the foot and ankle experts, and using orthotics for the treatment of patients is how we treat numerous foot conditions. No other profession has the background in assessment and diagnosis of lower limb pathology combined with the physics of human movement and biomechanics. Add in a podiatrist's strengths of knowing footwear, how to treat and manage all foot and ankle issues and you've got the perfect profession to prescribe you an effective orthotic device.
An area that podiatrists excel at with orthotic therapy is that they are not the only treatment modality we use. Orthotics are but one way to treat a variety of complex foot and ankle problems. Like all other complex problems, a multi-faceted treatment plan is best. Spending time with your podiatrist working out how much, if any, an orthotic will benefit you whilst looking at other options like strengthening, capacity building, footwear changes, gait retraining and more is valuable time spent.
How Orthotics Work
How do orthotics work is a question we podiatrists get asked from clients, from doctors, from physios. It seems everyone knows that they do something, but how? Is it magic?
There are a couple of ways we can answer it.
1. Orthotics work by "pushing" to help your muscles who work by "pulling" on your feet.
2. Orthotics work by altering the ground reaction force acting on the feet. The ground reaction force is converted to an orthotic reaction force. This turns small nudges into big pushes, or big pushes into gentle nudges.
3. Orthotics work by increasing the neurofeedback to our brains. Our feet have more nerve endings than almost anywhere else in the body so increasing stimulation on them via an orthotic changes how we consciously and unconsciously perceive and move our feet.
4. Orthotics work like other physical therapies where they take an injured tissue and improve the loading on it so our body can repair it back stronger again.
5. Orthotics deflect pressure from high loading areas on the skin like callus or corns and moving it to other areas.
6. Orthotics work by providing different support at different parts of the gait phase.
7. Or should we just say orthotics work by magic. Famous science fiction writer Arthur C Clarke coined his 3 laws, the third being. Any sufficiently advanced technology is indistinguishable from magic. If you had pain, and now you don't have pain, is it magic?
Conditions orthotics can treat
Orthotics can treat a great variety of lower limb foot and ankle conditions. Heel pain from plantar fasciitis or Achilles tendinopathy. Midfoot or arch pain. Forefoot pain from a neuroma or bursitis... These are all conditions that can be treated effectively with an orthotic.
Moving up the leg orthotics can also be used to reduce the risk and recurrence of ankle sprains and treat shin splints. Orthotics even have a place treating knee pain. Orthotics have been proven effective in providing relief not just in acute knee pain, but for chronic longstanding knee pain from arthritis.
If you can think of an overuse injury of the lower leg, foot and ankle then your podiatrist can likely come up with an orthotic prescription to help treat it.
But it doesn't stop there. Orthotics can also be used for chronic medical conditions as well. Not in the treatment of disease, but in managing the effects of the disease. For those with diabetes, orthotics can be used to reduce the peak pressure on the skin. This is a proven method for reducing corns, callus, diabetic foot ulcers and ultimately amputation.
Rheumatoid arthritis is another complex chronic medical condition where orthotics are recommended to limit foot pain, protect foot joints and slow rheumatoid related deformities progressing.
Different types of orthotics
If you'd like to come down the rabbit hole with us we'll talk about all the different types of orthotics. The first comparison is locomotion (walking or running orthotics) and non-locomotion (ski boot or cycling orthotics).
Non-locomotion orthotics like the P.Ride Cycling orthotic are just for cycling. For these non-locomotion movements our flexible and adaptable feet actually slow us down. These orthotics are designed to increase the stiffness of the foot to improve power output.
Locomotion orthotics are the largest cohort of orthotics where they can be prescribed for specific feet, specific injuries and specific movements.
For example a person with a sore heel could have a single orthotic for their work shoes, gym shoes and their casual shoes. Moving the device shoe to shoe as required. With this design the podiatrist would take into account the differences in footwear and movements and then prescribe an orthotic that can handle all these variables.
This could be contrasted with that same person have three different pairs of orthotics for their three different shoes and three different activity levels. The orthotic for the running shoe might be designed for maximal efficiency when running in straight lines. The work or casual orthotic could have design parameters that match more walking or standing vs. running as well. It would depend on the wearers goals and needs to determine if a single or multi orthotic approach is best.
Not everyone needs three different kinds of orthotics, but this hypothetical can show just how specific an orthotic prescription can be.
When thinking about whether orthotics are for pronated feet or supinated feet, or splitting them into categories of soft orthotics or hard orthotics, these old days are long gone. We now know that we can get great orthotic function with a soft orthotic, and also with a hard orthotic. Depending on what our goals are, and the orthotic function we need, will play a big part in deciding what type of orthoses you need (standard or custom).
Custom Orthotics Vs. Prefabricated Devices
Another way to consider the different types of orthotics available is to split them into custom foot orthotics and off the shelf categories.
A custom foot orthotic device that we discussed earlier can be much more personalised than an off the shelf device. Materials, design parameters and activities are more readily taken into account.
Prefabricated orthotics, also known as off the shelf devices, lose that specificity of a custom foot orthotic. This doesn't mean they are second best. Two huge benefits of prefabricated orthotics are that they are mass-produced which means you get the benefits of reduced costs due to scale, and some advanced manufacturing techniques that cannot be applied to a bespoke orthotic.
Evidence for orthotic therapy
The effectiveness of orthotic therapy in treating a variety of lower leg, foot and ankle injuries can not be denied. Each year that passes by more and more studies are conducted which have shown the effectiveness and limitations of orthotic therapy.
In recent times PridePlus Health podiatrists have been involved in studies conducted across Australia into orthotic therapy. One of these studies was conducted by our podiatrist Dr Jade Tan who completed her pHD into the use of orthotics for knee osteoarthritis in 2020.
Foot Orthoses For Plantar Heel Pain
- Foot orthoses were shown to be more effective than sham orthoses at treating heel pain in both the short and medium-term. This study was a systematic review and meta-analysis. Gold standard research.
- A randomised control trial of custom foot orthoses for the treatment of plantar heel pain found a nearly 6 fold increase in physical activity for those with a custom foot orthotic. The study compared custom foot orthotics, prefabricated orthotics with stretching and icing alone.
- Evaluation of orthotic insoles for people with diabetes who are at risk of ulceration found that orthotics prevented first ulceration for those with diabetes. This is a key marker in limiting the severe progression to amputation and morbidity.
- Effectiveness of medially wedged insoles for runners with flat feet is a study that showed wedging flat-footed individuals with an orthotic would change the movements and moments around the foot and ankle joints.
The clinical assessment process that goes into getting your orthotics from your podiatrist places you at the very centre. Your podiatrist will determine your needs and your goals and from there, if an orthotic is indicated take you through the best option(s) for you.
Step 1: History & Assessment
During your appointment time, your podiatrist will take a detailed picture of you, your activities and your needs. They'll combine this with a thorough foot examination taking into account your joint axis positioning, joint range and quality of motion, muscle strength, foot type and more. A weight-bearing video or visual gait analysis will further guide your podiatrist and your decision making.
Step 2: Orthotic Prescription
If an orthotic is appropriate as part of your treatment plan your podiatrist will guide you through the selection process. Consideration of your needs is paramount here. At PridePlus Health we stand by this process and offer our Orthotic Guarantee so you can be confident knowing that we'll get it right, or it's on us.
3D laser scanning is how your podiatrist will capture your foot in all its glory. Gone are the days of mucking about with plaster or foam boxes. Laser scanning allows a super accurate and fast three-dimensional representation of your foot which the orthotic can be designed around. For this, accuracy matters. Many orthotic design parameters are in the single degree or half mm measurements. Think of the feeling of a sock rolling up under your foot and being uncomfortable, it's not thick is it? Getting accurate digital "casts" is paramount to have the most comfortable orthotic for your feet.
A foot scan is only required for a custom foot orthotic as prefabricated orthoses are prescribed more like a pair of shoes. Once you have your shoe size you'll be on track to getting your prefabricated orthotic size right.
Step 3: Orthotic Fitting
The fitting process for your orthotics will involve you and your podiatrist ensuring that your new orthotic is perfect for your feet, your shoes and your activities. Much like the initial assessment, there will be a lot of checking, measuring and gait analysis to confirm that an orthotic is going to do what we want it to do, comfortably. These days this is a timely service as orthotic manufacturing times have reduced with modern processes.
Step 4: Orthotic Review
Your podiatrist and you will review how your orthotics are going as part of your entire treatment plan. Remembering that an orthotic is often one part of a successful strategy to treat your foot and ankle needs an orthotic review might involve some modifications to the devices themselves. Other parts of the orthotic review process include checking in on where you are in relation to your overall goals, adjusting exercise plans and setting new challenges.
Common myths about orthotics
Myth 1: Orthotics are only for people with flat feet.
Orthotics provide support, stability, efficiency and neuro-feedback to the wearer. People with flat feet often need some extra support under the arch however that is not just what an orthotic can do. High arched people are much more likely to suffer from ankle sprains as the sub-talar-joint axis laterally deviates in these cases. This means it's much easier for the foot to roll out rather than roll in. An orthotic for a high arch can provide this extra lateral support too.
Myth 2: Orthotics are rigid and will give you foot pain.
The wrong orthotic can give you foot pain. The right orthotic for you for the wrong activity can give you foot pain. We'd never recommend walking or running with a cycling orthotic. An orthotic that is too stiff in areas that your foot does not appreciate stiffness can give you foot pain. But an orthotic that is prescribed for you and your needs, and used accordingly will not give you foot pain. We guarantee it.
Myth 3: Orthotics make your feet weak and you become dependent on them.
This myth has been debunked by science many times over yet still keeps popping up. It's one of those things that we think intuitively must be true... An orthotic provides support therefore if I use it my muscles don't work and they get weak. After all, we all know that if we don't use them we lose them.
This is wrong. Orthotics cannot take the work a muscle does to zero. They can be used to increase or decrease work, but not make it disappear (as that would be breaking the laws of physics). If a muscle is overworked it becomes weak and injured. So if you're prescribing an orthotic to take the overload from that muscle, and bring the load back into the muscles ideal loading zone you'll actually build strength from that muscle.
Ask any muscle-bound gym rat what are the important principals of building and maintaining muscles strength and they'll tell you. Work out, refuel and recover.
An orthotic helps our muscles recover as they are no longer overworking. The workout part still needs to be completed by you and refuelling is all about dietary intake.
Myth 4: If you are wearing orthotics, you don’t have to wear good shoes
An orthotic pushes on your foot, but needs to push back against something else to actually help you out. This is the sole of your shoe and how it interacts with the ground.
If you have a very flexible soled shoe and you need to be able to push back on your foot the shoe will bend away, and the orthotic won't be doing what it could and needs to do.
Good shoes come first, great orthotics come second.
Myth 5: Over the counter orthotics work the same as custom orthotics
They don't work the same but they can have the same results in very specific circumstances. Your podiatrist will be able to tell you if this is the case for you.
This could be that both a custom foot orthotic and an over the counter orthotic will reduce your heel pain to zero. One might do it for 3 months, the other for 3 years. Or one might be able to do it very comfortably in all shoes whereas the other only in certain runners.
Frequently asked questions about Orthotics
The cost of orthotics depends on a few variables. We go into detail more on the cost of orthotics here. The range in price for a custom foot orthotic is between $480 and $580. For a prefabricated orthotic the range is $60 to $150. Your podiatrist will be able to give you a clear understanding of the cost of your orthotics and also what codes you can claim with your health insurer to pick up some of the tab.
Depending on what type of orthotic and what they're prescribed for will change what shoes you can put them in. Almost all orthotics will fit into well-made runners or gym shoes. For casual, walking or business attire your shoe will need to have appropriate fit and fixation. Shoes that have a removable liner make orthotic fitting much easier. If your shoes pass the "twist test" then they're more likely to be a good platform for your orthotic to be effective.
We've been able to comfortably put orthotics in a variety of dress shoes of all different shoe sizes. Even some high heeled shoes can accommodate a custom foot orthotic.
The only shoes you can't put an orthotic in are thongs. Luckily there are other options.
In Australia, orthotics are prescribed primarily by podiatrists. Podiatrists have the most expertise in all aspects of assessment, diagnosis and fabrication. That does not mean that podiatrists alone use orthotics. Prosthetists, physiotherapists, and chiropractors are all fellow health care professionals who utilise orthotics in their clinical practice. Sadly even non-health trained retail staff can sell orthotic services and devices as they are not yet a protected medical category. Yet.
Knowing that your PridePlus Health podiatrist is highly trained and stands by your orthotic prescription with our orthotic guarantee helps provide certainty for you when you're looking for an orthotic solution.
This high level of service coupled with the range of services that your podiatrist can provide is why podiatrists are the best profession to see for orthotics.
You can put orthotics in Skechers, if they are the right orthotic and the right type of Skechers shoe. The Skechers Go Run shoe for example is much better at accommodating a foot and an orthotic than the Skechers Go Walk. If you want to put your orthotics into Skechers or any other type of shoe bring them with you to your podiatry consultation to discuss with your podiatrist.
Speaking from both personal and professional experience orthotics can help bunions. A sore bunion is from either rubbing on the outside of a shoe, overload inside the joint or both. Orthotics are effective at reducing the overload inside the big toe joint of a bunion to reduce pain and maximise function.
Unfortunately medicare does not cover an orthotic treatment for plantar fasciitis or any other injury. If you have a chronic medical condition then medicare can provide up to five rebates for podiatry care in a calendar year. While this does not cover your orthotic device it can be used to cover the costs of assessment and reviews.
These medicare rebates are capped at 5 in a calendar year for all allied health care professional visits that you might have.
The type of orthotic that you need is personal to you. What are you doing on your feet? What's your injury or need? What do you want to do? What shoes will you wear? These are all questions to consider with your podiatrist as you go through your orthotic assessment.
Ankle-foot orthoses are a much more bulky type or orthotic that prosthetists prescribe for those with foot drop. An ankle-foot orthosis has more control of the up / down movements of the ankle than a custom foot orthotic.
Orthotics are effective in helping painful flat feet back to healthy feet in many cases. Something that we've learned in the podiatry and medical fields over the last 20 years is that the asymptomatic (not sore) flat foot is not something that needs fixing. So if you have flat feet and are in pain, then orthotics could be for you. If you have healthy feet, and a healthy foot function, not sore but still a little flat, an orthotic will not change your overall foot structure.
Orthotics have been proven effective at treating but acute knee pain and chronic knee pain. We're very proud of the work our own Dr Jade Tan has done in this area.