Based on the current status of orthotic technology, all orthotics for hyperpronation are based on mid- and rearfoot correction. Methods for determining the optimal orthotic dimensions vary from plaster casts and foam box imprints of the foot to fancy electronic gadgetry which many believe adds little information, but dazzles patients. The discussion of what is most appropriate, weight bearing or non-weight bearing cast is ongoing, and seems driven by proponents of different orthotics suppliers.
Forefoot or rearfoot posting is sometimes incorporated to support a “Roots forefoot varum” or to force the heel to become perpendicular to the ground if arch supports seem insufficient. In most cases the measurements are static in nature, and even if the measurement is dynamic (walking over a pressure plate) the orthotics that are produced provide static support only, and become useless as the body weight shifts to the forefoot.
To contrast Dr. Rothbart’s simple and different methods, let us first take a look at current static technology.
Arch supports are so common today that people expect to see them in their shoes. Interestingly, most arch supports found in shoes are merely cosmetic. Material softness and position causes most people to have little or no sensation of its presence (does not support the Navicular). Some shoes incorporate functional arch support, and many people find them uncomfortable because all of a sudden they feel pressure under the arch; a sensation they are unaccustomed to and that most people do not need or want.
Functional arch supports are very important for people with near or completely collapsing arches (flat feet). Their arch may look functional when the foot is not weight bearing (patient sitting), but it collapses fully to the ground when standing naturally on the foot. These people need functional arch supports.
A majority of suppliers of orthotics recommend arch supports for everyone - low arches or high arches. This is a disservice to the patient. Arch supports immobilize the foot. Would you leave a neck brace on a patient for an indefinite time? Only if their neck muscles were incapable of holding the patient’s head. For normal active people, you should only provide arch supports to patients who do not have functional arches. Without arch support, the foot will be free to move naturally, strengthening the muscles controlling it. If a patient has suffered an injury that needs a temporary arch support, think of it as a neck brace and remove it as soon as possible to allow the patient’s muscles to recover and strengthen.
Occupational activity may also be a consideration for arch supports. Consider a surgeon or a machine operator who stands in the same place for hours. Arch supports can help alleviate back pain and sore feet but perhaps it would be advisable to wear them only intermittently during the times while standing stationary.
A very common theory is to control hypermobility of the heel by using heel cups. Hypermobility of the heel stems from torsional forces in the foot occurring as the foot hyperpronates. When the arch collapses, the heel bone will twist outward as the ankle drops inward. The theory is to restrict rotational forces in the foot by locking the heel in place using a heel cup. A heel cup is typically used in combination with an arch support. Even when used with good lacing systems and firm heel counters, you will still see the wear pattern from the twisting heel on the lateral heel counter inside the shoe.
Wedges are most often used under the heel bone to force the heel to become more perpendicular to the ground. This posting successfully straightens the heel while standing, and positions the subtalar joint (STJ) closer to its neutral position. The effectiveness of a heel wedge is lost as the weight transfers to the forefoot and the heel lifts off the ground.
When a medial heel wedge is inserted, the effective elevation of the first metatarsal and the big toe is increased which has the potential to cause plantar and arch pain.
Wedges are not used as frequently under the forefoot, but when they are, they are typically posting the first through the fifth metatarsal to fill the “Root’s forefoot varum.” This may be helpful for patients who are flat footed, but it is typically uncomfortable for people with a fully or partially functioning arch.
The foot is frequently referred to as having several arches. The most common is the internal or medial longitudinal arch, most commonly referred to as “the arch”. A lesser known arch is the transverse arch that spans the metatarsals. We have found no particular evidence that there is a definite connection between supporting the transverse arch and improved biomechanical function of the foot. A metatarsal pad may however provide some amount of cushioning, particularly under the second and third metatarsal head. This is where most of the pressure focuses while approaching toe-off during normal walking. The reason for lack of even pressure distribution under the metatarsals is the elevated first metatarsal and big toe.