The orthotics debate: How running shoe inserts are dividing the experts

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Like all runners, Nicole Haber dreads any injury that keeps her from her sport. So when she found herself struggling after an ankle injury two years ago, Haber, a 32-year-old regular in New York City road races, was open to all solutions to get back to running. When her orthopedist suggested custom-made orthotics she went for them, even at the steep cost of $500.

Haber is in good company when it comes to orthotics. Physicians have prescribed them to injured runners for years, and there is no slowdown in sight. According to a study from IndustryARC, the foot orthotic insole market is likely to grow at a rate of 5.8 percent annually to reach $3.5 billion by 2020.

But not everyone is on board with the philosophy that orthotics are a panacea. Many in the industry, in fact, rally against the widespread recommendation that runners add either over-the-counter or custom insoles to their collection of gear.

Dr. Mark Cucuzzella is a professor at the West Virginia University School of Medicine and a proponent of natural running. He says that too often, runners and their physicians turn to orthotics before trying other methods.

"The first step should be to retrain and restructure the foot to its natural state and function," he said.

Cucuzzella is particularly troubled when runners with no structural deformities use the supports.

"It's one thing if you are an 85-year-old with a 40-degree bunion," he said. "But if you are a younger runner without a deformity, your foot should be able to do its job and not rely on orthotics."

Dr. John Senatore, a podiatrist with MedStar Health in Baltimore, represents the other side of the argument. He says orthotics play an important role in keeping injury at bay for many runners.

"The pressures going through the foot when you run are two to three times your body weight," he said, "and if you've got excessive pronation, you need a good shoe and an orthotic."

Senatore argues that keeping the foot in a neutral position will lessen the load on the bones, tendons and muscles of the feet and ankles.

"When I see someone with an issue, I first recommend over-the-counter insoles," he said. "But if that doesn't help, then I move them into custom orthotics."

This was the path that Haber followed with her podiatrist.

"I started with over-the-counter inserts, but they didn't meet my arch, so every step I took put strain on my hurt ligament," she said. "The custom orthotics helped close that gap."

Like Haber, Micah Young, a 36-year-old Colorado-based English teacher, has high arches and said she likes that her orthotics hug her feet. Originally prescribed to her almost a decade ago after a series of stress fractures, Young is now working her way to running without them, mostly because of their high cost.

"Instead of orthotics, I've been wearing high-cushioned shoes and have cut back on my mileage, adding in swimming, cycling and rock climbing," she said. "I think this is the solution for me."

So ... what's a runner to do?

Unfortunately, as evidenced above, there isn't a consensus among the experts. There are steps you can take, though, if you'd like to avoid orthotics or stop using them.

"Yes, orthotics can diminish and even eliminate pain," said Stephen Gangemi, a North Carolina chiropractic physician, "but they are generally masking the symptoms and not addressing the problem. They are like aspirin in your footwear."

Instead, Gangemi said he believes runners should aim to drill down, find the root cause of pain and wean out of the orthotics.

"If you've been wearing supportive shoes with orthotics for years, the transition is going to take time," he said. "But eventually, if you are healthy and uninjured, you should be able to walk barefoot and run without all the support."

It's just like a brace for a neck injury -- you wouldn't keep it on once you heal. So why would you stay in orthotics?
Dr. Mark Cucuzzella

Cucuzzella agrees. "If you stay in an orthotic of any sort, your intrinsic muscles will weaken," he says. "It's just like a brace for a neck injury -- you wouldn't keep it on once you heal. So why would you stay in orthotics?"

Cucuzzella points to research published in the British Journal of Sports Medicine as a reference point for retraining the foot. "If you do foot posture exercises, you can strengthen the intrinsic muscles needed to support a neutral stance," he says.

Senatore disagrees, and says that even in the best case scenario, runners should have "supportive" shoes and that anything less -- a la a minimal shoe -- is harmful. He also doesn't buy that orthotics can weaken the foot. "Patients come to us with weak feet and orthotics help them overcome that," he maintains.

As for the runners, Haber has no plans to wean away from her orthotics. "At this point, I'd be too nervous to run without them," she says.

Young, who has figured out a way to run sans the inserts, says she still uses her old custom pair in her hiking boots, and will always remain cautious. "I rarely go barefoot, even around my apartment, because my feet just always feel a little fragile," she admits.

Gangemi sympathizes with this mindset. "I understand how orthotics can so easily be the go-to treatment," he says. "If that's the case, however, patients still need to address overall function and health."

With no clear agreement, the debate over orthotics and their utility is sure to rage on -- but there's one thing all the experts do agree on: Everyone should be able to run, healthy and pain-free, so keep trying different solutions until you to get to that point.

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