The orthotic device – locomotion gone loco? Part 1

When I lecture on low back pain I pointedly report that the ‘dynasty of the disc’ is over. This is based on there being plenty of good research showing random associations between disc herniations and low back pain. (NEJM published unheralded stuff way back in 1993.) Similarly, I’ve just returned from a Myopain Seminar in Bethesda where my mentor, the neurologist Robert Gerwin MD, ventured that there is little difference between 2 year follow-ups of people having laminectomies and those using a manual therapy approach to their low back pain. Surely the ‘dynasty of the laminectomy’ is also over.

The topic of this particular blog has been bugging me for a while now. Orthotics. Things you put in your shoe because your foot is incompetent. The same foot that has twenty six bones, double the number articulations and double again the number of ligaments. This incompetence is meant to be under the control of 20 muscles located within the foot itself and 12 more in the lower leg.

I have to ask myself, and you readers, what has gone wrong with hundreds of thousands of years of natural selection. Why does our foot need so much help? The answer may lie in the shoe.

Most of us have perfectly good feet, but they only perform if we give them stuff to do. Tasks include sensing the terrain underfoot, absorbing shock, contouring to various surfaces, performing like coiled springs to facilitate locomotion, and sending critical messages to higher structures as to where we are in space.

Here’s the thing – the modern sneaker can do a lot of this too. The sneaker can shock absorb for sure. It can recoil too. It doesn’t need to contour because we’ve paved the world so flat. Does this make the foot redundant? Possibly. Should we not just have a hoof? I think it was Tom Myers who promoted the modern shoe as being ‘a leather coffin’.  It may indeed be housing a neglected, atrophied, distorted and very distant relative.

Back in the late eighties, during my marathon running phase, I tried to buy shoes that would prevent the usual running injuries like plantar fasciitis, tendonitis and shin splints. I figured out that with my short and bowed legs I wasn’t such a good pronator. I landed lateral and stayed there. In the shoe shop I chose the shoe with the most cushioning in the heel. I bounced up and down on my heel in various brands until I found the softest. This served me well – up to a point.

Running injuries happen. Runners always live on a knife-edge. Of course, I ended up spending $300 on some bits of custom-made foam designed to help me through these bad times. I tried to like them; you have to, having spent the money. Months later Holly, my Boxer, found them and chewed them up. I saw it as a sign.

I’m now of the impression that an orthotic is a temporary device to help get you through a bad patch – kind of like crutches or slings when you damage extremities.

I’ve always encouraged my patients to do foot-gym. Exercises to wake up, stimulate, recognize and strengthen your foot muscles. On January 18th, an article in the New York Times on orthotics came along with similar views. This will be the subject of a future blog.

One small step for man…