Are Orthotics the Appropriate Approach to Pain and Tendinopathy in Runners?

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This is a great question.  I am someone who makes custom orthotics, or rather, I have the ability to.  In the 16 years that I have been practicing, for every year that passes, I make less and less.  Part of that is that as I have gotten better at identifying the abnormal things that can occur in clients and in tying that into appropriate treatment, I find that I need orthotics less and less.  That being said, people who have foot pathology or foot alignment that predispose them to greater pronation, which is probably the more common foot alignment issue, can oftentimes be helped by strengthening at the hip and by working on flexibility.  But very often there is going to be a group of people that have alignment issues that cause them to pronate way more than they are going to be able to control with muscle strength alone.  I think that if you identify that alignment as it relates to overloading the tissue, changing footwear and/or adding an orthotic device can be helpful.  The one piece that I think is critical with an orthotic device is the consideration that excessive pronation is sometimes a compensation for limited ankle dorsiflexion. Often, a therapist will watch someone walk and say look at all that pronation. Then, they will give them an orthotic which has taken away their compensation for something else.  For me in my practice now, it tends to not ever be the first intervention that I go after.  I tend to try and maximize the intrinsic things such as flexibility and strength.  If there continue to be issues, then I may start to take a look at something like orthotic intervention.  I think patients will oftentimes appreciate that because it is an out-of-pocket expense. In the Northeast, most insurances do not pay for foot orthoses.  If I can help them get better without having that extra cost, it can be beneficial.  But, certainly there is going to be a group of people that orthotics are very appropriate for.