"Does this patient need orthotics?" If you're unsure of the answer, consider these observations:

Whenever a patient shows a need for flexible, custom-made foot orthotics, you must decide which style of orthotics to order. This is not a decision to be taken lightly, because only by selecting the appropriate type(s) of orthotics can you ensure a good response and outcome. Which orthotics you select must reflect the patient's health needs and lifestyle.

While it's easy to supply a well-designed, well-made pair of custom orthotics, if they don't fit the patient's shoes properly, or if they're not designed to hold up to the types of activities in which the patient participates, they won't function as needed. If the patient can only wear the orthotics occasionally in certain shoes, the feet, spine, and pelvis will be exposed to the additional stress of varying amounts of support.

In order to do the job right, you will want to make sure that the orthotics have been designed for your patient's shoes, activities, and physical condition. Let's review some of these variables.

Contemporary dress shoes are usually slim, fashionable slip-ons, and standard orthotics just won't fit. For both men and women, non-lacing dress shoes usually require orthotics with dot fasteners, which anchor the orthotics into the shoes' lower heel counters and slimmer lines. Thankfully, many women are avoiding high heels presently, but those who do wear heels over 1" must be supplied with an orthotic which is specifically designed to take the plantarflexed position of the foot into account.

Lace shoes such as oxfords, work boots, and sports shoes can handle traditional orthotics, although full-length coverage may be desired in athletic shoes when the generic insert is removed. Western boots remain popular in parts of the country and require yet another specialty orthotic due to their unique methods of construction and fit.

An orthotic's worst enemy is probably moisture, especially perspiration from the feet. If a patient works in a high humidity environment, or if he or she perspires excessively, the average leather orthotic can be warped or corroded by constant contact with moisture and foot sweat. In such cases, a specialty orthotic is recommended.

Other variables which can affect orthotic choice include physical conditions such as diabetes (the skin will not withstand the pressures of most standard orthotics) and arthritis. A softer, more flexible orthotic will work much better for these patients.

Many patients are helped by orthotics which decrease the intensity of the shock waves which course through the body with each heel strike. Geriatric conditions such as heel pad thinning, joint arthritis (especially knee and hip), and spinal disc degeneration are helped immensely by improving shock attenuation. Heel spurs need shock absorption and occasionally specially-shaped padding to relieve pressure on sensitive areas.

When your patient is overweight, a firmer orthotic designed to withstand the increased biomechanical forces is important in order to maintain sufficient support. The combination of firmness and flexibility required of such an orthotic makes orthotic style selection especially critical for larger patients.

The recreational and occupational stresses that a patient's feet are exposed to vary tremendously. Your sedentary patient will appreciate softer, very flexible orthotics, while more active patients and those who are on their feet at work need orthotics which provide more support along with good shock absorption.

Your success rate will depend on how specific you can be when selecting a corrective orthotic for your patient. And you will want to be sure the spinal foundation is corrected at least 80% of the time your patient is standing, walking, or running. In most cases, therefore, your patients will need more than one pair of orthotics to provide the necessary level of support throughout the day, during all their various activities.

In many cases, it is advisable to prescribe what is known as an orthotics "combo," two pairs of flexible, custom-made orthotics – one set for dress shoes and one set for recreational lace shoes. When a patient receives a "combo," he or she will be supported during both dress and sport activities.

When a doctor orders orthotics designed to fit the patient's lifestyle, the biomechanical support is more comprehensive, and the results are more gratifying. Everyone involved appreciates a job that's done right, and not half-way.

1. Schafer RC. "Chiropractic Management of Sports and Recreational Injuries." Baltimore: Williams & Wilkins, 1982:517.

2. Hyland JK. "Spinal Pelvic Stabilization: A Practical Approach to Orthotic Application." Roanoke, VA: Foot Levelers Educational Division, 2002:15.