July 2005

What about over‑the‑counter orthotics?

by Dr. Terry A. Rondberg

Often, when a patient returns repeatedly to a chiropractic office, unable to "hold" an adjustment, an examination reveals that the problem rests with the patient's feet or legs.

Leg length inequality, imbalanced gait, pes planus, hyperpronation and other irregularities can have an intense and negative impact on spinal health. The answer is often orthotics to correct the imbalance and restore normal spinal alignment.

But even knowing that, we have another decision to make. Do we explain to the patient the need for orthotics and send him or her to the local Walgreens to buy a package of Dr. Scholl's shoe inserts, or do we recommend custom made orthotics?

The former solution is far less expensive (at least in the short run) and for minor problems, over‑the‑counter (OTC) insoles and arch supports might even help somewhat. Yet, for serious or chronic situations, these "one size fits all" products can do more harm than good.

According to Rock Positano, DPM, a foot and ankle specialist at the Hospital for Special Surgery (HSS) in New York City, some OTC orthotics may exacerbate pre‑existing medical conditions. "Orthotics are like prescription drugs," he explains. "When indicated and prescribed correctly, they are beneficial to the user. When unnecessary or prescribed incorrectly, they can be dangerous."

The reason is simple. Any orthotic, even the most benign‑seeming OTC arch support, as Dr. Positano explains, "alters the way a person walks, stands and absorbs shock from the ground." Unless the orthotic is customized to that person's foot, and made to correct the problem in the proper way, the changes it causes can aggravate rather than diminish the problem.

Kevin A. Kirby, DPM, MS, editor of PodiatryNetwork.com, agrees that customized orthotics have great advantages over their OTC counterparts. "Since they fit so exactly to the person's foot, they can be made with relatively rigid, durable materials with a minimal chance of discomfort or irritation to the patient's foot," he explains. "Prescription foot orthoses also have a much greater potential to effectively and permanently treat painful conditions, all the way from the toes to the lower back, since they are designed specifically for an individual's biomechanical nature... Even though the over‑the‑counter inserts do help some people with mild symptoms, they do not have the potential to correct the wide range of symptoms that prescription foot orthoses can since they are made to fit a person with an 'average' foot shape."

Kirby also offers a great analogy to help DCs ‑‑ and their patients ‑‑ understand that need for customized orthotics. "Prescription foot orthoses may be considered to be analogous to prescription eyeglasses," he says. "Over‑the‑counter eyeglasses may work for some people since they are made to correct for the average eye. However, over‑the‑counter eyeglasses will almost never work as well as prescription eyeglasses. Prescription foot orthoses, since they are custom made to each foot of a patient, are almost always more corrective and comfortable than over‑the‑counter foot inserts, even though over‑the‑counter inserts do work for some people."

This is particularly important to remember when caring for children, whose foot and skeletal structure is still forming. Even the insurance industry recognizes the need for customized orthotics for young patients in need of corrective foot or gait devices. Aetna, for example, states clearly that "over‑the‑counter orthotics are not appropriate for children."  

Knowing that custom orthotics are better for most patients, however, creates a difficult problem for some practitioners. We're all sensitive to the perception of chiropractors as excessively money motivated. That's why some DCs cringe when they realize a patient requires long‑term care. They don't want to recommend adjustments three times a week for 12 weeks and risk appearing "greedy," or having an insurance company say they're "over‑utlizing" chiropractic for personal financial gain.

To avoid having anyone think badly of them, they may tell the patient "we'll try two or three adjustments and see what happens." They also tell patients to go to the local pharmacy and pick up a pair of arch supports in hopes that they'll correct their gait without intervention.

But, in attempting to reinforce an image of chiropractors as compassionate and selfless healers, they run the greater risk of failing to provide the best care possible to their patients. When faced with the difficult decision of saving money for our patients or helping them lead healthier lives, we really have no choice. We have to always choose to do what's best for our patients, and put aside our own fears that they may think we have 'ulterior motives' for our recommendations.

(Dr. Terry Rondberg is president of the World Chiropractic Alliance and publisher of The Chiropractic Journal and the Journal of Vertebral Subluxation Research. A popular speaker at chiropractic conferences and seminars, Dr. Rondberg is also a frequent guest on TV and radio shows. He has written numerous articles on chiropractic for the profession and the public, as well as several best‑selling books, including "Chiropractic First," "Under the Influence of Modern Medicine," and, with Timothy J. Feuling, the "CBS Malpractice Prevention Program," and "Chiropractic: Compassion and Expectation.")