Orthotics and Running: Essential or Overhyped?

In France, if you get a running injury, there's a good chance you'll be prescribed orthotics. Podiatry is somewhat revered in French medical culture, and foot orthotics are sometimes touted as THE miracle solution for all runner's pains. But from what I've read, what does the science really say? Are orthotics as essential as they're made out to be, or are they over-prescribed?

Real Indications: When Orthotics Make Sense

It's not about rejecting them entirely. In certain cases, orthotics are genuinely justified:

Symptomatic Flat Feet

Having flat feet isn't an issue in itself — many elite runners have fallen arches without any problems. However, when your flat feet are accompanied by pain (recurrent fasciitis, posterior tibial tendinopathy, inner knee pain), arch support can relieve overloaded tissues. Scientific reviews (Banwell et al., 2014) show moderate benefits in such cases.

Significant Structural Asymmetries

If you have a leg length discrepancy of more than 10-15 mm, a heel lift might be justified. Significant asymmetries in joint or foot architecture can also be partially corrected. But beware: small asymmetries (< 10 mm) are common for almost everyone and aren't necessarily a problem.

Specific Pathologies

Certain stubborn injuries — shin splints, patellofemoral pain syndrome with a true biomechanical component, iliotibial band syndrome (runner's knee) — may benefit from an orthotic as part of a comprehensive treatment plan. The key word here is "comprehensive": an orthotic alone rarely solves the problem.

The Problem of Over-prescription

Despite these legitimate cases, I personally believe there's a real issue of over-prescription of orthotics among runners.

An Overly Simplistic Biomechanical Rationale

The classic model suggests: the foot is a foundation, any 'defect' propagates upwards (knee, hip, back), and the orthotic corrects at the base. This reasoning is appealing but overly simplistic. Your body is a complex, adaptive system. Pronounced pronation isn't necessarily a defect — it's often just how your foot absorbs impact, and it works perfectly fine.

Mixed Scientific Evidence

The Cochrane Review by Hawke et al. (2008, updated in 2022) concludes that orthotics provide a low to moderate benefit for some foot problems, but evidence is lacking for most common indications among runners. What's more, the effect is often comparable to that of inexpensive, basic insoles — which raises questions about the cost-effectiveness of custom orthotics.

The Placebo Effect: Powerful and Underestimated

The placebo effect in podiatry is very real. Simply wearing an orthotic — whether 'corrective' or not — can reduce pain for a runner who believes in it. This isn't insignificant (the placebo has true therapeutic value), but it does challenge the necessity of spending 200-300 € on custom orthotics.

Sports Podiatrist vs. General Podiatrist

If you're considering orthotics, choosing the right practitioner is crucial. A sports podiatrist — who understands the specific demands of running — will approach your situation very differently from a general podiatrist.

A sports podiatrist will consider:

• Your training volume and intensity (a runner doing 20 km/week is different from one doing 80 km/week)
• Your current footwear — an orthotic interacts with the shoe, and some combinations can be counterproductive
• Your biomechanics in motion (gait analysis, not just your static standing posture)
• Your injury history and what you've already tried

A good sports podiatrist won't prescribe orthotics to everyone. They might also recommend strengthening exercises, a change in running shoes, or refer you to a physical therapist if the problem is more muscular than joint-related.

Gradual Adaptation: An Often-Overlooked Aspect

When orthotics are prescribed, the adaptation phase is crucial — and it's something many practitioners and runners underestimate.

An orthotic changes the distribution of forces on your foot and the entire kinetic chain above it. Heading out for your long run immediately with new orthotics is a common mistake. Here's how to gradually adapt:

• Week 1: Wear them while walking, 2-3 hours per day
• Week 2: Wear them while walking all day
• Week 3: Start running with them (short, easy runs)
• Week 4+: Full use for running, with adjustments if needed

If you experience new pain during adaptation, it's a warning sign: return to your podiatrist for an adjustment. An orthotic that still causes pain after four weeks is likely not properly fitted.

The Alternative: Foot Strengthening

A complementary — or even alternative in some cases — approach is foot muscle strengthening. These small muscles have long been ignored, but they play a huge role in maintaining your arch and absorbing impact.

Recent studies (Sulowska et al., 2019; Ridge et al., 2019) show that targeted exercises improve foot stability and reduce some pains typically treated with orthotics. Here are the most studied exercises:

• Short foot exercise: Contract your arch without curling your toes
• Barefoot walking on different surfaces (grass, sand, mat)
• Toe gripping exercises: Picking up marbles, scrunching a towel
• Single-leg balance: First on a stable surface, then unstable
• Calf raises: Slow eccentric raises for the calf and Achilles tendon

Foot strengthening doesn't replace orthotics in all cases — a rigid flat foot of bony origin won't 'muscle up'. But for many runners with flexible, mobile feet, this active approach can be at least as effective as a passive orthotic, with the added benefit of addressing the cause rather than just the symptom.

Finding the Right Balance

The real question isn't 'orthotics or no orthotics,' but 'orthotics for whom and in what context.' Orthotics are a legitimate tool when they address a real indication, prescribed by a competent practitioner, as part of a comprehensive management plan.

It becomes problematic when prescribed automatically, without thorough assessment, and presented as THE sole solution to injuries with multiple causes (too much volume, muscle weakness, unsuitable footwear).

My advice: approach the question with a critically informed mindset — neither dogmatic rejection nor blind acceptance. And if you're already wearing orthotics without fully understanding why — which is more common than you might think — a re-evaluation by a sports podiatrist could be very insightful.