What are braces?
Over the years, orthotics have come to describe a wide range of products designed to provide support and comfort to the foot. Despite this range, a true functional orthosis (as developed in the middle of the last century) is defined by a device that is formed from a cast of the foot while that foot is held in a neutral position of the subtalar joint. The subtalar joint exists below the ankle joint and allows the foot to flatten and increase its arch according to the direction of its movement. The neutral position is when the subtalar joint does not flatten (prone) the foot, nor does it create a higher arch (supination). It is well established that a wide variety of foot conditions are the result of poor subtalar joint mechanics. Hyperpronation occurs when the subtalar joint allows for excessive pronation than is anatomically typical. The opposite occurs if very little pronation is available, as the foot becomes “cavoid” or high arched, although this is much less common. Many foot problems occur directly as a result of overpronation, including plantar fasciitis, posterior tibial tendonitis, tarsal tunnel syndrome, hammer toes, bunions, and neuromas. An orthosis will be effective in controlling this overpronation, thus eliminating the underlying cause of numerous foot conditions. If used for treatment alone, the brace is likely not beneficial as the inflammatory (pain) part of these conditions still needs to be addressed. However, as part of a multifaceted treatment plan in which the orthosis is used for long-term structural support, the orthosis is likely to provide significant benefit. The orthopedic design must accurately capture a person’s specific subtalar joint in a neutral position to provide the maximum amount of anatomical structural support. By doing this, the orthosis will reduce overpronation, allow the foot and leg to function more anatomically, and significantly reduce structurally caused foot problems. Orthotics are generally made from a thermoplastic, but other composite materials can be used to make them thin enough to fit into women’s dress shoes. Fabric upper covers can be used, not so much to increase comfort as to provide a platform for modifications to help the ball of the foot. For example, an orthosis itself goes from the heel to just in front of the ball of the foot. To help further unload the ball of the foot under certain conditions, more accommodative padding is needed further down the length of the foot, beyond where the orthosis itself ends. This adds an additional benefit to the function of the orthosis. Without a top cover, this padding cannot be attached to anything. However, in most cases, the upper covers are not necessary and their absence helps the orthosis to fit a wider variety of shoes. As the orthosis is a prescription device, a full biomechanical examination by a foot specialist is needed to get the “ correct ” prescription, as some patients require further adjustments to align the back of the foot with the front. of the foot by changing the way the orthosis is angled and certain conditions require a more dramatic modification of the usual cast. These more dramatic modifications can include wedges, cutouts, taller heel cups, and other significant changes to the plastic shell of the orthosis.
What about over-the-counter inserts?
Over-the-counter inserts have been used for many years for a variety of purposes. Overall, they provide decent arch and sole padding and cushioning, reducing shock and, in some designs, provide limited structural support. These devices typically consist of a felt, foam, gel, or polymer padding designed to push volume toward the arch. Some designs are made of plastic, emulating braces in appearance, but not in function. These inserts have firmer support, but are not as well tolerated as the inflexible plastic can irritate the sole tissue as it is not really molded for the wearer’s specific foot, let alone a proper neutral position. of the subtalar joint. In certain conditions that simply need more cushioning or minimal support, over-the-counter inserts are a good option for therapy and present a viable option as an initial treatment for conditions that require more support, provided that functional orthoses are ultimately used at length. long term. control. These inserts can potentially belong to a class called a accommodative orthosis. Although this generally involves inserts made from a cast of the foot without placing it in a neutral position of the subtalar joint, the definition has apparently been broadened to include most over-the-counter inserts and soft orthopedic inserts. Together, these devices increase shock absorption, benefiting arched feet. They also reduce pressure, which is beneficial for diabetics and those with painful rheumatoid arthritis. However, they are insufficient to provide adequate long-term structural support and are far inferior to traditional orthotics for that specific purpose. In essence, over-the-counter inserts have a notable role to play in a course of foot treatment, but are insufficient for those who need full biomechanical control.
Who provides braces?
Many suppliers now produce braces or inserts that claim to be braces. Beyond podiatrists, some orthopedic surgeons and traditional orthopedists / orthopedists, physical therapists, chiropractors, shoe stores, and self-describing insert stores offer orthotics. Like everything else, quality is directly related to the training of those who provide the service. As long as a full biomechanical examination has been performed and the foot has been placed in a neutral position of the subtalar joint, the orthosis will generally be sufficient for use. I have definitely seen good orthotics from therapists and chiropractors due to their knowledge of general biomechanics. On the flip side, I’ve also seen accommodative padded inserts masquerading as functional braces. Unfortunately, many non-traditional retail suppliers of orthotics and inserts have little understanding of how the foot actually works and cannot make an accurate assessment of aggravating foot problems that may need to be addressed in the manufacture of orthotics. The devices produced are often inadequate to provide rigorous support and, while not uncomfortable at first, they tend to fail in the long run. This often comes at a great financial cost. In some cases, customers are given what are said to be orthotics, when in reality they are simply over-the-counter inserts that correspond to a person’s shoe size. Some retail stores charge hundreds of dollars for these devices, where actual orthotics may be covered by insurance and may not even be that expensive if they are not covered.
What conditions do orthotics benefit and what are their limitations?
As discussed above, braces will benefit numerous conditions in which hyperpronation plays a central role in the overall development of the condition. By achieving maximum control of the subtalar joint, braces work more effectively and efficiently than other insert designs. Orthotics may also play a role in treating conditions that require greater shock absorption, as seen in high-arch feet, where plantar fasciitis is a direct result of poor shock absorption from the upper arches. When soft inserts do not provide sufficient shock absorption in these cases, the stiffness of these inserts absorbs weight-bearing energy and disperses it into the orthopedic plate itself rather than the sole of the foot. Braces are also used to transfer weight-bearing pressure in cases where painful corns, pressure sores, or arthritic joints require rigorous structural support to avoid major surgery or complications. In these cases, removing weight from the specific part of the foot to be addressed requires rigorous casting technique and an understanding of how this “weight reduction” will affect the rest of the foot. Finally, braces are used successfully to reduce arch fatigue created by overpronation, which can sometimes cause stress on the knee, as well as hip and back problems if severe enough. This fatigue is seen especially in children, and the use of a flexible flatfoot orthosis will eliminate the need for reconstructive surgery in most of these pediatric cases.
Orthotics have their limitations and are certainly not a panacea for all foot conditions. In almost all cases, they are ineffective in reducing the deformity that has already developed. For example, retail stores that sell inserts have told many people that their ‘braces’ will reduce hammer toes and bunions. This is simply not true, as even a functional orthosis will only slow the progression of such deformities by controlling the underlying factor – flattening of the feet. The deformity itself can only be corrected by surgery. Braces are also ineffective in people with a rigid flatfoot deformity, as there is little pronation left on those feet to support. In general, functional orthoses should only be used in conditions that have a structural cause of the foot, that are not yet fully developed from the bony point of view and are flexible enough from the feet that the orthosis allows reduction of movement in the foot. subtalar joint. Otherwise, its benefit and efficacy may be questionable.
