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Orthoses within a neutral running shoe or within a support running shoe?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by philbrizell, Jul 23, 2006.

  1. philbrizell

    philbrizell Member

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    I have read some of the threads concerning this issue but still remain a little confused. As a newly qualified Podiatrist, can any body help me with some general guidelines as to what type of running shoes should orthoses be fitted into. I know that there may be many variables in this decision making but would appreciate a 'starting point'.
  2. Phil,

    I spend most of my clinical time working with runners. Unfortunately I don't think that there is a simple answer to your question- I've fitted devices into every brand of shoe in the local running store whether they be neutral or whether they be full-on motion control. A question I get asked a lot is: if I wear orthoses does that mean I can wear neutral shoes? The answer is dependent on the individual though. For example, some runners I work with come to me with a shoe with a fair amount of "pronation control" built in- however they are still getting problems- we can talk about why another time. Depending on the individual and depending on the pathology, sometimes with their orthoses in situ these people can "drop down" to a cushion shoe. At the other end of the scale, I am currently working with a female marathon runner, who presented with sinus tarsi syndrome I made her a 15 degree medial heel skive device which got her through Belfast marathon, but now her training has stepped up in prep. for her next marathon we are working with 15 mediaL heel skive + external rearfoot posting AND she wears Brooks Beasts (full motion control shoe)- She is running pain free for the first time in years. BTW she is fully aware of potential problems with these devices, but more than happy to go for it while she can. So you see some people need all the help they can get.

    Also, if people continue with some pronation control in their shoe it enables me to be slightly less "aggressive" with the orthoses, this, I believe, seems to help with comfort and "compliance".

    My main problems with running shoes is that they come in pairs, great if you got symmetrical foot function, not so clever if you haven't.
  3. Phil:

    Simon makes some very good points above. I also spend a lot of my practice treating runners and, at one time, I was a half-way decent long distance runner myself. So I have a lot of opinions regarding this subject.

    Running shoes are divided into three basic categories: neutral, stability and motion control. Even though some shoes are somewhere in-between these basic categories, in general, the firmer the midsole, the higher the medial rearfoot midsole durometer, the stiffer the heel counter and the more straight the medial border of the shoe sole, then the more likely this shoe will be a motion control shoe. Neutral shoes are lighter, have lower durometer midsoles with no increase in medial rearfoot midsole durometer, have more flexible heel counters and will have a more concave medial border of the shoe sole. Stability shoes are somewhere in between these two categories.

    Like Simon, I also recommend shoes depending on the patient's weight, running style, specific complaints and pathology, their foot type and gait findings. I will often recommend the patient use a less-controlling shoe (i.e. go from motion control to stability) if they have pronation-related symptoms and I will be making a custom foot orthosis for them. However, if they are having significant symptoms and poor gait function even with a motion control shoe, then I will still continue to recommend a motion control shoe for them when I make them custom foot orthoses. It all depends on the patient.

    One point that I think is poorly understood by most podiatrists and rarely taught in podiatry schools, is that a person's body weight alone will greatly affect the type of shoe that they are most comfortable and efficient in. Research has shown that soft midsoles do not always absorb more shock for runners. A shoe that has too soft of a midsole may actually decrease the shock absorbing ability of a shoe for a heavier runner just the way a truck with less stiff shock absorbers/springs on their suspension may create a harsher ride when it has a heavy load (i.e. both the shoe midsole and truck springs "bottom out" before the center of mass of the person/vehicle has reached its lowest point).

    In addition, I see many female runners who are 110 -120 pounds that have been put into heavy motion control shoes by the running shoe store (since they have pronation related symptoms) when they nearly always function much better and run much more efficiently when they are put into a lighter stability shoe with a prefabricated orthosis or custom orthosis inside their shoe. In other words, these small women just don't have body mass to compress the high durometer midsole of the motion control shoes to get adequate shock absorption from the shoe midsole. Shoes must be "tuned" to the runner for optimum comfort and performance, just like their foot orthoses should also be "tuned" to their specific pathology and foot type.

    Hope this helps.
  4. The other point I wanted to make here is that there are very few shoes which attempt to provide forefoot control- Go check them out in your local store- short medial rearfoot "block", medium length rearfoot block and long length rearfoot block. So if you have a forefoot striking patient, unless you can get the heel down, all the motion control in the world within the heel of the shoe isn't going to do a great deal. Also, if the pathology your patient is suffering from stems from forefoot/ propulsive phase problems quite often the "control" within the shoe will be inadequate.

    I know from talking with Simon Bartold that some shoes are in development/ in store from various manufacturers with greater thought given to forefoot shoe mechanics e.g. Nike caesium (patients either love it or hate it -in my experience).

    Also worth noting is that the materials break down with use and time!!!
  5. philbrizell

    philbrizell Member

    Thank you Simon and Kevin for your replies!

    All your infromation is gratefully recieved. It seems that at the end of the day it all comes down to experience and havig a good understanding of running shoe design. As you have stated, the weight of the runner must play a large part in the choice of footwear. I know that the Runners World general guidlines suggest, that any body over 13 stone should be looking at motion contol shoes (irrespective of foot function?).

  6. Phil,
    Again not as simple as that. I see guys who are big, but run really light on their feet and so get away wearing lightweight racing shoes just to train in. I also see little ladies who weigh next to nothing but stomp down real heavy and destroy shoes in next to no time.
  7. efuller

    efuller MVP

    Timing of pronation and control

    Hi all,

    A lot of pronation control shoes work by having a dual density midsole or some other configuration that makes the medial side of the heel midsole firmer than the lateral. What this does is it shifts the center of pressure under the heel more medially, which is the same thing a medial heel skive orthosis does. The medial shift of the center of pressure will change the moment from ground reaction force to an increase in supination moment or a decrease in pronation moment. This only happens when the heel is on the ground. That is how the shoe works.

    Some people are ground reaction force pronators and others are muscular pronators. Ground reaction force pronators are people with a more meidally positioned STJ axis and the center of pressure under the foot will more likely cause a high pronation moment from the ground. These people will do well in the "dual density" shoe. Muscle pronators are people with a more laterally positoined STJ axis. The center of pressure under the foot will tend to cause a very small pronation moment or even a supination moment about the STJ. These muscular pronators often, while walking as opposed to running, will tend to tend to be in a more supinated position in early stance and then exhibit STJ pronation just about the time the heel lifts off of the ground. In these feet, at this time in gait, there is a small pronation moment from the ground and increasing supination moment from the Achilles tendon. If the Achilles tendon were the only muscle acting this foot would supinate toward the end of range of motion. In response, these people use their peroneal muscles to achieve a net pronation moment and hence a pronation motion of the STJ around the time of heel lift. These people do not do well in "dual density" motion control shoes.

    The dual density anti pronation shoes are designed to treat proantion caused by ground reaction force and not pronation caused by muscles. It is very important to understand the relationship between the center of pressure and the position of the STJ axis to be able to recommend the correct shoe. The other points mentioned by Simon and Kevin are important as well.


    Eric Fuller
  8. yehuda

    yehuda Active Member

    I personally run in the cesiums they as far as understand have a 3 deg rf wedge and no ff control (could be wrong) my only complaint is they seem to soft ie not enough cushioning.

    Also there is the pearl Izumi syncroguide which sems to control pronation without bulky medial posting

    I tell my patients never to wear their running shoes for more than 600 km max
  9. I thought the "strip" sub 1st MTPJ in the cesium was supposed to enhance windlass function?

    And Mizuno wave system. Watch out for the neutral Mizuno's though- seem to break- i.e. flex under load at the mid-foot- seen a lot of midfoot problems in people wearing these lately.
  10. Phil Wells

    Phil Wells Active Member


    It is also worth bearing in mind that when a dual density shoe is used, as Eric mentioned, they are also dual durability. It is highly likely that if a runner if striking the ground on the lateral border of the shoe at initial foot strike, the GRF may be significant. The COForce may then move medially but may be diminished by the bodies and shoes natural hysteresis and force attenuation mechanisms.
    This may lead to the lateral border 'wearing' excessively and compressing. This may eventually lead to a shoe that is 'inverted' relative to the ground. This may be good or bad but worth bearing in mind when taking a patient history. In my case, when by back starts to hurt after lunges and squat thrusts in the gym, it is time to change my shoes.

  11. yehuda

    yehuda Active Member

    Re the cesium thats what they say but i still wear more orthoses with a plantar fascia groove and domb, I tried without the domb pad and my ITBS came back the first 10 mile run I did.

    The only Mizuno's that have some forefoot control is the Nirvana which I have found to be more controlling than the Kayanos but less cushioned and their MC shoes (wave renegade) I will probably try the pear izumi next (trying to convince my accountant that running shoes should be tax deductible :D )
  12. chazcheh

    chazcheh Member

    I agree with Simon and Phil on many of their respected theories.
    The only advice I can give is to watch out that you do not fall into the area of 'over correction'.

    I remember I was working in a shoe store at one stage and a runner came in to buy a pair of shoes and the staff recommended the brooks beast as this was the most supportive. The uneducated staff also new that he was wearing orthotics but thought nothing of it. This runner came back in 6 weeks later abusing the staff because he found that the recommended shoes plus the orthotics actually caused such an increased inversion that the runner first experience lateral knee pain but then sprained his ankle as the orthotic and shoe combined caused the supination of the foot.

    All I am saying is be careful, to be safe, if you are prescribing an agressive orthotic it would be better to prescribe it to a neutral shoe.
  13. That is not good advice for all patients. Some patients require not only an "aggressive orthotic" but also a motion control shoe such as the Brooks Beast to become asymptomatic. This is, as I stated earlier, very individual and depends on many factors so one should be careful not to over-generalize when concerning running shoe and orthosis selection for patients.
  14. chazcheh

    chazcheh Member

    Not looking to generalize but would'nt you think that it would be safe to prescribe a high controlling orthotic to a neutral shoe and if the patient requires more control then you can actually adjust the orthotic device. Rather than putting the patient at risk of injury due to over correction.
    I state this remebering that every patient is different and will definatley require a different degree or amount of control so building an orthotic up to a certain level over a period of time could be easier to modifiy and also easier to comply with than initially recommending such a controlling shoe.

    Your thoughts.
  15. Good question. I prefer to make the orthosis with a specific shoe type already in mind for my runner patients. Some patients due to excessive weight, severely medially deviated STJ axis or severe pronation symptoms may need a motion-control shoe and an orthosis with extra pronation-control measures. This same patient may remain symptomatic if you allowed them to run in a neutral shoe. It is always fairly easy to reduce the varus control of an orthosis a degree or two if it is over-controlling the patient and causing symptoms (I love my grinder!!). However, it is a lot more work (and sometimes impossible) to try and increase the pronation controlling ability of an orthosis in a shoe with soft midsole (i.e. neutral shoe). I guess it all comes down to preference of the clinician. However, when I train my residents on orthosis prescription, I always tell them it is much easier in a busy practice to add too much correction and then grind a little out than to add too little correction and have to cut, glue and grind extra correction into the orthosis.
  16. philbrizell

    philbrizell Member

    Forefoot control

    I never realised that there were running shoes for forefoot runners - I'm interested to know more.
    In fact, all of my reading has been about controling the rear foot (extending to the midfoot) and have not found any articles on how I may deal with a forefoot striker, especially a track runner who walks through your door complaining of shin splints etc.

    In this forum, I am a baby in the precence of the giants of the biomechanics world and grateful for all your advice. Not looking for everything on a plate but maybe point me in the right direction in my readings etc.

    Much obliged

    Last edited by a moderator: Jul 28, 2006
  17. Craig Payne

    Craig Payne Moderator

  18. P OMalley

    P OMalley Member

    Surely the most important factor here which no one has mentioned would be patient comfort. We can advise all we like on what type of trainer but if they are not comfortable will they be functional?
    Personally I tend to start neutral but if the patient has history of wearing motion control shoes that are comfortable then I will work from there.
  19. yehuda

    yehuda Active Member

    Very good point I have a friend who runs sub 3 hr marathons (in his late 40's) without injury but looks like a duck putting out a forrest fire. I personally recomend a stabilty shoe as that will generally support the orthotic device which will support the foot but still have a decent amount of cushioning.

    Next question for the runners out there which is the most cushioned MC shoe
    Last edited by a moderator: Jul 30, 2006
  20. csmcinnes

    csmcinnes Welcome New Poster

    I am confused as to why it took so long for someone to metion STJ when selecting a running shoe.

    Having worked Part time in a specialist running shoe store and having manufactures classing shoes in the categories neutral, stability and motion control doesn't mean they fit that category for every person.

    Some shoes Are designed to control RF, MF and FF. (FF shoes: Nike Caesium, Mizuno Nirvana & Asics gel 3010. Becareful who you give a FF controling shoe to though as in most cases the FF post crosses the 1st MTPJ stiffening it affecting saggital plane facilition (they can act to a degree like a morton's extension.))

    Just because Asics Kayano and Brooks Trance market there shoes against each other and at a similar price point doesn't mean they control the same...they don't and will control differently on people you may percieve to have a very similar foot type.

    Whether a person is wearing an orthotic or not in the shoe or not, in my opinion the only way to tell if it controls the foot is to assess gait dynamically for a particular individual in the shoe with the orthoses if they wear them.

    I know there are numerous stores in Australia and the UK where is can be done.
    I will always have a shoe or number of shoes in mind for a pt when prescribing orthoses for them but don't tell them they must get the exact one's I say for the above reason's. I send them to the stores and let them be assessed and fitted.

    It is a good idea to get into one of these stores and check out how they work.
    In Australia most of them only hire pod or physio students close to completion of their degree so they have a good knowledge base to work off. I always try to provide as much detail as to mechanics as I can as well.

    Good luck with it all.
  21. Rich Blake

    Rich Blake Active Member

    Phil, Read my blog post on the variables we need to think about. You make your best bet prescribing the type of orthotic device, and then combining with a type of shoe. Always ask what are you trying to accomplish? The shoe is the easiest to change, but if confused, start with stability shoe and balanced orthotic and go from there. I hope this helps some. Rich Blake


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