Orthotics for knee pain: does pronation matter after all?


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After last week’s discussion of the presumed death of the “pronation control paradigm,” I came across this new Australian study posted online at the British Journal of Sports Medicine about using orthotics to combat patellofemoral pain syndrome (PFPS — the nasty affliction sometimes known as “runner’s knee”).

The basics: 52 volunteers suffering from PFPS were given off-the-shelf three-quarter-length orthotics to insert in their shoes, with “built-in arch supports and 4 [degree] varus wedging.” They were then immediately tested to see whether they had less pain and could do more single-leg squats, step-downs and rises from sitting. The results:

Prefabricated foot orthoses produced significant improvements (p<0.05) for all functional outcome measures.

Hurrah! But here’s the rub:

A more pronated foot type and poorer footwear motion control properties were found to be associated with reduced pain during the single-leg squat and improvements in the number of pain-free single-leg rises from sitting when wearing foot orthoses.

Hold on, I thought we decided pronation and motion control don’t matter because they were just invented to make money for shoe companies! But that’s not what the authors think. In fact, they conclude that

foot orthoses have greater effects in poorer-quality shoes, possibly as a result of a greater potential to improve motion control properties.

Let’s step back for a moment. This study has a lot of limitations, not least of which is the fact that it wasn’t blinded, randomized or controlled. Also, if you look closely, the results are rather mixed. For step-downs, 57% got better, but 27% got worse; for squats, only 38% got better, while 20% got worse. Is this because orthotics made pronators better and supinators worse? Maybe… sort of… but not quite. Even the researchers had to waffle a bit in their discussion:

Although supportive of traditional theory, the associations of foot posture and change in foot posture with functional improvements were only fair.

So what can we take from this? Well, this study certainly doesn’t “prove” the pronation paradigm. But the fact that more than half the people in the study got immediate relief from a shoe insert tells us that monkeying around with joint forces is capable of affecting running injuries, for better or worse. Now, if you put those knock-kneed, flat-footed volunteers on a minimalist program, it’s entirely possible that they’d compensate for their weaknesses and imbalances and get rid of their knock knees and flat feet — eventually. Proper shoes, on the other hand (or in this case, orthotics), seem to cure the problem for some people immediately.

In a perfect world, we’d all be patient, careful, and dedicated to our exercise regimens — and no one would need running shoes. But this study suggests to me that the pronation control paradigm is able to offer quick fixes to some people, in some circumstances. As a result, while I expect the minimalism trend to continue to grow (and I’ll be glad to see that), I also don’t expect current running shoe technologies to disappear. Not because shoe companies are evil, but because some people will continue to want what those shoes can offer.

8 Replies to “Orthotics for knee pain: does pronation matter after all?”

  1. I haven’t seen the paper, but I’m curious if these people were runners? Was their PFPS a running-related injury? How much bearing can this have on the running shoe issue if none of the outcome measures were running related?

    Other studies showing the benefit of orthotics to runners are certainly out there, so in that sense these results wouldn’t surprise me. It is curious, however, that you indicated that even Asics is abandoning motion control shoes – makes one wonder if orthotics and shoe design are two separate issues.

  2. Orthotics can relieve pain but at the cost of worsening the problem by letting the supporting muscles get weaker. Perpetually upgrading the orthodics sounds like a recipe for disaster. You’ll eventually get to a point where a larger orthodic is no longer feasible and the pain will persist.

    Strengthening the muscles to provide the same support that the orthodics would is a much better long term solution.

  3. I have to echo Peter on this – for this study to be relevant to runners, it must be known if the study participants are runners and how they got their injuries.

    For running, orthotics are really just a temporary fix. If the study is correct, they may lessen pain temporarily but they are not solving the problem – whether that’s muscle weakness, imbalance, or poor running form.

  4. Thanks for sharing this information! The more useful and knowledgeable information out there the better. Please consider custom orthotics for treating foot pain in cases of flat feet or high arched individuals.

    Dr. Michael Horowitz, Vancouver Orthotics

  5. Lots of interesting comments — thank you all for the input. It’s a fair point that the study wasn’t restricted to runners and didn’t test running. Obviously this is a limitation! That being said, in my own two-year struggle with PFPS, I found my ability to do pain-free one-legged squats to be a pretty good indicator of whether I’d be able to run pain-free.

    As for Richard and Jason’s point that orthotics are a temporary fix that don’t get to the root of the problem… I understand the point, but I’m not convinced that it HAS to be true. I had a gait analysis that showed a really pronounced roll in my right foot (the bad leg), and then had custom orthotics made that propped my right arch up to reduce that roll. My PFPS went away, and I ran in those orthotics for another five years. The problem never recurred.

    In my case, the orthotics were designed to address a specific abnormality in my gait. As Peter points out, that’s quite different from the blanket prescription of running shoes to everyone. On the other hand, the researchers in this paper clearly view shoes and orthotics as part of the same continuum. For example, they write “changing footwear in PFPS individuals who wear poor-quality footwear could be of equal or perhaps greater importance than foot orthoses prescription.”

    Having just read Amby Burfoot’s interview with Michael Ryan, the author of the recent “shoes don’t work” study, I think the point I’m trying to make is similar to what he’s saying. What we seem to learning is not necessarily that shoes don’t work — it’s more that the simplistic categories we’ve been using to assign shoes to people don’t work. But shoes and orthotics DO have effects, and for the right person under the right circumstances, those effects could be very valuable.

  6. It seems to me like no one really has a straight answer here. I am a avid runner in college who has suffered from PFPS in both knees and has had chronic medial tibial shin pain. I have been in and out of orthotics and am trying to experiment with new shoes without orthotics now. I would definitely agree that proper strengthening and postural integrity is absolutely necessary to become more efficient and injury free. But how realistic is the minimalist approach that people are jumping on so quick? its hard to make sense of all the information that is out there and different peoples opinions all seem to make sense. where is a good place for someone like me to start? I am a over pronator that is about 170 lbs that just currently switched from the asics 2150s to the brooks adrenaline and is running about 30 to 40 miles a week? I appreciate any help or suggestions

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