Are Custom Orthotics Worth It?

Custom orthotics cost big money and typically insurance doesn't cover them, so before you hand over the $200 to $800 they cost, make sure you really need them. And if you do, find out how to get the most for your money.

THE BASICS ---

• Custom orthotics are expensive, costing anywhere from $200 to $800, which doesn't take into account the associated office visits.
• Making custom orthotics is a multi-step process that includes a thorough exam of your foot, taking a cast of your foot, and the manufacture and fitting of your orthotics. Find a provider with years of experience fabricating custom orthotics to make sure yours are done right. 
• Unless you have a complex foot disorder, are diabetic, are a high- performance athlete, or have a recurring injury that over-the-counter insoles can't address, you likely don't need custom orthotics.
• For those who don't require custom orthotics, a semi-custom over the counter insole like Tread Labs Pace is a great option. They come in four different arch heights and are made with medical-grade support for a close-to-custom fit.

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WHAT YOU NEED TO KNOW ---

If you're thinking about spending the money on custom insoles, you'll want to know exactly what you’re paying for so you can decide whether it’s a good fit for you. To help you along, we'll review:

• all of the expenses to consider before purchasing
• what you’re paying for
• what doctors have to say about them
• and how they're different from over-the-counter insoles

How Much Do Custom Orthotics Cost?

Custom orthotics run anywhere from $200 to $800, but you'll also need to factor in other costs. This includes the associated office visits required to fabricate your custom orthotics as well as the cost to replace the top surfaces when they wear out. Resurfacing can cost $50 to $100.

After prolonged use, the plastic or EVA foam material used in the orthotic will wear out, which means you'll need to buy another pair of custom orthotics. Over a lifetime, those costs add up to a big number.

Does Insurance Cover Custom Orthotics?

If your health insurance covers the cost of custom orthotics, you'll usually only have to pay 10-50% of the total price. However, more often than not, insurance doesn't cover them. Make sure you check with your insurer before you get fitted.

Also, ask yourself if you really need them. A 2009 study came to the following conclusion: "At two to three months and at 12 months, prefabricated orthoses were as effective as custom orthoses ... There is no evidence that custom orthoses are more effective than prefabricated ones."

Some people absolutely do need custom orthotics. Dr. James Ioli, DPM, Chief of Podiatry at Brigham and Women's Hospital in Boston, says people with certain conditions like the following do need custom orthotics:

• Complex foot disorders
• Diabetes who have loss of feeling in their feet
• Poor circulation
• Severe foot deformities caused by arthritis 

However, the majority of people, including those suffering from Achilles tendinitis, plantar fasciitis, arch pain, heel pain, and kinetic chain pain, over-the-counter orthotics will work well and are significantly less expensive.

Are Custom Orthotics Worth It?

The actual manufacturing cost of custom orthotics (including materials) is normally $100 or less, so why are custom orthotics so expensive? It's because you're paying for the exam, casting of your feet and a hefty mark-up.

Here's what goes into the total cost of prescription orthotics:

• Examination – Remember, the podiatrist is doing a thorough analysis of your lower extremities, gait, and lifestyle. This can include X-Rays, gait analysis on a treadmill and other tests.
• Casting – A podiatrist takes a non-weight bearing cast of your feet.
• Mark-up – Feet, after all, are still a business.

As podiatrist Dr. Robert Eckles of Manhattan notes, “It's hard to see the value in the plastic.” But he reminds us that we’re “paying for a comprehensive diagnosis of present and future problems” and not simply the orthotic itself.

It is helpful to ask your podiatrist to break the cost down for you, so you can understand the exact cost of each element. A reputable podiatrist will be able to provide this for you. If the price of your custom orthotic insoles is high but your podiatrist isn’t thoroughly examining your feet or even taking a cast, be wary.

What Do Doctors Think About Custom Insoles?

Sports podiatrist and Doctor of Podiatric Medicine (DPM) Richard Braver considers orthotics a “cure-all” for many lower-body injuries and pain. According to Braver, “orthotics can prevent and cure a problem by reducing and eliminating the stress that caused it.” Clearly, orthotics are important additions to our shoes. But do they need to be custom to work?

Some sports medicine doctors aren’t convinced they are worth the cost. Dr. William O. Roberts, a sports medicine physician in St. Paul, Minnesota says, "If your main business is feet, and part of your income is prescribing orthotics, then you might prescribe them 90, 100 percent of the time. It’s a financial issue, and I don’t think there's a huge need for custom orthotics.”

Orthopedic surgeons often agree with this line of thinking about custom insoles for shoes. Dr. John G. Kennedy, an orthopedic surgeon in Manhattan contends, "There is a big problem with orthotics out there and people are not aware of it. The number of orthotics that I see prescribed in this city is far greater than is warranted by the number of pathological reasons.”

One factor in this difference of opinion between medical doctors (MD) and podiatrists (Doctors of Podiatric Medicine, DPM) is their training:

• Physicians attend school for four years, where they learn many general concepts before doing three years of highly-specialized residency.
• Podiatrists go to four years of school, learning specifically about the foot and ankle before doing one more year of podiatric residency. While this can make them experts at anything foot- and ankle-related, they might miss other larger structural problems that a sports medicine or orthopedic physician will consider. Nevertheless, a good podiatrist will consider the overall picture before prescribing custom orthotic inserts.

Who Makes Custom Orthotics?

When you're finding a provider to make your custom orthotics, there are a few things you'll want to think about:

1. Hands-On Evaluation – Great custom-molded orthotics cannot be made without a face-to-face visit. There are a variety of providers who will send out a "Stomp Box," a piece of impression foam in a box. You are instructed to step into the box with each foot and send the resulting impressions off to make your orthotics. Unfortunately, without an experienced provider to position your foot as it makes the impression, your dysfunctional biomechanics may be built into the design of your orthotics.
   
2. Type of Provider – A certified Pedorthist (C. Ped) diagnoses foot problems and prescribes orthotics. C. Peds often have the most hands-on experience with orthotics and functional biomechanics. Podiatrists are doctors who specialize in feet. They can diagnose foot problems and prescribe orthotics as well as perform surgery to fix problems.  A chiropractor is involved with the diagnosis and treatment of musculoskeletal disorders. Some provide custom orthotics.
3. Years of Experience – Getting custom orthotics right is a challenging mix of art and science. It takes years of experience to learn the subtleties of making custom orthotics that meet both the functional and the comfort needs of the client. Choosing someone with a long history of success will increase the chances that the orthotics will be right – the first time.
4. Hands-On Fabrication – Some practitioners evaluate a client's needs, then transmit the info to a lab that creates the actual orthotics. While this system can work, having the orthotics made at the place of the diagnoses prevents errors in communication and insures that modifications can be easily made if necessary.

How Are Custom Orthotics Made?

Creating quality, custom-made orthotics is a detailed and involved process. As Richard M. Olsen, DPM, states, “The manufacture of functional foot orthotics is thus a multi-step process involving detailed and intricate cast correction, orthotic fabrication and application of additional items prescribed by your podiatrist for the treatment of your specific condition.”

Step One: Evaluation

When you see your podiatrist for custom orthotics, you can expect to start with a thorough examination that includes:

1. A Range of Motion Test- Your podiatrist will measure the motion of all your lower-extremity joints (such as your hips, knees, and ankles) in order to identify any irregularities in joint motion like excessive flexibility or extreme limitation. Your doctor will also establish the weightbearing and non-weightbearing functional positions of these joints by testing them while you're standing and walking on them, and when you are lying down.
2. A Muscle Examination- Your podiatrist well test the lower-extremity muscle groups like the quadriceps and calves to identify any overly weak or tight areas. This will show if your muscles are adding to your injury, symptoms, or biomechanical problems. 

You can also expect your doctor to take measurements, ask about your lifestyle and inspect your shoes for a specific wear pattern to better understand your gait mechanics. Podiatrists look for the following patterns:

• Symmetry- Is the wear equal and in the same location on both shoes?
• Tipping at the Heel- If you place the shoes on a table and look at them from the back, do the shoes tip in at the heel (pronation) or out (supination)? Does one shoe tip in a different direction than the other? That can be indicative of leg-length discrepancies.
• Toe Wear- Are there holes in the mesh part of the shoe where your toes have popped up? Do the toe creases run straight across the front of the shoe? If not, it could be a sign of poor fit.

Step Two: Casting the Foot

Once your exam is complete, you'll have your feet casted. You're podiatrist should: 

• Non-Weightbearing Neutral Position Cast of the Foot- Your podiatrist will cast your foot to provide a model for the orthotic laboratory. As Dr. Olsen says, “The specific method of casting is critical and must be done accurately in order to achieve an accurate impression of the foot in its neutral position.”
• Place your foot in a neutral position. Your podiatrist will need to see your knee in relation to your foot and set your foot into the desired position.

The most common method of taking this cast is by using plaster. Wet plaster strips are wrapped around the foot. The hollow, “negative foot mold” is then sent off to the orthotics lab. The lab will fill in the cast and discard the shell. The resulting “positive cast” looks like your foot.

While the plaster hardens (it usually takes 5-10 minutes), your podiatrist will watch your foot position to make sure it doesn't change. The plaster usually takes a full 24 hours to harden completely, so after your podiatrist removes the cast, it will be stored before being sent to the lab.

Step Three: The Lab

After your podiatrist takes the proper non-weightbearing cast of your feet, the negative foot mold and your custom prescription are sent to an orthotics laboratory.

Your prescription will include not only the materials, dimensions, and accessories to be used in the orthotics' manufacturing, but also the specifications for the correction of the cast. These measurements are taken from the in-depth exam your podiatrist conducted before casting your foot.

Once the positive cast has been constructed, the lab constructs the orthotics through the following steps:

1. Under extreme heat, your individual cast is pressed against a sheet of graphite or plastic material.
2. A cover made of comfortable yet durable material is attached to the harder heel and arch structure.

Step Four: Materials

For your custom made orthotics to provide optimum results, they must be constructed from materials that can resist the various forces and motions you put on your feet. Materials need to be rigid enough to control for irregular injury-producing motion, while still flexible and comfortable enough to be compatible with your activities.

There are two main types of materials used for the rigid foundation of your orthotic:

• Plastics– Most plastics come from the polyolefin family. Polypropylene is the most common plastic used.
• Material thickness often ranges from 1/8” to 1/4”
• Flexibility of plastics have a wide spectrum, ranging from very flexible to relatively rigid

• Graphite – The graphite family is lighter and thinner than plastics.
• Material thickness is half that of plastic (1/16” to 1/8”)
• Also has a wide range of flexibility and rigidity

Cushioning materials such as Neoprene and open- and closed-cell forms are often used to complement the harder plastics or graphite and provide added comfort. Remember, these softer materials should never form the core structure of your orthotic.

The most common materials used to cover the plastic or graphite arch-support and heel cup come from the polyethylene foam family. These are closed-cell forms best for total-contact, pressure-reducing orthotics. Individual materials include:

• Ethyl-vinyl cetates (EVAs)
• Crepes/neoprenes
• Silicones

A good podiatrist will take your lifestyle and body type into account when choosing materials for your orthotics. According to podiatrist Simon Spooner, PhD, the patient’s weight and activity level are important. “I work with professional rugby players who weight about 280 lbs and can sprint nearly as fast as Usain Bolt. Trying to provide foot orthoses that can cope with those kind of forces is a challenge. You’ve got to pick the right horse for the right course.”

Your individual foot requires individual attention. Materials that work well for one person might not be good for another. 

What's The Difference Between Custom vs. Over-The-Counter Orthotics?

As the American Podiatric Medical Association explains, custom molded orthotics are insoles that have been prescribed by a doctor, often a podiatrist, sports medicine physician, or orthopedic surgeon after conducting a thorough evaluation of your feet, ankles, and legs. They are built for your specific foot and gait, and accommodate your individual foot structure.

Over-the-counter inserts encompass a variety of different foot products including arch supports, insoles, heel liners, and foot cushions. Not all prefabricated insoles are made alike, however, especially when it comes to the level of support they offer.

While scientific research has proven that that insoles help treat and prevent leg, foot and lower-extremity injuries,  studies have not found a significant difference between prefabricated and custom orthotics. If you've decided that you don't need custom orthotics or want to try over-the-counter insoles before spending the money on custom, you'll find you have a lot of choices.

What To Look For In Over-The-Counter Orthotics

The most important thing to consider is that not all over-the-counter inserts are made alike. Their quality and effectiveness varies greatly. Understanding the different types of over-the-counter insoles available is helpful. 

Heat-moldable insoles and stomp-boxes are a "fit-at-home” option. However, because these inserts take weightbearing casts of your feet, they build the biomechanical issues you are trying to correct into the very structure of the insert supposed to correct it. Moreover, if the materials are soft enough to heat, they are not going to provide the firm structure your feet need.

Structured insoles like those from Superfeet or the electronically-fitted Dr. Scholls line provide more structured inserts with deep heel cups and arch support. But, unlike Tread Labs, neither brand provides a choice of arch heights like Tread Labs.

When choosing your over-the-counter insoles, there are some specific features to look for to make sure you're getting the support you need.

• Multiple Arch Heights - Arches are not one size fits all, so it makes sense that your insole shouldn't be either. The arch of your insole should match the contours of your foot and provide full contact from one end of your arch to the other whether you're a low arch or an extra high. 
• Medical-Grade Support - High-quality, durable arch support comes from strong, firm support that holds up against the pressure you put on it. Cushy foam and gel do not provide the support your arch needs to address the foot fatigue or pain you're experiencing.
• Deep Heel Cups - Your foot has a fatty pad under the heel bone that helps cushion each step you take. Look for an insole that has a deep heel cup that will help enhance your foot's natural shock absorption. You'll get greater comfort and stability from it.

Whether you choose to invest in custom orthotics or start with over-the-counter insoles, getting the proper support for you feet will help control pronation issues, prevent and relieve foot pain you may have, and most importantly, support your active life.

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