Footwear and Orthoses

A shoe has a few parts worth knowing. The upper holds the foot, with a toe box whose depth and width matter for forefoot and lesser toe problems, and a heel counter that stabilises the rearfoot. The sole runs from the outsole, which meets the ground, through the midsole, which provides cushioning and any stability features, to the insole under the foot. The heel-to-toe drop, the height difference between heel and forefoot, can influence where load falls: a lower drop may increase load on the calf, Achilles and forefoot, though the effect depends on the runner, the foot strike and the shoe's other properties. Running shoes are grouped loosely into cushioned or neutral, stability, and minimalist or maximalist designs, though these categories are marketing as much as biomechanics.

Foot orthoses are insoles that sit inside the shoe. They are broadly functional, aiming to control or alter foot motion and load, or accommodative, aiming to cushion and offload without changing mechanics much. Common features include a contoured arch support, a heel cup, medial or lateral posting to influence rearfoot position, a metatarsal dome or bar placed just proximal to the metatarsal heads, not directly under them, to lift the shafts and offload the painful heads, and a heel raise. They work by redistributing plantar pressure, altering the forces and, to a lesser and less predictable degree, the motion of the foot and leg, and by cushioning. The exact mechanism is not fully understood, and comfort itself appears to matter.

Footwear and orthoses are considered across a range of load-related presentations. Plantar heel pain, often called plantar fasciitis, is a common reason a foot orthosis is used, as one part of management alongside calf and plantar fascia stretching, strengthening and load management rather than on its own. Metatarsalgia and lesser toe problems benefit from a metatarsal dome, a wider toe box and cushioning. Tibialis posterior dysfunction and a painful flatfoot may be supported with medial arch support and posting. First metatarsophalangeal joint pain and hallux problems benefit from a stiff-soled or rocker shoe that limits painful motion. In selected patients, footwear and orthoses may help ankle instability, patellofemoral pain and medial tibial stress syndrome as an adjunct, after condition-specific assessment rather than as a routine measure. Diabetic and other insensate feet need protective footwear and offloading to prevent ulceration, which is a priority rather than an option.

Choosing footwear and orthoses is mainly a clinical process. The history covers the sport, training surface, symptoms and previous devices, and examination assesses foot posture, range, strength and any deformity, alongside the presenting problem. The shoes themselves are examined for fit, appropriateness for the activity and wear pattern, which can hint at loading. Gait assessment, usually observational, links the movement to the symptoms and is covered in the gait analysis topic; plantar pressure mapping can show where load concentrates and guide offloading. Imaging has no role in selecting footwear itself, and is reserved for diagnosing the underlying condition, for example when a stress injury or joint problem is suspected.

Prescribing starts with the problem and the person. For most painful conditions a prefabricated foot orthosis is a reasonable first choice, used alongside exercise and load management rather than alone, since for plantar heel pain custom and prefabricated devices give similar results, and custom devices are reserved for a significant deformity, a specific offloading need or when a prefabricated device has failed. The choice of functional versus accommodative depends on the aim: control and load redistribution for a mobile, correctable problem, cushioning and offloading for a painful, fixed or insensate foot. Footwear is matched to the activity and the foot, with a roomy toe box for forefoot problems, a stable heel counter and appropriate cushioning, and a stiff sole or rocker for painful first metatarsophalangeal or forefoot conditions. Changes are introduced gradually, since an abrupt move to a lower-drop or minimalist shoe can increase load on the calf, Achilles and metatarsals and cause injury, a point covered in the running biomechanics topic. Orthoses complement rather than replace strengthening and load management. Podiatry and orthotics are key partners, and the diabetic foot is managed within its dedicated pathway, with any active foot problem referred promptly, within one working day.

In rehabilitation, footwear and orthoses are one part of a plan rather than a standalone fix. They can reduce pain enough to let a person load and exercise, which is where the lasting gains come from, so they are used to support progressive rehabilitation, not to replace it. Any device is reviewed as symptoms settle and strength returns, and many can be weaned once the tissue tolerates load, particularly where the underlying problem was correctable. For athletes, a change of shoe or a new orthosis is introduced in training before competition and phased in gradually, watching for new symptoms as load rises, so that the device helps rather than becomes a fresh source of injury.

• •Foot orthoses reduce pain in plantar heel pain in the medium term, with little benefit in the short or long term; they are used alongside exercise and load management, and custom and prefabricated devices perform similarly.
• •Because custom and prefabricated orthoses give similar results for plantar heel pain, a prefabricated device is a reasonable and cost-effective first choice for most.
• •In diabetes, protective footwear and offloading reduce plantar pressure and the risk of ulceration, and current NICE guidance on diabetic foot problems supports offloading and footwear within a foot protection pathway.
• •A stiff-soled or rocker shoe reduces painful motion at the first metatarsophalangeal joint and forefoot.
• •Abrupt transitions to minimalist or very low-drop footwear can shift load and cause injury, so change is introduced gradually.

• •Foot orthoses are functional (alter load and motion) or accommodative (cushion and offload).
• •Custom and prefabricated orthoses give similar results for plantar heel pain, so prefabricated is a reasonable first choice.
• •A lower heel-to-toe drop may increase calf, Achilles and forefoot load, depending on the runner and shoe.
• •A stiff-soled or rocker shoe limits painful first metatarsophalangeal and forefoot motion.
• •An insensate diabetic foot needs protective footwear and offloading to prevent ulceration.
• •Introduce footwear and orthosis changes gradually to avoid overload injury.