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By Carol Saline

The Agony of the Feet

I grew up with a desperate desire to wear loafers. All my friends wore penny loafers to school, but I had to wear an ungainly pair of black and white saddle oxfords with a Thomas heel and a steel shank. I complained to my mother that I was too young for old-lady shoes, but, bless her good intentions, she truly believe these monstrosities would cure my aching feet—which are as flat as a slice of bologna.

Well, Mom was wrong. The corrective shoes didn’t do a thing. My feet still hurt, but at least I’m no longer ashamed to walk the streets. Today I can buy perfectly stylish pumps and treat my aching feet by putting something called an orthotic inside my shoes.

Orthotics are one of the many advances in a branch of medicine that’s changed in about every way, including its name. Nobody goes to a chiropodist anymore. The proper term for a foot doctor is a podiatrist, and the upgraded training for the degree doctor of podiatric medicine is, in its own way, nearly as rigorous as that of a physician. It takes four years of undergraduate study to gain admission to the Pennsylvania College of Podiatric Medicine (one of seven podiatric colleges in the nation). Once there, students spend four years studying a curriculum of basic sciences that includes anatomy, biochemistry, pharmacology, and surgery, with a particular focus on problems that occur below the belt. It’s not all that uncommon, for instance, for pain in a knee or hip to be caused by a walking pattern, that puts stress in the wrong places.

Given the workload the foot endures, it’s a remarkable piece of machinery. This web of 26 bones and interlocking ligaments must bear up to two times our weight when we’re strolling in the park and up to five times the load when we increase the pace to a run. In the foot and ankle, there are three families of major joints that allow the foot to move up and down, left to right, and inside and outside. (The toes are a wholly separate system.) But while all feet have the same basic parts, no two pairs pound the pavement in quite the same way.

Our feet are adaptively idiosyncratic. Depending on the shoes we wear and the surfaces we walk on, even the most minor anatomical irregularity is likely to be exacerbated by our individual gait and the particular pressure we exert on our size 6 narrows or size 11 wides. For years most information about feet came from X-rays that revealed only structural abnormalities. The other primary diagnostic tool was the doctor’s eye. The patient would walk across the office while the doctor watched how the feet flattened and rolled, then delivered a diagnosis based on whatever he or she saw. Now it's possible to observe scientifically the function of a foot in motion—and that’s a major breakthrough in understanding why feet hurt.

At the Pennsylvania College of Podiatric Medicine, there’s something called The Gait Study Center, which has the capability to measure the ways you strut your stuff. While you walk up and down a special runway both barefoot and with shoes, an array of sophisticated equipment measures things like impact force, pressure points, joint angles, and muscle contractions. Then it spews out a color-coded analysis, tables, and/or graphs. "To really diagnose a foot problem we have to analyze it in motion," explains center director Howard Hillstrom. "Then we can design an appliance or therapy program to relieve the pain and help the patient perform better."

That "appliance" would be an orthotic. This small innersole that slips easily inside any flat shoe has taken hold in podiatry the way contact lenses swept through optometry. Everybody seems to be recommending them, often at a considerable expense—they can run as high as $400.

If the rage for orthotics has you wondering whether you need a pair, hold on. Not everyone does. The primary indicator of need is pain. The second is a congenital deformity. For example, orthotics can’t cure bunions, but they can slow down their progression, perhaps avoiding surgery. ("See if the Shoe Fits—You don’t have Bunions", November 1993.) Dr. Kieran Mahan, dean of PCPM and a proponent of orthotics in general, thinks they’re under-prescribed for children and over-prescribed for adults: "They won’t help everybody or every foot condition. It depends on the individual’s foot structure and how his foot moves." Whether you have a high arch or flat feet doesn’t matter. The key factor is stability. The more unstable the foot—the more it flattens and rolls when you walk—the more you will benefit from the control offered by an orthotic. Instability is easy to spot: Look for an excessive amount of wear on certain spots on the sole or heel of your shoe.

The precursor to today’s orthotic was the old arch support, or "cookie" as it was sometimes called, which developed from the theory that propping up the sagging arches would relieve the pressure that causes sore feet. We now know that the back of the foot dictates much of the walking pattern, and to properly control the movement of the foot you need something that supports the heel as well as the arch. The modern orthotic hit the scene about 15 years ago as a byproduct of the fitness craze, particularly jogging.

Orthotics ordered from podiatrists are normally custom-made in a laboratory from a mold of your foot. The word "custom" is used rather loosely to describe something that follows the contour of your foot but isn’t made to compensate for how you walk. A few podiatrists will remedy that by adding individualized padding when the orthotic gets mailed back from the lab. And some doctors actually hand-make orthotics themselves.

Before dipping into your bank account for the so-called custom models, you might want to follow the suggestion of the Gait Study Center’s Dr. Gilbert Hice and try an off-the-rack version from a sporting goods store like Herman’s. If you get relief maybe that’s all you need. If not, then consider seeing a podiatrist. Hice says, "You don’t demand too much from a walking orthotic, but a sporting orthotic has to be very precise. In athletics, a little bit of correction makes a major difference."

That difference has led to a lucrative business for Bala Cynwyd podiatrist Simon Small. Small travels around the country on behalf of his company, Pro Support Systems, fitting professional athletes with a special three-layered, custom-mold orthotic devised by a professor at PCPM. His client list includes Joe Montana, Larry Bird, John MacEnroe, and Chris Evert. His encounter with Evert shows how critical a good orthotic can be to an athlete’s performance. She was plagued by pain in the bottom of her heel resulting from impact bursitis. Years ago it was believed that surgically removing heel spur—little outcroppings of bone—would cure the problem. But the pain often remained after the operation, and we now know that spur is a symptom caused by excessive stress on the tissue that runs from the heel to the toe.

Small found that Evert had a high arch and a tight Achilles tendon that created undue tension on the back of her legs and the bottom of her feet. He built a special wedge into her custom orthotic that in essence raised the floor up to her foot and reduced the pressure brought to bear every time she lunged for the ball.

Few of us are tennis champs, but half of us walk around on high-heeled shoes, which are easily the most significant cause of sore feet since humans began walking upright. I tried four kinds of orthotics before I wound up with a soft pair I could use in something other than flats. It was made for me by, of all people, a chiropractor. My podiatrist tells me it’s practically worthless. I think I’m caught in a turf battle.

There is another alternative for women who refuse to seek to relief with the yuppie cure of cruising the streets in jogging shoes and stockings. It’s a plain but attractive pump from easy spirit that looks and feels good because it's constructed with the same built-in cushions and supports as a sporting shoe. Trying on a pair made me think of the words of Dr. Arthur Helfand, a podiatrist who teaches at Thomas Jefferson University Hospital. He told me, "It’s a misconception that feet are supposed to hurt." And he sent me something to read about orthotics.

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