Stressed Foot Forward -- Orthotics Are Finding Their Way Into The Shoes Of An Increasing Number Of People, Not Just Hard-Core Athletes

Few 14-year-olds are as passionate about soccer as Nicole Tomita. She practices three times a week with her Premier League team, in addition to weekly games. Last summer, the eighth-grader from Mercer Island even grunted through an intensive weightlifting program.

But in July she hit the wall. Or, more accurately, her legs and feet hit the wall.

"My knees were hurting all the time, my ankles off and on, and I got really bad shin splints," Tomita said. "It felt, like, really bad playing soccer."

Her mother took her to see Dr. Stanley Newell, a Seattle podiatrist who specializes in sports medicine. "She had Achilles tendinitis," Newell said, "shin splints, condromalasia (pain under the knee caps), an internal hip rotation, a tight heel cord and an unstable forefoot." Newell prescribed a set of custom orthotics, plastic foot supports that fit inside shoes.

Two months later, almost all the pain was gone. "It was, like, it didn't hurt, nothing hurt anymore," Tomita said. "Now I wear them in all my shoes."

Foot orthotics are defined as shoe inserts that restore a normal walking pattern by changing the angle at which the foot strikes the ground. An outgrowth of the running boom of the 1970s, they are designed to make standing, walking and running more comfortable. While orthotics are often used to treat "overuse" injuries of hard-core athletes like Tomita, they're also finding their way into the shoes of an increasing number of weekend warriors, workers who are on their feet all day, pregnant women and women whose feet are crimped by stylish shoes, and the chronically overweight.

The stresses on feet

It's no wonder the foot orthotic business is running rampant these days. Because people are living longer, it's estimated that most folks walk the equivalent of 3.5 times around the equator in a lifetime: more than 9,000 steps a day. By the time an average person reaches 50, his feet have logged more than 75,000 miles.

The legs of even casual athletes absorb an astonishing amount of shock. The American Podiatric Medical Association estimates that a 150-pound person, walking one mile, exerts the equivalent of 127,000 pounds - 63 tons - on each foot. And there's a lot that can go wrong among a single foot's 26 bones, 33 joints, 107 ligaments and 19 muscles and tendons.

Orthotics come in a confusing range of prices, styles and materials. Expensive custom orthotics, which go for $120 to $450 a pair, are made from casts of your feet and prescribed by either podiatrists (not M.D.s, but trained "doctors of podiatric medicine")

or orthopedists (M.D. bone and joint specialists). Physical therapists also may order them. Over-the-counter orthotics, anything from Dr. Scholl's foot pads to models that mimic custom orthotics, run from $20 to about $60.

Choosing an orthotic

Say you have some foot pain. Perhaps a day hike turned into a day-and-a-half hike, and the bottoms of your feet ached when you got home. Or you're a woman who prefers stylish but utterly uncomfortable shoes (women are more likely than men to have foot pain, much of it attributable to ill-designed shoes). Are you a candidate for orthotics? If so, what kind?

The degree and location of pain, and how long it lasts, should determine your course of action, several foot experts agreed. If it's only a mild pain in your foot that lasts less than a couple of weeks (or it's a temporary condition, caused by a pregnancy, for instance), you might be able to get by with pre-made footbeds. These are available at most drugstores, shoe shops and outdoor-equipment retailers. These vary from cheap, flat pads that do little more than prevent feet from sliding around inside the shoe to models that have beefier cushioning, with extra support under the arch.

Even some doctors may recommend an inexpensive foot support, at least initially. "We'll often prescribe an over-the-counter orthosis (the technically correct way to refer to an "orthotic") first," said Dr. Carol Teitz, an associate professor of orthopedics at the University of Washington School of Medicine. "That way you've only spent $20."

Teitz said to look for a pre-made orthotic with ample arch support: "A rule of thumb, so to speak, is that if you can flatten (the arch) with your thumb and finger, it's not going to hold your body up." Firmer, more supportive models are available at some specialty shoe and medical equipment stores.

Going to a specialist

If the pain persists, it's probably time to visit a foot specialist. If you're in a managed-care plan, you'll first have to visit your primary-care doctor, who may refer you to a specialist recognized by your insurance company. Or you may be able to get a recommendation from a friend who's had a similar problem, or from a sports medicine clinic.

Chances are about 50-50 your insurance company will cover orthotics. If a case can be made for their "medical necessity" - say a doctor prescribed them to cure a specific ailment - an insurance company would at least consider covering them, said Jim Stevenson of the Washington State Insurance Commissioner's Office.

In a foot exam, doctors look for the following common problems that could indicate a need for orthotics:

-- Plantar fasciitis: inflammation of the connective tissue on the bottom of the foot that runs from the heel to the toes. Often associated with heel pain.

-- Excess pressure on any of the metatarsal bones.

-- Kneecap pain, especially in runners who have flat feet.

-- Stiff big toe joint.

-- Bunions: localized painful swelling at the base of the big toe, often caused by friction against footwear, especially ice skates and ski boots.

-- Shin splints: pain along the muscles that surround the shins.

An exam might also include a gait analysis. A treadmill and video camera monitor stride patterns. In some practices, a computer is hooked up to a pressure-sensitive plate on the floor. Patients tread barefoot across the plate several times with each foot. Then a sophisticated software program creates a highly detailed report on where pressure is applied on the foot during a typical footfall. This gives the specialist additional data to use in making a diagnosis.

If a custom orthotic is prescribed, an "impression" of your feet is taken. The most common method is plaster casting, although some outfits use a computer-aided device to create a three-dimensional image of the foot. Casts are then sent to a lab, either local or out of state, where the orthotic is made. (If an orthotic is fabricated locally, adjustments to fit, if necessary, take less time.)

Turf battles among foot docs

Like an ill-fitting shoe and a growing bunion, friction exists between the several medical disciplines that prescribe orthotics. Some podiatrists say orthopedists and physical therapists don't know much about feet or biomechanics (the study of how the body moves). Some orthopedists say podiatrists don't place enough emphasis on pre-made orthotics and exercise.

"It has to do with territory and wanting to control as much as you can," observed Newell, the podiatrist and sports medicine specialist.

Just about everyone in the medical community is concerned about the proliferation of nonmedical custom orthotics, often sold at places like county fairs. "They're in it just for the money, not for good medicine," said Dr. Edward Blahouse, a Seattle podiatrist. "In general, they don't take impressions of the foot in an appropriate manner," but do so in a way that exaggerates foot problems.

Foot specialists prescribe one of three different types of custom orthotic, all costing about the same if an impression needs to be made:

-- A hard plastic orthotic, designed to precisely control the position of the foot. It may last for up to 20 years, but three to seven years is more common. It's used primarily for walking or dress shoes.

-- A soft orthotic, made of leather or foam, absorbs shock, increases balance and relieves pressure from sore spots. Although more comfortable to wear than a rigid orthotic, it wears out faster, sometimes in less than a year.

-- A third type, semi-rigid, is used in athletic shoes and is designed to increase an athlete's balance. It's usually made from laminations of leather, cork and a plasticlike material.

Experts say that even the best orthotics won't do much good if placed inside unsupportive or poorly fitting shoes. Women have an especially difficult time finding shoes that are both comfortable and stylish, yet still accommodate orthotics. (Some orthotics, thinner and shorter than standard models, are designed to fit inside dress shoes, but they're not as effective at correcting foot problems.)

. Like a car with 100,000 miles on it, feet start to develop more problems as people reach middle age. Ailments such as stretched ligaments, bunions and plantar fasciitis become more common. With the increasing age of the baby-boom generation, more and more people are probably going to experience foot pain. The good news is that orthotics may keep at least some people from having to live with it.