Custom foot orthoses are one of the most powerful tools in a podiatrist’s bag of tricks. Like any powerful tool, they can cause problems when they are not matched carefully to the patient in front of you. The old medical principle of “do no harm” applies just as much to orthotic prescribing as it does to any other clinical intervention. Here are four key principles worth keeping front of mind every time you write a script.
Don’t Compromise the Shoe Fit.
An orthotic device that does not play nicely with the patient’s footwear is not doing its job; it is creating a new problem. Bulky devices can crowd the toe box, lift the heel out of the shoe, or reduce the volume available for the foot, leading to blisters, pressure areas, and general discomfort that undermines compliance. Before finalising a prescription, think about the shoes the patient will be wearing it in. A device built for a roomy walking shoe will not necessarily translate well into a narrow dress shoe or a snug-fitting soccer boot.
Avoid Overdosing the Prescription.
More correction is not always better. It is tempting to address every biomechanical finding in one device, but stacking wedges, posts, and additions can overwhelm a patient’s tolerance, particularly in someone new to orthotic therapy. Over-dosed prescriptions often lead to poor compliance, skin irritation, or compensatory movement patterns elsewhere in the kinetic chain.
A more conservative starting prescription, reviewed and adjusted based on the patient’s response, is usually safer and more effective than trying to correct everything at once. This also makes prescribing subsequent pairs much easier, as often only subtle changes are needed and these have already been tested through the original device iterations. This is particularly important in athletes who have presented with their first bout of lower-limb complaints. These individuals may require a very low dose to bring their tissue threshold back into balance with their demanding training schedule.
Match the Prescription to Activity Level and Type.
The demands placed on an orthotic device vary enormously depending on what the patient is doing while wearing it. A prescription that ignores activity-specific loading patterns risks doing more harm than good.
Take a semi-elite soccer player, for example. Their sport involves frequent lateral movement, cutting, and rapid changes of direction. Heavily medial in a device for this athlete could restrict the natural motion they rely on for performance and may increase injury risk. The prescription needs to reflect the biomechanical demands of the sport or activity, not just the static assessment findings.
Be Cautious Prescribing for Reduced Joint Range.
Older patients often present with reduced range of motion at the ankle and subtalar joints, whether from osteoarthritis, previous injury, or general age-related stiffening.
Prescribing an aggressively corrective device for a joint that simply does not have the range to accommodate it can cause discomfort, skin breakdown, or create a device that the patient physically cannot tolerate wearing.
In these cases, the goal shifts from correction and perfect ‘straight lines’ on the back of the leg, to accommodation and adequate support, working within the patient’s available range rather than trying to force it.
“A gentler, more supportive prescription is often far more successful, and far kinder, than one aiming for textbook alignment.”
Good orthotic prescribing is not just about correcting biomechanics on paper it is about designing a device the patient can actually wear, in the shoes they actually own, doing the activities they actually do, within the physical limits they actually have. Keeping “do no harm” at the centre of every prescription helps ensure the device you send out the door is one your patient will thank you for.
