Question 1. What are podiatrists traditionally taught about footwear, support and orthotics?

“That idea of a ‘good shoe’ was based on this idea of a ‘good foot’, which is now antiquated.”

We’re definitely taught that shoes should be slightly heeled, stiff around the heel cup, fixed onto the foot, only flex across the metatarsal heads, be stiff between the heel and the metatarsal heads, be wide at the base of the toes rather than at the tips, and have cushioning and support. These are the things traditionally considered to make a good shoe.

The issue is that this often relates back to what we were once taught about the foot: that there is, or can be, this perfect foot shape, and that anything outside it is more likely to get injured. Yet we now know feet are more like noses. They come in all different shapes and sizes, and we can mostly breathe and smell through them just fine. Feet are much the same - they vary hugely, and most still function just fine.

That idea of a “good shoe” was based on this idea of a “good foot”, which is now antiquated. We’re now seeing that the newer, more research-backed theory is that our feet are meant to feel the ground. From feeling the ground, the foot sends a message to our central nervous system, which relays a message back to the foot so it can react to its environment.

So the traditional idea of a good shoe doesn’t make as much sense anymore. It’s stiff, only allowing movement at the metatarsophalangeal joints; it’s stiff around the heel; and it’s cushioned, which reduces the foot’s ability to feel. We’re taught that cushioning is good, but we know differently now.

Support is supposedly good too, but if you support something over and over again, it doesn’t need to do the work itself. It’s that old “if you don’t use it, you lose it” analogy.

Orthotics came about because we had these ideas about the foot needing to move or sit in a certain way, especially the static foot. You’d look at a foot and go, “Oh, that’s a certain structure, and we need to move it into this other structure.” So we would use an orthotic to change the shape of the foot. That’s what I was taught.

I think we’re now taught more that orthotics change force, and they do change force in different areas. So you can use them for certain periods of time while you’re unloading a structure that might be sore. But there’s still this idea that there’s something inherently wrong with your foot that needs fixing with the orthotic.

I think we can move away from that and understand that someone may have overloaded a tissue through activity, lifestyle factors or any number of things within that biopsychosocial model. If we’re just looking at biomechanics, it’s a very small subset of it. I don’t think we need to use orthotics to the level that we do.

A big part of what we’re taught at university is that pain is the thing we’re measuring. You know that visual analogue pain scale? I don’t even ask people what their pain is on the scale. They often tell me anyway. Obviously I want to know where their pain is, but when pain becomes the primary measure, you’re going to support it, cushion it and use orthotics because those things stop the foot moving and take load away from the painful area.

Personally, I’m more likely to have function as the goal. If someone wants to build up to walking five kilometres again, let’s start them walking. Pain might stay the same for a while, but if function is improving, we’re seeing a positive change. Pain is so complex.

I really focus on function, and I don’t think the podiatry schools are doing that just yet. I think they’re still focusing on pain. That’s why we see people in an orthotic and a Hoka, which is like putting someone in a moon boot. We even see people with plantar heel pain in a moon boot because they’re so desperate to get someone out of pain rather than worrying about function. A Hoka and an orthotic, or a moon boot, can be such a dysfunctional thing.

If we educate someone well and reassure them about their injury, we’re more likely to get them on board with doing rehab and putting up with a little bit of pain along the way. If we tell someone it’s okay to go for a walk even if it gets a little more painful in the short term, we can often take a much more proactive approach.

Obviously, you don’t want to do any long-term damage, and it depends on the injury. But if we focus on function rather than pain alone, we can start moving forward. People leave my consultation saying, “Oh, there’s hope,” and they often feel better simply because we’ve talked about what pain is, reassured them about their injury and helped them understand it.

That’s where the focus should be: on function rather than pain, which is where the focus has traditionally been.

Question 2. How has your own thinking about foot health and footwear changed over time?

“My children are highly functional with feet that don’t look textbook.”

I finished university in 2000, and I’d done an honours year where we looked at how stiffening the big toe affected the ankle, the knee and the other joints. We tried to stiffen the big toe with tape and then watched people with dots all over them to see what happened at the knee. The assumption was that it would increase knee flexion and therefore, if someone had a stiff big toe, they might be more likely to get patellofemoral pain.

Through that year I was also teaching first- and second-year undergraduate students in the clinic, and I really enjoyed teaching and educating people. I thought, “Maybe I’ll go into the teaching side of this.” But I also understood that it would be better if I had some experience, so I got a job as a podiatrist and really enjoyed that even more. It was probably more financially viable too, so I went into practice rather than down the teaching route.

I’ve now come full circle to teaching and educating more. But every consultation is an opportunity to teach someone who doesn’t know about foot health and help them on that journey, so I’ve always had that opportunity.

I went into my own private practice with a business partner in 2001, and we had our own little lab, which was unusual. We would take a cast of the foot - now people are scanning feet for orthotics - and I’d make the orthotic myself. I used to joke that I didn’t make many orthotics because spending three or four hours on each one meant my workload outside clinical time was going to be huge. So I really did have a reputation for not over-prescribing, even all the way back then.

Making them myself also gave me a wonderful understanding of how and why orthotics might work. Interestingly, if you went to an optometrist with an eye condition, I’m pretty sure you’d get the same personalised script if you went to another optometrist. But when you go to a podiatrist, there’s an art to making an orthotic.

I saw this because my business partner would make one, and it wouldn’t be the same orthotic I would have made for that client. Now I see it because people come in with six different pairs of orthotics that are all different for the same foot.

So if this is a customised approach, it’s customised towards what the podiatrist does, not necessarily towards the client in front of you. That’s an issue with orthotic manufacturing that I probably saw very early on. There’s still a lack of understanding around exactly how they work, which speaks to that as well. The science behind it is not great.

My practice grew, and I would see a lot of normal podiatry - nails and calluses, corns, ingrown toenails - as well as some biomechanics. But once you’re good at the basic stuff, your book fills up with it. You end up doing less biomechanics, and then when you do see it, you tend to be doing the same things because you’re seeing less of it. It got a bit tedious.

I was probably looking outside my career for enjoyment, and I was into cycling, golf and things like that. I actually had four concussions in two years from falling off my bike, so I had to quit cycling. For some reason, I went to a yoga class two or three months later, and I’d also started running again.

I had a running background, but I kept getting injured. Orthotics didn’t help me. I just kept getting stress fractures. So I’d quit running years earlier and taken up cycling.

Then I took up yoga, started running again and started going to the gym for the first time in my life. There was someone at the gym training barefoot, and I thought, “That’s a bit weird,” because we’d been told as podiatrists that we couldn’t train the feet, just like we can’t train eyes. The muscles are too small. You don’t train the foot muscles; you just need to support them.

I remember the FiveFingers running boom around 2010 and people coming in saying, “Can I run in these?” And I’d be like, “Oh no, you can’t. You can’t change your foot. Your foot needs this. You need to stay in those shoes.” It’s a bit embarrassing now, but we all grow and move on.

By around 2016 or 2017, I was 16 or 17 years into my career. I was going to yoga regularly, and they were giving me cues on how to train and change the shape of my feet. I was thinking, “Wow, my feet are getting stronger.”

I was still in traditional shoes, still wearing orthotics and still wearing a heeled, almost dressy boot every day to work. I remember going for a run - I’d started running in my ASICS - and then I’d heard about changing running technique and things like that. I went for a run in a pair of casual Adidas shoes, which you can imagine were pretty flat and flexible, and my calves just completely lit up.

I started exploring all these different things and came across The Foot Collective. I remember listening to Nick explain things on his podcast, and it was really helpful. Then I found Gait Happens as well and did one of their courses when they came out to Australia.

That was a really powerful time around 2018 and 2019. I also found it increasingly difficult knowing someone could book into the same practice and receive a very different treatment protocol depending on who they saw. There were a few things going on, and I left that practice at the end of 2019 or start of 2020.

I started reaching out to health practitioners in my area who could see through my Instagram that I rehabbed feet like we would rehab the rest of the body. That leads me to the last five or six years, where I’ve been refining the art of this and getting back to teaching, both my clients and other people through The Foot Collective and courses.

I think we could summarise this by saying that I learned through my own experiences of changing my own feet.

I also had children whom I put in orthotics from when they were three or four because they had feet like their mother’s, which are low-arched and their heels tip in. We’re taught in podiatry that that’s going to be a problem and, if you straighten it, that’s going to fix things.

So I put my kids in orthotics from when they were three or four until they were seven and nine. Then we took them out and put them in barefoot shoes. They haven’t looked back.

Their feet still don’t look textbook, but what is textbook? We now know that a low arch and everted heel at rest doesn’t matter. My 19-year-old daughter can run 10 kilometres in a barefoot shoe. My children are highly functional with feet that don’t look textbook.

I remember clearly, probably 15 years ago, seeing someone with that textbook foot - the foot that looked just right - who was still injured. I was really flummoxed. This foot is perfect biomechanically, so why are they injured?

We really didn’t understand the biopsychosocial model of pain, or overuse, or lack of capacity. Over the last five or six years, I’ve learned that there are so many factors involved in someone being in pain. Often, it’s to do with lifestyle factors.

The foot needs to be loaded to be healthy. Often it gets sore when it’s not loaded well or not loaded enough. If we find where it’s at in terms of mobility and strength, and then slowly build up its capacity in a graduated way, we see a foot that’s more able to cope with the rigours of what that person wants to do with their life over the long term.

It doesn’t mean they’re not going to get injured. There are so many other factors that cause pain and injury. But at least we’re ticking that biomechanics box by having someone as resilient as possible because they’ve worked on their mobility and capacity and allowed their foot to do its natural thing.

Question 3. When are orthotics or insoles genuinely useful?

In my practice, I have this idea that I’m always going to meet someone where they’re at. Often people come to me with orthotics and they’re quite used to them, and they don’t even mind them. Removing them could be a goal of theirs, or it might not be. If it’s not, then I’m probably not going to remove them. But if I educate them well, often they might want to.

Generally speaking, I hardly ever prescribe them. If I do, it’s more likely to be for something congenital or hereditary.

For example, I look after a hypermobile child whose arch doesn’t easily get out of pronation and into supination, so we use an insole up against the skin to create some proprioception and encourage that arch to activate. It’s not limiting her movement. If anything, it might be encouraging it. She doesn’t have pain, but we’re trying to encourage that movement of the foot.

Or if someone has had a club foot and surgery, they may still need an orthotic to change the way the weight flows around. In situations like that, they can be really useful, and we’re lucky to have them in our toolbox.

Then there are acute injuries. For example, with a tibialis posterior injury where the foot is really low-arched and struggling to get out of that position, we can use the force of an orthotic to take some load off the tibialis posterior while gradually increasing movement and capacity in the muscle.

There are also situations where one joint is stiff and the joints around it are having to work harder than their usual capacity. An orthotic might help in the short or medium term during periods where you’re asking more of the foot. That’s generally how I would use them in the short to medium term.

The longer-term situations are more likely to be congenital, hereditary or following a serious injury. I had someone in today who had an ankle injury 20 years ago, which probably led to changed mechanics. Her hip started giving her issues around 10 years ago, then she had a hip replacement, which changed her leg-length difference.

Nearly everyone has some leg-length difference and is totally fine because they’ve grown up with it and their body has adapted. But when you impose something like a traumatic ankle injury, which then leads to a hip issue and another structural change, the body isn’t used to it and can struggle to adapt.

In a situation like that, you might use a permanent insole on the shorter side to lift it a little and change the load. That’s a good example of an injury meaning we might need some type of insole.

So they can be genuinely useful, and we’re really lucky to have them in our toolkit. But unfortunately, they’re also very financially viable for businesses.

People are always trying to do better. If there’s something wrong with me, I need to fix it. If my kid has low arches, I need to make sure they don’t have problems in the future.

And unfortunately - and this is me being a bit negative towards our profession - whether people don’t know better, like I didn’t, they can end up telling people things about their foot structure that mean they need an orthotic ongoing.

I know this because I deal with it every day. People come in to see me with preconceived ideas about their feet, whether it’s their auntie, uncle, the shoe shop or their last podiatrist or physio saying there’s something wrong with their foot and they need this permanently.

And that is rarely the case.

Question 4. What are the limitations of relying on orthotics or supportive footwear long term?

Orthotics definitely can be used in the short to medium term for conditions that require offloading, and longer term for congenital or hereditary issues, or after significant injuries or surgery. In those situations, they may be part of a long-term solution.

However, for most foot conditions, they’re not required long term. If they are used, I generally see them as something for a shorter period of time.

When we become reliant on an orthotic, it can limit the shoes we can wear. It can also build into this idea that there’s something inherently wrong with our feet simply because of their shape or the way they move.

Our feet are all different and move differently anatomically. There’s no such thing as the perfect foot. So I think it’s important that our brains can realise our feet are just fine the way they are, rather than becoming reliant on an orthotic.

There’s also the physiological aspect, especially with some orthotics that are very stiff and hard. If they’re crossing a joint that’s meant to move, that joint won’t move as freely, and therefore the muscles crossing that joint may not be as strong or supple as they otherwise might have been.

So there’s this idea that we may be restricting the way the foot would naturally move without the orthotic. The research is thin on the ground when it comes to how orthotics might weaken feet or change the way feet move. But it’s common sense that if you put something stiff across a joint, it’s going to change how that joint moves and have an effect on the joint and the tissues crossing it.

That’s one of the limitations of using them long term, I think. If someone is very accustomed to using them, though, we definitely shouldn’t be reducing their use too quickly.

If we are going to reduce them, we need to make sure the foot is strong enough and mobile enough to cope with that change. That’s where rehab plans come in.

I also think that when we wear a shoe that allows for a straight big toe, it can help reduce the need for an orthotic and the amount of support within it, because a straight big toe acts as a blocker for pronation. It allows the foot to pronate, but when you get to the straight big toe, it helps the foot get out of that position into supination.

If the big toe is pushed sideways, that might be one reason why we need more support in the foot in the form of an orthotic. So when we have room to keep the big toe straight and use it in a properly wide shoe, I’ve found we don’t need as much orthotic support.

Also, when we go to a shoe with less heel-to-toe drop, we have fewer pronatory moments. With a higher heel-to-toe drop, we’re more likely to put the foot into pronation. So in a zero-drop shoe there are fewer pronatory moments and, therefore, less support may be needed.

The way I help someone transition out of an orthotic is to put the orthotic into a flatter shoe that allows them to use their big toe. Then we slowly reduce either the amount of time they use the orthotic or the strength of the orthotic itself, which a skilled podiatrist can do by thinning the shell.

And we go from there.