Orthotic shoe inserts are very effective in providing symptomatic relief of lower extremity complaints in running athletes. Inserts adjust the biomechanical-variables associated with running injuries and reduce the effect of high stresses produced by running activities. Orthotic treatment is based on an understanding of complex coupling of rotation of the lower extremity with pronation and supination of the subtalar joint. Orthotic fabrication is initiated by determining the neutral position of the foot and obtaining an accurate cast of this position. Successful treatment with orthotic shoe inserts is dependent on careful evaluation of the runner and formulation of a properly fitted orthosis. When correctly utilised, orthotic shoe inserts are beneficial for a broad range of disorders experienced by runners. Since biomechanical deficits may be related to injuries along the entire lower extremity, specific diagnoses may be of lesser indication; however, accurate identification of the underlying biomechanical deficit is critical. Problems related to excessive or prolonged pronation are most amenable to orthotic treatment. While treatment of the cavus foot with orthotic shoe inserts is sometimes worthwhile, the clinician should be aware of limited success in this instance. Finally, orthotics are only one facet in the overall treatment plan for injured running athletes. Most overuse syndromes will respond to rest, training modification, and a change in the running surface or shoe. Equally important is the use of a proper conditioning and stretching programme both for injury prevention and for treatment of specific injuries. Treatment with orthotic shoe inserts should not be used as a substitute for any of these approaches.