Prescription Shoes for Foot Pathology - Podiatry Management

OCTOBER 2011 | PODIATRY MANAGEMENT | 165www.podiatrym.com

Humans have worn someform of foot coveringover their feet for thou-sands of years. This hasbeen demonstrated by

the intact pair of fur moccasins wornby a hunter who lived 5,300 yearsago and was recently discovered

frozen in the mountains separatingItaly and Austria. People have longworn foot coverings for a number ofobvious reasons, including to serveas protection from the environment,as an aspect of fashion or status, asan aid to functioning in varioussports and work endeavors, and to

assist in ambulation when there is animpairment to normal gait. Whileshoes are generally worn to protectthe foot, recent studies performed todetermine the causes of lower ex-tremity amputations have identifiedthat for nearly half of the amputees

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Following this article, an answer sheet and full set of instructions are provided (pg. 176).—Editor

PrescriptionShoes for FootPathology

Goals& Objectives

After reading this article,the physician should be ableto:

1) Recognize the indica-tions for prescription shoesand shoe modifications.

2) Properly measure a pa-tient’s foot for prescriptionfootwear.

3) Select appropriatefootwear for various types offoot pathologies.

4) Understand the propermethod of taking an impres-sion cast for the fabrication ofcustom-made molded shoes.

5) Prescribe shoe modifica-tions for a wide variety of footdisorders.

Using footwear properly addsto your treatment armamentarium.

BY MARK A. CASELLI, DPM

FOOTWEAR & PODIATRY

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FOOTWEAR AND PODIATRY

PRESCRIPTION SHOES

166 | OCTOBER 2011 | PODIATRY MANAGEMENT

in the various study groups, theinitial event that lead to the am-

putation was either shoe-related ormight have been averted by wearingappropriate shoes.

Most of the shoe-related amputa-tions occurred in older individuals

with multiple pathomechanical andpathophysiologic problems, such asfoot deformities accompanied by dia-betes and poor lower extremity cir-culation. In order to utilize footwearto protect the foot from injury andimprove ambulation, the podiatricpractitioner must be thoroughly fa-miliar with the many functions thatshoes can serve, the proper methodof fitting shoes, the factors that gointo determining the patient’sfootwear needs, and the types of spe-cialized shoes and shoe modifica-

tions that are available to fillthese needs.

The Function of ShoesThe basic functions of a shoe

are foot protection, support, andpain relief. Protection includes

shielding thefoot from theharmful exter-nal environ-ment of sharpobjects, caus-tic chemicals,insect and an-imal bites andextremes oftemperature.Protectionmust also beprovided fromthe internal stress-es placed upon thetissues of the footby the enclosedshoe. A shoe

should provide support for the footand increase lower extremity stabili-ty, especially in the presence of weak

and sensitive feet. Finally, a shoeshould provide pain relief by trans-ferring weight-bearing stresses awayfrom painful areas, shielding painfullesions from external irritations,guarding against skin breakdown ofthe hypo-esthetic and poorly vascu-lar foot, and separating painful struc-tures from physical contact.

Further considerations for theuse of shoes and shoe modificationsin the management of foot pathologyshould include the following specificfunctions that shoes can serve:

1) Accommodate for fixed orrigid foot deformities such as severehallux abductovalgus, hammer orclaw toes, and tailor’s bunions;

2) Diminish pressure on dorsaland plantar aspects of the feet;

3) Redistribute weight bearing

from areas of excessive pressure orpain;

4) Support the foot and leg in thepresence of neuromuscular weaknessas present in systemic diseases suchas advanced rheumatoid arthritis,polio, neuromuscular disorders, anddiabetes;

5) Improve foot function by re-ducing excessive pronation orsupination;

6) Incorporate partial foot pros-theses;

7) Limit painful joint movement;8) Equalize limb length discrep-

ancy;9) Provide cosmetic and function

improvement for poorly matchedfeet;

10) Accommodate for edema;and

11) Serve as an alternative to footsurgery.

Fitting of ShoesIn order for a shoe to achieve its

desired function and not be harmfulto the foot, it must first and foremost


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Figure 3: Open and closed-toed post-operative shoes

Figure 1: The Brannock device (top) and Ritz stick are used to determineshoe size.

Figure 2: A tongue pad is placed in the shoe(right) of the shorter foot to ensure snug fit

In order for a shoe to achieve its desired functionand not be harmful to the foot,

it must first and foremost fit properly.



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fit properly. Three essential measure-ments are required to determine shoesize: the overall foot length (heel totoe), arch or ball length (heel to 1stmetatarsophalangeal joint), andwidth. The proper shoe size is theone that accommodates the head ofthe 1st metatarsal (i.e., the widest

part of the foot) in the widest part ofthe shoe. It is for this reason thatshoes must be fit by arch lengthrather than by overall foot length.Both the Brannock device, which isavailable in three types, for men,women, and children, and the Ritzstick give the ball width, the heel toball length, and the heel to toelength, and are commonly used in

determining the shoesize (Figure 1).

Foot measure-ments should betaken with the patientstanding, since thefoot tends to spreadon full weight bear-

ing. Becausethese shoe-mea-suring devicesgive only two-dimensional mea-surements, and feet are three-di-mensional, these devices giveonly a rough estimate of theproper shoe size to fit the pair ofmeasured feet. Shoe sizes alsovary considerably with theirstyle, construction, brand, heelheight, last type, and shoe mate-

rials. Good shoe fitting should there-fore include proper fit to the foot’soverall length, ball width, heel toball length, arch height, heel width,instep width, and great toe jointheight.

Allowances should also be madefor the increases in foot volume thatoften occur under varying circum-stances. There can be as much as a

five percent in-crease in foot vol-ume in a normal footfrom the morning tothe evening as wellas increase in footvolume after com-pleting a rigorous ac-tivity, such as jog-ging, walking, oreven a long day of

shopping. Feet should be measuredfor shoes at the end of the day orafter frequently performed physicalactivities. Foot volume also tends toincrease during warm and humidweather and in the presence ofpathological edema.

If one foot measures slightlylonger, the patient should always be

fit for the longer foot. A tongue padcan be used in the shoe for the short-er foot to ensure a snug fit. A tonguepad can be made of adhesive backedfelt and placed on the underside ofthe tongue. The thickness of the padis determined by the amount ofspace that is available when the shoeis examined, but generally 1/8 to 1/4


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Figure 7: Plastizote toe filler to be used in the depth inlay shoe

Figure 5: Healing shoe with Velcroclosure

Figure 4: Post-operative shoe with weight-dispersinginsole

Figure 6: Depth inlay shoe with removable insole to accommo-date a foot orthosis

Prescriptions often include modificationsto shoes which can reduce the motion of specific

painful or arthritic joints.

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inch is adequate. It functionsby holding the foot farther back in

the shoe, thereby keeping the ball ofthe foot in the widest part of theshoe and the heel snug against thecounter of the shoe (Figure 2).

Foot Evaluationfor Prescription Footwear

When considering the use of pre-scription footwear for the manage-ment of foot pathology, the clinicianmust perform a thorough foot evalua-tion and list all of the patient’s pedalabnormalities since the eventual shoeand shoe modifications must addressall these issues. A careful inspectionof the patient’s current footwear isalso useful in determining the mostappropriate prescription.

Skin color and temperature of thepatient’s foot should be assessedwith special attention to areas thatare erythematous since they mayidentify locations of increased fric-tion or pressure that must be re-lieved. Cyanotic, cool areas are ofequal importance as they may indi-cate locations of poor circulation andpotential areas for tissue breakdownfrom minimally applied stress fromthe shoe. Joint ranges of motionmust also be assessed as to their de-gree of motion and whether or notthere is pain with movement of thejoint. The most important joints toevaluate include the ankle, subtalarand midtarsal, and the metatarsopha-

langeal joints, withspecial attention tothe 1st metatarsopha-langeal joint.

Prescriptions ofteninclude modifications

to shoeswhich canreduce themotion ofspecific painful or arthriticjoints. The presence of le-sions, ulcers, or callositiesand their specific location

as well as any biomechani-cal deformities such as bunions or ham-mertoes should be recorded and addedto the shoe prescription. Foot size dis-crepancy is an important considerationin determining what type of shoe might

be necessary. A smalldifference in lengthcan be easily accom-modated as describedearlier, while a signifi-cant variation in footsize resulting from acongenital abnormali-ty, partial foot ampu-tation, or unilateral

edema would require an entirely dif-ferent approach to footwear.

Gait abnormalities such as adropfoot, limp, abducted, adducted,

circumducted, or shuffling, apropul-sive gait will determine many as-pects of the shoe prescription, espe-cially if the shoe must accommodatea brace. A leg-length difference mustbe assessed as to its duration (recent

or existing for manyyears) as well as to theexact measurement ofthe difference, as thesefactors will determinethe degree of correctionindicated and thus thetype of shoe required.

The presence andseverity of edema of thefoot must also be evalu-ated. It is important todetermine if the edema isa recent occurrence andtemporary, as mightoccur after lower extrem-ity surgery, or a chronicproblem. For temporaryswelling, shoe fittingshould be postponeduntil the edema resolves.In the case of chronicedema, shoe fit shouldbe checked frequently,since the edema may get

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Figure 9: Women’s dress style depth-inlay shoe

Figure 10: Bunion last shoe offering extra-wide toe-box

Figure 11: Custom-made molded shoes for varying degrees of footdeformities

Figure 8: Athletic style depth inlay shoe

A careful examinationof the patient’s current footwear can

give the practitioner a wealth of informationin determining what type of shoe

and shoe modifications might be needed.




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worse or improve, and the shoe mayhave to be changed frequently. Thismay be a major factor in selecting ashoe, especially if the patient reportsa history of varying edema.

Complicating FactorsIn addition to the specific pedal

problems that may direct a clinicianto consider utilizing prescriptionfootwear, the following conditionstend to add complicating factors tothe patient’s pedal condition andmust be considered when selectingshoes and shoe modifications. Theseconditions also tend to be most se-vere in the geriatric population,which is the population that mostoften requires prescription footwear.

1) Loss of elasticity of fibrous tis-sue in the skin, ligaments, and fascia.Severe forms of mechanical correctionwith a shoe should be avoided. No at-tempt should be made to force thefoot into any new or different positionwherever resistance is met.

2) Atrophy of adipose tissue inthe sole of the foot. This results inlittle or no shock absorbing cushion-

ing to protect thesensitive osteoporot-ic bones or the frag-ile plantar skin fromthe trauma of ordi-nary weight-bearing.

3) Reduction ofmuscle potential de-creases the efficien-cy of the locomotorapparatus.

4) Peripheral vas-cular disease resultsin guarded viabilityof tissues andpretrophic areasaround biomechani-cal faults.

5) Peripheral neu-ropathy results inloss of protectivesensation, commonin diabetes, greatlyincreasing thechance of infectionand ulceration atareas experiencingeven only a slight in-crease in pressure.

6) The arthridi-ties, especially osteoarthritis andrheumatoid arthritis. The degenera-tive articular changes in osteoarthritisare greatly increasedwhen there is a biome-chanical pathology suchas a hallux valgus defor-mity, a condition forwhich prescriptionfootwear is often uti-lized. It must be there-fore recognized that thiscondition may deterio-rate even when appro-priate shoes are worn.Rheumatoid arthritisdoes not only compli-cate the already existingbiomechanical patholo-gy but produces furthersoft tissue atrophy andlateral deviation andoverlapping of the toes.

7) Osteoporosis canresult in fractures fromcomparatively minorinjuries.

Finally, a careful ex-amination of the patient’s

current footwear can give thepractitioner a wealth of informationin determining what type of shoe andshoe modifications might be needed.Both the interior and exterior of theshoe should be examined for wear. Theinsole should be assessed for both loca-tion and depth of depressions. The inte-rior of the toe box should also be exam-ined for elevated areas, as well as wear,both indicating pressure points createdby bony prominences. Heel and solewear should also be noted. A detailedhistory of custom shoe use and shoemodifications can be most helpful.

Selecting a ShoeWhen being presented with a pa-

tient requiring prescription footwear,there are some initial concerns thatshould be taken into account beforeproceeding on to the shoe prescrip-tion, since they may alter the type ofshoe selected.

1) Immediacy of need—Whendoes the patient require the shoe andhow soon can one be obtained? Theuse of the “ideal” shoe may have tobe postponed in order to get the pa-tient into footwear now.

2) Cost—The perfect shoe has novalue if it cannot be provided to the


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Figure 14: Hoke ball-and-ring stretcher

Figure 15: Standard shoe stretcher

Figure 12: Custom-made shoes for marked limb-length difference

Figure 13: Bivalve impression cast with plaster positive and resulting cus-tom-made molded shoe

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PRESCRIPTION SHOES


patient. An affordable shoe thatmeets the patient’s most critical

needs will do the most good.3) Style—A prescription shoe is

of no benefit if the patient refuses towear it because of the way it looks.This aspect of using prescriptionfootwear should always be discussedwith all patients, both men andwomen. The need for the prescrip-tion footwear and its importance tothe foot health, even foot survival,must be stressed. A compromise onstyle, if appropriate, should also bepresented. If possible, both spousesshould be included in this consulta-

tion session. The patient’s spousemay serve as an advocate or an an-tagonist to the patient wearing the

“orthopedic” shoes. It is not uncom-mon to have a wife complain that a

prescribed shoemakes her hus-band look an oldman, even if thehusband is over80 years old!

4) Patient’sability to put onand removeshoes—If the pa-tient cannot per-form this task dueto a medical condi-tion or mental sta-tus, it must be de-termined whetheror not there issomeone elseavailable to takeon this responsibil-ity before a customprescription shoeis ordered.

Basic Types ofPrescriptionShoes

There are threebasic types of pre-scription shoesused for patientswith various formsof foot pathology:1) post-operativeshoes; 2) depthinlay shoes; and 3)custom-mademolded shoes.

Post-OperativeShoe

Post-operativeshoes were initially

designed to be used following surgeryin order to accommodate extremeswelling and bulky dressings. They are

constructed with a wide forefoot andare available as either open or closedtoe models (Figure 3). The uppers aremade of canvas or more commonlynylon mesh with either Velcro strapsor lace closures. Most come with arigid rocker sole to allow the patient towalk while limiting joint motion. Oneof the major advantages of this type ofshoe is its very low cost, making itpossible for the clinician to keep themon hand in the office, providing imme-diate availability to the patient.

In addition to being used in ac-commodating for swelling, edema, ordressings, the post-operative shoecan be used to relieve both dorsaland plantar foot pressure on bonyprominences from rigid foot deformi-ties. To relieve plantar pressure, aweight-dispersing insole can beadded due to the abundance of spaceavailable (Figure 4).

The post-operative shoe can beused as the primary footwear for pa-tients who are engaged in minimalambulation or are non-ambulatory.They can also be used as interimfootwear while waiting for anothertype of prescription shoe. The majordisadvantage of the post-operativeshoe is the limited size selection,most being available in women’ssmall, medium, and large, and men’ssmall, medium, large, and extralarge.

A sturdier modification of thepost-operative shoe is the healingshoe. This is a closed-toe, extra-wideshoe made from a nylon-coveredmoldable polyethylene foam and canbe molded directly to the patient’sfoot (Figure 5). Its indications are thesame as the post-operative shoe. Un-


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Figure 18: Elastic band closure for easy insertion of foot in shoe

Figure 17: Cut-out of shoe upper to reduce pressure on bony prominence

Figure 16: Splitting upper of shoe to accommodate for foot deformity

A depth-inlay shoe is usually one size longer (1/3 inchlonger) and two sizes wider (1/2 inch wider in

circumference at the level of the metatarsophalangealjoints) than the corresponding regular shoe.



PRESCRIPTION SHOES

like post-operative shoes, healingshoes come in a wide range of sizes,providing a better fit. They are muchmore expensive than post-operativeshoes so they are not practical tokeep in stock in an office. They areindicated when this type of footwearis required for a longer period oftime in an ambulating patient.

Depth-Inlay ShoeThe depth-inlay shoe, often re-

ferred to as an added-depth or in-depth shoe, is the most commontype of prescription footwear utilizedin the management of numerous footpathologies. The depth-inlay shoe isa roomy shoe with a removable in-sole measuring 1/4 inch to 3/8 inchin thickness. Commercially availableor custom-made orthoses and otherfoot appliances can be easily insertedinto this kind of shoe after removingthe original insole (Figures 6 and 7).

As a rule, a depth-inlay shoe isusually one size longer (1/3 inchlonger) and two sizes wider (1/2inch wider in circumference at thelevel of the metatarsophalangealjoints) than the corresponding regu-lar shoe. The depth inlay shoe usual-ly comes in a basic oxford style, butis more recently available as both anathletic and dress shoe (Figures 8and 9). They are available in a wide

range of shapes and sizes for bothmen and women and can be used forall but the most severely deformedfeet.

The two most common shapes,or last modifications, ordered are thebunion last and the combination last.In the bunion last shoe, the forepartof the last swings medially to accom-modate the bunion deformity andthen swings outwardly to accommo-date the fifth metatarsal head. Abunion last oxford shoe is a lowheel, laced or Velcro closured shoewith a broad toe box made of softleather to provide ample room for asevere bunion deformity (Figure 10).A combination last shoe combines anarrow heel and a wider ball. The

heel measurement is often twowidths narrower than the ball. Thistype of shoe is indicated for a patientwith a wide forefoot, but a small nar-row heel, in order to prevent heelslippage. Depth inlay shoes can beordered with a Plastizote liner to ac-commodate for pressure points aswell as with a variety of heel andsole modifications.

Custom-Made Molded ShoesA custom-made shoe is a shoe

constructed from a model made froma cast of the patient’s foot. This typeof footwear is needed only in caseswhere a depth-inlay shoe cannot bemodified to meet the patient’s needs.Indications for custom-made moldedshoes include:

1) Severe foot deformities such astalipes equinovarus, equinovalgus,extreme hallux valgus, rigid hammer-toes, and Charcot foot (Figure 11).

2) Marked leg-length discrepancy(Figure 12)

3) Marked foot size discrepancy,congenital absence of various partsof the foot, or foot amputations oftenrequire the combination of moldedshoes and various foot fillers so that

these patients can wear match-ing shoes.

4) Feet with peripheral neu-ropathies resulting in loss of protectivesensation may require a molded shoefor protection from repeated traumathat can produce skin necrosis.

5) Feet with severe peripheralvascular disease that heal very slow-ly from even minor injuries.

6) Feet with severe arthritis, suchas rheumatoid arthritis, which in-volves numerous joints producing syn-ovitis, deformities, exostoses, instabili-ty, subluxations, and dislocations thatmake them prone to injuries.

The shoe upper of custom-mademolded shoes can be ordered with ahigh toe-box and is usually con-

structed of soft leather with thewhole lining also made of leather.When a bony prominence is presenton the dorsum of the foot, a 1/8 inchthick, soft density, Plastizote liningcan be built into the shoe’s upper.The insole is usually ordered with1/2 inch thick Plastizote, the top 1/4


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Figure 19: Surgical lace-to-toe closureFigure 20: Flare heel increases rearfootstability

A custom-made shoe is neededonly in cases where a depth-inlay shoe cannot be

modified to meet the patient’s needs.

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inch made of a medium-densityPlastizote for cushioning, and the

bottom 1/4 inch made of firm-densi-ty Plastizote for support.

The insole extends from the heelto the toes andprovides totalcontact for theentire plantarsurface of thefoot. The mold-ed shoe usuallyhas a flat solethat permitsmaximumground contactand support.Since the rela-tively thickrubber sole isnot too flexible,and both theinsole and out-sole cradle thefoot, there isminimumamount ofdorsi-flexion,plantar-flexion,and medial andlateral rotationof the foot dur-ing ambulation,resulting inminimumstress on the

foot. This stiffness can sometimespresent the problem of heel slippagein the more active patient with apropulsive gait. A rocker sole can beadded if this occurs.

A foot cast is required for thefabrication of a custom-made moldedshoe. The cast must capture the con-tours of the foot exactly and be re-moved without damaging it or the

foot. The foot cast is taken with pa-tients seated with their feet on afoam-covered platform. The castshould be taken in a semi-weightbearing position encompassing boththe foot and ankle with the knee at90 degrees flexion and the ankle alsoat 90 degrees if possible. Casts arecommonly taken in a bivalve, twopiece form (Figure 13).

A full weight-bearing tracing ofeach foot should also be taken to ac-company the cast to the laboratory.

The main disadvantage of the cus-tom-made molded shoe is its expense,a pair usually costing the patient be-tween $400 dollars to over $1,000 dol-lars. Because these shoes are hand-

crafted from a cast of the patient’sfoot and follow its contours, they mayhave an unusual shape and are oftenconsidered cosmetically unacceptableby many patients.

Shoe ModificationsThe various parts of the shoe

upper can be enlarged or maderoomier to accommodate for bonyprominences, ulcers, or pre-trophicareas. One of the advantages ofusing leather for shoe construction isthat leather not only conforms to thefoot through the course of normalwear, but can also be forced-con-formed by stretching. Spot stretching

can be accomplished with the use ofa Hoke ball-and-ring stretcher (Fig-ure 14) or a shoemaker’s swan.These devices are used in conjunc-tion with the application of a stretch-ing fluid, which is a fifty-fifty mix ofrubbing alcohol and water.

Another type of stretching is usedto increase the width, and to a lesserdegree, the length of a patient’sfootwear. There are two types of de-vices used for this purpose. One is thetraditional shoe stretcher, which isavailable in various configurationsand can easily be used in the office(Figure 15). The other, the Eupidusdevice, is used for general stretchingand is found in shoe repair, pedorth-

ic, and orthotic facilities. This devicehas the advantage of greater leveragein stretching the shoe and is neededfor shoes that are constructed of thickleather.

Splitting or making cruciate cutsthrough the shoe leather and its un-derlining (Figure 16), or by simplycutting out the impinging portion ofthe shoe upper (Figure 17), can offerimmediate reduction in pressure. Amore permanent method of accom-modating for an isolated bony promi-nence is applying a balloon patch tothe shoe. A balloon patch involvesthe cutting of the upper of the shoe

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Figure 24: Basic rocker-sole modification

Figure 22: Sole lift for leg-length discrepancy

Figure 23: Metatarsal bar modification

Figure 21: Stabilizer (orbuttress) adds support toshoe

One of the advantages of using leather for shoeconstruction is that leather not only conforms to the footthrough the course of normal wear, but can also be

forced-conformed by stretching.




PRESCRIPTION SHOES

away from the area of the affectedtoes or joints. Once the leather hasbeen removed, a patch of deerskin orother soft material is applied looselyover the cut-out and dyed to matchthe shoe.

Shoe closures can also be cus-tomized and should be selected tomatch each patient’s needs. Com-mon closures include eyelets andshoe laces, elastic bands, Velcrostraps, and zippers. Elastic bandsallow for easy insertion of the footinto the shoe while keeping the shoeon the foot (Figure 18). Velcro andzipper closures are beneficial for pa-tients who have difficulty in tyinglaces, such as those with severe

arthritis or paralysis of their hands.A surgical lace-to-toe closure haslace stays or Velcro straps that ex-tend all the way to the toe (Figure

19). This closure is useful for pa-tients who have difficulty gettingtheir foot into a shoe. It is common-ly used with ankle orthoses, for anedematous foot and ankle, for a flac-

cid or obese foot, or for feet af-fected by neurological disorders,such as cerebral palsy andmyelomeningocele.

Modifications of the Heel andOuter Sole

Medial or lateral heel, or heeland sole wedging, is added to


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A B

C D

Figure 25: a,b,c,and d. Rocker-sole modifications for varying levels of foot amputations. The position of the apex of the rocker is noted by the arrow.

Medial or lateral heel, or heel and sole wedging, is addedto footwear to accommodate for excessive pronation or

supination and to improve stability.

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footwear to accommodate forexcessive pronation or supination

and to improve stability. The wedgecan be inserted between the upperand the sole or placed directly to thebottom of the shoe. A medial wedgemight be used for posterior tibial ten-don dysfunction, severe flexible flat-foot, or plantar fasciitis problems. Alateral wedge may be indicated forperoneal tendinitis.

A flare heel is used to increaserearfoot stability. The bottom of theheel in contact with the ground iswider than the top of the heel (Figure20). The extension of the flare is usu-ally equal to the widest part of theshoe counter. The flare heel increasesthe base of support, keeping the heelfrom turning over. It also decreasesstress on the heel and ankle.

The solid ankle cushion heel(SACH) consists of a wedge of shock-absorbing material that is insertedinto the posterior midsole of theheel. Its purpose is to provide a max-imum amount of shock absorption atheel contact and rebound immediate-ly for the next heel strike. The SACHheel is often used in conjunctionwith short-leg braces or leg prosthe-ses, after a calcaneal fracture, or forsynovitis of the ankle.

If a shoe’s upper shows signs ofbreaking down medially or laterallybecause of severe pronation orsupination, a medial or lateral stabi-lizer (or buttress) may be added tothe shoe. The stabilizer is an exten-sion placed on the side of the shoe,including the sole and upper (Figure21). The stabilizer is made from rigidfoam or crepe and provides greatersupport than the flare heel.

The sole lift is mainly used totreat leg length discrepancy (Figure22). The thickness of the sole de-pends on the amount of shorteningpresent, the length of time the dis-

crepancy has been present, and thedegree of compensation that has al-ready taken place. The sole lift is al-ways accompanied witha rocker sole.

Metatarsal BarsMetatarsal bars are

often placed on shoes toprovide pressure relieffor symptomaticmetatarsal heads andtheir adjacent struc-tures. A typicalmetatarsal bar is ap-proximately 1/8-inch to 3/8-inchhigh, made of leather or soling rub-ber, and is fixed transversely acrossthe bottom of the outsole with itsapex immediately proximal to themetatarsal heads (Figure 23). It is

often used for the treatment of sesi-moiditis, hallux rigidus, plantar cal-losities, and fractures of themetatarsals.

Rocker-SolesA rockersole modification is used

for any type of pathologic or path-omechanical condition that eitherlimits normal movement of the ankle,tarsal, or metatarsophalangial jointsor in situations where it is desirableto limit such motion. The rocker-soleprovides a smooth rocking motionfrom heel to toe to imitate the heelrise and push-off sequence of normalgait. It allows for very little motion tooccur at the metatasophalangialjoints with a significant reduction ofmotion at the ankle, subtalar, talon-avicular, calcaneocuboid, and tar-sometatarsal joints.

The rocker-sole can be used inthe treatment of metatarsalgia; frac-tures of the metatarsals and pha-langes; insensitive feet; arthritis, fu-sions, and subluxations of the ankleand joints of the rearfoot; and after

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Dr. Caselli is Staff Podi-atrist at the VA HudsonValley Health Care Sys-tem and is Adjunct Pro-fessor, Department ofOrthopedic Sciences atNYCPM. He is FormerChairman, Departmentof Orthopedic Sciencesat NYCPM.

partial foot amputations. The rockersole commonly extends from themidshank area to just proximal to

the anterior tip of theshoe, with its highestpoint at the ball of theshoe (Figure 24). Whenused for partial foot am-putations, placement ofthe rocker is governedby the level of amputa-tion. As the foot be-comes shorter, the apexof the rocker must beplaced more proximal

(Figures 25 a,b,c and d).A long (heel-to-toe) spring steel

shank is a strip of steel or carbonfiber that is placed between the lay-ers of the sole from the heel to thetoe box to provide rigidity for the en-tire outsole (Figure 26). It is mostcommonly used with a rocker-sole. Itprevents the shoe from bending andthus limits toe and midfoot motion.It is often used after transmetatarsalamputations and in the treatment ofpainful hallux limitus. PM

References1. Bumbo N: Utilizing footwear as a

therapeutic modality. In Valmassy RL(ed.), Clinical Biomechanics of the LowerExtremities, Mosby, St. Louis, 1996.

2. Cheskin M: Custom-moldedfootwear-one size only. Podiatry Manage-ment 2004; 23(8)

3. Janisse DJ: Orthoses, shoewear,and shoe modifications. In Myerson MS(ed.), Foot and Ankle Disorders, W.B.Saunders Company, Philadelphia, 2000.

4. Janisse DJ: Prescription footwearfor arthritis: a team approach. PodiatryManagement 2003;22(8)

5. Reiber GE: Who is at risk of limbloss and what to do about it? Journal ofRehabilitation Research and Development1994;31(4)

6. Shor RI: Preventive footwear for re-current diabetic foot ulcers. Podiatry Man-agement 2004;23(8)

Figure 26: Long (heel-to-toe)spring steel shank placed be-tween layers of sole.

The rocker-sole provides asmooth rocking motion from heel to toe to imitatethe heel rise and push-off sequence of normal gait.

CME EXAMINATION

1) The most important criteriafor the use of a shoe in the man-agement of foot pathology is thatthe shoe must:

A) Address all of the footpathologies presentB) Reduce foot pronationC) Fit properlyD) Be custom made

2) Which one of the following isnot a commonly used measure-ment when fitting a shoe?

A) Overall foot lengthB) Arch heightC) Arch or ball lengthD) Width

3) The main problem withrelying solely on the measure-ment obtained with a Brannockdevice for proper shoe fit isthat:

A) A Brannock device onlymeasures adult sizes.B) A Brannock device cannotmeasure ball width.C) A Brannock device onlygives a rough estimate ofsize.D) A Brannock devicemust be used with aRitz stick for a propermeasurement.

4) How should a patient befit for a shoe if one foot mea-sures slightly longer than theother?

A) Fit for the shorter footand stretch the shoe for thelonger foot.B) Fit for the longer foot andadd a tongue pad to the shoefor the shorter foot.C) Fit for the longer foot andadd a heel pad to the shoefor the shorter foot.D) Fit for the longer foot andadd a toe filler to the shoefor the shorter foot.

5) When arthritis results in se-vere joint stiffness, mechanicalcorrections in a shoe should:

A) Strive to maintain subta-lar neutral position.

B) Reposition deformed footsegments.C) Maintain and protect thefoot in its presenting position.D) Align the heel so that it isvertical to the ground.

6) Which one of the following isnot an advantage of a post-opera-tive shoe?

A) Affords excellent foot pro-tection from the external envi-ronmentB) Is inexpensiveC) Immediate availabilityD) Easily accommodates se-vere edema

7) What type of shoe might beused when a sturdier version of apost-operative shoe is required asin the treatment of a conditionthat requires foot bandaging for along period of time?

A) Custom-made molded shoeB) Orthopedic oxford shoeC) Added-depth shoeD) Healing shoe

8) The most common type of pre-scription footwear used in themanagement of foot pathology andulcer prevention is:

A) Depth-inlay shoeB) Tarso-supinator shoeC) Custom-made shoeD) Molded polyethylene foamshoe

9) The key feature of the depthinlay is:

A) A soft leather upperB) A Velcro closureC) An ample removable insoleD) A rocker-sole

10) What would be the best shoeto prescribe for a patient with awide forefoot and a narrow heel?

A) Custom-made molded shoeB) Combination last shoeC) Healing shoeD) Depth-inlay shoe

11) An eighty five year old patientwith a severe talipes equinovarusfoot deformity would best be fitted

with which one of the followingshoes?

A) Custom-made moldedB) Bunion last depth-inlayC) Combination last depth-inlayD) Healing shoe with customorthosis

12) Custom-made molded shoesare usually prescribed with re-movable insoles made of what ma-terials?

A) 1/4 inch medium Plastizotetop with 1/4 inch firm Plasti-zote bottomB) 1/2 inch firm PlastizoteC) 1/2 inch neoprene rubberD) 1/4 inch Poron top with 1/4inch medium Plastizote bottom

13) What modification can beadded to a custom-made moldedshoe to reduce heel slippage?

A) More rigid soleB) High heel counterC) Rocker-soleD) Metatarsal bar

14) What type of cast is requiredfor the fabrication of a custom-made molded shoe?

A) Off-weight-bearing slipper castB) Semi-weight-bearing slippercastC) Off-weight-bearing foot andankle impression castD) Semi-weight-bearing footand ankle impression cast

15) A patient presents with a newpair of depth inlay shoes. He com-plains that his 3rd toe is rubbingon the top shoe. You find he has arigid 3rd hammertoe. What is thebest shoe modification in thissituation?

A) Cut a hole in the shoe overthe hammertoe.B) Make a linear cut in theupper of the shoe over thehammertoe.C) Spot stretch the upper ofthe shoe over the hammertoe.D) Add a rocker bar tothe shoe.


SEE ANSWER SHEET ON PAGE 177.


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CME EXAMINATION

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16) What type of shoe modification can beprescribed for a patient with a spastic equinusfoot who has difficulty in slipping his footinto a shoe?

A) Velcro closuresB) Surgical lace-to-toe closureC) Elastic band closureD) Zipper closure

17) A patient presents with a prosthetic limbfollowing a below-knee amputation. Whatheel modification is recommended for theshoe that is to be fitted to the prostheticlimb?

A) Flare heelB) Medial heel wedgeC) Lateral heel wedgeD) Solid ankle cushion heel

18) A patient presents with severe footpronation which results in the breakdown ofthe medial aspect of his shoes, even whenusing supportive in-shoe orthoses. Whatmodification can be added to his shoes tooffer greater support?

A) Lateral sole wedgeB) Medial stabilizer (buttress)C) Rocker-soleD) Flare heel

19) What shoe modification would be used torelieve the joint pain caused by a halluxlimitus?

A) Rocker-soleB) Sole liftC) Medial buttressD) Lateral sole wedge

20) Which one of the following is not trueabout a rocker-sole modification?

A) A rocker-sole decreases midfoot jointmotion.B) A long (heel-to-toe) spring steel shankis often used with a rocker-sole.C) The apex of the rocker is always placedin the same location on a shoe.D) It provides rocking motion from heelto toe.

See answer sheet on page 177.

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LESSON EVALUATION

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__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

EXAM #8/11Prescription Shoes for Foot Pathology

(Caselli)

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Prescription Shoes for Foot Pathology - Podiatry Management

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