Shoes + Modifications

A well designed shoe is the necessary foundation for many _________

many LE orthotics and for prosthetic alignment and an energy efficient gait

Components of a Good Shoe

• minimizes stress on all portions of the feet

• provides support, and acts as a shock absorber of ground reaction forces

• your feet should not hurt every time you walk with your shoe

A well-designed shoe provides a:

a broad heel base, ankle collar, and close-fitting heel counter

Perfect Shoe - Harvards

1. Take a tracing of your foot with you. Place any shoe you think you might buy on top of the tracing. If the shoe is narrower or shorter than the tracing, don’t even try it on

2. Shop for shoes during the afternoon – your foot naturally expands with the use during the day

3. Wear the same type of socks to the store that you intend to wear with the shoes

4. Have a salesperson measure both of your feet – and get measured every time you buy new shoes. Feet change with age, often growing larger and wider. If one foot is larger than the other, buy a size that fits the larger foot

5. Stand in the shoes. Press gently on top of the shoe to make sure you have about a half-inch of space between your longest toe and the end of the shoe. This provides enough room for your foot to press forward as you walk. Wiggle your toes to make sure there’s enough room

6. Walk around in the shoes to determine how they feel. Is there enough room at the balls of the feet? Do the heels fit snugly, or do they pinch or slip off? Don’t rationalize that the shoes just need to be “broken in.” find the shoes that fit from the start

7. Trust your own comfort level rather than a shoe’s size or description. Sizes vary between manufacturers. And no matter how comfortable an advertisement claims those shoes are, you’re the real judge

8. Pay attention to width as well as length. If the ball of your foot feels compressed in a particular shoe, ask if it comes in a wider size. Buying shoes that are a half-size bigger – but not any wider – wont necessarily solve the problem

9. Feel the inside of the shoes to see if they have any tags, seams, or other material that might irritate your foot

10. Examine the soles. Are they sturdy enough to provide protection from sharp objects? Do they provide any cushioning? Take note of how they feel as you walk around the shoe store. Try to walk on hard surfaces as well as carpet to see how the shoe feels on both

Heel height can create stress on the?

forefoot during gait

Two primary determinants of proper shoe fit

shoe shape and size

Refers to the shape of the sole and the upper

Shoe shape

Proper shoe fit is achieved when the ___________

shoe shape is matched to foot shape

Shoe sieze is determined by _________, not by overall foot length

arch legnth

Shoe - Upper

• The portion of the shoe over the dorsum of the foot

• Vamp: anterior component

• Quarter: the posterior component

• In a laced shoe, the vamp contains the lace stays,

• which have eyelets for shoelace

Blucher / Derby Shoe

• lace stay is preferable; it is distinguished by the separation between the anterior margins of the lace stays and the vamp

• The Blucher opening permits substantial adjustability, an important feature for the patient with edema

Oxford / Balmoral Shoe

• lace stay is continuous with the vamp

Low Quarter vs High Quarter shoe

Low Quarter	High Quarter
terminates below the malleoli and is satisfactory for most clinical purposes This style does not restrict foot or ankle motion Promotes mobility rather than stability	covering the malleoli, is indicated to cover the foot having rigid pes equinus Promotes more stability rather than mobility

For individuals wearing orthoses and those with foot deformity, the _____ closure is preferable to the ____ closure

Blucher > Balmoral

Shoe - Sole

• protects the plantar surface of the foot

• heavy thick sole protects the foot against irregularities in the walking surface

• The traditional sole consists of two pieces of leather sewn together with a layer of compressible cork in between

Shoe - Welt

inside piece of the external sole

Shoe - Insole

situated next to the foot

Shoe - outsole

• portion that is most external

• outer sole should not contact the floor at the distal end; slight rise of the sole is known as toe spring which allows a rocker effect at late stance

Shoe - Heel

• The portion of the shoe adjacent to the outer sole

• A broad, low heel provides greatest stability and distributes force between the back and front of the foot most evenly

• A high heel places the ankle in greater plantarflexion range and forces the tibia forward

• Compensation: either by retaining slight knee and hip flexion or by extending the knee and exaggerating lumbar lordosis

• Wearing high heels accentuate your butt area making you look “sexier”

Purpose of Toe Box

in the vamp, protects the toes from stubbing and vertical trauma

Toe box - should be high enough to accommodate ________

hammer toe or similar deformity

Area that lies between the heel and the ball of the shoe

Shank

Shank - prevents _________

collapse of the material between the heel and the ball of the foot to provide extra support

• sometimes made of steel

In most athletic shoes, the sole is _____ to provide maximal traction

sole

Rubber soles absorb shock, thereby, minimizing ________

heel impact forces

Found in the most posterior portion of the shoe all the way to the anterior portion of the heel

Counter

Purpose of Counter

• stiffens the quarter and generally terminates in the anterior border of the heel

• secure the shoe to the anatomic heel and provide stability to the posterior portion of the foot

Medial counter helps to support the ____________

support the medial arch of the shoe

Heel counter aids in controlling the ______

rearfoot

Shoes are contructed over a model of the foot, called a ______, which is styled from wood, plaster, or plastic

last

The LAST determines the _______ of the shoe

shape of the shoe

Types of Last

1. Conventional Last

2. Straight Last

3. Inflared Last

4. Outflared Last

Conventional Last

• forefoot is directly slightly lateral to the midline

• to accommodate the natural externally rotated position o

Straight Last

• symmetric around the midline

Inflared last

• directs the forefoot medially

• counteract valgus position

Outflared last

• directs the foot more laterally than a conventional last

• counteracts a foot in varus position

is pain around the metatarsal heads that result from compression of the plantar digital nerve as it courses between the metatarsal heads

Metatarsalgia

Shoe prescription for metatarsalgia

• Wide width to reduce pressure on the transverse metatarsal arch

• Long fitting to eliminate plantarflexed MTP joints

• Cushion soles to enhance shock absorption

• A high toe box to allow forefoot flexion and extension

the configuration of the foot in which the second toe is either the same size as the great toe or slightly longer than the great toe

Morton Syndrome

Shoe Prescription for Morton Syndrome

• Long medial counter for rearfoot support and stability

• straight or flared last to accommodate foot shape

• A high wide toe box to reduce compression across the transverse metatarsal arch

• A large enough shoe size to accommodate the long second toe

• A Thomas heel or wedge sole to support the medial longitudinal arch

A consequence of loss of the longitudinal arch in conditions such as pes planus or of undue stresses created in the forefoot with tightness of the gastrocnemius and soleus muscles or an elevated longitudinal arch

Plantar Fasciitis

Shoe Prescription for Plantar fasciitis

• Long medial heel counter to limit heel valgus and limits the stretching forces of the plantar fascia

• A high heel to reduce tension on the plantar fascia and Achilles tendon and adequate length to minimize compression and promote supination from midstance to toe-off

  • Positions foot into plantarflexion

• The types of shoe modifications that may be useful

  include a posterior heel elevation to reduce tension

  on the plantar fascia and Achilles tendon

pronation of the midfoot that results in a failure of the foot to supinate during midstance

Pes Planus

Shoe Prescription for Pes Planus

• long medial heel counter, thomas heel (medial extension)

• Firm wedge sole

• Straight Last

• Custom shoe for severe cases

• Medial heel wedge → correct eversion and reduce pronation

• Medial heel and sole flare in extreme cases

Orthosis Nomenclature

Clinical Objectives of Orthotic Treatment

• relieve pain

• manage deformities

• prevent excessive ROM

• increase range of joint motion

• compensate for abnormalities of segment length or shape

• manage abnormal neuromuscular function

• protect tissues

• promote healing

• provide other effects

Functional Requirements of Orthoses

• prevent, reduce, or stabilize a deformity

• modify the range of motion of a joint

• add to the length or alter the shape of a segment

• compensate for weak muscle activity or control muscle hyperactivity

• reduce or redistribute the load on tissues

Inserts are made of resilient materials to reduce ____________

reduce impact shock and shear → protecting painful or insensitive feet

General Disadvantage of Inserts

tends to reduce the shoe volume

Advantage of Inserts

does not alter the aesthetic appearance of the shoes

Full-length insert - tends to reduce ________ by improving proprioception from the increased foot contact area

reduce gait unsteadiness

Acts like a second skin if the patient has difficulty in positioning the feet in relation to its body position

Full-length insert

Full-Length insert - used to relieve pain and activity limitation in relation to patients who suffer from________

pes cavus

convex component that may be incorporated in an insert or may be a resilient domed piece glued to the inner sole so its apex is under the metatarsal shafts

Metatarsal pad

Metatarsal pad is effective in reducing __________

plantar pressure for patients who suffer from insensitivities

Longitudinal arch supports are intended to prevent _____________

depression of the subtalar joint and flattening of the arch

Longitudinal arch supports are helpful for patients suffering from ______

pes planus

allows minimum support that is positioned at the medial border of the insole with the apex between the sustentaculum tali and the navicular tuberosity

Scaphoid pad

aka navicular; in front of talus; primary keystone of medial longitudinal arch

Scaphoid

Scaphoid pad is given when?

• there is presence of a decreased scaphoid bone to correct a flat medial longitudinal arch

• weakness in the plantar muscles and other structures of the MLA

University of California Biomechanics Laboratory (UCBL) insert is for?

• internal modification to address a midfoot issue (fracture, flat foot, posterior tibial malfunctino)

UCBL insert - used to realign a __________, immobilize ______, and correct ________

realign - flexible flat foot

immobilize - midfoot fracture

correct - posterior tibial malfunction

An external modification ensures _________

that the patient wears the appropriate shoes and does not reduce shoe volume

Heel wedge alters alignment of the ______

rearfoot

Medial heel wedge & Thomas Heel are intended for?

flexible pes valgus and correcting over-pronation

Medial heel wedge: attached to the medial part of the heel elevating the medial part of the foot to counteract _________

over-pronation and automatically position the forefoot to neutral

modification at the heel part where there are medial extensions; support a depressed scaphoid

Thomas Heel

Lateral wedge compensates for ________

fixed forefoot valgus allowing the entire distal foot to contact the floor

Lateral wedge counteracts a foot that is _______

Over-supinated

presence of an extension of the heel part on the lateral component, supporting the lateral longitudinal arch

Reverse Thomas Heel

Medial Heel wedge - To correct flexible:

• pronation

• eversion

• pes valgus

• pes planus

Medial heel wedge - to accomodate rigid:

• supination

• inversion

• pes varus

• pes cavus

Lateral heel wedge - to correct flexible:

• supination

• inversion

• pes varus

• pes cavus

Lateral heel wedge - to accomodate rigid:

• pronation

• eversion

• pes valgus

• pes planus

Cushion heel indication

• indicated when the patient wears an orthosis with a rigid ankle

Shoe lift is commonly used for?

• leg length discrepancies

• raise one foot in order to shift balance

a flat strip of firm material placed posterior to the metatarsal heads

Metatarsal Bar - for pts with metatarsal pain

Metatarsal Bar - at late stance, the bar transfers stress from the ______ to the ________

metatarsophalangeal joints → metatarsal shafts

convex transverse band affixed to the sole proximal to the metatarsal heads; tends to create a smoother transition from heel strike to foot flat

Rocker Bar

Rocker Bar Indications

• for patients with difficulties of transitioning from heel strike to initial contact, all the way to foot flat

• pts with neurological / nerve impingement syndromes in LE

True/False: The rocker bar increases the distance the wearer must travel during stance phase, improving late stance, as well as shifting load from the metatarsophalangeal joints to the metatarsal shafts

False; Reduces the distance

Purpose of Ankle joint rocker

inhibits demand for motion in ankle joint

• weak ankle proprioception / ankle pain

Met-head rocker - reduced ground-reactive forces to the ______

ball of the foot

Heel rocker - reduces ground-reactive forces to the _____

heel

Lisfranc rocker - reduces propulsive force to ______

midfoot

• for pts with midfoot fracture / pes cavus / pes planus with difficulty transitioning

Healing rocker - holds foot in what position?

dorsiflexed to offload forefoot

• pts with mild drop foot deformity