Slipping on the heel and feeling that shoes are too tight or too big are sensations that we have all experienced with shoes that do not fit properly. We know not to wear shoes when they do not fit or feel right on our feet. Factor in those who are dealing with the effects of neuropathy, poor circulation, edema and obesity, and it is clear that shoes are not just a fashionable accessory, but essential medical devices that help protect and manage certain conditions we treat. Shoes are the foundation for podiatric treatment. Even more importantly, in the realm of wound healing, surgical intervention is wasted without ensuring that patients wear the proper footwear after the procedure. Our patients need help and advice on what they put on their feet. This can be a difficult issue because of the emotions and subjective nature that are linked with shoes. However, the therapeutic shoe bill has helped facilitate a renewed awareness of shoes in the podiatric community. Approximately 10 percent of DPMs are dispensing shoes, a dramatic increase over eight years ago when the therapeutic shoe bill was at its inception. However, fewer than 10 percent of DPMs are dispensing more than 10 pairs of shoes per month. Key Factors To Keep In Mind When Fitting Shoes Even though fitting shoes starts with a simple measurement of the foot, it is not always easy. In addition to obtaining a measurement, assessing the shape, volume, anatomy and even the function of the foot are important factors in determining what type of shoes will work and fit best. Putting everyone in the same style or type of shoe not only does not work, it is not good practice. With the many different foot types in our population, different lasts or shapes of shoes are necessary. The most accurate way to find out what shoes are right for your patients is to actually have them try on different shoes in different widths, sizes and lasts. Ordering individual shoes based on measurement alone is guesswork at best. This approach will only serve to frustrate you and the patient when the shoe does not fit properly. You may wind up sending the shoes back, reordering another pair or, worse yet, talking yourself or the patient into believing the fit of the shoes is “good enough.” This is no different than going into a shoe store and finding out your size is not in stock. If a shoe salesperson brought out a larger width or size and told you it was close enough, there is a good chance you would be put off by this kind of service. If clinicians do this to patients who have neuropathy or peripheral vascular disease, they are putting them at risk too. Some feet that we treat cannot possibly fit into a pair of shoes taken off the shelf, no matter how wide or large a size you try. In those cases, custom molded shoes are necessary. An estimated 5 percent of our population actually needs custom molded shoes because of severe deformities. (There are various pros and cons to the casting, fabrication and dispensing of custom molded shoes, a subject that is beyond the scope of this article.) On the fringe of this population of people are individuals who can almost fit into off-the-shelf shoes but need a little bit of extra help. For these people, customizing shoes is clearly the best option. This approach has many advantages. Customizing shoes facilitates ready acceptance by patients from a cosmetic standpoint. These customizations are easily reproducible and repairable. Indeed, the latter advantage makes customizing shoes cost effective as well. Once one has ensured that a pair of shoes fits properly, there are many ways to safeguard the foot. Simply incorporating a multidensity insert may be all that is necessary to protect and prevent problems. However, custom orthoses — whatever the type — may not be enough. In those situations, the shoe functions as the starting point for several biomechanical controls that can affect the foot and gait in a positive way. Modifying shoes is an excellent way to gain mechanical advantage over the foot. There are several different shoe modifications one can employ. These modifications can prevent surgical intervention, help patients walk better and even earn you money by doing the right thing. A Primer On Rocker Sole Shoe Modifications The rocker sole shoe modification has many variations and one can actually perform this modification in a variety of ways in shoes of different styles. A rocker sole is simply an additional amount of crepe that one adds to the midsole and bevels from a point just proximal to the metatarsal heads distally to the toe. It is analogous to stepping off a curb with the curb under the distal part of the arch. Variations on rocker soles include moving the apex of the rocker sole either further proximal or distal. One may rotate the apex as well. For instance, if someone has an out-toed gait, the apex should not be perpendicular to the long axis of the shoe. One should rotate the apex to match the angle of gait. How one constructs a rocker sole is purely dependent upon the goal of treatment. If there is an ulcer under the first metatarsal head, for example, the apex of the rocker sole should be proximal to the ulcer. Additionally, if the patient has a painful range of motion at the first metatarsophalangeal joint, then stiffening the rocker sole with a steel shank may be helpful. You can employ different strategies with the same modification. The steel shank is a thin piece of steel about an inch in width and just thick enough not to bend. It should extend from the central portion of the heel to just past the ball of the foot. By burying this in the crepe, one completely eliminates the flexibility of the shoe. This is analogous to a cast boot. The sole of the boot is rounded and the boot does not bend, enabling the patient to ambulate while keeping the foot stable and almost at rest. One may also use this approach with rocker soles and a steel shank to help manage other conditions such as stress fractures and first MTP joint arthritis. Altering the apex location and orientation are ways to change the function of rocker soles. Another option is changing the heel height. Raising the heel height can either reduce pressure from the heel region and even the forefoot in certain situations such as equinus. One can do the reverse as well. Lowering the heel to a level below the ball of the foot — also known as a negative heel — may be helpful in reducing pressure from the forefoot. This might be advantageous when trying to offload a forefoot ulcer. Note that altering the heel height will change the gait. Therefore, proper patient education is critical in ensuring that these modifications work properly. Another variation is the amount of crepe one adds when making a rocker sole. For a mild rocker effect, less than 3/8-inch of additional crepe might be necessary. This amount of material will only slightly stiffen the shoe, and may still allow the foot and shoe to bend, partially negating the complete effect of the rocker sole. Adding more crepe can accentuate the rocker effect and reduce the flexibility of the shoe. If you add enough crepe, you may not even need the steel shank since the additional amount will serve to stiffen the shoe. There are other variations of rocker soles that have been written about and used as well. One is the double rocker sole, which is also known as the midfoot rocker sole. In this variation, one would offload the region directly inferior to the midfoot by removing some of the crepe. During gait, the pressure is transferred from the heel to the ball of the foot — alleviating pressure on the midfoot — during midstance. There are a number of variations of rocker soles so it is important to write explicit instructions as to what you want for each patient and even each foot. It is a good idea to mark the shoe on both the medial and lateral sides as to where you want the apex of the rocker to be located. After all, podiatrists are the ones who know best how our patients function biomechanically. It is important in most instances to write for a pair of rocker soles in order to keep the elevation the same between feet. However, one may mix different types of rocker soles between feet and employ a single steel shank or a pair of shanks. As Arnie Davis, CPed, a well-known custom shoemaker, once said, “rocker soles are like an aspirin for the foot.” Pertinent Pointers On External Counters The external lateral counter is an excellent modification for those individuals who need additional motion control. This modification works very well in individuals who roll laterally off the base of the shoe. In other words, they supinate too much or do not pronate enough. Other individuals who may benefit from this modification are those with increased external hip rotation or excessive tibial varum or even genu valgum. In essence, this modification is helpful for anyone who forces his or her way through the lateral counter of the shoe. This modification strengthens the lateral counter as the addition of crepe keeps it from collapsing. In addition, it provides a wider base of support at heel strike. It can be as short as the counter itself or extend all the way out to the fifth metatarsal head. This modification is so effective that the counter simply will not break down. The heel of the shoe will wear out first and can be replaced easily. People who benefit from this modification will see their shoes last two, three or even four times as long, provided they keep the heel of the shoe in good repair. If the patient has the opposite problem and rolls medially off the base of the shoe, you can perform the same modification medially instead of laterally. Take care not to make the medial counter too stiff. Since the navicular may be prominent, having it hit up against the stiff crepe may actually be intolerable. This is rarely the case on the lateral aspect of shoe where the more rigid the support, the better the shoe and the patient will function. How Openings, Relasts And Plugs Can Improve Fit And Function Several other modifications may also be of use in your practice. One can create a lace to toe opening on any lace-up shoe. It simply means extending the opening closer to the toe of the shoe by making the tongue longer. This will allow more room for the toes, allow for edema and make it easier to get the foot inside the shoe. This modification may be very helpful for someone who has rigidly contracted hammertoes, overlapping toes and/or does not or cannot undergo surgical correction. By extending the tongue and allowing more depth in the shoe, the toes do not get as irritated. One can take this a step further and change it from a lace to toe opening to a Velcro closure. It is almost like converting it into a surgical shoe, but one that is enclosed and can accommodate an orthotic device along with other external shoe modifications. What if a shoe is not wide enough? Relasting of the shoe can also be of benefit to the patient. For individuals who have experienced collapse of the hind or midfoot or Charcot arthropathy, fitting into a shoe can be a challenge. In many instances, custom shoes may be necessary. However, there are ways to customize a shoe in order to obtain a better fit. If the deformity has occurred unilaterally, then one shoe will fit fine while the other may not even go on the foot. Even if it does, the foot will be hanging off either the medial or lateral edges. Relasting the shoe will make it wider. You can do this by splitting off the outer sole and then cutting completely through the shoe longitudinally along the long axis of the shoe from the distal part of the heel forward to the metatarsal head region. Once you make that cut, pry the shoe open even further by placing additional material in the opening to hold it in this position. Then fill the opening with crepe or similar material and reapply the sole. Since the inside of the shoe is cut, make sure the interior of the shoe still has a smooth surface. Placing orthotic devices in a shoe with this type of modification works well. The width of the foot will help you decide how much more the shoe needs to be widened. Keep in mind that by making the shoe wider, the shoe will also get shorter, especially in the region of the lesser toes. It is probably better to do this modification on a shoe that is at least half a size larger in order to be safe. If that is the case, take extra care to fit the other foot as well. Adding a plug to a shoe is a relatively simple modification one can employ to reduce pressure in a localized area. After marking the area of the foot and transferring the mark to the interior of the shoe, drill out this spot and fill it with either a viscoelastic material like PQ or even ppt or poron. Anything that will provide cushioning and shock absorption for the foot will be helpful. There is a variety of other shoe modifications one can make. You can simply add wedges, flares and lifts to the shoe or perform these modifications in a neater fashion by covering them with leather in order to conceal the modification and make them more cosmetically acceptable. Final Thoughts The modifications described here are only a few of the things that can be done to shoes. Each patient has different needs requiring individual solutions. Therefore, creativity with shoe modifications adds to the benefits you can provide to your patients. The shoe is the ultimate biomechanical controller. Even with the best orthotic device and most intricate surgery, getting a shoe to work with the foot instead of against it will go a long way in improving the function of a patient’s foot. Many of these modifications can be performed separately or in conjunction with each other. Once you have created an efficient combination, you can easily reproduce it once the shoes wear out. This makes for a cost effective treatment option for patients. Doing shoe modifications yourself may be a suitable option for some podiatrists. However, it is not only messy but time consuming as well. The better option is selecting someone whom you can either send shoes to — like most do with casts for orthotic devices — or have someone whom you can directly refer to with an explicitly written prescription. Although it certainly helps to understand how to do each modification, it is even more important to know when to use them. Using shoe modifications in your practice gives you another tool in providing better care for your patients. Dr. Levine is in private practice and is also the director and owner of Physician’s Footwear in Frederick, Md. CE Exam #123 Choose the single best response to each question listed below: 1. It has been estimated that _____ percent of the population in the United States needs custom-molded shoes due to severe deformity. a) 3 percent b) 5 percent c) 9 percent d) 12 percent 2. If the patient has an ulcer under the first metatarsal head, the apex of the rocker sole should be … a) proximal to the ulcer b) distal to the ulcer c) perpendicular to the long axis of the shoe d) stiffened with a steel shank 3. Raising heel height will … a) reduce pressure from the heel b) reduce pressure from the forefoot c) a and b d) none of the above 4. Which modification will work well for patients who supinate too much? a) relasting b) lace to toe opening c) double rocker sole d) external lateral counter 5. For a patient with an out-toed gait, a rocker sole apex should … a) be perpendicular to the long axis of the shoe b) be rotated to match the angle of gait c) be stiffened with a steel shank d) none of the above 6. ______ is a relatively simple modification one can employ to reduce pressure in a localized area. a) adding 3/8-inch crepe b) splitting the outer sole c) adding a plug of softer material to the shoe d) none of the above 7. A lace to toe opening is helpful for which patients? a) patients with hammertoes who cannot undergo surgical correction b) patients who have overlapping toes c) patients who have rigidly contracted hammertoes d) all of the above 8. Which of the following modifications is effective for a patient with Charcot arthropathy? a) steel shank b) plug c) lateral counter d) relasting e) a and d 9. Which of the following is false? a) With rocker soles, one should write for a pair in most instances in order to keep the elevation the same between feet. b) One should never mix different types of rocker soles between feet. c) One may mix different types of rocker soles between feet and employ a single shank or a pair of shanks. d) All of the above. e) None of the above. Instructions for Submitting Exams Fill out the postage-paid card that appears on the following page or fax the form to the NACCME at (610) 560-0502. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam. Responses will be accepted up to 12 months from the publication date.