Inside Insights On Shoewear Modifications

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Continuing Education Course #123 — September 2004

I am pleased to introduce the latest article, “Inside Insights On Shoewear Modifications,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education, consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

Finding shoes that fit can be difficult for patients who have certain conditions such as hammertoes or Charcot arthropathy.

With this topic in mind, David Levine, DPM, CPed, offers an insightful article full of practical insights on various shoe modifications that one can perform or recommend to help treat patients.

At the end of this article, you’ll find a nine-question exam. Please mark your responses on the postage-paid postcard and return it to HMP Communications. This course will be posted on Podiatry Today’s Web site ( roughly one month after the publication date. I hope this CE series contributes to your clinical skills.


Jeff A. Hall
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 61 and successfully answering the questions on pg. 66. Use the postage-paid card provided to submit your answers or fax the form to NACCME at (610) 560-0502.
ACCREDITATION: The North American Center for Continuing Medical Education (NACCME) is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by the NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Levine has disclosed that he has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of his presentation.
GRADING: Answers to the CE exam will be graded by the NACCME. 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.
RELEASE DATE: September 2004.
EXPIRATION DATE: September 30, 2005.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• describe the potential impact of rocker sole modifications for patients;
• discuss the benefits of combining rocker sole modifications with steel shanks;
• explain how the use of external counters can benefit patients; and
• discuss the use of relasts and plug modifications.

Sponsored by the North American Center for Continuing Medical Education.

Here one can see an external lateral counter. This shoe modification is helpful when patients supinate too much or roll laterally off the base of the foot.
A lace-to-toe shoe modification was employed for this patient’s hammertoe. The modification extends the tongue and allows more depth so toes are not irritated.
In this lace-to-toe shoe modification, the tongue of the shoe was extended down toward to the toe. This treatment is effective for patients with hammertoes, overlapping toes or those who cannot undergo surgical correction.
This shoe was modified using a rectangular steel shank, which stiffens the sole. Shanks are helpful in treating patients with conditions such as stress fractures and first MTPJ arthritis.
Here is a rocker sole, which one would create by adding additional crepe to the midsole. The construction of the rocker sole is dependent upon treatment goals. For a patient with an out-toed gait, one would rotate the axis to match the angle of gait.
By David J. Levine, DPM, CPed

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.

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