You may prescribe orthotics for a variety of problems. However, the success or failure of treatment may depend on the type of shoes your patients wear along with the type of modifications which you make to the shoe. With this in mind, our expert panelists address the use of shoe modifications as an adjunct to care.

Q: What type of modifications do you use most often and how does this affect patient symptoms?
A: Nicholas Sol, DPM, says he most commonly prescribes a double rocker sole. He says most of his colleagues have a supply of these soles in the form of their cast shoes and boots.
“I find (the double rocker sole) very helpful for patients with limitation of ankle ROM, non-articulated AFOs and most propulsive phase pathomechanics,” says Dr. Sol. “This simple shoe modification can provide an additional 25 to 50 percent of symptom relief when you combine it with a custom foot orthotic or non-articulated AFO.”
Howard Dananberg, DPM, says he commonly uses the rocker sole modification since it is often effective in cases of hallux ridigus in which no motion is available. He says using the rocker sole can often assist in providing rapid relief and will often ease lower back pain if this is associated with a patient’s gait style.
Footwear and shoe modifications have controlled sagittal plane influences (motion control, impact and sheer forces) most effectively, according to Justin Wernick, DPM.
Dr. Wernick recommends using elevations to offset the effects of a tight heel cord and a limb length difference. Often, you can use a beveled heel modification and a SACH heel to delay heel strike, which decreases impact of the body at heel contact, according to Dr. Wernick.
“Midfoot and forefoot rocker modifications are designed to assist the body in moving rapidly over the arch area and the ball,” explains Dr. Wernick. “Flaring the heel of the shoe medially or laterally will increase the frontal plane stability of the rearfoot and is very useful in controlling medial and lateral instabilities of the foot. Footwear selection includes heel and sole height and design for optimum sagittal plane movements.”
Dr. Sol warns DPMs to avoid two common pitfalls of making shoe modifications. He says you should ensure adequate material thickness, noting that he usually prescibes 3/8 inches. Dr. Sol also emphasizes being aware of any limb length discrepancy.

Q: What is the most common mistake patients make while obtaining shoes?
A: People believe a lightweight shoe equals a comfortable shoe, when what they really need is more support, points out Dr. Wernick.
“They think heel slippage equals too big when in reality, they are now in a proper fitting shoe and it feels too big,” he says. “Then they fit themselves too short. They often choose style over comfort.”
Dr. Sol concurs, noting that fashion is the primary consideration in most shoe purchases. To keep the cost of inventory in check, retailers have responded by providing a greater selection of styles but a restricted size inventory. As a result, according to Dr. Sol, most retailers stock “B” width for women’s shoes and “D” width for men’s.
Dr. Dananberg adds that many people make the mistake of buying shoes that are too stiff across the forefoot.
“The foot is flexible at the toe joints for a reason,” notes Dr. Dananberg. “When shoes use stiff insole boards, outsoles or are platform type and do not have sufficient rocker to them, symptoms often result.”
In Dr. Sol’s experience, the most common mistake everyone makes in purchasing shoes is compromising length for width.
“The blunder occurs when we ask for a half-size larger shoe just to get a little extra width,” explains Dr. Sol. “This moves the flex line of the shoe away from the flex line of the foot.”

Q: Fitting shoes can often be an issue to patients. What are some of the tricks you use to assist in a shoe fit when the precise size is just not available?
A: “Proper shoe fit is a ‘feel,’ not a size,” says Dr. Sol. He says a size like an 8-C varies among lasts, models, styles and manufacturers. Even with the increasingly rare assistance of knowledgeable fitters, consumers will continue to assess proper fit “based upon how they’re used to ‘fit’ feeling,” points out Dr. Sol.
Dr. Sol says the subjective criterion for shoe fit varies among individuals. To help people visualize “fit,” he asks them to remove the insoles from their shoes and simply stand on them. “This simple maneuver can save consumers both time and money in the selection and purchasing process,” he says.
Dr. Wernick advises consumers to fit the bigger foot whenever possible and try to match the shoe last to the foot shape.
“Never fit short. It’s OK to fit narrow if the length is long,” says Dr. Wernick, who recommends matching the first met to the widest part of the shoe at the “ball” of the foot. Both he and Dr. Dananberg advise people to use tongue pads and half insoles (called “jimmies”) to help improve heel, toe and instep fit.
“Measuring of feet can be helpful, but I caution patients that fit of shoes varies from company to company,” says Dr. Dananberg. “There is value in understanding which of the two feet are larger, and then this is the shoe that needs to be fit via size.”

Q: Along the same line of thinking, how do you assist patients when they have two feet of different sizes?
A: For Dr. Wernick, it depends upon the patient’s size differential. He says usually a size difference of one to one and one-half sizes may require two different pairs of shoes. Usually, a shoe store will charge for a pair and a half and if it is one-half size different, then a cork “jimmy” in the forefoot will make up for the difference, according to Dr. Wernick.
Although shoes are made symmetrically, most feet are not, Dr. Sol reminds patients, and most of us have feet of two different sizes.
“The old adage is true: try on shoes later in the day and fit your larger foot first,” says Dr. Sol. “If the difference is one full size or greater, I recommend buying two pairs and refer the patient to the National Odd Shoe Exchange in Phoenix, Ariz. (480-892-3484).”

Dr. Dananberg (pictured) practices in Bedford, N.H.
Dr. Sol founded the Walking Clinic, PC and practices in Colorado Springs, Colo.
Dr. Wernick is Professor and Chairman of the Department of Orthopedic Sciences at the New York College Of Podiatric Medicine (NYCPM). He is also a Diplomate of the American Board of Podiatric Orthopedics and is the Medical Director of Eneslow Comfort Shoes and Langer, Inc.
Dr. Wernick also acknowledges Robert Schwartz, C.Ped, the Director of the Eneslow Pedorthic Institute and an Adjunct Instructor of NYCPM, for his assistance in his respones.