Orthotic Modifications And Shoewear For Specific Jobs

Clinical Editor: Nicholas Sol, DPM, CPed

When patients have certain occupations, you may have to take a different approach to try to control abnormal forces in the foot. Obviously, performing a biomechanical evaluation is essential as you have to identify individual demands before tackling occupation-specific modifications. With this in mind, our panelists address the more demanding occupations and what considerations come into play with orthotic modifications.

Q: How and why do you modify your orthotic prescriptions for patients whose jobs require standing in place for prolonged periods?
Milton J. Stern, DPM, and Ambika Mathur, DPM, contend these patients have abnormal heel to toe ambulation. Instead of propulsion with increased pressures from heel to midfoot to forefoot, they maintain constant pressure on the entire plantar surface. “Muscular activity is more for balance than propulsion,” point out Drs. Stern and Mathur. “It seems in static stance, the peroneals and the tibialis anterior and posterior stabilize each other.”
“Prescribing orthotics for complaints and pathology related to industrial situations and environments can be a frustrating or rewarding experience,” says Paul Scherer, DPM. “There is no substantial documentation in the literature about which devices with which additions work best. There seems to be some anecdotal evidence, albeit through the orthotic labs, that certain devices are more commonly used in certain situations.”
“There appears to be a big need for further research into the foot complaints of workers who stand for long periods of time,” says Lowell Scott Weil Sr., DPM. “Many of these individuals seem to suffer similar complaints that may be irritated by their occupations.”

Why Shoewear Is An Important Consideration
It’s important to evaluate the patient’s work shoes. As Drs. Stern and Mathur point out, an orthotic device controls more foot motion when the shoe has more stability. For example, they note that a high-top work boot or gym shoe will control the foot better than a loafer or flat. Dr. Stern notes each of these activities seems to put more pronatory pressure on the foot. If the orthotic is going to work, it needs help from the shoe above. A high top shoe that controls the medial foot and ankle provides more function. In a low top shoe and even more so in a loafer, the foot can pronate over the device, decreasing its effectiveness.
If workers can choose their shoes, Dr. Weil emphasizes footwear that offers good support with stiff shank, is shock absorbent and breathable. He says running shoes often fit the bill for those who aren’t required to wear steel toe shoes. If they can wear running shoes, Dr. Weil recommends removable inserts that can be changed when the shock absorption wears out or, in the case of the need for an exchange, an insole that offers additional support and cushioning.
Dr. Weil says he recently discovered the Z-COIL shoe, which has been remarkable in providing comfort to the standing worker.
“We have performed E-Med computerized footprint studies on this shoe, using the E-Med insoles and the reduction in loading of the foot is significant,” explains Dr. Weil. He notes the shoe is especially beneficial for patients suffering from heel pain syndrome but also works well in treating metatarsalgia. Dr. Weil says the shoe is roomy enough to accept a custom orthotic and he is currently evaluating the benefits of the shoe in patients with diabetes.

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