A Guide To Shoe Gear Selection Following A Transmetatarsal Amputation

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Author(s): 
Valerie L. Schade, DPM, AACFAS

   The researchers studied the following six combinations of orthotics, shoe gear and bracing:10
• the patient’s own full length shoe with lamb’s wool in the toe box;
• a custom full length shoe with a total contact insert (TCI) and an ankle foot orthosis (AFO);
• a custom full length shoe with a rocker bottom sole (RBS) and a TCI;
• a custom full length shoe with a rocker bottom sole, a total contact insert and an AFO;
• a custom shortened shoe with a rocker bottom sole and a total contact insert; and
• a custom shortened shoe with a rocker bottom sole, a total contact insert and an AFO (see the below table “How Shoe/Orthotic And Bracing Combinations Compare With Lamb’s Wool In The Toe Box”).

   The total contact insert was custom molded and fabricated with ½-inch of white Plastazote and 3/16-inch polypropylene plastic. The rocker bottom sole was just proximal to the residual metatarsals and was fabricated at a 20 degree angle. The patients received instructions to wear each combination of orthotics, shoe gear and/or bracing for 30 days.

   When comparing these combinations to the use of a full-length shoe with lamb’s wool in the toe box, the authors noted improvements in functional capacity and walking speed with the use of a custom full length or shortened shoe with a rocker bottom sole and a total contact insert, and with the use of a custom shortened shoe with a rocker bottom sole, a total contact insert and an AFO.10 The authors defined functional capacity as activities such as putting a book on a shelf, donning and doffing a jacket, picking a penny up from the floor, walking 50 feet with a turn and climbing one flight of stairs.

   In the study, ipsilateral peak plantar pressures were decreased for every combination of rocker bottom sole, total contact insert and AFO in comparison to the patient’s own full length shoe with the lamb’s wool in the toe box.10 Plantar pressures to the contralateral limb were decreased for every combination in comparison to the patient’s own full length shoe with the lamb’s wool in the toe box, except for those with a shortened shoe. More than 50 percent of the patients did not tolerate the combinations with the AFO due to the restricted ankle joint motion. Patients with an associated dropfoot or proximal TMA did find the addition of an AFO beneficial.

   In terms of cosmesis, the combinations involving custom shortened shoes were the least tolerated with most patients refusing to wear them.10 The four patients with a bilateral TMA did like the shortened shoes due to the ability to make the shoes similar in appearance.

   The most widely accepted combination in terms of patient adherence with use was the custom full length shoe with a rocker bottom sole and total contact insert.10 A total of 86 percent of the patients completed the entire 30-day use of this combination.

   Contrast this with only 43 percent of patients who completed the entire 30-day course of use of their own full length shoe gear with lamb’s wool in the toe box.10 The custom shortened shoe with a rocker bottom sole and total contact insert was the second highest combination when it came to rate of adherence with 70 percent of patients completing the entire 30-day course of use.

Further Insights On Shoe Modifications

Research has found the use of a rocker bottom sole decreases peak plantar pressures up to 50 percent in the central forefoot.12 The addition of a steel shank in the sole of the shoe or a carbon fiber plate in the shoe has been another option in prosthetic management of the patient with a TMA.

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