Podiatrists routinely fit patients for diabetic shoes but what about shoes for feet with less severe pathology? What about the patient who is a runner and has a bunion? What do you do when an orthotic causes squeaking in your patient’s shoes and using powder to stop the squeak does not work?
As podiatrists, we can teach our patients easy and fast shoe modifications that can mean the difference between comfort and pain, and solidify your reputation as an expert on all things feet, including shoes.
With this in mind, let us take a closer look at some of the most common pathologies we treat and ways to modify regular shoes to accommodate those pathologies.
Bunions are one of the most frustrating conditions patients can have when it comes to shopping for shoes. If patients are able to find a shoe wide enough to accommodate the forefoot, they subsequently experience heel slippage because of the correspondingly wide rearfoot in the shoe.
In patients who have bunions, lace shoes are always best because this allows for a variable fit. Ideally, you want to find shoes that lace to at least to the level of the metatarsophalangeal joints distally as this will help better accommodate a wide forefoot. Most patients will try to loosen the laces to ease forefoot pressure but loosening the laces is generally not sufficient to alleviate constriction. Loosening the laces also increases transverse and sagittal plane motion, which contribute to heel slippage and improper fit.
A better approach is to skip the most distal set of eyelets entirely, starting the lacing instead at the second set of eyelets. This significantly reduces forefoot compression and allows for an instant increase in forefoot width without affecting rearfoot fit.
Another recommendation is for bunion patients to purchase shoes with forgiving material (such as mesh or cutouts) over the medial eminence. Medial and lateral mesh uppers allow for expansion at the forefoot without causing heel slippage at the rearfoot.
Patients with bunions will also want to avoid any stitching or trim over the medial eminence as this will make that part of the shoe less forgiving. If your bunion patient purchases a running shoe with trim in this area, you can easily remove it with a scalpel blade. Running shoe trim is generally not incorporated into the upper but is stitched on and is more decorative in nature.
Shoe stretchers also work well. Most patients are not aware that there are several different types of shoe stretchers in at least five different sizes including those for boots, flats and high heels. Stretchers also have holes for plugs, which you can strategically place where needed for extra stretching over bony prominences.
Hammertoes. As with bunions, instruct patients to find shoes that have forgiving material in the toe box. Again, mesh and cutout uppers work particularly well. Patients can purchase a vamp or toe box stretcher which, unlike a traditional width stretcher, will create extra depth in the sagittal plane as opposed to the transverse plane.
High heels frequently do not have sufficient toe box depth and many women experience dorsal joint irritation as a result. An easy solution is to cushion and relax the toes with toe combs. Patients typically use these soft foam spacers plantarly in the sulcus but when patients use them dorsally on the toes, they prevent friction irritation from the shoes.
Retrocalcaneal exostosis. Many patients with a retrocalcaneal exostosis are resigned to wearing an open back or soft heel counter shoe. In cases in which there is a bursae or painful exostosis, adding off-weight padding to the inside of the shoe where the prominence rubs can really make a difference.
Typically, the inside counter of the heel of the shoe will have a wear pattern. After identifying this pattern, apply a ½-inch wide strip of adhesive felt to either side of the pattern. This modification is initially temporary but once you are sure of correct placement, make the accommodation permanent by gluing on 1/8-inch covered Poron®.
Metatarsocuneiform exostosis. When a patient has a dorsal metatarsocuneiform exostosis, shoe irritation over the prominence is common. Lace shoes are preferred in this case as patients can skip the corresponding laces and reduce pressure across the site.
In some sports (skiing, hockey and skating), modified lacing is not possible or is insufficient to eliminate pressure. In these cases, one can use a doughnut pad to surround the prominence and offload the area. Doughnut pads can be adhesive or non-adhesive, and one can use them in conjunction with lacing modifications if desired.
Patients frequently complain of having narrow heels when they actually have a low volume forefoot. Instead of using heel grips, which push the foot forward, a tongue pad can take up the excess volume in the forefoot, resulting in a more secure fit. One can use commercially available pre-cut tongue pads or trim 1/8-inch adhesive felt and size it to fit.
When heel slippage happens, most people intuitively tighten the shoelaces closest to the ankle, which will not help with slippage. The laces that need to be laced tightest are those farthest away from the ankle. It takes more time but each and every time patients lace their shoes, they should tighten the laces closest to toes first and progressively cinch up until they reach the ankle.
If heel slippage still occurs, especially when patients are using an orthotic, then patients can tighten the laces utilizing the lock lace method. This creates a more secure fit by preventing slipping of the shoelaces at the level of the ankle.
Orthotic squeaking is usually caused by friction of the orthotic plate against the insole of the shoe. In most cases, sprinkling powder or cornstarch into the shoe prior to placing the orthotic will eliminate the squeak. In those instances in which this does not work, covering the distal half of the orthotic with athletic tape or moleskin, or gluing vinyl to the underside of the orthotic will solve this problem.
I am constantly surprised when patients come into my office after seeing another podiatrist who made no mention of shoes. A well fitting, structured shoe is important to the success of many podiatric treatments. Most of the in-office modifications I have discovered arise from utilizing a common sense approach of matching shoes to pathology in an effort to optimize outcomes.
The aforementioned examples are simple and effective ways to improve patient adherence as well as stimulate thinking on ways to incorporate everyday shoe modifications into our overall podiatric treatment plans.
Dr. Sanders is in private practice in San Francisco. She writes a monthly blog for Podiatry Today. For more information, please visit www.podiatrytoday.com/blogs . Dr. Sanders also blogs at www.drshoe.wordpress.com .
Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine.