It is always a challenge to fit orthotic devices in cowboy boots. First of all, let me say that since I practice in Seattle, I am not the most experienced practitioner in fitting orthoses into cowboy boots. I am sure my colleagues in Phoenix, Austin, and other parts of the Southwest have much, much more experience using these types of devices. Given that, I have had several patients for whom I have made orthotics for cowboy boots. While I have ended up frustrated several times, I seem to have found a formula that works well.
The biggest problem seems to be that even when I make an orthosis that fits fairly well into the boot, it can take up excessive volume inside the boot and will often cause excessive pressure between the top of the foot and the vamp of the boot. Since one cannot really adjust the boot, this can make fit somewhat difficult.
I think the first key is to advise the patients that some cowboy boots simply do not have enough room to accept both the foot and an orthosis. This means that you cannot guarantee that any orthotic device will fit well with boots they own. I think you can certainly guarantee that the orthoses will fit in a boot but whether there is enough room for both orthoses and their foot to fit into a particular boot is always the question.
If the patient is open the possibility of needing to purchase new boots after getting the orthotic devices, there should be no trouble.
There are two good options for orthotic devices that will fit well into a cowboy boot. These are the Cobra orthosis and a graphite orthosis. I personally like the Cobra orthosis better. It takes up less room and adapts to different heel heights more effectively than the graphite. However, I have also found that a graphite shell with no post and a Vinyl top cover to the sulcus works well. With these devices, I will prescribe them with an 8 mm heel cup and a standard width.
An even better idea is to send the boot to the lab so we can fit the orthoses directly to the boot. However, even though we can then guarantee that the orthosis will fit into the boot, we still cannot guarantee that their foot will then fit into the boot with the orthotic device.
Editor's note: This blog was originally published at http://www.prolaborthotics.com/Blog/tabid/90/EntryID/502/Default.aspxand  has been adapted with permission from Lawrence Huppin, DPM, and ProLab Orthotics. For more information, visit www.prolaborthotics.com  .