When prescribing orthotics for athletes in widely varying types of sports, one must take into consideration both the needs of the athletes and the advantages and disadvantages different types of shoes may offer. With that said, these panelists offer their expertise on orthotic modifications they use to keep their patients on the athletic field. Q: What influence does athletic shoegear have on sport specific orthotics and orthotic modifications? A: For Stephen M. Pribut, DPM, the patient’s specific shoe category and sport have a “major impact” on the orthotics he prescribes. He also emphasizes that one should be aware of differences between different models of shoes for a specific sport. When the contours of the shoe arches vary, it can have a significant impact on how the orthotic functions, according to Dr. Pribut. He is often surprised to find an orthotic placed on top of the shoe’s sock liner or insole. Dr. Pribut says this can tilt the orthotic into an improper position, pushing the orthotic too far forward or tilting it too far into varus. To remedy this, he advises removing the liner from certain shoes. In his experience, Dr. Pribut has found that if you remove the liner from many Asics shoes, the footbed becomes flat and orthotics will generally fit well inside the shoe. However, if one places the liner below the orthotic, then Dr. Pribut recommends cutting the arch, heel and any “rim” around the posterior aspect of the liner in order to facilitate a flat fit into the shoe. Since the arch is prominent in many Adidas shoes, Dr. Pribut will sometimes trim the insole and place it below the orthotic so the orthotic will be in a more functional position in the shoe. Timothy Dutra, DPM, says it is best to try to fit shoes to the orthotic in order to maximize control for that particular sport. For example, when treating a sprinter, one may need a special pair of orthotics specifically for use in shoes with spikes. Dr. Dutra says he often sends the athlete’s shoes with the negative casts to the orthotic lab to ensure the best fit, especially when cleats or spikes are involved. He says a graphite orthotic commonly works well as it is thinner and may fit with more narrow spikes or cleats. Since cleats for field sports may or may not have a removable insole, that will help determine the type of cover and accommodation one can use, according to David Levine, DPM, CPed. If the insole that comes with the shoe is thin and tightly adhered, Dr. Levine says one needs to address this with the thickness of the orthotic, the cover and the forefoot extension. While the forefoot extension should be “fairly thin,” Dr. Dutra says it should have enough cushioning for a heavy athlete and durability to facilitate changing between shoes. However, he warns of a loss of some control when employing a thinner, narrower orthotic with a shallow heel cup. Dr. Dutra adds that for most sports, adding a rearfoot post to the shoe is “essential to get the rigidity needed to adequately control shoe function for the sport.” Q: What is the importance of various modifications in your orthotic prescription for athletes? A: Modifying the thickness of orthotics is important for Dr. Dutra, who notes that thicker orthotics are more rigid. Although one can add an arch fill to help facilitate better control for a heavier athlete, Dr. Dutra says the arch fill can make for a bulkier orthotic. He likes to use a wide orthotic plate and as deep a heel cup as possible to maximize motion control for the athlete. In order to maximize control of the foot, Dr. Dutra says rearfoot posting is essential for most athletic shoes. He notes there are some sports exceptions, such as sprinting and volleyball, sports that don’t require athletes to be on their heels that much. Adding a medial skive or inverted technique can be helpful when it comes to increasing control of pronation. Dr. Dutra frequently uses a medial skive of 2 to 4 mm to facilitate maximum control of pronation without adding bulk to the orthotic. Dr. Dutra says employing forefoot extensions can help in offloading metatarsal heads and cushioning the transverse metatarsal arch area. They are especially helpful when athletes are participating in sport activities in which they are mainly using their forefoot and midfoot, according to Dr. Dutra. However, he says one should exercise caution when adding bulk in the toebox of the shoe, especially in shoes with cleats. Dr. Pribut commonly modifies orthotics for sesamoid problems. He says incorporating a sesamoid pad, offloading the first metatarsal or using first ray cutaways can be beneficial. When treating metatarsal stress injuries, Dr. Pribut uses orthotic modifications to offload one or more metatarsals. He also notes that in the past few years he has come to use only intrinsic posting on orthotic devices. Dr. Levine says the athlete’s foot mechanics combined with considerations of the demands of the specific sport will determine what kind of orthotic to prescribe. He recommends using more flexible devices for those who participate in court sports. Q: What orthotic modifications can one use to control first ray pathology? A: Dr. Pribut has found sesamoid accommodations or other first ray modifications, such as the kinetic wedge, reverse Morton’s or long or short first metatarsal cutaways, to be useful when dealing with first ray dilemmas ranging from turf toe and hallux limitus to sesamoid injuries. He also notes that some of these conditions may overlap or coexist in certain cases. If a patient complains of pain on the dorsum of the first metatarsal, Dr. Pribut says one should examine both the medial and lateral sesamoid bones for tenderness. If one observes a limitation of dorsiflexion and pain upon dorsiflexion, Dr. Pribut says the patient likely has a concomitant sesamoid pathology. Dr. Pribut rarely finds shoe modifications such as a rocker sole necessary to treat these problems. When attempting to control first ray pathology, one should restrict pronation as well as the ground reactive force to the first metatarsal head, according to Dr. Dutra. He employs modifications like the Kirby medial skive and Blake inverted orthotic techniques to help control excessive pronation. If one leaves the anterior edge of the orthotic full-thickness, Dr. Dutra says it will act as a metatarsal bar and help offload the first metatarsal. He adds that this technique is also helpful in treating sesamoid pain along with a forefoot extension two to five and leaving a full thickness anterior edge on the orthotic. One can control the first ray with a dancer’s pad, Morton’s extension, reverse Morton’s extension or a short or long first ray cutout, advises Dr. Levine. However, one should assess the foot mechanics before deciding on a modification and Dr. Levine says video gait analysis and pressure mapping are the best way to do that. Q: What specific modifications should be considered when treating runners? A: Clinicians should initially ensure that their patients are wearing an appropriate running shoe. When treating patients who present with a difficult case of plantar fasciitis, Dr. Pribut says one should check their running shoes to see if they exhibit flexion stability and torsional stability. Drs. Dutra and Pribut recommend checking out the list of running shoes at www.aapsm.org , the Web site of the American Academy of Podiatric Sports Medicine, in order to determine which is appropriate for patients. Once the runner is wearing the right type of shoe, Dr. Levine says one can then design an orthotic that fits properly. Dr. Pribut uses a deep heel cup for most long-distance runners. He uses a full-length orthotic that is as thin as possible for sprinters. Dr. Pribut tailors his modifications to the basic devices he employs for the particular injury he is treating. Dr. Dutra likewise tailors his orthotic modifications based on the type of shoe or spike the athlete uses. Normally, he prefers to use a topcover to the toes that is made of a high-density material. He adds that it should be as thin as possible so it does not take up too much room in the toebox. Runners normally prefer a lightweight and flexible orthotic, according to Dr. Dutra. He adds that one may need to adjust the heel width of the orthotic in order to ensure a secure fit in the back of the shoe. In Dr. Dutra’s experience, many runners who are smaller and lighter prefer a graphite orthotic for fit and control of pronation. He says it is important for the running shoe to be stable in order to get the maximum control from the orthotic. Often, he waits to make additions or modifications to the orthotic after finding out the desired fit and control. Q: Do you use prefabricated or pre-custom orthotics? A: Although Dr. Dutra prefers custom functional orthotics in the majority of cases, if issues with cost arise, the pre-fab and pre-custom inserts can help determine if a functional device will help. Dr. Levine concurs, noting that “using prefabricated devices is often a good test to see if mechanical control will be helpful.” Dr. Dutra cautions that most of the prefabricated inserts are more accommodative than functional, mostly because they will not be a custom fit. Dr. Pribut does not dispense prefabricated orthotics. He does recommend over-the-counter devices when he feels they are appropriate or he may temporarily modify the insole of the shoe to limit pronation and unload segments of the forefoot. Dr. Dutra is a Vice President and Fellow of the American Academy of Podiatric Sports Medicine. He is a Fellow of the American College of Foot and Ankle Orthopedics and Medicine. He is a team podiatrist for the University of California at Berkeley and California State University, Hayward. He is also an Assistant Clinical Professor at the California School of Podiatric Medicine at Samuel Merritt College. Dr. Pribut is a Fellow of the American College of Foot and Ankle Surgeons and President-Elect of the American Academy of Podiatric Sports Medicine. He is a Clinical Assistant Professor of Surgery at George Washington University Medical Center and is a Consultant with the Georgetown University Athletic Department. He has a private practice in Washington, D.C. Dr. Levine is a Fellow of the American Academy of Podiatric Sports Medicine. He is in private practice and is also the director and owner of the Frederick, Md.-based Physician’s Footwear, a fully-accredited pedorthic facility.