With winter sports in full swing, the panelists discuss their experiences with the unique nature of footwear, biomechanics and orthotics for these athletes.
Q: With winter sports in full swing, do you have any pearls to share when it comes to prescribing and creating custom orthotics for these sports?
David Haley, DPM, FACFAS, FASPS, FAAPSM emphasizes that winter sports such as skiing and skating have important aspects a podiatrist must consider when creating an orthotic. Cold temperatures, hard surfaces, high levels of impact and often hard materials inside the sport shoe/boot all come into play, according to Dr. Haley. He also notes that high levels of moisture may be present as well as jarring and unusual biomechanical stresses.
“(In these winter sports), patients also frequently don heavier clothing and pass more weight on to their feet,” maintains Dr. Haley. “Athletes pass eight times their body weight through their feet upon exertion and engaging in winter sports may even stress this concept even further.1 One must keep all of these aspects in mind when prescribing an orthotic.”
All of the panelists agree that space constraints within winter sports shoe and boot gear is a primary factor in how they design the ideal orthotic in these situations. They each note that skiers (downhill and cross-country) and skaters (figure skaters, hockey players, synchronized skaters) as being the most common winter athletes presenting with foot and ankle concerns.
Dr. Haley relates that with most of these sports, there are greatly altered percentages in the phases of gait that can restrict normal expected biomechanics. Dalia Krakowsky Clausen, DPM, FACFAS, FAAPSM agrees and adds that the stiffness of the orthotic device is an issue as well, depending on the sport or footwear item. She says downhill skiers, hockey players and figure skaters generally require a stiffer device while cross country skiers need some flexibility for toe push-off.
“For all of the aforementioned athletes, I prefer no heel lift and intrinsic rearfoot correction in order to avoid causing an abnormal elevation of the athlete's heel within the skate or boot. This elevation can cause injury as well as alter performance,” maintains Dr. Krakowsky Clausen.
Dr. Haley says he also uses limited and mostly intrinsic orthotic posting. Overall, knowing the design and function of the sport-specific footwear as well as the purpose within that sport is valuable information, shares Dr. Krakowsky Clausen.
Gregory Rouw, DPM, FACFAS, FASPS, DABPM points out that each winter sport has unique characteristics and different biomechanical concerns.
“With figure skates … one also needs to consider the level of the athlete and the related exertional forces,” notes Dr. Rouw. “Is this an ice dancer using very deep edges and thus requiring excellent control of both pronation or supination? Is it a single or pairs skater needing maximum support to essentially make the foot/orthotic and boot all become one? I tend to use a much thinner device in figure skating boots and work with some of the support in the boot itself. This usually involves a very low profile rearfoot post and engineered nylon or graphite shell.”
In his experience, Dr. Rouw has found that hockey skates have more room and can often accommodate reasonably normal orthotics with excellent support for the medial arch and limiting of excess pronation.
He points out there are two different “techniques” with Nordic or cross-country skiing that podiatrists need to take into account when writing orthotic prescriptions.
“The classic style (in the tracks) technique offers little supinatory contact phase nor pronatory propulsion. There needs to be full flexibility at the forefoot/metatarsophalangeal joints. These athletes seem to do best with a more flexible longitudinal arch and minimal rearfoot post,” points out Dr. Rouw. “Freestyle or skate ski technique puts the skier in a pronatory position most of the time. The boots are not as rigid as hockey boots or figure skating boots. Therefore, you need to rely on the control you can achieve with the orthotics device in the limited space available. I generally use a low profile rearfoot post as well as a deeper heel cup and higher medial flange.”
Dr. Rouw relates that with all three sports (figure skating, hockey and skiing) he always makes a full-length device that allows removal of the original insole, which improves the fit and positioning of the orthotic in the boots. He always asks the athletes to bring their sport boots with them during the clinical evaluation. Dr. Haley also says that he tries to utilize materials in his orthotics that replace the insulation from the cold ground that the athlete loses when removing the original insole. However, he reinforces that one must continue to keep space constrains in mind with the shoe gear and likely thicker socks.
Q: If the mechanically ideal orthotic is not possible for use during these activities of these athletes, what alternatives (padding, taping, OTC insoles, orthotics in street shoes, modifications to the shoe/boot itself, etc.) would you employ?
Alternatives in winter sport gear can include custom-molded or heat-molded items in downhill skiing boots as well as hockey or figure skates. One can greatly customize the inner portions of this shoe gear at a specialty store, according to Dr. Krakowsky Clausen. If you are using an over-the-counter insole, she recommends opting for a thin, full-length device so it does not move around. Dr. Krakowsky Clausen says a heat-moldable device is preferable.
Dr. Haley agrees with a frequent need to make modifications both inside and outside of the shoe gear.
“Figure skate blades can be adjusted medially and laterally as well as to different heights and many other features,” notes Dr. Haley. “One might make modifications in the boot construction such as accommodative padding or reinforcements in the lateral or medial boot ankle as well as additional ply leather or changes with heat molding, depending upon the boot.”
Dr. Haley also points out that many boot manufacturers have certified distributors at our rinks and ski shops that allow custom alterations during production. If necessary, it may be possible to leave more room during production for bulkier orthotic needs, according to Dr. Haley.
Dr. Rouw relates that he finds taping effective, especially if the athlete or the footwear cannot tolerate an appropriate orthotic. He says one can also use taping in addition to an orthotic. Patients are often able to apply taping themselves with proper instruction or can do so with the help of a coach or trainer, according to Dr. Rouw. If there are only minor biomechanical abnormalities or a patient with an inherently stable foot who is just experiencing overuse/stress from a winter sport, he says taping, over-the-counter insoles or padding can give adequate relief.
However, Dr. Krakowsky Clausen reminds readers of one potential pitfall of padding.
“Padding can shift and it is a challenge to remove footwear mid-sport so this is not always a great option,” contends Dr. Krakowsky Clausen. “However, sport taping tends to stay in place.”
Dr. Rouw says it is also important to remember the patient’s activity outside of the main sport.
“Normal ambulation all day and running or other cross-training workouts can cause significant overuse or strain that becomes amplified by the winter sport,” says Dr. Rouw. “Often, it is helpful to make sure to use a different prescription device for other shoes/activities or at least consider a good over-the-counter insole/arch support.”
Q: What is your experience with customized products (orthotics/insoles) made by ski shops or by skate/ski boot companies? How do these products compare to your prescriptions and how do you answer patient questions about the role of these products?
Each of the panelists feel these retail-supplied customizable products can have a place under the right circumstances but maintain there are some situations in which a prescription custom device will still be best.
“If you are just looking for some more general support to an otherwise healthy foot, then the customized devices can sometimes be sufficient,” says Dr. Rouw. “For those just wanting to go skiing a few times each winter with an otherwise stable and healthy foot, they might be fine and save some money with a store made/boot supplied insole. However, serious athletes and those with unstable feet will almost always perform better with a prescription device.”
Dr. Haley says he can offer help to patients who have questions about products from the larger skate boot and ski boot manufacturers and shops that he knows. In his experience, though, Dr. Haley has found some products his patients receive from skate and ski shops and manufacturers very unsatisfactory.
“I do my best to help in any situation but sometimes we must start from scratch when the products are impossible to make work,” says Dr. Haley. “A prescription orthotic can help in all aspects of the gait contact phase and swing phase. Sometimes this is necessary and these other products just won’t do.”
Dr. Krakowsky Clausen shares that the right professionals in these retail or distributor positions can provide genuine know-how for these athletes.
“There are incredibly knowledgeable fitters for ski boots and skates, and they in fact have certifications themselves,” says Dr. Krakowsky Clausen. “They are aware of different materials utilized and have excellent knowledge of biomechanics and function within those particular sports. A good and knowledgeable ski boot or skate fitter can effectively provide necessary custom accommodations for deformities or biomechanical abnormalities.”
Q: Are there any particular cases regarding winter sports and orthotics that you would like to share that made a significant impact for you or the athlete?
Dr. Krakowsky Clausen also relates enjoying seeing great positive changes for local athletes, some of whom go on to collegiate, Olympic or professional levels.
“Often, winter athletes present to my office underperforming and hindered by injuries that I alleviated with the correct orthotic for the sport and boot we are working with,” shares Dr. Rouw. “I had figure skaters come to me after having their blades mounted almost off the sole of the boot in an attempt to “control” pronation, putting them seriously off balance and unable to achieve. Most importantly I find that you must take the time to understand the mechanics of the sport, the equipment/shoe gear of that athlete and the level of these athletes to help them achieve maximum care and their fullest potential in their sport.”
Dr. Haley is a Fellow of the American College of Foot and Ankle Surgeons, the American Society of Podiatric Surgeons and the American Academy of Podiatric Sports Medicine. He is a past President of the Delaware Podiatric Medical Society and is the Chief of the Podiatric Surgical Service at Christiana Care Health System in Newark and Wilmington, Del. He is a member of the U.S. Figure Skating Team National Physician Network and is endorsed by the U.S. Figure Skating Sports Science and Medicine Committee. He is in private practice in Wilmington and Middletown, Del.
Dr. Krakowsky Clausen is a Fellow of the American College of Foot and Ankle Surgeons and the American Academy of Podiatric Sports Medicine. She discloses that she also owns a local ski shop and ski school in Wisconsin. She practices in Minocqua, Wis.
Dr. Rouw is a Fellow of the American College of Foot and Ankle Surgeons and the American Society of Podiatric Surgeons and a Diplomate of the American Board of Podiatric Medicine. He is a past member of the U.S. Figure Skating Sports Medicine and Science Committee and volunteers as a National U.S. Figure Skating judge and technical specialist. He is in private practice in St. Cloud, Minn.
1. Chan CW, Rudins AR. Foot biomechanics during walking and running. Mayo Clin Proc. 1994;69:448-461. Available at: https://www.mayoclinicproceedings.org/article/S0025-6196(12)61642-5/pdf . Accessed November 24, 2020.