O and P Almanac November 2012 : Page 20
IMPORTANCE OF IN PEDORTHICS SHOES 20 O&P ALMANAC NOVEMBER 2012
The Importance Of Shoes In Pedorthics
One of the most important components of an orthotic foot or ankle intervention—the shoe—is too often the least regarded, according to many pedorthists. In fact, “the shoe is the ultimate orthotic device,” says Robert Schwartz, C.Ped., owner of Manhattan-based Eneslow Shoes and Pedorthics. “It is the foundation and frame for all other devices and the foot.” <br /> <br /> Unfortunately, shoes get short shrift. Insurance does not reimburse for shoes, with the exception of diabetic footwear, and, other than pedorthists, health professionals are not trained in footwear therapy. Patients tend to judge shoes more by their appearance than their function and desire specific kinds of footwear for different settings.<br /> <br /> “Shoes can be one of the hardest things we do,” says Dennis Janisse, C.Ped., president and CEO of Milwaukee-based National Pedorthic Services. “They have to be the right size and width, the right shape- and, for most patients, the right style and color.” Yet the success of any foot orthosis, from an AFO to an orthotic insert, depends on the proper choice of shoe.<br /> <br /> For an effective orthotic intervention, “you have to have a marriage between the foot, the shoe, and the orthotic,” explains William Boettge, executive director of the Pedorthic Foundation. “A good orthotic matched with the wrong type of foot or the wrong shoe will not work. If the shoe is too short or long or wide or narrow, you’re not going to get the kind of foot management that you want.”<br /> <br /> The Basics: Size, Construction, Materials, Comfort <br /> <br /> While size is an obvious consideration in selecting an appropriate shoe, the range of sizes, particularly width, is limited in today’s footwear. “Feet come in many different widths, but you’re lucky to find a shoe available even in narrow-medium or mediumwide,” says Boettge. When a shoe isn’t sufficiently wide, patients will usually go for a larger size, which can cause problems with slippage and comfort.<br /> <br /> Shoes need to match the shape of the feet. A pointed toe box is not suitable for a wide foot with stubby toes, for example, and tapered toes won’t fit in a squared-off shoe. A shoe with a high heel or a flat with a low-cut profile offers little to hold the foot in place, unlike shoes with laces or straps across the midfoot that keep the foot from pushing forward.<br /> <br /> To provide stability, footwear should have as much contact as possible with the ground, and that can be difficult to find. “Today’s trends in shoe styles are probably the worst,” notes Ted Colaizzi, C. Ped., of Colaizzi Pedorthic Center in Pittsburgh. “When we want to control biomechanics and foot position, we want as much shoe touching the floor as possible. But fashionable design features reduce contact between the shoe and the walking surface.”<br /> <br /> Shoe materials play an important role as well. Synthetic lining materials that don’t breathe contribute to a warm, damp environment for the foot, which can lead to blisters, fungi, and infection. Synthetics are seldom best for the upper part of the shoe because they are not as forgiving as leather. “Upper materials should have some give,” says Schwartz. The way the leather is cut and sewn together has an impact on comfort as well, he explains. “Good shoe designers know how to put the leather together, so the shoe will stretch in the same direction as the foot, from side to side.” <br /> <br /> Soles that provide some shock absorption and cushioning, yet are lightweight, are preferable, particularly as patients age.<br /> <br /> Many shoes today are constructed with removable insoles, enabling pedorthists to insert an orthotic. For some interventions, a pedorthist wants a shoe that allows the entire sole bottom to be detached, leaving behind only the upper. “Rather than adjusting the plastic molded bottom, we prefer to remove it and create a therapeutic replacement,” says Colaizzi.<br /> <br /> The placement of seams often matter with patients who have bony protuberances, such as bunions. Typically, fewer parts means a lighter, less structured shoe; more parts tend to create more stability. Depending on the goal, either is desirable. “People with rigid, fixed deformities need a softer, more flexible shoe,” explains Schwartz. “Those with flexible feet need a more stable environment to support the foot, and therefore, the whole body.”<br /> <br /> Patient comfort in a shoe is an important sign that the fit is appropriate— with some exceptions. Diabetic patients who have compromised sensation in their feet tend to want shoes that fit snugly, so they feel securely attached. But tight shoes are exactly the wrong choice for neuropathic patients because friction can compromise the skin and, unnoticed and untreated, can result in ulcers and infection.<br /> <br /> Shoes for Different Conditions <br /> <br /> While every foot is unique, pedorthists treat some conditions more frequently than others, starting with fundamental procedures that incorporate shoe guidelines.<br /> <br /> Plantar fasciitis, an inflammation of the thick tissue on the bottom of the foot, is a common disorder, says Schwartz. It calls for a supportive, stable shoe, perhaps with a slightly higher heel. “Most people with plantar fasciitis need some orthotic intervention, such as an arch support or a heel lift,” he says.<br /> <br /> For some of his patients with this condition, Colaizzi constructs an orthotic that supports the arch but offloads the band of tissue running the length of the foot. He recommends shoes with bottoms that absorb impact but are not too flexible.<br /> <br /> Forefoot problems, such as bunions, hammertoes, and metatarsal pain, need a higher, wider toe box and a shockabsorbent sole, according to Schwartz.<br /> <br /> Arthritic conditions of the midfoot are common among older people, says Colaizzi. “For this, we are looking at enhancing support and not getting too aggressive. The shoe needs to improve stabilization and support, and allow the whole foot to touch the floor.” Patients need a shoe that can be modified with an insert to treat this condition.<br /> <br /> Diabetic shoes are the only footwear covered by insurance, yet “we’ve ended up being somewhat dictated to by reimbursement, and that’s not a good thing,” says Jannise. The goal of diabetic shoes is to accommodate the foot, to eliminate any areas of high pressure. “I prefer soft leather, which will mold to subtle changes in the foot,” he says. Fewer seams also present fewer opportunities for aggravating the skin.<br /> <br /> The overlooked importance of shoes—in both the prevention and treatment of foot problems—is frustrating to many pedorthists. They see the prevalence of style over substance and the damage that can cause. Pedorthists, the only medical professionals who include footwear in their purview, are well positioned to educate their patients and the wider population that shoes are literally the basis of our relationship with the ground. “If you don’t have the right shoe,” says Janisse, “nothing else, including the body, can function properly.”<br /> <br /> TIPS on Advising Patients <br /> <br /> Whether your patients need shoes as part of an orthotic intervention or they want to avoid foot problems that stem from ill-fitting or badly designed footwear, experts offer the following suggestions:<br /> <br /> • Suggest patients go shoe shopping in the afternoon, not the morning. “Feet get larger as the day wears on,” notes Robert Schwartz, C.Ped., owner of Manhattan-based Eneslow Shoes and Pedorthics. “If you try on shoes later in the day, you have a better chance of getting the proper fit.”<br /> <br /> • Check wear patterns on the patient’s current shoes. “Look for excessive wear in an area to see what the forces are that the shoe is affecting, inside and out,” Schwartz says. “The outsole is very telling in how a person walks.”<br /> <br /> • Check and recheck shoe fit, inspecting the shoes with feet inside, patient standing, to be sure they are the right size.<br /> <br /> • Typically, people want their toes to touch the end of the shoe, so the heel doesn’t slip, says Dennis Janisse, C.Ped., president and CEO of Milwaukee-based National Pedorthic Services. “But it’s okay for the heel to move,” he explains, “and a short shoe can contribute to plantar fasciitis and other problems.” Allow at least 3/8 of an inch of toe room from the tip of the longest toe to the end of the shoe.<br /> <br /> • When working with diabetic patients who want their shoes to fit snugly, Schwartz suggests going up a half size rather than increasing two widths. “Don’t give them big boxes, but add enough room. Education is an important component of the treatment.”<br /> <br /> Deborah Conn is a contributing writer to O&P Almanac. Reach her at debconn@ cox.net.