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Orthopedic footwear: Custom-made and commercially manufactured footwear
ORTHOTICS AND PROSTHETICS FOR THE FOOT AND ANKLE
1083–7515/01 $15.00 .00
ORTHOPEDIC FOOTWEAR Custom-Made and Commercially Manufactured Footwear Martin E. Roberts, CO, and Charles E. Gordon, DDS
Shoes have been a part of human lives for centuries. Although shoes from ancient times were more or less sandals, they made travel easier and helped extend humans’ walking distance and pleasure. Europeans and Arabians created these sandals before the first century A.D. Common materials for constructing sandals included papyrus leaves, tree bark, and, most common of all, animal skins. Shoes of the Renaissance were owned primarily by the wealthy and were considered sophisticated when compared with ancient sandals. The styles were plentiful, and some were silly in appearance. At this time, footwear began to take on a more true-to-life appearance because they were being made using lasts. A shoe last is essentially a wooden model of a person’s foot. The lasts were constructed out of oak or ash wood and were durable enough to withstand routine modifications and have thousands of shoes made from them. Initially, only straight lasts were in use and available. The nineteenth century brought about the individualized last (i.e., lasts for the left and the right foot). SHOE CONSTRUCTION Shoes contain 4 main components: the upper, and insole, outsole, and heel. The remainder of the shoe is constructed around these initial
From Bolt Systems, Inc, Orlando, Florida (MER); and Gordon’s Shoes, Inc, Pittsburgh, Pennsylvania (CEG)
FOOT AND ANKLE CLINICS VOLUME 6 • NUMBER 2 • JUNE 2001
243
244
ROBERTS & GORDON
components. The ball of the shoe is where the metatarsal heads of the feet are located. The area between the ball and the heel is the shank, which has a thin, rigid reinforcement of steel, leather, or wood. The forepart of the shoe starts at the ball and ends at the tip of the shoe. The toe box is located at the tip of the shoe. This portion of the shoe tends to be shaped more for fashionable appearance rather than function. Western-style cowboy boots and dress boots as well as ladies’ fashion heels are examples of sleek and shapely footwear. Although attractive in appearance, they generally are not tolerated by the feet wearing them. The vamp is the section of the shoe behind the tip, over the ball and instep that attaches to the back and sides of the upper. Various materials are used to produce shoes, and these materials serve different purposes. A large percentage of footwear is constructed from plastic and rubberized plastic byproducts. This makes it possible to produce lightweight, durable, and inexpensive shoes. Shoes made from plastics and other man-made materials, although less expensive than leather shoes, tend to be hot on the feet; they do not breathe and can be dangerous when dealing with certain types of foot ailments. Leather is the best choice for footwear construction. Leather is durable, it can be dyed various colors to enhance appearance, and it is not significantly heavier than plastic. Leather provides a healthy benefit in that it breathes, allowing circulation of air and wicking away perspiration. Commercially made leather footwear generally costs 2 to 4 times more on average than plastic and man-made shoes. Leather footwear provides a better overall value, however. Commercial footwear or production footwear represents what most of the population wears. There are many types of shoes in the marketplace today: dress and casual, sports of every kind, work related, and Western-style cowboy boots and seasonal footwear. Most commercial shoes are constructed from an average-sized set of lasts. These fit most of the shoe-wearing population. The sizing of footwear is manufacturer specific and typically addresses only the length. The widths of shoes vary widely from letter to numeric differences as well as the simple standard narrow, medium, and wide. More costly footwear tends to provide a more accurate fit by offering sizes to fit a combination of last sizes that vary according to length and width. Higher cost does not reflect better quality. The cost generally reflects fashion and appearance and has little to do with function. When dealing with a compromised foot, fit is as important as the function of the shoe because typically function follows form. COMPROMISED FOOT Problems associated with the feet may begin as early as infancy. When a fetus is large and remains in the mother’s womb for 9 months, the extremities must fight for space. Foot deformities are traced back to the prebirth experience. Common childhood foot ailments include
ORTHOPEDIC FOOTWEAR
245
metatarsus adductus and pronated feet. Early treatment includes outflared shoes for adductus and in-flared shoes for pronation. More often, foot problems develop later in life. The onset of disease and trauma are the most commonly addressed foot issues. When significant deformities are affecting the foot, orthopedic shoes are beneficial in providing more space for the foot to live inside the shoe. Some deformities and complications include high arch or pes cavus feet, flat feet or pes plano valgus, and toe deformities such mallet toes or hammertoes. The orthopedic shoe provides more depth and width, along with removable inserts that can be modified or removed to the increase the space needed for the foot. Orthopedic shoes include commercially made and custom-made footwear. Disease and traumatic injury frequently result in deformities that require orthopedic footwear. When the presentation of the foot does not allow for standard footwear, the shoes need to be fabricated from a model of the patient’s foot. The feet are casted to produce a negative mold, and plaster of Paris is poured into the cast to achieve a positive replication of the patient’s foot. The model can be modified to enhance the therapeutic benefit to be derived from the custom-made shoes. Modifications include relieving areas of dangerous pressure and providing enough room for the foot to move around safely while housed in a secure environment. If a portion of the patient’s foot has been amputated, the foot model can be modified to add in a toe block or filler to help the patient walk better. The secondary benefit is to produce a shoe that is cosmetically attractive as well. The goal of the shoemaker is to provide safe, functionally sound, and appealing footwear whenever possible. Custom shoes commonly are made from soft materials combined with thin rigid material. Soft leathers and foams are used for liners and the uppers. Toe boxes and heel counters are made from paper, skived leather, or molded plastic. Various foam densities are combined to make insoles, providing a comfortable and intimate fit. Closures include buckles, laces, buttons, Velcro, and laces. Producing a pair of custom orthopedic shoes is labor intensive, and with this added to expensive materials, the cost is high. When properly diagnosed and casted, the benefits of wearing custom-made footwear to accommodate a compromised foot far outweigh the cost to produce them. Whether custom-made or commercially produced, shoes may need to be modified to accommodate the wearer. FOOTWEAR MODIFICATIONS Almost every shoe can be modified to a greater or lesser extent. Modifications include wedges, pads, insoles, lifts, relasting, and building up to accommodate leg-length discrepancy. Wedges in between or attached to the bottom of the sole are added to the medial or lateral side of the shoe. This modification generally is used to balance an unstable foot. A wedge added just proximal to the ball of the foot acts as a metatarsal bar to unload the metatarsal heads. This wedge also aids in
246
ROBERTS & GORDON
relieving pain at the level of the toes. Full-length or partial-length lifts are used for balancing leg-length discrepancies and creating parity between the left and right leg. A common modification to orthopedic footwear is the rocker-bottom sole. Rocker soles are a buildup on the sole of the shoe in a shape similar to a rocking chair rail. The action of the sole imitates the rolling effect of the chair to help patients maintain fluidity in their gait. When a patient has had an ankle fusion or is wearing a solid ankle-foot orthosis, the rocker sole makes walking much more comfortable and steady. Heel wedges or lifts are used to reduce tension on the Achilles tendon or to level a leg-length discrepancy. Medial and lateral heel wedges help balance calcaneal valgus and varus. Ankle instability is supported through the use of a heel flare, which is widened at the base. A solid ankle cushion heel softens heel-strike and reduces ground reaction forces. This cushion is placed as a wedge between the midsole and the outer sole of the shoe. Most heel modifications are added in under the outer sole to enhance to durability of the buildup and to allow the patient to ambulate on the same sole surface. Modifications can be added to the interior of the shoe and to the uppers. For the uppers, the most common modification is changing the closure design. For patients with arthritic hands, laces may be difficult, if not impossible, to manage. Velcro straps may be the best alternative for secure and safe closure. Complete insoles are available over-thecounter and custom-made. The inlay that is provided with the shoe from the factory generally is removed before adding another insole or orthotic. Orthopedic footwear is designed to allow for custom orthotics to be introduced and still leave room for the foot. The addition of modifications can distract from the appearance of the shoe and cause the patient to cease wearing it. Adding insoles or custom-made orthotics tend to increase weight and bulkiness and may lead to the patient’s reluctance to wearing the shoes. Care always should be taken to assess the needs of the patient, including his or her lifestyle and walking habits. Orthopedic shoes are designed to enhance and improve the ability of an individual to walk safely. Additions such as braces and modifications contribute to this end.
SUMMARY Shoes and footwear have been a part of human lives for centuries. Many take good foot health for granted. For those individuals, the commercial shoe store has hundreds of varieties of shoes in every price range. For individuals with compromised, at-risk feet, the options are reduced greatly. The foot health industry today has made available many viable options to meet specific needs. Footwear can augment successfully the treatment of foot and ankle pathology and when properly applied improve the health and lifestyle of patients.
ORTHOPEDIC FOOTWEAR
247
References 1. McGann DM, Robinson LR: The Doctor’s Sore Foot Book. New York, William Morrow & Co, 1991 2. Tremaine DM, Awad EM: The Foot and Ankle Sourcebook. Los Angeles, Lowell House, 1995 Address reprint requests to Martin E. Roberts, CO Bolt Systems, Inc 1700 Silver Star Road Orlando, FL 32804
1083–7515/01 $15.00 .00
ORTHOPEDIC FOOTWEAR Custom-Made and Commercially Manufactured Footwear Martin E. Roberts, CO, and Charles E. Gordon, DDS
Shoes have been a part of human lives for centuries. Although shoes from ancient times were more or less sandals, they made travel easier and helped extend humans’ walking distance and pleasure. Europeans and Arabians created these sandals before the first century A.D. Common materials for constructing sandals included papyrus leaves, tree bark, and, most common of all, animal skins. Shoes of the Renaissance were owned primarily by the wealthy and were considered sophisticated when compared with ancient sandals. The styles were plentiful, and some were silly in appearance. At this time, footwear began to take on a more true-to-life appearance because they were being made using lasts. A shoe last is essentially a wooden model of a person’s foot. The lasts were constructed out of oak or ash wood and were durable enough to withstand routine modifications and have thousands of shoes made from them. Initially, only straight lasts were in use and available. The nineteenth century brought about the individualized last (i.e., lasts for the left and the right foot). SHOE CONSTRUCTION Shoes contain 4 main components: the upper, and insole, outsole, and heel. The remainder of the shoe is constructed around these initial
From Bolt Systems, Inc, Orlando, Florida (MER); and Gordon’s Shoes, Inc, Pittsburgh, Pennsylvania (CEG)
FOOT AND ANKLE CLINICS VOLUME 6 • NUMBER 2 • JUNE 2001
243
244
ROBERTS & GORDON
components. The ball of the shoe is where the metatarsal heads of the feet are located. The area between the ball and the heel is the shank, which has a thin, rigid reinforcement of steel, leather, or wood. The forepart of the shoe starts at the ball and ends at the tip of the shoe. The toe box is located at the tip of the shoe. This portion of the shoe tends to be shaped more for fashionable appearance rather than function. Western-style cowboy boots and dress boots as well as ladies’ fashion heels are examples of sleek and shapely footwear. Although attractive in appearance, they generally are not tolerated by the feet wearing them. The vamp is the section of the shoe behind the tip, over the ball and instep that attaches to the back and sides of the upper. Various materials are used to produce shoes, and these materials serve different purposes. A large percentage of footwear is constructed from plastic and rubberized plastic byproducts. This makes it possible to produce lightweight, durable, and inexpensive shoes. Shoes made from plastics and other man-made materials, although less expensive than leather shoes, tend to be hot on the feet; they do not breathe and can be dangerous when dealing with certain types of foot ailments. Leather is the best choice for footwear construction. Leather is durable, it can be dyed various colors to enhance appearance, and it is not significantly heavier than plastic. Leather provides a healthy benefit in that it breathes, allowing circulation of air and wicking away perspiration. Commercially made leather footwear generally costs 2 to 4 times more on average than plastic and man-made shoes. Leather footwear provides a better overall value, however. Commercial footwear or production footwear represents what most of the population wears. There are many types of shoes in the marketplace today: dress and casual, sports of every kind, work related, and Western-style cowboy boots and seasonal footwear. Most commercial shoes are constructed from an average-sized set of lasts. These fit most of the shoe-wearing population. The sizing of footwear is manufacturer specific and typically addresses only the length. The widths of shoes vary widely from letter to numeric differences as well as the simple standard narrow, medium, and wide. More costly footwear tends to provide a more accurate fit by offering sizes to fit a combination of last sizes that vary according to length and width. Higher cost does not reflect better quality. The cost generally reflects fashion and appearance and has little to do with function. When dealing with a compromised foot, fit is as important as the function of the shoe because typically function follows form. COMPROMISED FOOT Problems associated with the feet may begin as early as infancy. When a fetus is large and remains in the mother’s womb for 9 months, the extremities must fight for space. Foot deformities are traced back to the prebirth experience. Common childhood foot ailments include
ORTHOPEDIC FOOTWEAR
245
metatarsus adductus and pronated feet. Early treatment includes outflared shoes for adductus and in-flared shoes for pronation. More often, foot problems develop later in life. The onset of disease and trauma are the most commonly addressed foot issues. When significant deformities are affecting the foot, orthopedic shoes are beneficial in providing more space for the foot to live inside the shoe. Some deformities and complications include high arch or pes cavus feet, flat feet or pes plano valgus, and toe deformities such mallet toes or hammertoes. The orthopedic shoe provides more depth and width, along with removable inserts that can be modified or removed to the increase the space needed for the foot. Orthopedic shoes include commercially made and custom-made footwear. Disease and traumatic injury frequently result in deformities that require orthopedic footwear. When the presentation of the foot does not allow for standard footwear, the shoes need to be fabricated from a model of the patient’s foot. The feet are casted to produce a negative mold, and plaster of Paris is poured into the cast to achieve a positive replication of the patient’s foot. The model can be modified to enhance the therapeutic benefit to be derived from the custom-made shoes. Modifications include relieving areas of dangerous pressure and providing enough room for the foot to move around safely while housed in a secure environment. If a portion of the patient’s foot has been amputated, the foot model can be modified to add in a toe block or filler to help the patient walk better. The secondary benefit is to produce a shoe that is cosmetically attractive as well. The goal of the shoemaker is to provide safe, functionally sound, and appealing footwear whenever possible. Custom shoes commonly are made from soft materials combined with thin rigid material. Soft leathers and foams are used for liners and the uppers. Toe boxes and heel counters are made from paper, skived leather, or molded plastic. Various foam densities are combined to make insoles, providing a comfortable and intimate fit. Closures include buckles, laces, buttons, Velcro, and laces. Producing a pair of custom orthopedic shoes is labor intensive, and with this added to expensive materials, the cost is high. When properly diagnosed and casted, the benefits of wearing custom-made footwear to accommodate a compromised foot far outweigh the cost to produce them. Whether custom-made or commercially produced, shoes may need to be modified to accommodate the wearer. FOOTWEAR MODIFICATIONS Almost every shoe can be modified to a greater or lesser extent. Modifications include wedges, pads, insoles, lifts, relasting, and building up to accommodate leg-length discrepancy. Wedges in between or attached to the bottom of the sole are added to the medial or lateral side of the shoe. This modification generally is used to balance an unstable foot. A wedge added just proximal to the ball of the foot acts as a metatarsal bar to unload the metatarsal heads. This wedge also aids in
246
ROBERTS & GORDON
relieving pain at the level of the toes. Full-length or partial-length lifts are used for balancing leg-length discrepancies and creating parity between the left and right leg. A common modification to orthopedic footwear is the rocker-bottom sole. Rocker soles are a buildup on the sole of the shoe in a shape similar to a rocking chair rail. The action of the sole imitates the rolling effect of the chair to help patients maintain fluidity in their gait. When a patient has had an ankle fusion or is wearing a solid ankle-foot orthosis, the rocker sole makes walking much more comfortable and steady. Heel wedges or lifts are used to reduce tension on the Achilles tendon or to level a leg-length discrepancy. Medial and lateral heel wedges help balance calcaneal valgus and varus. Ankle instability is supported through the use of a heel flare, which is widened at the base. A solid ankle cushion heel softens heel-strike and reduces ground reaction forces. This cushion is placed as a wedge between the midsole and the outer sole of the shoe. Most heel modifications are added in under the outer sole to enhance to durability of the buildup and to allow the patient to ambulate on the same sole surface. Modifications can be added to the interior of the shoe and to the uppers. For the uppers, the most common modification is changing the closure design. For patients with arthritic hands, laces may be difficult, if not impossible, to manage. Velcro straps may be the best alternative for secure and safe closure. Complete insoles are available over-thecounter and custom-made. The inlay that is provided with the shoe from the factory generally is removed before adding another insole or orthotic. Orthopedic footwear is designed to allow for custom orthotics to be introduced and still leave room for the foot. The addition of modifications can distract from the appearance of the shoe and cause the patient to cease wearing it. Adding insoles or custom-made orthotics tend to increase weight and bulkiness and may lead to the patient’s reluctance to wearing the shoes. Care always should be taken to assess the needs of the patient, including his or her lifestyle and walking habits. Orthopedic shoes are designed to enhance and improve the ability of an individual to walk safely. Additions such as braces and modifications contribute to this end.
SUMMARY Shoes and footwear have been a part of human lives for centuries. Many take good foot health for granted. For those individuals, the commercial shoe store has hundreds of varieties of shoes in every price range. For individuals with compromised, at-risk feet, the options are reduced greatly. The foot health industry today has made available many viable options to meet specific needs. Footwear can augment successfully the treatment of foot and ankle pathology and when properly applied improve the health and lifestyle of patients.
ORTHOPEDIC FOOTWEAR
247
References 1. McGann DM, Robinson LR: The Doctor’s Sore Foot Book. New York, William Morrow & Co, 1991 2. Tremaine DM, Awad EM: The Foot and Ankle Sourcebook. Los Angeles, Lowell House, 1995 Address reprint requests to Martin E. Roberts, CO Bolt Systems, Inc 1700 Silver Star Road Orlando, FL 32804