Shoe Modifications for Physical Therapy Students

• SHOE & SHOE MODIFICATIONS for students of Physical and Occupational Therapy

Learning Objectives

• Shoe modifications are differentiated by area, effect, and principles
• Specific shoe modifications are prescribed efficiently for given cases
• This allows assessment of the kinesiological effect of a given shoe modification
• Shoe modifications will be produced for specific cases supported by research

SHOE

• Used for functional and cosmetic purposes
• Therapeutic footwear acts as a foundation of good orthosis
• Therapeutic shoes can enhance shock absorption
• These shoes will reduce shear stresses on the foot
• Accommodate and support foot deformities
• Accommodate or relieve pressure-sensitive areas
• Accommodates shoe inserts and other orthotic devices worn inside the shoe

Men's Shoe Styles

• Includes Oxford, Blucher/Derby, Brogue, and Monk styles

Women's Shoe Styles

• Includes Pump/Court, Ballet/Dolly, High Heeled/Stilettos, and Mary Janes

Other Shoe Styles

• Includes Athletic, Clog, Boots, and Sneakers

Shoe Composition

• Shoes are composed of three general parts: the upper, the sole, and reinforcements

Parts of a Shoe

• Sole
• Heel
• Upper
• Linings & Reinforcements
• Quarter heights
• Shoe lasts
• Closure

Parts of a Shoe: Upper

• It is the superior aspect of the shoe
• The anterior section is the vamp (toe box)
• The posterior section is the quarter

Parts of a Shoe: Sole

• It is the inferior aspect of the shoe
• The sole is made of the inner sole and outer sole with filler

Parts of a Shoe: Heel

• It is the inferior posterior aspect of the shoe
• It is made of the proximal and distal heel

Non-Athletic Shoe Parts

• It is made of the counter, topline, tongue, lacestay with eyelets, quarter, throat, vamp, toe box, sole, heel, heel breast, shank, outsole, welt, and insole

Athletic Shoe Parts

• Includes an Achilles tendon notch, collar, lace lock, saddle/stabilizing strap, counter, rear foot stabilizer, lacestay with eyelets, throat, vamp, toe box, outsole, toe wrap, midsole, and insole (removable, fixed)

SOLE

• The material to which the upper attaches and is located under the foot

Parts of the Sole

• Outsole
• Welt
• Midsole
• Insole
• Heel
• Shank

Outersole

• Provides cushion impact, usually made of leather, especially if external modifications are to be attached

Innersole

• Lies under the foot

Filler

• It separates the inner and outer sole

Ball

• Widest part of the sole
• Beneath the metatarsal heads

Shank

• Consists of a steel shank (stirrup attachment)
• Between the ball and anterior part of the heel
• Extends from the heel to the metatarsal heads

Toe Spring

• Space between the anterior portion of the sole & the floor
• Allows rocker effect
• Facilitates toe-off
• Reduces wrinkling of the upper part of the shoe

Welt

• Strip leather, rubber, or plastic that is stitched to the upper & insole of a shoe
• It acts as an attachment point for the sole

HEEL

• Usually directly under the anatomical heel (calcaneus)

Characteristics of Heels

• Height
• Size
• Resilience or ability to compress

Two Parts of the Heel

• Proximal portion made of leather
• Distal portion (Plantar surface) is in contact with the ground
• The men's portion is made of medium soft rubber
• Women's and children's heels are made of hard rubber

Breast

• Forward extension of the anterior surface of the heel
• Increases the base of the support of the heel

Heel Height

• Affects the relative loading of the anterior and posterior portions of the foot
• The distance from the outer sole to the plantar surface of the heel
• The higher the heel, the greater the weight is borne on metatarsal heads (Ex. Metatarsalgia)

Types of Heel Height

• Spring, which is 1/8 inch
• Oxford, which is 6/8 or 8/8 inch (standard)
• Military, which is 10/8 inch
• Cuban, which is 12/8 inch

Pitch

• Inclination of the posterior portion of the heel from the vertical
• The higher the heel, the greater the pitch
• Aims to provide central distribution of weight

UPPER

• Part of the shoe that covers the dorsum, the sides, and the back of the foot

Vamp

• Anterior section of the shoe's upper
• Generally made of soft leather or fabric to minimize pressure on the dorsal areas of the foot

Quarter

• Consists of low quarter shoe- a lateral quarter is lower than the medial quarter
• Height of the quarter terminates just distal to the malleoli (low-top shoe)

Tongue

• Strip of leather under the laces

Throat

• Base of the tongue where the foot enters and where the shoe closure attaches to the quarters

Throat Style – Blucher (Derby)

• Aka Derby
• Preferred for use with most orthoses
• Greater adjustability for changes in foot volume
• Large opening, easier to don and doff the shoe
• The tongue is an extension of the vamp
• Anterior edges of the quarters are free to open and fold back during donning and doffing shoe

Throat Style – Bal or Balmoral

• Aka Oxford
• The tongue is a separate piece of material sewn to the vamp and quarters
• The anterior edges of the quarters are connected together, making the opening for the foot smaller and less adjustable
• Restricting

Throat Style – Open to the Toe

• Aka Surgical
• The quarters and the tongue extend all the way to the toe of the shoe
• Prescribed for clients with severe spasticity, rigid deformities, healing ulcers or wounds, or orthoses with very rigid ankle-foot componentry
• Easiest to don/wear

Toe Box

• Part of the vamp that guards the dorsum and tips of the toes against trauma
• Consideration for individuals with deformities (hammer toes, claw toes, bunion.)

Linings and Reinforcements: Cotton Vamp Lining

• Absorbs perspiration

Linings and Reinforcements: Inner Sole and Quarter Linings

• Made of cotton reinforced with leather to protect the foot

Linings and Reinforcements: Lacestay with Eyelets

• Standard number is four to five pairs

Linings and Reinforcements: Counter

• Preserves the shape of the shoe in the area of the anatomic heel
• Reinforcement of the posterior aspect of the quarters that cups the heel and stabilizes the hindfoot
• Can be extended
• If not proper= calluses and other deformities

Heel Counter

• Supports different areas of the heel

Shoe Lasts

• Model of the weight-bearing foot
• Determine the comfort and walking characteristics of the shoe
• Typically has a greater inward curvature on the medial side of the foot with the forefoot portion angled medially to the heel by about 7°

Types of Lasts

• Regular, Straight, Outflare, and Inflare

Regular Last

• Duplicates the healthy foot
• 7 degrees -15 degrees Ficks Angle/Toe angle

Straight Last

• For younger children

Outflare and Inflare Lasts

• Adults: accommodate fixed deformities
• Inflare: adducts the forefoot
• Outflare: abducts the forefoot

Quarter Heights: Oxford

• Low shoe
• Just below the malleoli
• Cosmetic and does not restrict ankle motion
• Most orthotic applications

Quarter Heights: Boot

• High shoe that covers the malleoli
• Provides stability to the rearfoot controlling unwanted mediallateral instability
• For foot drop and spasticity

Closure

• Can be adjusted using lace, buckle, and velcro
• Non-adjustable closures includes zipper and elastic

Evaluation of Fit

• There should be adequate room for the foot to expand during weight-bearing
• The shoe should be 1/2 inch longer than the longest toe
• The widest part of the shoe should coincide with the broadest part of the foot
• Heel to ball dimensions of the foot and shoe should be equal
• Quarter should not gap excessively
• Counter should fit around the anatomic heel

Shoe Modification Purpose

• Improve balance and function during standing and walking
• Relieve pain

Shoe Modification Function

• Transfer forces to tolerant areas
• Reduce friction & shear
• Modify weight transfer patterns
• Correct flexible deformities
• Accommodate fixed deformities
• Limit motion when needed

Types of Modification

• External and internal

External Modifications

• Include heel modifications, sole modification, and combination heel & sole modifications

Internal Modifications

• Heel modification and sole modification

External Modification Advantages

• Do not reduce shoe volume

External Modification Disadvantages

• Separated from plantar surface of the foot
• Visible from the outside
• Subject to wear and tear

Heel Modifications: Cushion Heel

• Aka as SACH (Solid Ankle Cushion Heel)
• Between the outer sole and thinned regular heel
• Reduces the stress on the heel and ankle just after heel strike
• Diminish the moment of force to flex the knee
• The range of plantar flexion (PF) required to bring sole in contact with the floor is decreased
• Creates a dorsiflexion (DF) moment

Heel Modifications: Heel Flare

• Plantar surface of the heel is extended outward
• Works around the subtalar joint
• Medial flare resists eversion of the hindfoot
• Lateral flare resists inversion
• Both flares provide greater stability

Heel Modifications: Heel Wedge

• Incorporated in the medial or lateral portion of the heel
• Medial heel wedge leads to hindfoot inversion
• Lateral heel wedge leads to hindfoot eversion
• The opposing quarter should be firm to resist the tendency of the hindfoot to slide

Heel Modifications: Extended Thomas Heel

• Projection at the medial portion of the breast
• Supports the medial longitudinal arch
• Extends laterally: Reverse Thomas heel supports the lateral aspect of the hindfoot

Heel Modifications: Heel Elevation

• It acts as compensation for leg length discrepancy and fixed equinus deformity
• Aligns the pelvis
• For elevations less than 0.5cm it is placed inside the shoe

Sole Modifications: Rocker Bar

• Firm material skived anteriorly and posteriorly across the sole
• Rounded apex of the bar is positioned parallel to the MT heads
• Shifts the rollover point posterior to the MT heads - transferring pressure to the MT shaft
• Limited ankle motion

Sole Modifications: Metatarsal Bar

• A bar positioned posterior to the MT heads
• Transfers pressure to the MT shaft
• Plantar surface is flat, producing a broader area of contact with the floor
• Less resistance to rollover

Sole Modifications: Sole Wedge

• Incorporated in the medial or lateral half of the sole
• Lateral placement tends to evert or pronate the forefoot
• Medial placement tends to invert or supinate the forefoot
• Used to accommodate fixed deformities of the forefoot

Sole Modifications: Sole Flare

• Greater stability
• Resists inversion/eversion of the foot

Sole Modifications: Steel Sole Bar

• Spring steel between the inner & outer sole
• Reduces stress at the phalanges & MT
• Usually used with a rocker bar

Combination of Heel and Sole Modifications

• Cushion heel and rocker bar
• Heel & sole wedges
• Sole elevation is necessary if heel elevation is higher than 0.5 cm to prevent the foot from assuming an equinus position

Internal Shoe Modification

• Glued to the inner sole
• Closer to the foot which means it is mechanically more elective than the external shoe modifications
• Reduce the space available within the shoe for the foot

Heel Modifications: Heel Cushion Relief

• Tapered pad that covers the entire heel to provide relief from pressure
• Can be rounded or horseshoe-shaped pad
• Excavations are usually made up of Plastizole or hard, firm sponge rubber

Heel Modifications: Medial Heel Wedge

• Laterally tapered pad that covers the entire heel seat
• Tends to invert the hindfoot
• 0.2 to 0.5 cm thick
• Lateral wedge everts the hindfoot & relieves cuboid pressure

Heel Modifications: Interior Laced Ankle Support

• Reinforced fabric ankle corset prevents mediolateral motion of the hindfoot
• For those with ankle deformities

Heel Modifications: Metatarsal Pad

• Domed pad made up sponge rubber
• Increases the load of the MT shaft & reduce MT head load
• The apex of the dome is posterior to the MT heads with a height of 0.2 to 0.5 cm

Heel Modifications: Metatarsal Pad Extensions

• Morton's extension goes distal to 1st MT head
• Sesamoid pad goes proximal to 1st MT head
• U-shaped pad goes to 3rd MT

Heel Modifications: Medial Longitudinal Arch Support

• Also known as the scaphoid pad, navicular pad, and cookie pad
• It provides more even distribution of weight
• Fixed to the lining and lower portion of the upper
• Extends 1cm posterior to the 1st MT head to the anterior tubercle of the calcaneus
• Apex of 0.5 to 1cm is located between the sustentaculum tali (talonavicular joint) and navicular tuberosity
• Provides resilient support producing more even distribution of weight bearing, upward and laterally directed

Heel Modifications: Toe Crest

• 1cm wide crescent-shaped pad placed behind 2nd through 4th toes
• Crest fills the void under each proximal phalanx transfers the stress from toes to the hollow (sulcus) beneath the toes
• Resists the tendency of the foot to slide forward

Foot Orthoses

• Aka as inserts or inlays
• Removable appliance placed in the shoe
• A three-quarter length or full-length insert is contoured to provide medial longitudinal arch support
• Will relieve pressure from MT heads

Foot Orthoses: UCBL Insert (Gold Standard)

• Rigid molded plastic of the midfoot & hindfoot
• Contains the heel & ends posterior to the MT heads
• Side walls below the malleoli provides effective longitudinal arch support
• Maintains the optimal position of the calcaneal relative to the talus

Foot Orthoses: Heel Seat

• Heel cup
• Rigid plastic insert that covers the heel & surrounds its posterior, medial & lateral side
• Used for flexible flat foot

Foot Orthoses: Sesamoid Platform

• Three-quarter length insert with 0.2 to 0.4 cm elevation distal to the halluces sesamoid
• Stabilizes the 1st MT & reduces pressure on the 1st MT head shifting to the MT shaft

Foot Orthoses: Inner Sole Excavation

• A portion of the inner sole under one to three painful metatarsal heads may be removed to provide greater area and reduced load for the heads

General Rule

• New shoes should be purchased for every 350 miles.

When Should You Buy?

• Buy when the foot is swollen
• Opt for a wide toe box

Criteria For Shoes To Buy

• Should allow at least 1/2 inch of room between the toes and front of the shoe
• Should not be too narrow

Characteristics of a Good, Safe Running Shoe

• Low heel-toe drop (6mm)
• Neutral
• Lightweight (10 ounces or less for a men's size 9; 8 ounces or less for women's size 8)

What to Avoid in Shoes

• High, thick cushioning
• High profile shoe
• Extra arch support inserts or store based orthotics

Shoe Prescription Considerations

• Ankle and subtalar joints
• Midfoot and Hindfoot
• Forefoot
• Fractures
• Leg length discrepancies

Ankle and Subtalar Joints: Arthritis

• Objectives are to prevent or limit motion, accommodate deformities, and cushion impact loading
• The prescription is a soft upper with reinforced quarters and high quarter shoe, rocker bar, metatarsal bar, cushion heel, heel flare, and UCBL insert

Ankle and Subtalar Joints: Arthrodesis

• Objectives are to Absorb shock at heel strike, Improve comfort & efficiency at push off, and Accommodate any shortening or residual equinus
• Prescription are cushion heel, rocker bar, and metatarsal bar

Ankle and Subtalar Joints: Instability

• Objective is to support unstable intertarsal joint
• The prescription is a high quarter shoe with interior laced ankle support

Midfoot and Hindfoot: Pes Planovalgus (Flaccid and Spastic)

• Objectives are to correct eversion, support MLA, and relieve ligamentous strain
• Prescription: MLA support, Extended Thomas Heel and long medial counter, Medial heel wedge, and Heel Seat to hold calcaneus vertically UCBL insert with reinforced medial and heel counters

Midfoot and Hindfoot: Pes Equinus

• Objectives are to reduce tendency of ankle to PF, reduce load on MT heads and stabilized the intertarsal joints
• Prescription: Lower or remove external heel, elevate the sole and MLA supports

Midfoot and Hindfoot: Fixed Pes Equinus

• Objectives Include containing the entire foot in the shoe, and Reduce the load on the MT head
• Prescriptions Include proximal extension on a lower quarter shoe the anatomic heel, a High quarter shoe for pediatric patient, a Heel elevation to reduce metatarsal load and Contralateral heel elevation

Midfoot and Hindfoot: Talipes Equinovarus

• Objectives: Maintained improvement achieved, Provide improvement, and for correction in order to abduct (pronate) the forefoot, evert the midfoot & hindfoot, and reduce PF
• Prescription: To abd forefoot; outflare last, which can be worn with Denis Browne splint in non-ambulatory correction, to evert the midfoot & hindfoot with a lateral heel & sole wedge with Reverse extended Thomas heel, a long medial counter to reduce PF, lower or remove the external heel & elevate sole

Midfoot and Hindfoot: Fixed Equinovarus

Objectives: Modify weight bearing pattern by accommodating the deformity The Prescription includes a medial heel and sole wedge and heel elevation

Midfoot and Hindfoot: Pes Cavus

• Objectives are to Reduce load on the lateral border, MT head and heel, and constrained the deformed foot
• The Prescription Includes MLA support and a metatarsal pad or bar, as well as a high quarter and high toe box

Midfoot and Hindfoot: Plantar Calcaneal Bursa, Spurs & Fasciitis

The objective is to transfer pressure to tolerate areas The prescription is a heel cushion with resilient sole and an MLA support

Forefoot: Metatarsalgia

• Objectives include transferring pressure to tolerant areas and reducing friction by stabilizing the MTP joint
• The prescription is sufficient hosiery & shoe length, lower the heel height, metatarsal pad, sesamoid platform, and inner sole excavation

Forefoot: Metatarsus Adductus (Congenital)

• The objective is to correct deformity
• Prescription is an outflare last

Forefoot: Hallux Valgus; Bunion

• Objectives include reducing friction & pressure, accommodating abn width of forefoot, limiting motion of the 1st metatarsal & phalanges, and transferring pressure laterally
• Prescription includes sufficient hosiery and shoe length, High wide toe box, resilient wedge sole, lower heel height, and a sesamoid platform
• If flexible deformity: MLA support, and occasionally splints

Forefoot: Morton's Foot

• The objective is to Transfer load from 2nd to 4th metatarsal to 1st metatarsal
• The Prescription is a Sesamoid platform

Forefoot: Claw, Hammer, and Mallet

• Objective is to Transfer pressure from sensitive areas & reduce friction, limit motion of forefoot, and correct the tarsal deformity
• The Prescription is sufficient hosiery and shoe length, a high toe box with lower heel height to transfer pressure to the hindfoot
• Also toe crest to remove pressure from toes, a metatarsal pad to support transverse arch, and a steel sole bar to limit forefoot motion

Forefoot: Hallux Rigidus

• Objectives include limiting motion of the 1st metatarsal and Reduce pressure from the hallux laterally
• Prescription: Sufficient hosiery and shoe length, Rocket bar, Sesamoid platform, and a steel sole bar

Fracture

• The objective is immobilize the injured portion
• Prescription includes a metatarsal pad; phalangeal Fx, a rocket or MT bar; forefoot Fx, an MLA support; Forefoot, midfoot and subtalar Fx, and a steel sole bar; midfoot and hindfoot fx
• Use a soft upper and resilient sole

Leg Length Discrepancy

• Objective: Minimize length discrepancy for optimum gait
• Prescription: Less than 1 inch: heel elevation and more than 1 inch: elevate entire shoe

Heel Stress

• Requires A. Heel cushion and B. Solid Ankle Cushion Heel

Metatarsalgia

• Involves A. MT pad = 2nd-4th MT heads, B. U-shaped pad = 3rd MT head, C. Sesamoid pad = PROXIMAL to 1st MT head, D. Morton's extension = DISTAL to 1st MT head, and E. MT bar = 1st to 5th MT heads

Toe Pain

• Requires use of A. Toe Crest = sulcus behind 2nd to 4th toes

MLA weakness

• Requires A. Scaphoid, navicular, or cookie pads, B. Steel shank and C. Thomas heel

Varus-Valgus correction

• Entails A. Heel Wedge/Flare (RF/HF) where Medial = corrects ankle valgus, and Lateral = corrects ankle varus as well as B. Sole Wedge/Flare (FF) where Medial = corrects FF valgus and Lateral = corrects FF varus

Leg Length Discrepancy(LLD)

• Requires A. Heel elevation = < 1 inch and B. Sole/Shoe elevation = > 1 inch