FILLING THE GAP BETWEEN
THE DOCTOR AND THE SHOE STORE

What’s Right For My Problem

Have a shoe problem but aren’t sure which of our solutions is right for you? We can help narrow things down.

Click on the condition you are suffering from to learn more about the available remedies.


Hard-to-fit Feet

People who have never felt much foot pain (usually young people) seem to be able to stuff their feet into any shoes they happen to like. If they’re a bit tight, so what, they’ll break them in. Others can’t tolerate any discomfort on their feet whatsoever. These are the people for whom shoes purchased out of a box, no matter what the size, just don’t cut it. Purchasing shoes that are extra wide to accommodate wide forefeet generally don’t fit well around the mid-foot and the heel, and people with very narrow feet are simply not serviced well by shoes stores, because the economics of producing and inventorying extra sizes for a minority of customers doesn’t work out well for retail. Then there are the people with 2 different sized feet, feet that are too tiny for adult styles, or feet too big to be fitted in anything but basketball shoes. These are the people who will require some customization of their footwear.

$ Self Help

  • Feet are not that sensitive but not a common size
  • Internet
  • www.zappos.com
  • www.shoes.com
  • Comfort shoe stores that specialize in carrying in carrying a large size inventory.
  • In San Francisco, we recommend On the Run on 9th Avenue and Shoes and Feet on Lombard Street.
  • There are also pedorthic centers that have extensive inventories of ready made shoes in multiple widths.

$$ Self Help

  • Feet are very wide at the ball and toes, or you have bunions
  • Over the counter shoes that are made of elasticized materials, soft weave leather uppers, or very soft kidskin or deerskin.
  • For quick break-in, wet the uppers with alcohol and water, and then wear them until they are almost dry.

$$$ Pedorthist or Shoe Repair Shop

  • Feet that are too sensitive to break shoes in
  • Have them stretched professionally

$$$ Pedorthist

  • Feet that hang over the side of the shoes after they were stretched
  • Cut and spread technique

$$$ Pedorthist

  • Feet are misshapen to the degree that you can’t find comfort by the previous options
  • Be fitted with special therapeutic (not necessarily unfashionable) shoes that come in a wide variety of widths and also have extra depth designed into them.
  • Custom orthotic devices can inhibit feet from spreading and elongating as much on weightbearing.

$$$$ Pedorthist and/or Custom Shoemaker

  • Feet are deformed to the degree that they are no longer shaped like ready made footwear
  • You are unable to find an acceptable style in shoes that fit and are comfortable.
  • Custom made footwear

Common Foot Ailments

There are a number of common foot ailments that are mechanical at the source and can be addressed by footwear and appliances as opposed to surgery. For acute trauma, open sores, discoloration, swelling, heat, loss of sensation or muscle control of your feet, by all means, see a doctor before going to a pedorthist. Our function as pedorthists is to deal with chronic problems as opposed to medical ones.


Planter Fasciitis

One of the most common causes of heel and/or arch pain, that involves inflammation of the thick band of tissue called the plantar facia which runs across the bottom of your foot and connects your heel bone to your toes. A tight Achilles tendon combined with a foot that pronates excessively (arches flatten out on weigh bearing), will precipitate this condition. It may occur in one or both feet.

$ Self Help

  • Occasional pain in the heel or arch with excessive walking in unsupportive shoes.
  • Stretching the Achilles tendon, rest.
  • Supportive shoes with slight heel elevation.
  • Anti-inflammatory medication and hot and cold contrasting baths.
  • Dansko clogs are sometimes helpful, as are shoes with rocker bottom soles.

$$ Retail or Internet Store

  • Consistent pain on weight bearing, even when wearing supportive shoes
  • Over-the-counter inserts that are not too soft of squishy can be helpful. A firm heel cup gives more relief than flat cushioning.
  • There are many brands available, but avoid the cheapest kind found in the drug stores.
  • Ones from sports and athletic shops tend to be better and more supportive.
  • Try on several pairs to determine which are most comfortable and designed for your foot type.

$$$ Pedorthist, Podiatrist or other Foot Care Specialist

  • Constant pain that interferes with your ability to stay active
  • Custom orthotic devices are usually indicated for more severe cases. Besides capturing the exact contours of the bottom of your feet, the surface of the device, by design, manipulates the joints of foot to assume the ideal position for each phase of the gait cycle. A custom orthotic device acts as an interface between the floor of your shoe and your foot with all the joints properly aligned.

Hallux Rigidus / Limitus

In these conditions, the big toe will not bend upwards as the foot propels over it. Not only can it be painful, but compensations made in gait to avoid the pain can cause repercussions throughout the muscular skeleton system. Hallux limitus allows for some movement but the movement can be just as or more painful. Treatment for hallux rigidus involves devices or shoe modifications that inhibit the need for motion in the big toe joint during gait, and treatment for hallux limitus does the opposite, it facilitates motion in the big toe joint, provided the joint has not yet spontaneously fused as it is in hallux rigidus. The root cause of these disorders is excessive pronation.

$ Retail or Internet Store

  • Acquire shoes with stiff, thick soles, preferably shoes where the sole is thicker under the ball of the foot than it is under the toes. This allows the foot to roll forward without bending the toes. These are referred to as rocker soles and there are several ready-made shoes that have them, to one degree or another.

$$ Pedorthist or Other Foot Care Specialist

  • Along with the rocker soles, a thin carbon fiber plate can be inserted into shoes, under the insole, to make the shoe stiffer.

$$$ Pedorthist

  • Nearly any shoe can be modified (orthopedic alteration) to incorporate custom rocker soles. Even if the problem is on one side, the rockers must be put on both shoes because it involves elevating the shoes about ½”.

$$$ Pedorthist or Other Foot Care Specialist

  • Custom Orthotic Devices. Since excessive pronation is the root cause of the problem, it stands to reason that controlling the pronation would effectively slow down or stop the progression of hallux limitus into hallux rigidus. Once the big toe joint (1st metatarsal phalangeal joint [MPJ]) has become rigid, supporting the joint (lifting it) will diminish forces to the area and reduce pain. To lift the joint with hallux limitus could precipitate hallux rigidus, so it should not be done. This amount of control and specificity can only be accomplished with custom orthotic devices.

Posterior Tibial Dysfunction / Tendinitis (PTTD) or Rupture

The PT tendon is the primary supinator or lifter of the inside of the foot and by firing it, you can actively control pronation. Under certain conditions, and in the presence of mal-alignment, the tendon is put under excessive strain which can cause it to become inflamed, tethered, or, in a worse case, ruptured. If one of your feet collapses inward, and the arch suddenly drops beyond your control, you have, more than likely, suffered a ruptured or tethered PT tendon. That is an acute injury and should be diagnosed and treated by a doctor. You may have to wear a special rehab boot, and in severe cases, surgery may be indicated. Subsequent to healing, you can be treated pedorthically.

$ Self Help

  • Of course, rest and anti-inflammatories will help, but if you have inflammation that runs down the inside of your lower leg, behind the inside ankle bone, and under the arch, see a doctor. Don’t mess around with it yourself. A doctor will probably recommend the next option.

$$ Medical Supply Store Or Sport Rehab Store

  • These can fit you with an over-the-counter ankle brace that will give the tendon some support. High to boots may also help, but only in conjunction with custom orthotic devices, assuming the tendon is just inflamed.

$$$ Pedorthist or Other Foot Care Specialist

  • Custom orthotic devices would be indicated, and they should be designed with maximum correction, at least until the problem is resolved. If you live where the terrain is uneven, an articulated AFO (ankle foot orthoses) will stabilize the foot using the lower leg as a pillar of support.

$$$ Pedorthist

  • Ready-made shoes or boots can be modified to be wider in the arch area thereby giving more support from the ground to the affected area.

$$$$ Pedorthist or Custom Shoemaker

  • If one of your arches has completely collapsed, and become deformed with a prominent bone protruding in the arch, custom shoes or boots would be indicated to accommodate the shape.

Achilles Tendonitis

An overuse syndrome that tightens the calf muscles and puts extra strain on the Achilles tendon. Inflammation can occur where it inserts into the back of the heel, or along the middle of the tendon, higher up on the leg.

$ Self Help

  • If swollen, ice and anti-inflammatories are recommended. Then a slow and cautious routine of stretching the calf and tendon. Wearing shoes with a higher heel elevation will also relieve stress on the tendon when walking or standing.

$$ A Medical Supply Store or Sport Rehab Store

  • Purchasing heel cups or lifts to insert in your shoes can help, but shoes must be deep enough to accommodate them without causing heel slipping in the shoes.

$$$ Pedorthist

  • Boots can usually be elevated internally but shoes may need to be elevated externally at the heel by ¼” to ½”. This can throw shoes out of balance so it is best done by a pedorthist rather than a shoe repair shop.

Knee Pain

knee pain

Poor foot function is a contributor to knee problems. When the foot pronates, the lower leg simultaneously rotates internally. The upper leg can internally rotate too, but may not rotate in conjunction with the lower leg because it’s held firmly at the hip, thereby causing a torque at the knee. Pain is usually on the inside (medial) side of the knee. A high-arched foot (supinator) that tends to fall towards the outside, can contribute to lateral instability and pain on the outside (lateral ) part of the knee. A very high arched foot can also cause the knee to hyperextend (bend backwards) causing pain in the front or back of the knee. For many people, the knee starts hurting before the foot does, so people are often unaware that the solution starts by correcting the foot. Other factors are involved in knee pain that relate to wear and tear, over-use, and intensive activities, and a doctor should be consulted to determine the course of action. If the damage is already done, it may be too late to reverse it with orthotic devices, but suffice it to say, it’s a good idea to look at the foot before doing surgery. It is also a good idea to correct poor foot alignment as a prevention to knee problems.

  • $ Sport or athletic shoes known under various brand names as anti-pronators are good for feet that pronate excessively or are very flexible. They are firmer and broader at the base on the medial (inside) where the extra load is borne with that type of foot.
  • $$ Ready-made orthotic devices, which can be obtained at sporting goods stores or shoe stores that specialize in sport shoes. Often there are designations for feet that are over pronators or over suppinators. Drug store ready-made devices tend to be a step down in quality and function compared to the ones at sport shops. Look for devices with a firm heel cup and some firmness in the arch.
  • $$$ A certified pedorthist can modify ready made devices to improve their therapeutic functionality after after assessing mechanical deficiencies in your gait through a biomechanical evaluation.
  • $$$$ Custom Orthotic devices take the previous solution option to a higher level of specificity. Taking molds of the feet not only captures the anatomy, but when done by an expert, the joints are aligned appropriately to one another during the molding process to capture a 3D image of the foot positioned for best function. Then the orthotic devices act as an interface between the foot with all the joints aligned, and the floor of the inside of the shoes. That is why casting should never be done in the weight bearing position. During weight bearing, in unstable feet, everything shifts out of kilter to line up with the floor.

Metatarsalgia

Metatarsalgia is a term used to describe pain in the balls of the feet. It usually occurs with a wearing away of the natural fat pads on the bottom of the feet and occurs with callousing from pressure and shearing. The wear and tear can be the result of having high arched feet, which have less surface contact to share the load, or it can be the result of pronating flexible feet where the long bones of the feet, (the metatarsals), are moving, when they should be stable. The tissue, or fat pads, then gets ground away from the inside by getting caught between a rock (metatarsal bone), and a hard place (inside of the shoe or ground).

Notice the dark areas indicating high pressure spots at the ball on this footprint example.

Notice the dark areas indicating high pressure spots at the ball on this footprint example.

metatarsalgia-2
  • $ Ready-made shoes with soft soles and padded insoles usually help.
  • $$ Rocker soles are also helpful in that they diminish the shearing and pressure on the ball of the foot at the propulsive phase of the gait cycle. The toes also bend less with rocker soles which keep the metatarsal-toe joints (met heads) from protruding.
  • $$ You can purchase matersal pads, which are domed pads that redistribute the pressure to behind the ball at drug, shoe or shoe repair stores.
  • $$$ Ready-made orthotic devices can have metatarsal pads integrated into them and also offer better weight dispersement. Ones with gel in the ball area cut down on the shearing affect that precipitates callousing.
  • $$$$ Custom orthotic devices can be designed to alleviate pressure under specific metatarsal head bones that are painful and calloused. They can also control motion in the metatarsal bones to reduce trauma from underneath the skin.

Morton’s Neuroma

morton's neuroma

A neuroma is a thickening of nerve tissue which, when it affects the foot, most commonly occurs between the third and fourth toes although it can occur in other parts of the foot. The thickening, or enlargement, of the nerve that defines a neuroma is the result of compression and irritation of the nerve. This compression creates enlargement of the nerve, eventually leading to tingling, burning, or numbness and pain. Some describe a feeling that something is inside the ball of the foot or that there’s something in the shoe or a sock is bunched up. Ultimately, if gone unchecked, nerve damage can occur in the guise of numbness in the fourth toe. It is caused by a combination of flexible feet and tight or high heeled shoes. People who are predisposed to this annoying problem usually have very flexible feet where the metatarsal bones are mobile or unstable at the propulsive stage of gait. Instead of just callousing like in metatarsalgia, the nerve is getting pinched between the two metatarsal bones as they move, causing inflammation and swelling, which only exasperate the problem by making the nerve thicker.

  • $ Wear shoes that are not so tight across the ball of the foot. Pumps and ballet flats are not recommended because they must be slightly tight at the ball to stay on the heel and have very thin flexible soles. For women’s dress shoes, switching to a Maryjane style to hold it on will allow for wearing a wider or longer size.
  • $ Shoe stretching can help with shoes that are too tight.
  • $$ Ready-made orthotic devices with a significant metatarsal elevation can also be helpful.
  • $$$ Custom orthotic devices from a certified pedorthist will stabilize the metatarsal bones and reduce the irritation especially if a significant metatarsal pad is incorporated to elevate the fourth metatarsal and thereby increase the spacing between the bones. A pedorthist can also counsel you on proper footwear and integrate the devices with the footwear.
  • $$$$ If non-invasive treatments don’t quite cut it, a cortisone injection my help and in a worse case scenario, surgery can remove the affected nerve with the result being a numb 4th toe.

Hammertoes and Bunions (Hallux Valgus, HAV)

Hammertoes and bunions are fairly common foot deformities. They result from an imbalance of the intrinsic muscles of the feet. Just as any muscle in the body will shorten with overuse, small muscles within the foot, when contracting to overcome structural (bones and joints) deficiencies, will literally pull the foot out of shape to while trying to compensate for those deficiencies. Picture the foot elongating as it takes the load from above while muscles and tendons that run from the back of the foot to the front of the foot are hanging on to both ends. Somethings got to give. Muscles attached to the ends of the toes pull the tips backward causing hammer toes. The medial side of the foot, where the arch is, stretches forward the most causing the muscles attached to the big toe (hallux) to pull it off of the metatarsal bone that is behind it. In most cases it pulls it towards the second toe (valgus, away from the midline of the body) while the metatarsal bone goes the other way making its appearance as a bunion. In less common cases, the hallux moves towards the midline of the body (hallux varus), a more profound deformity making store bought shoes nearly impossible to fit into comfortably.

$ Self Help

  • Over the counter shoes can sometimes work if they are fitted snugly in the back (narrower size than you think), but have elasticized or soft weaved leather uppers, or are made with a very soft kidskin or deerskin. This will allow the upper to form easily over the contours of your bunions and hammertoes. Be careful of shoes that have a hard toe box (the stiffener over the very front of the shoes that help it keep its shape), that area won’t break in. Dampening the shoes in the front with a 50/50 combination of water and rubbing alcohol in a spray bottle will facilitate the break-in, but remember, once they don’t look new anymore, you can’t take them back.

Pedorthist or Shoe Repair Shop

  • $$ You can bring your shoes to a pedorthic facility or shoe repair store to have them spot stretched in the sensitive hammer toes and bunions. Make sure they have equipment that will spot stretch areas without making the whole shoe too big, unless that’s what you need. Any good leather upper can be stretched to greatly improve the fit and accommodate bony prominences.

Pedorthist

  • $$$ If your feet are misshaped to the degree that you can’t find comfort on your own, the next stop would be to go to a pedorthic facility (which you can locate in your area via www.pedortics.com) that specializes in extra wide and extra deep shoes. The therapeutic brands of shoes that they carry are a bit more expensive than shoes from a shoe store, but this is where you will be fitted by someone who will take the time to do it properly. Of course custom orthotic devices will diminish the progression of the deformities by reducing the forces that initially caused the deformities. Typically, the devices won’t reverse the deformities, just make them less painful. Only surgery can re-straighten the toes and reduce the bunion deformity, but without subsequently fitting custom orthotic devices, the deformities could re-occur.

Pedorthist or Custom Shoemaker

  • $$$$ If your feet are deformed to the degree that they are no longer shaped like ready-made footwear, then custom footwear would be indicated. Another indication would be that you cannot find an acceptable style in shoes that also fit and are comfortable. Custom shoes can be quite expensive, especially dressy ones, when compared with ready-made shoes, but they can become one of your most precious possessions. Our company developed a less expensive alternative to fully custom shoes called San Francisco Molded Shoes. They are fabricated by a process where ready-made shoes are deconstructed, then reconstructed over custom lasts made from molds of your feet.

Diabetes

diabetes

It is not the disease itself that makes professional shoe fitting so important, it’s the loss of protective sensation that often gets people with diabetes in trouble. 80% of all below knee amputations in this country are performed on people with diabetes whose problem started with a foot ulcer most commonly caused by improper footwear. That is why diabetes is the only condition in which Medicare and other medical insurance will cover therapeutic footwear. It has been proven that it saves limbs and saves money to the system.

  • $ If you have good sensation and no foot deformities or callouses, you can get by with normal comfort footwear purchased in a shoe store.
  • $$ If you have diminished sensation, but no foot deformities or callouses, you should be fitted by a professional with Ready-made in-depth footwear, and with a soft ready-made insert. Sometimes the ones that come with the shoes are ok.
  • $$$ If you have diminished or absent protective sensation (diabetic neuropathy), mild deformities (hammer toes and bunions), and callousing on the bottom of the foot, you should be fitted by a professional with ready-made in-depth footwear with soft uppers and a custom accommodative insert. Rocker bottoms soles are also helpful in dispersing pressures to the forefoot and toes.
  • $$$$ If you have no sensation, profound foot deformities, callouses, or a history of ulcers, toe or forefoot amputations, you should be fitted with custom molded shoes with rigid rocker bottom soles. If one of your feet are completely collapsed, or if you’ve had an amputation of the forefoot, high top boots would be advised, and in some instances, a brace boot would be prescribed.
  • $$$$$ Dress shoe designs are available for people with diabetic neuropathy, but they are for occasional wear and would be a bit on the bulky side as compared to store bought dress shoes.

Rheumatoid Arthritis

rheumatoid arthritis

Is a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, ankles, and feet. Modern drugs have been able to slow the deforming factors of the disease in people recently diagnosed, but people who have suffered for many years with the disease may have very profound foot deformities. These are the people who come into our office wearing fuzzy bedroom slippers, Crocs, or Uggs, because nothing else is soft and flexible enough to fit over their feet.

  • $ If you have profound foot deformities, but are on a restricted budget, Fuzzy bedroom slippers, Crocs, or Uggs would be your least expensive first line of defense. They offer little support, but can generally accommodate a wide range of unusual foot shapes.
  • $$ If your feet are moderately misshapen, with no bony prominences on the bottom of your feet, you can get by with shoes that have elasticized synthetic or weaved leather uppers.
  • $$$ If you do have bony prominences on the bottom of your feet, but deformities are only on the forefoot, such as hammer toes and bunions, you should have in-depth shoes with elasticized or soft dear skin uppers and custom made inserts.
  • $$$$ If your rigid deformities that involve the entire foot and ankle, with bony prominences on the bottom, custom molded shoes with rocker bottoms are the best solution.
  • $$$$$ If motion in the ankle area is painful during gait, and there are multiple deformities, brace boots or AFO’s may be the solution to reduce painful motion.
ra-2ra-3ra-1

Charcot-Marie-Tooth Disease

charcot1 charcot2

Charcot-Marie-Tooth disease is a group of hereditary disorders that damage the nerves in your arms and legs (peripheral nerves). Charcot-Marie-Tooth is also known as hereditary motor and sensory neuropathy.

The main signs and symptoms of Charcot-Marie-Tooth disease are muscle weakness and decreased muscle size. You may also notice decreased sensation in affected areas. Foot deformities such as hammertoes and high arches are common in Charcot-Marie-Tooth disease. Symptoms usually begin in your feet and legs, but they may eventually affect your hands and arms.

What we notice most often are feet that are week and laterally unstable, (tend to fall to the outside).

  • $ Ready-made high tops, basketball or hiking boots can often add needed extra stability. Also, it’s important to look for shoes that have a wide heel base, that are not too soft and squishy on the bottom. Velcro straps can address hand involvement of the disease.
  • $$ In the presence of marked weakness and lateral instability, flaring and/or lateral wedging are modifications that can be done to ready-made shoes to make them more stable laterally.
  • $$$ For increased lateral stability, and to address hammer toes and bony prominences on the bottom of the feet, in-depth high top shoes with custom inserts would be indicated.
  • $$$$ When walking and balance is profoundly affected by the disease, bracing of the foot and ankle to the lower leg would be indicated (AFO). These can be made independently and worn in ready- made shoes or fabricated into boots with zippers for ease of entry and closure.
  • See braces and brace boots below:
cm-1cm-3 cm-2cm-5 cm-6cm-4

Lymphedema

lymphedema

Lymphedema is a condition characterized by localized fluid retention and tissue swelling caused by a compromised lymphatic system. It most often affects a single limb creating fit issues with footwear. Compression stockings are commonly used to control swelling and reduce stresses on the stretched tissues.


  • $ Ready-made store bought footwear can be used if the shoes open down low on the instep for adjustability, (Fig. 1) and at times, 2 sizes must be purchased. A medium for the unaffected side and an extra wide for the swollen side. Sandals with adjustable straps or lacing will also accommodate a good bit of swelling, (Fig. 2) and simple stretching is also affective as a first inexpensive resort.
  • Fig. 1

    Fig. 1

    Fig. 2

    Fig. 2

  • $$ Ready-made shoes can be modified to make them wider and more accommodating. It is most easily done with sandals by lengthening straps, but shoes can also be cut and split through the bottom to make them wider.
  • l-3 l-4 l-5
  • $$$ Custom made footwear can accommodate nearly any size foot. Effort is always made to obscure the size discrepancy as much as possible.
  • l-6 l-7 l-8 l-9

Post-Polio

post-polio

Polio can have manifested in a person in a large variety of ways, and we see many people in their 60’s and 70’s that are now suffering from post-polio-syndrome, which is a moderate relapse of the disease causing increased weakness in extremities which may have been weak to begin with.

Our experience has taught us that the best approach we can provide is one which re-creates the situation in which a person has become used to walking. Introducing “improvements” to their gait often ends unsuccessfully. That is the reason that people who come in to our office with this condition are often wearing shoes that are 20 or 25 years old. The prospect of getting new footwear can conjure up nightmares from early childhood, and a visit to the shoemaker is often put off until the old shoes are falling off of their feet. Most are already wearing braces on the legs and if they aren’t, this is usually not the time to start.

  • $ Often a person is wearing two different sized ready-made shoes, and one may be altered with an elevation for a leg length discrepancy. In this case, the shoes are usually brought to us and we do our best to modify them to function like their old shoes.
  • $$$ At times, a client will have had custom shoes made in the past and wants a new pair to duplicate the pair that they have since worn out. We may have to transfer the braces from an old pair of shoes to a new pair.
  • $$$$ In some situations, an individual will have worn braces, but now want to try brace or brace boots. Integrating the braces with the footwear will facilitate putting the footwear on, and add a level of convenience.
pp-1pp-2 pp-3

Club Foot Disorders

club-foot1club-foot2

As Pedorthists, we most often see club foot disorders in adults, who as children, had surgical or serial-casting treatments to correct this surprisingly prevalent birth defect. The early treatments (soon after birth) are intended to re-position the feet from turning severely inwards and upwards, to the normal position where the bottoms face the supporting surface. In most cases, the treatments were effective enough to provide relatively normal functioning feet as people grew into adults. There are, however, a number of people whose treatments were not as effective. These people have often had multiple surgeries and can suffer from a neurological deficit of the lower extremities as well. Although their feet may align with the ground, they are by no means pain free and commercial footwear doesn’t come close to alleviating the pain or provide enough stability. Uncorrected club feet are not often seen in our area but when it has been presented, we have made custom boots or custom sandals.

  • $ Self Help: For those whose feet are flexible, but rather short and wide, look for shoes that come in wide widths and have a wide base. Athletic shoes are often the best choice when shopping in commercial stores. If you can’t find wide widths in the store, try shopping on-line where you can search by size and where inventories are more extensive than in stores. When feet are not flexible, and don’t absorb shock well, look for polyurethane bottoms that are bouncy, but they should be stable. Often high-tops like basketball shoes, hiking boots or work boots are helpful. For shoes that are more feminine, low-heel Maryjane’s can sometimes work, but not ones that have a narrow heel base. The heel base should be as wide as the shoes.
  • Narrow bottom, No

    Narrow bottom, No

    Wide bottom, Yes

    Wide bottom, Yes

  • $$ Pedorthist: For short, wide feet, pedorthic facilities have access to therapeutic brands that come in very wide sizes and are shaped more like feet than commercial shoes.
  • Pedorthist: For feet that are irregular on the bottom, custom orthotic devices can alleviate areas of high pressure. If shoes are not wide enough in the middle, they can be made wider by cutting through the center of the shoes longitudinally, opening the cut, then filling it (see illustrations).
  • $$$ Pedorthist or Orthotist: Where muscle weakness is involved because of a neurological deficit, a custom ankle brace may help stabilize the foot by using the lower leg for support. An “ankle gauntlet”, or other types of “AFO’s” are often covered by insurance companies (see illustration).
  • $$$$ Pedorthist or Custom Shoemaker: If the need is to combine stability, and accommodation with lifestyle needs, custom shoes, boots, or brace boots would be indicated. (see illustration)
cf-3cf-6 cf-4cf-5

Post Traumatic Foot Pain and Compartment Syndrome

Foot trauma would include gun-shot wounds, crushing injuries, traumatic amputations, lawn mower injuries, vehicle accidents, falls, or burns. Whatever the cause, the degree to which the foot is repaired is often influenced by the effectiveness of emergency care, and subsequent care. Whereas prescribed surgery is procedurally choreographed, neat, and sterile, post-traumatic surgeries are impromptu, ragged, and dirty. Often the intention is to merely salvage the foot and align it to the ground, ignoring the more dynamic functions that a normal foot is capable of. It’s the subtle dynamic functions that are so easily derailed when the foot suffers a trauma. Whether the damage is to the skin, the bones and joints, the nerves, the musculature, or all four, the result is usually a loss of motion and some profound degree of rigidity. Scar tissue and skin grafts don’t stretch, damaged joints don’t bend, and the muscles and nerves can’t activate appropriate motion. Compartment syndrome, which is swelling confined within the fascia surrounding the muscle body subsequent to the trauma, can cause intense pain.

Pedorthically, post trauma clients present with a relatively rigid foot with areas that can be hypersensitive to contact from footgear. Our goal with a rigid foot is to prevent compensation by other joints to move excessively, or beyond their normal range of motion to make up for the lack of normal motion in the affected foot. Depending on how many joints are affected, rigidity prevents the foot from absorbing shock, adapting to unevenness in the terrain, or staying planted on the ground while the trunk above rotates during gait. Shearing occurs on the skin tissues, especially at the heel, and the lack of suppleness in the tarsals and metatarsals can result in excessive callousing on the ball of the foot. Therefore, our goal is to inhibit the need for motion in the foot with Rocker Bottom Therapy, attenuate shock, shearing, and excessive pressure with Foot Orthotic Therapy, and if necessary, modify or custom make footwear to address the sensitive areas.

  • $ Self Help: Post Trauma, and its colleague compartment syndrome, can have so many degrees of severity that whatever a victim has found before seeking pedorthic help is usually the best choice. If your foot is rigid, you have probably sought out stiff footwear, like hiking boots, with gel type inserts in to attenuate shock and diffuse pressure.
  • $$ Pedorthist: If there is no major deformity, the next level of severity would require custom orthotic devices, made from soft accommodative and shock absorbing materials. Combining that with the application of a rocker bottom sole to a ready-made shoe should therapeutically address most issues.
  • $$$ Pedorthist / Custom Shoemaker: If there are foot deformities, history of ulceration, sensitive scar tissue, or partial amputations, then custom footwear can be designed from the ground up to address each issue specifically, by choosing designs that avoid scars, orthotics of unlimited thickness to attenuate shock and diffuse areas of pressure, sock linings that will absorb shear forces on burns, callouses, and scar tissue by stretching in all directions, and rocker bottom soles to inhibit the need from motion in rigid joints.
  • $$$ Pedorthist / Orthotist: In situations when terrain is uneven, like on a farm, or a construction site, a custom shoe, or possibly a ready-made shoe can be fitted over solid ankle braces made by an orthotist.
  • $$$$ Pedorthist / Custom Shoemaker: In cases where some motion is present, but the motion is limited and painful, then brace boots would be indicated. Brace boots are boots with braces built into the linings and function pretty much like a cast.

Neurological Disorders

Neurological disorders would include any conditions that affect the impulses from the central nervous system to the extremities. The condition may manifest in a lack of protective sensation like what occurs with Diabetes, or it may manifest as an interrupted message to fire a muscle caused by a stroke, brain or spinal injury, post surgical complication or diseases like Polio, Charcot-Marie-Tooths Disease, Multiple Sclerosis, and many many more.

In most cases, the approach is to stabilize a joint that can no longer be controlled by the muscles. Therefore, a device must be applied that can cross a joint while holding on the bones on either side of the joint. In our field, we are most often dealing with the ankle joint.

The ankle joint is stabilized by:

  • Drop foot
  • Lateral instability
  • Medial instability
  • Inability to plantar flex