Medical Education Continuing Prescription · Continuing Medical Education H umans have worn some form of foot covering over their feet for thousands of ... eases such as advanced

OCTOBER 2005 • PODIATRY MANAGEMENTwww.podiatrym.com 129

generally worn to protect the foot,recent studies performed to deter-mine the causes of lower extremityamputations have identified thatfor nearly half of the amputees inthe various study groups, the initialevent that led to the amputationwas either shoe-related or mighthave been averted by wearing ap-propriate shoes.

Most of the shoe-related ampu-tations occurred in older individu-als with multiple pathomechanicaland pathophysiologic problems,such as foot deformities accompa-

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You may enroll: 1) on a per issue basis (at $17.50 per topic) or 2) per year, for the special introductory rate of $109 (yousave $66). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the nearfuture, you may be able to submit via the Internet.

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Humans have worn someform of foot covering overtheir feet for thousands of

years. This has been demonstratedby the intact pair of fur moccasinsworn by a hunter who lived 5,300years ago and was recently discov-ered frozen in the mountains sepa-rating Italy and Austria. Peoplehave long worn foot coverings for anumber of obvious reasons, includ-ing to serve as protection from theenvironment, as an aspect of fash-ion or status, as an aid to function-

By Mark A. Caselli, DPM

PrescriptionShoes for FootPathology

Using footwear properly adds to yourtreatment armamentarium.

Goals and ObjectivesAfter reading this article, the

physician should be able to:

1) Recognize the indications forprescription shoes and shoe modi-fications.

2) Properly measure a patient’sfoot for prescription footwear.

3) Select appropriate footgearfor various types of foot patholo-gies.

4) Understand the propermethod of taking an impressioncast for the fabrication of custom-made molded shoes.

5) Prescribe shoe modificationsfor a wide variety of foot disorders.

The basic functions of a shoe are

foot protection, support,

and pain relief.

ing in various sports and work en-deavors, and to assist in ambula-tion when there is an impairmentto normal gait. While shoes are

perature. Protection must alsobe provided from the internalstresses placed upon the tissuesof the foot by the enclosedshoe. A shoe should providesupport for the foot, especiallyin the presence of weak andsensitive feet, to increase lowerextremity stability. Finally, ashoe should provide pain reliefby transferring weight-bearing

stresses awayfrom painfulareas, shield-ing painfullesions fromexternal irri-t a t i o n s ,g u a r d i n gagainst skinbreakdown ofthe hypo-es-thetic and poorlyvascular foot, andseparating painfulstructures fromphysical contact.

Further con-siderations forthe use of shoes

and shoe modifications in the man-agement of foot pathology shouldinclude the following specific func-tions that shoes can serve:

1) Accommodate for fixed orrigid foot deformities such as severehallux abductovalgus, hammer orclaw toes, and tailor’s bunions;

2) Diminish pressure on dorsaland plantar aspects of the feet;

3) Redistribute weight bearingfrom areas of excessive pressure orpain;

4) Support the foot and leg inthe presence of neuromuscularweakness as present in systemic dis-eases such as advanced rheumatoidarthritis, polio, neuromuscular dis-orders, and diabetes;

5) Improve foot function by re-ducing excessive pronation orsupination;

6) Incorporate partial foot pros-theses;

7) Limit painful joint move-ment;

8) Equalize limb length discrep-ancy;

9) Provide cosmetic and func-tion improvement for poorlymatched feet;

10) Accommodate for edema;and

11) Serve as an alternative tofoot surgery.

Fitting of ShoesIn order for a shoe to achieve

its desired function and not beharmful to the foot, it must firstand foremost fit properly. Threeessential measurements are re-

quired to determine shoe size: theoverall foot length (heel to toe),arch or ball length (heel to 1stmetatarsophalangeal joint), andwidth. The proper shoe size is theone that accommodates the headof the 1st metatarsal (i.e., thewidest part of the foot) in thewidest part of the shoe. It is forthis reason that shoes must be fitby arch length rather than byoveral l foot length. Both theBrannock device, which is avail-able in three types, for men,women, and children, and theRitz stick give the ball width, the


130 www.podiatrym.comPODIATRY MANAGEMENT • OCTOBER 2005

Prescription Shoes...

nied by diabetes and poorlower extremity circulation. In

order to utilize footwear to protectthe foot from injury and improveambulation, the podiatric practi-tioner must be thoroughly familiarwith the many functions that shoescan serve, the proper method of fit-ting shoes, the factors that go into

determining the patient’s footwearneeds, and the types of specializedshoes and shoe modifications thatare available to fill these needs.

The Function of ShoesThe basic functions of a shoe

are foot protection, support, andpain relief. Protection includesshielding the foot from the harmfulexternal environment of sharp ob-jects, caustic chemicals, insect andanimal bites and extremes of tem-

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Figure 3: Open and closed-toed post-opera-tive shoes

In order for a shoe to achieve its

desired function and not be harmful to the

foot, it must first and foremost fit

properly.

Figure 1: The Brannock device (top) and Ritz stick are usedto determine shoe size.

Figure 2: A tongue pad is placed inthe shoe (right) of the shorter footto ensure snug fit

heel to ball length, and the heelto toe length, and are commonlyused in determining the shoe size(Figure 1).

Foot measurements should betaken with the patient standing,since the foot tends to spread onfull weight bearing. Because theseshoe-measuring devices give onlytwo-dimensional measurements,and feet arethree-dimen-sional, thesedevices giveonly a roughestimate of theproper shoesize to fit thepair of mea-sured feet.Shoe sizes alsovary consider-ably with theirstyle, con-s t r u c t i o n ,brand, heelheight, lasttype, and shoem a t e r i a l s .Good shoe fit-ting shouldtherefore include proper fit to thefoot’s overall length, ball width,heel to ball length, arch height,heel width, instep width, and greattoe joint height.

Allowances should also bemade for the increases in foot vol-ume that often occur under vary-ing circumstances. There can be asmuch as a five percent increase in

foot volume in anormal foot fromthe morning to theevening as well asincrease in foot vol-ume after complet-ing a rigorous activi-ty, such as jogging,walking, or even along day of shop-ping. Feet should bemeasured for shoes at the end of

the day orafter fre-quently per-formed physi-cal activities.Foot volumealso tends toincrease dur-ing warm andhumid weath-er and in thepresence ofpathologicaledema.

If onefoot measuress l i g h t l ylonger, thep a t i e n tshould al-ways be fit

for the longer foot. A tongue padcan be used in the shoe for theshorter foot to ensure a snug fit. Atongue pad can be made of adhe-sive backed felt and placed on theunderside of the tongue. Thethickness of the pad is determinedby the amount of space that isavailable when the shoe is exam-ined, but generally 1/8 to 1/4 inch


Prescription Shoes... is ade-quate. Itfunctions byholding the footfarther back in theshoe, thereby keep-ing the ball of thefoot in the widestpart of the shoe andthe heel snugagainst the counter

of the shoe (Figure 2).

Foot Evaluation for PrescriptionFootwear

When considering the use ofprescription footwear for the man-agement of foot pathology, theclinician must perform a thorough

foot evaluation and list all of thepatient’s pedal abnormalities sincethe eventual shoe and shoe modifi-cations must address all these is-sues. A careful inspection of the pa-tient’s current footwear is also use-ful in determining the most appro-priate prescription.

Skin color and temperature of

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Figure 7: Plastazote toe filler to be used in the depth inlay shoe

Figure 5: Healing shoe withVelcro closure

Figure 4: Post-operative shoe with weight-dispersing insole

Prescriptions ofteninclude modifications to shoes which can

reduce the motion ofspecific painful or

arthritic joints.

Figure 6: Depth inlay shoe with removable insole toaccommodate a foot orthosis

occur after lower extremity sur-gery, or a chronic problem. For

temporary swelling,shoe fitting shouldbe postponed untilthe edema resolves.In the case ofchronic edema,shoe fit should bechecked frequently,since the edemamay get worse or

improve, and the shoe may haveto be changed frequently. Thismay be a major factor in selectinga shoe, especially if the patient re-

ports a history ofvarying edema.

ComplicatingFactors

In addition to thespecific pedal prob-lems that may direct aclinician to considerutilizing prescriptionfootwear, the follow-ing conditions tend toadd complicating fac-tors to the patient’spedal condition andmust be consideredwhen selecting shoesand shoe modifica-tions. These condi-tions also tend to bemost severe in thegeriatric population,which is the popula-tion that most oftenrequires prescriptionfootwear.

from a congenital abnormality,partial foot amputation, or unilat-eral edema wouldrequire an entirelydifferent approachto footwear.

Gait abnormali-ties such as a drop-foot, limp, abduct-ed, adducted, cir-cumducted, or shuf-

f l i n g ,apropulsive gait willdetermine many as-pects of the shoe pre-scription, especially ifthe shoe must accom-modate a brace. Alimb-length differencemust be assessed as toits duration (recent orexisting for manyyears) as well as to theexact measurement ofthe difference, as thesefactors will determinethe degree of correc-tion indicated andthus the type of shoerequired.

The presence andseverity of edema ofthe foot must also be

evaluated. It is important to deter-mine if the edema is a recent oc-currence and temporary, as might



the patient’s foot should beassessed with special attention

to areas that are erythematoussince they may identify locationsof increased friction or pressurethat must be relieved. Cyanotic,cool areas are of equal impor-tance as they may indicate loca-tions of poor circulation and po-

tential areas for tissue breakdownfrom minimally applied stressfrom the shoe. Joint ranges ofmotion must also be assessed asto their range of motion andwhether or not there is pain withmovement of the joint. The mostimportant joints to evaluate in-clude the ankle, subtalar andmidtarsal, and the metatarsopha-langeal joints, with special atten-tion to the 1st metatarsopha-langeal joint.

Prescriptions often includemodifications to shoes which canreduce the motion of specificpainful or arthritic joints. Thepresence of lesions, ulcers, or cal-losities and their specific locationas well as any biomechanical de-formities such as bunions or ham-mertoes should be recorded andadded to the shoe prescription.Foot size discrepancy is an impor-tant consideration in determiningwhat type of shoe might be neces-sary. A small difference in lengthcan be easily accommodated as de-scribed earlier, while a significantvariation in foot size resulting

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Figure 9: Women’s dress styledepth-inlay shoe

Figure 10: Bunion last shoe offering extra-wide toe-box

Figure 11: Custom-made molded shoes for varyingdegrees of foot deformities


Figure 8: Athletic style depth inlay shoe

A careful examination of

the patient’s currentfootwear can give thepractitioner a wealth

of information in determining what

type of shoe and shoe modificationsmight be needed.


betes, greatly in-creasing the chanceof infection and ul-ceration at areas ex-periencing evenonly a slight in-crease in pressure.

6) The arthridi-ties, especially os-teoarthr i t i s andrheumatoid arthri-tis. The degenera-t ive ar t icularchanges in os -teoarthr i t i s aregreatly increasedwhen there i s ab i o m e c h a n i c a lpathology such asa hallux valgus de-formity, a condi-t ion for whichprescription foot-wear is often uti-l ized. I t must betherefore recog-nized that thiscondition may de-ter iorate evenwhen appropriate

shoes are worn. Rheumatoidarthritis does not only compli-cate the already existing biome-chanical pathology but producesfurther soft tissue atrophy andlateral deviation and overridingof the toes.

1) Loss of elasticity of fibroustissue in the skin, ligaments, andfascia. Severe forms of mechanicalcorrection with a shoe should beavoided. No attempt should bemade to force the foot into anynew or different position whereverresistance is met.

2) Atrophy of adi-pose tissue in the soleof the foot. This resultsin little or no shockabsorbing cushioningto protect the sensitiveosteoporotic bones orthe fragile plantar skinfrom the trauma of or-dinary weight-bearing.

3) Reduction ofmuscle potential de-creases the efficiencyof the locomotor appa-ratus.

4) Peripheral vas-cular disease results inguarded viability oftissues and pretrophicareas around biome-chanical faults.

5) Peripheral neu-ropathy results in lossof protective sensa-tion, common in dia-

7) Osteoporosis canresult in fractures fromcompara t i ve l y minor injuries.

Finally, a careful examinationof the patient’s current footwearcan give the practitioner a wealthof information in determining

what type of shoe and shoe modi-fications might be needed. Boththe interior and exterior of theshoe should be examined forwear. The insole should be as-sessed for both locat ion anddepth of depressions. The interiorof the toe box should also be ex-amined for elevated areas, as wellas wear, both indicating pressurepoints created by bony promi-nences . Heel and sole wearshould also be noted. A detailedhistory of custom shoe use andshoe modifications can be mosthelpful.

Selecting a ShoeWhen being presented with a

patient requiring prescriptionfootwear, there are some initialconcerns that should be takeninto account before proceedingon to the shoe prescription, sincethey may alter the type of shoeselected.

1) Immediacy of need—Whendoes the patient require the shoeand how soon can one be ob-tained? The use of the “ideal” shoemay have to be postponed in orderto get the patient into footwearnow.


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Figure 14: Hoke ball-and-ring stretcher

Figure 15: Standard shoe stretcher

Figure 12: Custom-made shoes for marked limb-lengthdifference

Figure 13: Bivalve impression cast with plaster positiveand resulting custom-made molded shoe

When being presented with a patient

requiring prescriptionfootwear, there are

some initial concernsthat should be takeninto account before

proceeding on to theshoe prescription, sincethey may alter the type

of shoe selected.

vival, must be stressed. A com-promise on style, if appropriate,should also be presented. If pos-sible, both spouses should be in-cluded in this consultation ses-sion. The patient’s spouse mayserve as an advocate or an antag-onist to the patient wearing the“orthopedic” shoes. It is not un-common to have a wife complainthat a prescribed shoe makes herhusband look an old man, evenif the husband is over 80 yearsold!

4) Patient’s ability to put onand remove shoes—If the patientcannot perform this task due to amedical condition or mental status,

it must be deter-mined whetheror not there issomeone elseavailable to takeon this responsi-bility before acustom prescrip-tion shoe is or-dered.

Basic Types ofPrescriptionShoes

There arethree basic typesof prescriptionshoes used for pa-tients with vari-ous forms of footpathology: 1)pos t -opera t iveshoes; 2) depthinlay shoes; and3) custom-mademolded shoes.

Post-OperativeShoe

Post-operativeshoes were ini-tially designed tobe used follow-ing surgery inorder to accom-modate extremeswelling andbulky dressings.They are con-structed with awide forefootand are availableas either open orclosed toe mod-els (Figure 3).

The uppers are made of canvas ormore commonly nylon mesh witheither Velcro straps or lace clo-sures. Most come with a rigid rock-er sole to allow the patient to walkwhile limiting joint motion. Oneof the major advantages of thistype of shoe is its very low cost,making it possible for the clinicianto keep them on hand in the of-fice, providing immediate avail-ability to the patient.

In addition to being used inaccommodating for swell ing,edema, or dressings, the post-op-erative shoe can be used to relieveboth dorsal and plantar foot pres-sure on bony prominences fromrigid foot deformities. To relieveplantar pressure, a weight-dispers-ing insole can be added due to theabundance of space available (Fig-ure 4).

The post-operative shoe canbe used as the primary footwearfor patients who are engaged inminimal ambulation or are non-ambulatory. They can also beused as interim footwear whilewaiting for another type of pre-scription shoe. The major disad-vantage of the post-operativeshoe is the limited size selection,most being available in women’ssmall, medium, and large, andmen’s small, medium, large, andextra large.

A sturdier modif icat ion ofthe post-operative shoe is thehealing shoe. This is a closed-toe, extra-wide shoe made from




2) Cost—The perfect shoehas no value if it cannot be pro-

vided to the patient. An affordableshoe that meets the patient’s mostcritical needs will do the mostgood.

3) Style—A prescription shoeis of no benefit if the patient re-fuses to wear it because of theway it looks. This aspect of usingprescription footwear should al-ways be discussed with all pa-tients, both men and women.The need for the prescriptionfootwear and its importance tothe foot health, even foot sur-

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A depth-inlay shoe is usually one

size longer (1/3 inchlonger) and two sizes

wider (1/2 inch wider in circumference

at the level of themetatarsophalangeal

joints) than thecorresponding regular shoe.

Figure 18: Elastic band closure for easy insertion of foot inshoe

Figure 17: Cut-out of shoe upper to reduce pressure onbony prominence

Figure 16: Splitting upper of shoe to accommodate forfoot deformity


the level of the metatarsopha-langeal joints) than the corre-sponding regular shoe. The depthinlay shoe usually comes in abasic oxford style, but is more re-cently available as both an athlet-ic and dress shoe (Figures 8 and9). They are available in a widerange of shapes and sizes for bothmen and women and can be usedfor all but the most severely de-formed feet.

The two most commonshapes, or last modifications, or-dered are the bunion last and thecombination last.In the bunionlast shoe, theforepart of thelast swings medi-ally to accommo-date the buniondeformity andthen swings out-wardly to accom-modate the fifthmetatarsal head.A bunion last ox-ford shoe is a lowheel , laced orVelcro closured shoe with a broadtoe box made of soft leather toprovide ample room for a severebunion deformity (Figure 10). Acombination last shoe combinesa narrow heel and a wider ball.The heel measurement is oftentwo widths narrower than theball. This type of shoe is indicat-ed for a patient with a wide fore-foot, but a small narrow heel, inorder to prevent heel slippage.Depth inlay shoes can be orderedwith a Plastizote liner to accom-modate for pressure points aswell as with a variety of heel andsole modifications.

Custom-Made Molded ShoesA custom-made shoe is a shoe

constructed from a model madefrom a cast of the patient’s foot.This type of footwear is neededonly in cases where a depth-inlayshoe cannot be modified to meetthe patient’s needs. Indicationsfor custom-made molded shoesinclude:

1) Severe foot deformities suchas talipes equinovarus, equinoval-gus, extreme hallux valgus, rigidhammertoes, and Charcot foot (Fig-ure 11).

a ny lon-covered moldab lepolyethylene foam and can bemolded directly to the patient’sfoot (Figure 5). Its indicationsare the same as the post-opera-tive shoe. Unlike post-operativeshoes, healing shoes come in awide range of sizes, providing abetter fit. They are much moreexpensive than post-operativeshoes so they are not practicalto keep in stock in an off ice.They are indicated when thistype of footwear is required for alonger period of time in an am-bulating patient.

Depth-Inlay ShoeThe depth-inlay shoe, often re-

ferred to as an added-depth or in-depth shoe, is the most commontype of prescription footwear uti-lized in the management of nu-merous foot pathologies. Thedepth-inlay shoe is a roomy shoewith a removable insole measur-ing 1/4 inch to 3/8 inch in thick-ness. Commercially available orcustom-made orthoses and otherfoot appliances can be easily in-serted into this kind of shoe afterremoving the original insole (Fig-ures 6 and 7).

As a rule, a depth-inlay shoe isusually one size longer (1/3 inchlonger) and two sizes wider (1/2inch wider in circumference at

Prescription Shoes... 2) Marked leg-lengthdiscrepancy (Figure 12)

3) Marked foot size dis-crepancy, congenital absenceof various parts of the foot, orfoot amputations often requirethe combination of molded shoesand various foot fillers so thatthese patients can wear matchingshoes.

4) Feet with peripheral neu-ropathies resulting in loss of protec-tive sensation may require a mold-ed shoe for protection from repeat-ed trauma that can produce skin

necrosis.5) Feet with

severe peripheralvascular diseasethat heal veryslowly from evenminor injuries.

6) Feet withsevere arthritis,such as rheuma-toid arthritis,which involvesnumerous jointsproducing syn-ovitis, deformi-

ties, exostoses, instability, subluxa-tions, and dislocations that makethem prone to injuries.

The shoe upper of custom-made molded shoes can be orderedwith a high toe-box and is usuallyconstructed of soft leather withthe whole lining also made ofleather. When a bony prominenceis present on the dorsum of the

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A custom-made shoe is needed only

in cases where a depth-inlay shoe

cannot be modified to meet the

patient’s needs.

Figure 19: Surgical lace-to-toe closureFigure 20: Flare heel increases rear-foot stability


A foot cast is required for thefabrication of a custom-mademolded shoe. The cast must cap-ture the contours of the foot ex-actly and be removed withoutdamaging it or the foot. The footcast is taken with patients seatedwith their feet on a foam-coveredplatform. The cast should be takenin a semi-weight bearing positionencompassing both the foot andankle with the knee at 90 degreesflexion and the ankle also at 90degrees if possible. Casts are com-monly taken in a bivalve, two-piece form (Fig-ure 13).

A full weight-bearing tracingof each footshould also betaken to accom-pany the cast tothe laboratory.The main disad-vantage of thec u s t o m - m a d emolded shoe isi ts expense, apair usually cost-ing the patientbetween $400dollars to over$1,000 dollars .Because theseshoes are hand-crafted from a castof the patient’s foot and follow itscontours, they may have an un-usual shape and are often consid-ered cosmetically unacceptable bymany patients.

Shoe Modifications

The various parts of the shoeupper can be enlarged or maderoomier to accommodate for bonyprominences, ulcers, or pre-troph-ic areas. One of the advantages ofusing leather for shoe construc-

tion is that leather not only con-forms to the foot through thecourse of normal wear, but canalso be forced-conformed bystretching. Spot stretching can beaccomplished with the use of aHoke ball-and-ring stretcher (Fig-ure 14) or a shoemaker’s swan.These devices are used in conjunc-tion with the application of astretching fluid, which is a fifty-fifty mix of rubbing alcohol andwater.

Another type of stretching isused to increase the width, and to

a lesser degree,the length of apatient’s foot-wear. There aretwo types of de-vices used forthis purpose.One is the tradi-t ional shoestretcher, whichis available invarious configu-rations and caneasily be used inthe office (Figure15). The other,the Eupidus de-vice, is used forgeneral stretch-ing and is found

in shoe repair, pedorthic, and or-thotic facilities. This device hasthe advantage of greater leveragein stretching the shoe and is need-ed for shoes that are constructedof thick leather.

Splitting or making cruciatecuts through the shoe leather andits underlining (Figure 16), or bysimply cutting out the impingingportion of the shoe upper (Figure17), can offer immediate reduc-tion in pressure. A more perma-nent method of accommodating



foot, a 1/8 inch thick, softdensity, Plastizote lining can be

built into the shoe’s upper. Theinsole is usually ordered with 1/2inch thick Plastizote, the top 1/4inch made of a medium-densityPlastizote for cushioning, and the

bottom 1/4inch made off i rm-dens i tyPlastizote forsupport.

The insoleextends fromthe heel to thetoes and pro-vides totalcontact for theentire plantarsurface of thefoot. Themolded shoeusually has aflat sole thatpermits maxi-mum groundcontact andsupport. Sincethe relativelythick rubbersole is not tooflexible, andboth the in-sole and out-sole cradle thefoot, there ism i n i m u mamount ofdorsi-flexion,

plantar-flexion, and medial andlateral rotation of the foot duringambulation, resulting in minimumstress on the foot. This stiffnesscan sometimes present the prob-lem of heel slippage in the moreactive patient with a propulsivegait. A rocker sole can be added ifthis occurs.

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Figure 24: Basic rocker-sole modification

Figure 22: Sole liftfor leg-length dis-crepancy

Figure 23: Metatarsal bar modification

Figure 21: Stabilizer(or buttress) addssupport to shoe

One of the advantagesof using leather for shoe construction is that leather not only

conforms to the foot through the course

of normal wear, but can also be

forced-conformed bystretching.



ing the shoe on the foot (Figure18). Velcro and zipper closuresare beneficial for patients who

have difficulty in tying laces,such as those with severe arthritis

for an isolated bony prominenceis applying a balloon patch to theshoe. A balloon patch involvesthe cutting of the upper of theshoe away from the area of theaffected toes or joints. Once theleather has been removed, apatch of deerskin or other softmaterial is applied loosely overthe cut-out and dyed to matchthe shoe.

Shoe closures can also be cus-tomized and should be selectedto match each patient’s needs.Common closures include eyeletsand shoe laces, elastic bands, Vel-cro straps, and zippers. Elasticbands allow for easy insertion ofthe foot into the shoe while keep-

Prescription Shoes... or paralys is of theirhands. A surgical lace-to-toe closure has lace stays orVelcro straps that extend allthe way to the toe (Figure 19).This closure is useful for patientswho have difficulty getting theirfoot into a shoe. It is commonlyused with ankle orthoses, for anedematous foot and ankle, for aflaccid or obese foot, or for feetaffected by neurological disor-ders, such as cerebral palsy ormyelomeningocele.

Modifications of the Heel andOuter Sole

Medial or lateral heel, or heeland sole wedging, is added to foot-wear to accommodate for excessive

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Medial or lateral heel, or heel and sole wedging, isadded to footwear to

accommodate forexcessive pronation or

supination and toimprove stability.


A B

C D

Figure 25 a,b,c, and d: Rocker-sole modifications for varying levels of foot amputations. The position of the apex of therocker is noted by the arrow.

extends from the midshank area tojust proximal to the anterior tip ofthe shoe, with its highest point atthe ball of the shoe (Figure 24).When used for partial foot ampu-tations, placement of the rocker isgoverned by the level of amputa-

tion. As the foot be-comes shorter, theapex of the rockermust be placed moreproximal (Figures 25a,b,c and d).

A long (heel-to-toe)spring steel shank is astrip of steel or carbonfiber that is placed be-tween the layers of thesole from the heel to

the toe box to provide rigidity forthe entire outsole (Figure 26). It ismost commonly used with a rock-er-sole. It prevents the shoe frombending and thus limits toe andmidfoot motion. It is often usedafter transmetatarsal amputationsand in the treatment of painfulhallux limitus. ■

References1 Bumbo N: Utilizing footwear as a

therapeutic modality. In Valmassy RL(ed.), Clinical Biomechanics of theLower Extremities, Mosby, St. Louis,1996.

2 Cheskin M: Custom-molded foot-wear-one size only. Podiatry Manage-ment 2004; 23(8)

3 Janisse DJ: Orthoses, shoewear,and shoe modifications. In Myerson MS(ed.), Foot and Ankle Disorders, W.B.Saunders Company, Philadelphia, 2000.

4 Janisse DJ: Prescription footwearfor arthritis: a team approach. PodiatryManagement 2003;22(8)

5. Reiber GE: Who is at risk of limbloss and what to do about it? Journal ofRehabilitation Research and Develop-ment 1994;31(4)

6 Shor RI: Preventive footwear forrecurrent diabetic foot ulcers. PodiatryManagement 2004;23(8)



pronation or supination andto improve stability. The wedge

can be inserted between the upperand the sole or placed directly tothe bottom of the shoe. A medialwedge might be used for posteriortibial tendon dysfunction, severeflexible flatfoot, or plantar fasciitisproblems. A lateral wedge may beindicated for peroneal tendinitis.

A flare heel is used to increaserearfoot stability. The bottom ofthe heel in contact with theground is wider than the top ofthe heel (Figure 20). The exten-sion of the flare is usually equal tothe widest part of the shoecounter. The flare heel increasesthe base of support, keeping theheel from turning over. It also de-

creases stress on the heel andankle.

The solid ankle cushion heel(SACH) consists of a wedge ofshock-absorbing material that isinserted into the posterior mid-sole of the heel. Its purpose is toprovide a maximum amount ofshock absorption at heel contactand rebound immediately forthe next heel strike. The SACHheel is often used in conjunc-tion with short-leg braces or legprostheses, after a calcaneal frac-ture , o r fo r synov i t i s o f theankle.

If a shoe’s upper shows signs ofbreaking down medially or lateral-ly because of severe pronation orsupination, a medial or lateral sta-bilizer (or buttress) may be addedto the shoe. The stabilizer is an ex-tension placed on the side of theshoe, including the sole and upper

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n(Figure 21). The stabilizer is madefrom rigid foam or crepe and pro-vides greater support than the flareheel.

The sole lift is mainly used totreat leg length discrepancy (Figure22). The thickness of the sole de-pends on the amountof shortening present,the length of time thediscrepancy has beenpresent, and the degreeof compensation thathas already taken place.The sole lift is alwaysaccompanied with arocker sole.

Metatarsal BarsMetatarsal bars are often

placed on shoes to provide pres-sure rel ief for symptomaticmetatarsal heads and their adja-cent structures. A typicalmetatarsal bar is approximately1/8-inch to 3/8-inch high, madeof leather or soling rubber, and isfixed transversely across the bot-tom of the outsole with its apeximmediately proximal to themetatarsal heads (Figure 23). It isoften used for the treatment ofsesimoiditis, hallux rigidus, plan-tar callosities, and fractures of themetatarsals.

Rocker-SolesA rockersole modification is

used for any type of pathologic orpathomechanical condition thateither limits normal movement ofthe ankle, tarsal, or metatarsopha-langial joints or in situationswhere it is desirable to limit suchmotion. The rocker-sole providesa smooth rocking motion fromheel to toe to imitate the heel riseand push-off sequence of normalgait. It allows for very little mo-tion to occur at the metatasopha-langial joints with a significantreduction of motion at the ankle,subtalar, talonavicular, calca-neocuboid, and tarsometatarsaljoints.

The rocker-sole can be used inthe treatment of metatarsalgia;fractures of the metatarsals andphalanges; insensitive feet; arthri-tis, fusions, and subluxations ofthe ankle and joints of the rear-foot; and after partial foot amputa-tions. The rocker sole commonly

Figure 26: Long (heel-to-toe) spring steel shankplaced between layers ofsole.

Dr. Caselli isStaff Podiatristat the VA Hud-son ValleyHealth CareSystem and isAdjunct Profes-sor, Depart-ment of Ortho-pedic Sciencesat NYCPM. Heis Former Chairman, Department ofOrthopedic Sciences at NYCPM.

The rocker-sole provides a smooth

rocking motion from heel to toe to imitate the heel rise and

push-off sequence ofnormal gait.


neutral position.B) Reposition deformed footsegments.C) Maintain and protect thefoot in its presenting position.D) Align the heel so that it isvertical to the ground.

6) Which one of the following isnot an advantage of a post-opera-tive shoe?

A) Affords excellent foot pro-tection from the external envi-ronmentB) Is inexpensiveC) Immediate availabilityD) Easily accommodates se-vere edema

7) What type of shoe might beused when a sturdier version of apost-operative shoe is required asin the treatment of a conditionthat requires foot bandaging for along period of time?

A) Custom-made molded shoeB) Orthopedic oxford shoeC) Added-depth shoeD) Healing shoe

8) The most common type of pre-scription footwear used in themanagement of foot pathologyand ulcer prevention is:

A) Depth-inlay shoeB) Tarso-supinator shoeC) Custom-made shoeD) Molded polyethylene foamshoe

9) The key feature of the depthinlay is:

A) A soft leather upperB) A Velcro closureC) An ample removable insoleD) A rocker-sole

10) What would be the best shoeto prescribe for a patient with awide forefoot and a narrow heel?

A) Custom-made molded shoe

1) The most important criteria forthe use of a shoe in the manage-ment of foot pathology is that theshoe must:

A) Address all of the footpathologies presentB) Reduce foot pronationC) Fit properlyD) Be custom made

2) Which one of the following isnot a commonly used measure-ment when fitting a shoe?

A) Overall foot lengthB) Arch heightC) Arch or ball lengthD) Width

3) The main problem with relyingsolely on the measurement ob-tained with a Brannock device forproper shoe fit is that:

A) A Brannock device onlymeasures adult sizes.B) A Brannock device cannotmeasure ball width.C) A Brannock device onlygives a rough estimate of size.D) A Brannock device must beused with a Ritz stick for aproper measurement.

4) How should a patient be fit fora shoe if one foot measures slight-ly longer than the other?

A) Fit for the shorter foot andstretch the shoe for the longerfoot.B) Fit for the longer foot andadd a tongue pad to the shoefor the shorter foot.C) Fit for the longer foot andadd a heel pad to the shoe forthe shorter foot.D) Fit for the longer foot andadd a toe filler to the shoe forthe shorter foot.

5) When arthritis results in severejoint stiffness, mechanical correc-tions in a shoe should:

A) Strive to maintain subtalar

B) Combination last shoeC) Healing shoeD) Depth-inlay shoe

11) An eighty-five-year-old patientwith a severe talipes eqinovarusfoot deformity would best be fittedwith which one of the followingshoes?

A) Custom-made moldedB) Bunion last depth-inlayC) Combination last depth-inlayD) Healing shoe with customorthosis

12) Custom-made molded shoesare usually prescribed with removable insoles made of whatmaterials?

A) 1/4 inch medium Plastizotetop with 1/4 inch firm Plasti-zote bottomB) 1/2 inch firm PlastizoteC) 1/2 inch neoprene rubberD) 1/4 inch Poron top with 1/4inch medium Plastizote bottom

13) What modification can beadded to a custom-made moldedshoe to reduce heel slippage?

A) More rigid soleB) High heel counterC) Rocker-soleD) Metatarsal bar

14) What type of cast is requiredfor the fabrication of a custom-made molded shoe?

A) Off-weight-bearing slippercastB) Semi-weight-bearing slippercastC) Off-weight-bearing foot andankle impression castD) Semi-weight-bearing footand ankle impression cast

15) A patient presents with a newpair of depth inlay shoes. He com-plains that his 3rd toe is rubbingon the top shoe. You find he has a

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140 PODIATRY MANAGEMENT • OCTOBER 2005

rigid 3rd hammertoe. What is the best shoe modifi-cation in this situation?

A) Cut a hole in the shoe over the hammertoe.B) Make a linear cut in the upper of the shoeover the hammertoe.C) Spot stretch the upper of the shoe over thehammertoe.D) Add a rocker bar to the shoe.

16) What type of shoe modification can be pre-scribed for a patient with a spastic equinus foot who has difficulty in slipping his foot into a shoe?

A) Velcro closuresB) Surgical lace-to-toe closureC) Elastic band closureD) Zipper closure

17) A patient presents with a prosthetic limb follow-ing a below-knee amputation. What heel modifica-tion is recommended for the shoe that is to be fit-ted to the prosthetic limb?

A) Flare heelB) Medial heel wedgeC) Lateral heel wedgeD) Solid ankle cushion heel

18) A patient presents with severe foot pronationwhich results in the breakdown of the medial aspectof his shoes, even when using supportive in-shoe or-thoses. What modification can be added to hisshoes to offer greater support?

A) Lateral sole wedgeB) Medial stabilizer (buttress)C) Rocker-soleD) Flare heel

19) What shoe modification would be used to re-lieve the joint pain caused by a hallux limitus?

A) Rocker-soleB) Sole liftC) Medial buttressD) Lateral sole wedge

20) Which one of the following is not true about arocker-sole modification?

A) A rocker-sole decreases midfoot joint motion.B) A long (heel-to-toe) spring steel shank isoften used with a rocker-sole.C) The apex of the rocker is always placed in thesame location on a shoe.D) It provides rocking motion from heel to toe.

E X A M I N A T I O N

(cont’d)

See answer sheet on page 141.

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Additional comments and suggestions for future exams:

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EXAM #8/05Prescription Shoes for

Foot Pathology(Caselli)

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

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