Betsy Duncan: If the Shoe Fits

A Shoe Designed to Accommodate Charcot Foot Keeps Betsy Duncan on Her Feet [caption id="" align="alignright" width="250"] Duncan in her garden wearing her outdoor shoes. Photograph courtesy of Betsy Duncan.[/caption] When Betsy Duncan's daughter, Sarah, was in the fourth grade, she asked if her mother was going to wear "those ugly shoes" when Sarah got married. Duncan replied to her daughter, who is now a mother herself with a daughter, and a son on the way, "I am if you want me to come to your wedding." Duncan's shoes do not make a fashion statement despite the nearly $1,000 price tag, and she's the first to admit it. However, were it not for the specially designed shoes, she would most likely have to get around using her wheelchair when she's away from home. Duncan, 63, has diabetes and Charcot foot, a condition that causes changes to the bones in the foot and that can occur in people who have neuropathy. As the disorder advances, as it has with Duncan's right foot over the last 20 years, the joints collapse and the foot takes on an abnormal shape, such as a rocker-bottom appearance. "These shoes help me do as much as I am able," says Duncan, who lives in a Chicago, Illinois-suburb, and loves to work in her flower garden. She has four different pairs of shoes she wears depending on the occasion, the oldest of which she eventually designates as her outdoor shoes. "These are the most expensive garden shoes in the world," says Duncan, who wears her shoes from the time she gets up until she goes to bed. "I'll get up at night to go to the bathroom without them, but I would never walk down the stairs without a pair of my shoes on." An Active Participant Aside from Gregg, her husband of 41 years, whom she says she "depends on completely," there are two people Duncan credits with helping her live as full and as normal a life as possible with her health problems: her orthopedic surgeon, Michael Pinzur, MD, and her pedorthist, Harriet Cavanah Dart, CPed/L. Both have been treating Duncan for more than two decades. Pinzur, who is also a professor of orthopedic surgery at Loyola University Health System, Maywood, Illinois, has performed six surgeries on Duncan's right foot and ankle. Duncan says Pinzur was "aggressive and on the cutting edge" when he started treating her foot and ankle problems in the mid-1990s. "He had me wearing [an orthopedic] boot, which is common now but not back then. I wouldn't know what to do without him," says Duncan, who is retired now, but worked with her husband and her parents in their sporting goods business. Pinzur says patients like Duncan are special to him, and he tries to interact with them in a manner that "I would want people to interact with me." He says what makes treating Duncan so successful is that she participates in her own care. "I respect when patients want to participate, and Betsy has never asked for anything inappropriate," Pinzur says. "I attempt to educate [patients] and get them to both assist in their care and understand the difficulties in their care." Dart, who received her pedorthic education from Northwestern University Prosthetic-Orthotic Center (NUPOC), Chicago, and studied diabetic foot care and footwear under Paul Wilson Brand, MD, CBE, at the former National Hansen's Disease Center, Carville, Louisiana, agrees with Pinzur. "Betsy has always invested in her own care," says Dart, who has been with Scheck & Siress Prosthetics' Oak Park, Illinois, patient care facility since 2004. Prior to that, she and her husband, Roger, owned and operated Dart Pedorthic Footwear, a pedorthic shoe store and foot orthotic lab, for 15 years. Duncan began seeing Dart for her foot care when Dart had her own business and followed her when she joined Scheck & Siress. A friendship developed between the two women. Duncan says that, as with her orthopedic surgeon, she wouldn't know what to do if Dart wasn't her pedorthist. "What she does is magical," Duncan says. A Detailed Fitting Process Dart says the fitting process for Duncan is more of an art and craft, which includes listening and observing, rather than anything truly high tech. "I'm a foot mechanic," says Dart. "My evaluation for Betsy began with understanding her prescription and the goals and expectations of her and her physician." It has been important to Duncan to avoid amputation. "I want to keep what I came in with," she says. "I'm not prepared yet to let it go." Duncan says she would only consider amputation if her orthopedic surgeon told her it would be medically necessary. "He's the only one I would trust when it came to that," she says. When it comes to getting the right prescription for Duncan's shoes, Dart begins with what is perhaps the simplest part of the entire process. "My first step is to watch Betsy walk," she says. Next is a floor reaction, or force plate evaluation, using the Berkemann Harris Mat foot imprinter, which is similar to using an ink pad, says Dart. While the process isn't high tech, Dart says it has served her well in treating her patients during the 35 years she has been working in the therapeutic footwear field. "[The imprinting system] is more informative than any other method," Dart says. Duncan not only agrees, but she says she wouldn't have it any other way. "It's archaic," she says. "But no one but Harriet has been able to come up with anything better for me." Then Dart measures Duncan's foot with a Brannock Device® and determines the best shoe shape for her. Duncan's shoes are specially made by p.w. minor, Batavia, New York. Duncan says she stays with what has worked for her over the years. Though the style and pattern she wears have been discontinued, the factory continues to custom make her shoes, Dart says. The manufacturer also can accomodate Duncan's needs for a split size. "Her foot is high risk, and I want to be able to count on the shoe to fit and function safely," Dart says. Once Duncan's gait evaluation is completed, Dart does a biomechanical foot exam and a manual muscle test for strength. Then she takes a negative impression of Duncan's feet using compression foam. Before sending the impression to Advanced Orthotic and Prosthetic Solutions (AOPS), Hickory Hills, Illinois, a central fabrication facility and subsidiary of Scheck & Siress, Dart says she uses a paper clip to indent or mark the foam so she can tell the technicians how she wants the positive mold modified. Duncan then returns for another appointment to trial walk in her soon-to-be new shoes and foot orthotics. It is during this phase, Dart says, that she marks the upper portion of the shoe for the location of the apices for the forefoot rocker and the beveled heel. "This defines the stance phase of her gait," she says. The insole of Duncan's right shoe is marked where the shank will be split and spread wider. The single shoe is sent back to AOPS, where a pedorthic technician cuts through the shank area, Dart says. For Duncan's shoe, a full-length lateral flare is added. Since Duncan's right leg has atrophied over time and her limbs are now unequal in length, layers of crepe are added for an elevation with a rocker sole configuration. Once this process is completed, Duncan comes in for yet another appointment during which she trial walks in the now externally modified shoe with the new inserts. "Betsy is very perceptive of how stable she feels and how smoothly she can walk," Dart says. When the fitting process is finished, Dart completes the final phase for Duncan's shoe. "I will use the grinder in our local lab to fine-tune the modification, which has a slight medial heel and sole wedge, which is counterintuitive to the lateral flare," Dart says. "But [it is] necessary because of the position of her ankle fusion." Dart estimates that Duncan's special footwear to accommodate her Charcot foot has to be replaced about every 18 months. The entire fitting process can take six to eight months to complete, but Duncan and Dart say it is worth the effort. "Maintaining her footwear always requires attention to detail," Darts says. A Walk to Remember In July 2010, Duncan was called upon to wear the orthotic-style shoes her daughter had asked about for her wedding day. Sarah was married in the same Minnesota chapel her parents and her soon-to-be husband's parents were; it can accommodate up to 2,500 people. That meant Duncan would have to navigate a long aisle in order to be part of her daughter's big day. Duncan says she told Dart that using a wheelchair was not an option, and she was true to her word. Dart and her husband also attended Sarah's wedding. "It was a very touching moment...to watch Betsy walk down that aisle with her own two feet." HEEL-TO-TOE ROCKER SOLE USED IN DUNCAN'S TREATMENT Objectives: A. Define three phases of stance: heel strike, midstance, toe-off. B. Dissipate floor reaction force at heel strike. C. Replace lost motion at ankle. D. Limit midfoot motion at midstance. E. Increase propulsion at toe-off. F. Determine midstance time. G. Reduce forces to joints adjacent to fusion. Image courtesy of Harriet Dart. Betta Ferrendelli is a freelance writer based in Denver, Colorado.

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Betsy Duncan: If the Shoe Fits

A Shoe Designed to Accommodate Charcot Foot Keeps Betsy Duncan on Her Feet

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