Ultimate Pedorthics: Custom Shoe Therapy

Custom shoe therapy is a challenging, underutilized, but rewarding aspect of pedorthic practice. In fact it can achieve the level of "ultimate pedorthics," according to Arnie Davis, CPed, Davis Shoe Therapeutics, San Francisco, California. Armando Flores making lasts. Both the clinical complexities of the foot conditions, plus health and mobility issues of clients, can present above-the-ordinary challenges to pedorthic professionals, Davis noted. Although clients often must pay for expensive custom shoes out of their own pockets, having far greater control over the fit and therapy as compared to simply modifying readymade shoes makes the results overwhelmingly more effective for many cases, Davis asserted. Josh White, DPM, in an article titled "Custom Shoe Therapy: Current Concepts, Designs, and Special Considerations" in Clinics in Podiatric Medicine and Surgery , 1994, supports Davis' assessment of custom shoe therapy. "Custom orthopedic shoes represent the ultimate combination of function, accommodation, and aesthetics. Incorporating biomechanics with shoemaking, can redistribute ground forces, inhibit painful motion, facilitate ambulation, and decrease the probability of neuropathic ulceration." When a Custom Shoe Is Best Choice Molded vs. custom molded. When is it better to provide a custom shoe, rather than a readymade? Indications involve the location of the deformity, size differential, history, level of sensation, and cost or reimbursement, according to Davis, who presented a session on custom shoe therapy at the 2004 Pedorthic Footwear Association Symposium (PFA) in Orlando, Florida. Location of Deformity: Elaborating, he explained that fore-foot deformities can usually be accommodated with in-depth footwear; however, mid-foot and rear-foot deformities are better treated with custom footwear. Size differential: In most cases, people with different-sized feet can be fitted with readymade footwear simply by splitting pairs. However, if the differential is more than a couple of sizes, usually other problems are present, such as leg-length discrepancies, partial paralysis and weakness, or rigid and fused joints, Davis noted. Causes of these conditions can include lymphadema, post-polio syndrome, or childhood traumas affecting bone growth. By making shoes from scratch, upper patterns can be designed to cosmetically obscure internal lifts and fit excessive edema that cannot be adequately addressed with stock uppers. History: If the pedorthist has unsuccessfully tried in-depth shoes with modifications and inserts, the next step is custom shoes. "The process individualizes all aspects of the fit and therapy, giving you more control and room for fine-tuning adjustments," Davis pointed out. Customized athletic shoe. Level of sensation: The classification system developed for the Medicare Diabetic Shoe Bill identifies criteria for determining appropriate footwear for people with neuropathy. "If an individual has no sensation, and has deformities and/or a history of ulcers, custom shoes offer the best protection, hands down," Davis declared. Cost or reimbursement: Realistically, cost or reimbursement has to be considered. It is initially less expensive to modify existing or readymade shoes than to make custom-made shoes. If the client cannot afford custom shoes, the pedorthist must defer to modifying readymade shoes. However, in the long run, it may be more cost-effective to have shoes custom-made if they are well made, well cared for, and easily repairable. Davis has had clients wear one or two pairs of shoes for up to 15 years, and he said that two pairs interchanged daily will often last three to four times longer than one pair. The Last: Foundation of Shoemaking Modified last from wood blank. Davis pointed out that what distinguishes the various processes of custom shoemaking is the way lasts are made. "Everything in the shoemaking process evolves around the last, making it the most important component of the shoemaking process," Davis explained. The last dictates the appearance, fit, balance, pitch, therapy, function, accommodation, and comfort of every pair of shoes. When pedorthists take a mold of the foot in order to make custom-made shoes, he takes part in the most critical part of the process, whether the shoes are fabricated in-house or in an outside lab. Davis outlined the basic categories of custom-made shoes: Molded shoes - the plaster last is shaped like the foot. Lasts are made directly from a modified plaster mold of the foot, and the shoes are intended to be accommodative rather than corrective or functional. Upper leathers are soft, and components are synthetic and heat-moldable; bottoms are crepe wedges. These shoes, which are usually made in an outside lab specializing in high-volume manufacturing, are often thick and clunky with little regard for cosmesis. Custom-molded shoes - the last is of plaster or polyurethane reshaped like a shoe last. The last is made directly from a modified plaster mold, but modifications to the last are intended to enhance function and/or cosmesis. The shoes may include biomechanical balancing and upper leathers can range from calfskin for dress shoes to oil tan leathers for work boots, but are mostly made from soft cowhide. There is more individual consideration for lifestyle, fashion, and usage. Custom orthopedic shoes - the shoes are made from specialized wooden lasts shaped like a foot type, then modified. Components tend to be firm and corrective, such as leather soles and heels, leather counters and toe boxes, with firm calf leather being used. Custom-made shoes - made from production type and sized polyethylene or wooden lasts. These shoes are nearly always styled as dress shoes and are designed for difficult-to-fit feet with no serious problems. They are made over a pre-shaped customized last constructed from measurements; the bottom of the last is usually flat. Made-to-order shoes - made from production type and sized polyethylene or wooden lasts. They are made up in special colors or styles, with little or no custom fitting. Customized shoes - these shoes are made from any kind of custom last; the process involves tearing apart commercial shoes and re-lasting them over custom lasts. To Davis, the bottom-line question is: Will the foot and an uncompromised innersole both fit into an in-depth shoe? If the innersole must be made thinner, have less padding, correction, or accommodation to get the shoes to fit, it is better to make custom shoes.

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Can Evidence-Based Medicine Benefit Orthotics?

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