What's New in Shoe and Orthotics Material Technology

When it comes to at-risk feet, a good shoe can make a big difference. For some, the right shoe can help bridge the gap from a wheelchair to walking. For others, the proper shoe might help with circulation enough to keep them from losing a foot or toe to amputation. To keep these at-risk feet or feet with other special needs healthy, pedorthists and therapeutic shoe manufacturers are always on the lookout for better solutions and technology to help their patients and customers. The experts we interviewed say there has been a boon of newer materials, newer manufacturing processes, and more attractive therapeutic shoes in recent years. There have been developments to help keep feet drier, to provide degrees of stability and flexibility, and there have even been new ways to ensure that shoes don't fall apart under stress. Yet even with the new technology, there is still work to be done. [caption id="" align="alignnone" width="250"] SoleTech hopes to produce EVA sheets that combine materials of varying densities and hardness in a single piece. Image courtesy of SoleTech.[/caption] Materials Making a Difference Lori Watson, president of KeepingPace, Boston, Massachusetts, says her company recently transitioned to upgraded materials in its shoes designed for children who wear AFOs or other braces. In 2013, her company launched a line that uses a new material, SuperFabric. Watson says the fabric is popular because it's breathable, durable, and lightweight-traits that are especially important to have in the shoes of people with at-risk feet. These traits are also important factors in the mainstream shoe market where Super Fabric can be found in several different hiking boots and running shoes. According to materials released by SuperFabric's manufacturer, the material overlays fabric with tiny "guard plates" that are specifically arranged. The gaps in the plates allow for flexibility in the fabric. The shape and size of the plates, as well as the fabric they cover, can be varied depending on the attributes needed for the shoe. Watson says that she's found SuperFabric to be lighter than other materials she's used and more durable than leather. "SuperFabric was like hitting the lottery for KeepingPace," she says. The material, which Watson says is as expensive as fine shoe leathers, does come at a cost. However, the benefits of the material prompted her to make the switch for KeepingPace. Shane Hayes, CPed, CEO of Shane's Foot Comfort Center, Seattle, Washington, says he has been impressed with recent materials in Brooks running shoes, which also work well for people with at-risk feet. One of the new materials released by the company is a cushioning system in the Brooks DNA running shoe, Hayes says. [caption id="" align="alignnone" width="300"] Engineered from a non-Newtonian fluid, this midsole technology in the Brooks DNA running shoe responds to the amount of force placed on the foot and disperses the pressure. Image courtesy of Brooks USA.[/caption] According to Brooks, the material is made from a non-Newtonian fluid, which means it can act alternately as a liquid or as a solid. The material is made of molecule strands that are resilient and disperse pressure when needed. Thus, the cushioning differs depending on the wearer's weight and stride. "It literally changes consistency depending on the load it gets," Hayes says. "If it gets a lighter load it will be springier, and a heavier load will absorb more." The shoes, combined with his customizations for individual patients, have been a good fit for some of his clients, he says. "They are shock absorbing, have stability in the outsoles, [come in wider] widths, and have extra depth," Hayes says. "Those are all of the things you need for diabetic feet." SureStep, South Bend, Indiana, produces a brace-like product for children with low muscle tone that gives them stability while still being flexible. The company worked for years to perfect the plastic in its product to make sure it was strong while remaining flexible and thin to meet patient needs, says Bernie Veldman, CO, CEO and founder of SureStep. A solution was eventually found, but the company keeps quiet about it. Veldman says, "The plastic that we use is one of our trade secrets." [caption id="" align="alignnone" width="250"] Through the use of extremely thin, flexible thermoplastic, the SureStep SMO compresses the soft tissue of the foot. Photograph courtesy of SureStep.[/caption] New Manufacturing for Orthotics Some of the upcoming innovations for orthopedic shoes will be in the materials used in the manufacturing, says Tom Costin, CEO of SoleTech, headquartered in Nahant, New Hampshire. One of the more important innovations in the future for practitioners making custom orthotics for patients with diabetes, he says, will be EVA sheets of different densities and hardness that are manufactured as one piece instead of being laminated post-production. Custom orthotics are often made of two or three different materials with varying densities and hardness needed to cushion and support the foot. These laminated sheets of materials often have to be cemented together in the lab. The problem with this method, Costin says, is that it can be challenging to work with prelaminated sheets or to fabricate the laminations within the lab. Even when everything is done properly in the lab, he says, those laminated sheets may separate in the patient's shoes. "There are problems where it can delaminate over time," he says. "Heat and moisture are the worst enemies of the glue, and inside the shoe you have both." For patients in warm climates, Costin says, the shoes get hot over time with a lot of walking, and the heat and moisture may cause premature material failure. "It's the practitioner's nightmare to have to redo the orthotic." He says that SoleTech is working to create sheets in a process that combines two or three materials of different densities and hardness while they are being manufactured so they will no longer need to be glued. Costin continues, "We think this will be the next big step with materials for custom orthotics." He also says that other companies are working to figure out a solution to this problem. SoleTech is still in the testing phase and hopes to release a product in the next year. Style Versus Function When it comes to making therapeutic shoes, manufacturers are always trying to make shoes that are both attractive and functional for patients' needs. Finding that perfect balance seems to be a work in progress, according to experts. At KeepingPace, Watson says her company works to make their shoes look as mainstream as possible, without being too trendy and running the risk of stockpiling unwanted inventory because styles fall out of fashion. "You don't want to end up with a warehouse full of lime-green shoes that no one wants to wear," she says. Having an attractive therapeutic shoe is essential, especially for older children who may want to wear the same style shoes as their friends, she says. Even then, it's still hard to keep teens compliant with therapeutic shoes that look any different than their peers' shoes. "As much as we attempt to design a lightweight, contemporary-looking shoe, it's extremely challenging when you have to design a deep and wide shoe," she says. Pedors, Marietta, Georgia, has been producing orthopedic shoes since its "classic" shoe was first released in 1997. The classic is still the company's best-selling shoe and has a design focused more on foot accommodation and medical need. The company also has a Mary Jane style for women, which it first released in 2003 and then updated in 2010. Stephen O'Hare, president and cofounder of Pedors, calls the challenge of combining style and function the "holy grail" of the diabetic shoe industry and says it's tough to pull off. "The two concepts are diametrically opposed," he says. "A bus can't be made to look as sleek as a Jaguar, and a Jaguar can't offer the room of a bus.... [T]he foot needs [room] inside a shoe so that it's not compromised. Some manufacturers purport to have done it," O'Hare says. "I've yet to see it." [caption id="" align="alignnone" width="450"] From left: Pedors' Mary Jane shoe designed to provide style and function to individuals with diabetes, and its classic shoe. Photograph courtesy of Pedors.[/caption] This challenge made Costin rethink his company's line of therapeutic shoes for people with diabetes. The company specializes in producing orthopedic materials but also had developed and offered a line of therapeutic shoes for about 12 years. For a while, the shoe business was fine, but soon enough more competition came around and some companies were promoting beautiful shoes that he did not feel were in the patients' best interests. "If an older woman came in and was given a choice of a shoe that was better for her foot or more fashionable, [she] tended to choose something more fashionable," Costin says. "When it became a fashion business we decided to exit." Yet numerous mainstream shoes do have the ability to be customized, Hayes says. Some shoes already have the depth needed for people with diabetes or those wearing AFOs and, if the width of the shoes works with the patient's feet, the shoes could be a good fit. To pull it off, the shoes will likely have to be further customized for the patient, he says. However, he concedes that with the price of customization and the individual medical needs of patients, it's definitely not a solution for everyone who is in search of a trendy but functional shoe. O'Hare says patients are bound to be attracted to shoes that look good and claim to meet their medical needs. He cautions patients to focus first on their physical needs before style and discuss the issue with their pedorthists. "Patients need to be educated that what's important is to keep their feet healthy so they can continue walking, which is a critical component of longevity," he says. "Pedorthists can convey that. Few shoe sales clerks are even aware of the diabetic foot risk. A diabetic wearing Manolos is not going to walk very far for very long." More Change Needed Hayes was one of the pedorthists who helped lobby for Medicare's Therapeutic Shoes for Persons with Diabetes (TSD) benefit, which took effect in 1993. According to the experts we spoke with, one aspect of the bill they hoped would spur an increase in technology was the portion designed to help provide patients with diabetes inserts and therapeutic shoes with the depth, width, and stability they need to help protect them from ulceration, which can lead to foot or toe amputations. When the bill went into effect, many people with diabetes suddenly had a way to pay for their specialized footwear, and business improved for shoe manufacturers. With a built-in customer base, they had the financial ability to start developing better technology for the shoes they made. While Hayes is proud of that benefit, things have not improved quite as much as he had hoped when he first helped propose it. When the bill was first written in the 1980s, it was created for a type of shoe that then retailed at about $125. Since then, the Medicare reimbursement has not increased with inflation, and that same shoe would now retail for $250, he says. "Nobody uses those shoes for diabetics anymore because of the low reimbursement," Hayes says. "So what's happened is that there have been a number of manufacturers that have started making a lesser-quality shoe. Instead of the shoes getting progressively better over time, they have basically gotten worse." When it comes to therapeutic shoes specifically, those types of shoes are just not the focus of an increase in technology, he says. Instead, much of the new technology in shoes is coming out of other styles that may eventually flow down to be used in therapeutic shoes. The economic downturn in the past decade hasn't helped much either, he says. "Ever since the bust in 2008, shoe companies have dialed it back a bit," he says. "They are covering the basics rather than being experimental." Veldman says that he's seen the same trend. In truth, he has not seen technology expand as much as he would like simply because companies do not currently have the money to develop it. "Right now, there's just not a ton of money to be made in shoes," he says. Many of the companies that are still around are focused more on providing their patients with a solution that is affordable for both the patients and the manufacturer. Unless there's suddenly a big profit to be made, Veldman worries there might not be a lot of new ideas from new inventors. "If it were something covered by insurance and Medicare, then I think more people would throw their hat in the ring and say 'I have a great idea,'" he says. "But the volume of shoes required for a production run makes it more cost prohibitive." Maria St. Louis-Sanchez can be reached at msantray@yahoo.com

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