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Custom Shoes: Steps to Success
By Séamus Kennedy, BEng (Mech), CPed It is the middle of the week. Your day has started
well. As you pull into your parking space, you think, "Today will
be a day to focus on my patients and perhaps catch up on some of
that paperwork." As you enter the office, you are told that your
first patient is already waiting for you in room number three, and
she has a prescription for custom-molded shoes. The sunshine has
gone from your day.
 If the above scenario sounds familiar, you are
like the majority of O&P professionals who would rather not
have to deal with custom shoes. It is not that you cannot do them
well, but custom shoes seem to invite their own set of headaches
and difficulties. Many O&P practitioners see the molded shoe
business as a necessary evil that they must endure in order to
develop and sustain the vital relationships with their hospital
clinics and doctors.
The good news is that providing custom-molded shoes does not
have to be quite so frustrating. There are many tricks and tips
that we will look at to help ensure that with minimal time and
effort on your part, you get a properly fitting shoe that satisfies
the patient's needs.
Patient Evaluation
From the moment you enter the exam room with a molded shoe
patient, you can start to pick up some clues as to what may work
best for him/her. The two key steps are: 1) see what is working now
and might work for this patient, and 2) try to figure out what
his/her mindset is regarding custom footwear.
First, see what kind of footwear your patient is currently
wearing. Is it a fashion shoe? Is it a high-top? In general, it is
a good idea to make a custom shoe that closely resembles patients'
existing style of footwear, provided they will get the therapeutic
benefits they are seeking. However, this may not always be
possible, especially if new shoes are needed due to some recent
changes in the foot condition, such as partial amputations, the
fitting of a new brace, or the development of a pre-ulcerative
condition. Don't forget to look inside the shoes at their existing
insoles. Are the current shoes wearing in one spot, or are they too
tight?
Note the condition of the old shoe: does it have an obvious wear
pattern? Is it beaten and abused? You may need to design a more
durable, heavy-duty shoe to withstand the patient's demands. Chefs,
construction workers, and little old ladies will all have unique
requirements for their footwear that you can incorporate into the
design. Outsole wedging, flares, grip soles, etc., can all help
improve the function and longevity of the shoe.
Take note of the socks that the patient is wearing. Some
patients will wear heavy socks in the winter-resulting in a tighter
shoe-and change to light socks in the summer, resulting in a looser
shoe.
Just as important as the shoe type and construction is the
attitude that the patient has regarding footwear. From the outset
it is vital that you stress that these are functional, therapeutic
shoes. They are being custom made and custom designed to treat
specific problems with the feet. These shoes are rarely wardrobe
enhancers! It is a great idea to always keep a sample shoe close at
hand to show patients. You need to prepare them for a comfortable
accommodative pair of shoes that fits their feet, and usually those
shoes will come with a rounder toe box and flatter outsole than
they are used to. Pre-selling the medical reasons for the shoes and
their final appearance will greatly reduce tensions when
dispensing.
Try to avoid compromising too much on the shoe style. For
example, patients who want sandals or open-topped shoes for summer
have not really bought into the concepts of protective stabilizing
footwear, and they are apt to be disappointed, no matter what you
do. It is vital to manage their expectations.
Casting
It is often correctly stated that the single most important step
in making a custom-molded shoe is the cast. This cannot be
overemphasized! A good cast will determine the correct fit and
function of the shoe-and a bad cast never will. A few more minutes
spent at this crucial stage can avert hours of anxiety later.
I have listed my "Top Ten" tips for capturing the
true shape and size of the functioning foot in Table 1. As an extra
precaution, you can take photographs of the existing footwear and
feet, or, even better, send an old pair of molded shoes along with
the cast.
The choices on a shoe order form can often seem limiting and
confusing. Your goal is to describe the best shoe that meets the
original Rx and the patient's biomechanical, therapeutic, and
lifestyle requirements. The more information you can
supply-including diagrams, photographs, and color samples-the
better. Below are a few pointers to consider when designing
the shoe:
Shoe style-Generally, the higher the counter of
the shoe, the more control it will provide. Most patients will want
low-top shoes for aesthetic reasons. Examine what they are wearing
currently and ascertain if their shoes are working for them.
Low-top shoes are easier to don and doff, but there is a greater
chance of slippage and looseness at the heel. Patients with any
midfoot pathology, such as Charcot or PTTD, or those patients
wearing AFOs, braces, or bandages, will do much better in shoes
with higher counters i.e., chukkas or high-tops.
Shoe upper-The normal opening of a shoe goes
across the ball of the foot. A surgical opening occurs more
distally, almost over the toes. Surgical openings will make the
shoe look a little more orthopedic, but they are very useful
whenever the patient may have difficulty donning or doffing, such
as when there is limited ankle range of motion or the patient needs
help in dressing.
Velcro closures are quick and easy for people who have limited
use of their hands, such as arthritis patients or those who have
difficulty bending over to tie laces.
Padded collars are a good addition to help ensure a snug heel
fit and also to reduce the possibility of the heel pistoning out of
the shoe. Patients with fluctuating edema can also benefit from
padded collars and padded tongues.
Cast modifications-The typical molded shoe
comes with a standard 1/2"-3/4" toe elongation. This extra plaster
is added to the last and then checked against the weight-bearing
tracing. If the original cast and tracing are good, there should be
no problems with the fit of the shoe. Often patients will feel they
are "swimming" in the new shoes. This is usually because they are
used to tight and ill-fitting footwear.
Each cast gets a 1/4" addition of plaster over the toe box area.
Specifying an extra-high toe box will provide even more room for
those patients with severe hammer toes.
Shoe weight-This will depend on the patient's
weight and activity level. Molded shoes are normally designed to be
more accommodative to the foot, providing protection rather than
being rugged. If the patient is heavy and/or is a heavy-duty user
because he works outdoors or does a considerable amount of walking,
the shoes can be made tougher by choosing a stronger, heavy-duty
upper, adding sole stiffeners, using firmer soling materials,
etc.
Insole-The insoles can be made from a variety
of materials, depending on the patient's needs. Plastazote offers
the most protection, but EVA insoles tend to last longer. If the
patient is wearing a brace, AFO, or gauntlet inside the shoe, it is
best to make a cork insole that will hold up longer. Just as with
any custom orthotic, depressions, pads, and postings can be built
into the insole.
As an excellent insurance precaution I always recommend a spacer
under the insole. This separate 1/8" piece can be quickly and
easily removed if the shoe is a little tight.
Lifts-Shoe lifts can be added to the inside
and/or the outside of the shoe. Often patients will have their own
preference based on the look. Lifts up to 1/2" are not usually
noticeable to the untrained eye. It is often better to put a lift
on the outsole of the shoes as the height can easily be adjusted
later without affecting the internal fit of the shoe.
Outsole-A great deal of the biomechanics of the
shoe can be controlled by selecting or altering the outsole. A
standard shoe will have 3/4" of pitch from heel to ball. Rocker
soles are very useful for offloading met heads or aiding ambulation
in patients with limited gait cycles. Flares and wedges can be
incorporated to improve stability or alignment. In cases where the
final balance of the shoe depends on how the patient adapts to the
new support, it is often best to request that the outsole be left
off. This will allow you to modify the pitch and wedging in the
presence of the patient.
Fitting
It may sound elementary, but the first rule of success in
fitting custom shoes is that the person who cast the patient should
fit the shoe. If you have shown the patient a sample of a molded
shoe, pre-sold him/her on the benefits of proper fitting,
therapeutic footwear, and developed trust and rapport, then there
should be no surprises when the patient sees the shoes.
Check the shoes for fit and function, and, in particular, look
at the length and width. Patients will certainly feel that the
shoes are different from anything they have had before. Feeling
looseness at the heel is not uncommon. This is often due to a stiff
outsole that does not yet bend. Once the shoe has been worn a
little, the outsole will flex, and the heel will not feel so loose.
If the shoe is a little tight, you can remove the extra spacer
below the insole and/or adjust the insole.
Unless the shoes are obviously incorrect, regardless of how they
feel-good or bad-patients should break them in slowly over a period
of about two weeks, checking their feet daily. Start them with one
hour the first day and build the time up gradually. After two
weeks, patients will have had time to adapt to the shoes and, if
they need an adjustment, they will be able to tell you exactly what
is required.
With a good cast, a clear description of the shoe, and an
educated patient, you should be able to fit most molded shoes right
the first time. This will make the whole process more pleasant and
efficient-and the sunshine will return to your day.
TABLE 1 - Top Ten Tips for Functioning-Foot Casting
- Always take a full weight-bearing tracing of both feet on a
flat, hard surface. This acts as an important check for the length
of the last and shows the true orientation of toes, amputation
sites, etc.
- Seat the patient so that his feet rest firmly on the floor. You
want to get some weight-bearing to ensure that you capture the true
length and width of the forefoot.
- If the patient has a normal range of motion at the ankle, cast
the foot with the lower leg at 90 degrees to the ground. In cases
where there is severe equinus, leg-length discrepancy, or rigid
ankle, cast the patient in the position of function, and mark the
vertical alignment on the cast and Rx form.
- Tell the patient that you are trying to capture the shape of
the functioning foot so that he understands to not constrict his
toes or remove the downward pressure.
- If the patient is subject to edema, it is best to cast him
later in the day when the foot and ankle are most swollen.
- If the patient wears a permanent AFO, brace, gauntlet, or
compression stocking, take the cast while he is wearing the device.
However, be mindful that some orthotic devices, stockings, and
wound dressings are for short-term use only, thus potentially
affecting the long-term fit of the shoe!
- Place a 1/2" - 1" soft foam cushion under the foot in order to
allow the contours of the arch and heel to come out in the
cast.
- If possible, use a casting board with a 1/2" - 3/4" pitch under
the heel. This will create some plantarflexion and help ensure that
the toes are not dorsiflexed in the cast.
- The plaster "clam-shell" or "bivalve" techniques and the newer
casting socks are the best methods to capture the full foot with
all intricacies and contours. Try to avoid "wrap" techniques when
casting the foot. They can often be too tight and will poorly
reveal the definition and true length of the toes. Although they
can be the cleanest and quickest (at the time!), fiberglass wraps
result in the most problems.
- Before you cut or remove the cast, score the surface with some
pencil lines to show the correct alignment
Séamus Kennedy, BEng (Mech), CPed, is president and co-owner of Hersco Orthotic Labs, Long Island, New York. 
Table Of Contents - March 2003
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