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Ultimate Pedorthics: Custom Shoe Therapy
By Miki Fairley 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.
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Armando Flores making lasts. |
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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
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Molded vs. custom molded. |
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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.
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Customized athletic shoe. |
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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
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Modified last from wood blank. |
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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.
Table Of Contents - May 2005
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