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Leaders pinpoint the best ways to meet footwear challenges

Solving problems presented by patients with diabetes, hindfoot varus or valgus, metatarsalgia and other conditions considered.

Issue: December 2005

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Part I: Orthopedists, pedorthists collaborate to treat foot problems

Moderator: Carol C. Frey, MD Assistant Clinical Professor of Orthopedic Surgery, University of California Manhattan Beach, Calif.; Foot and Ankle Section Editor, Orthopedics Today Panelists: Dennis Janisse, CPed President and CEO of National Pedorthic Services Inc.; Clinical Assistant Professor, Dept. of Physical Medicine and Rehabilitation, Medical College of Wisconsin Michael S. Pinzur, MD Professor, Adult Orthopedics & Rehabilitation Foot and Ankle Surgery Loyola University Medical Center, Maywood, Ill. Jeffrey E. Johnson, MD Associate Professor, Orthopedic Surgery, Orthopedic Surgery Center, Center for Advanced Medicine, Shriners Hospital for Children, The Sports and Orthopaedic Center St. Louis, Mo. Pierce E. Scranton Jr., MD Orthopedics International Ltd., Seattle David Levine, DPM, CPed ACFAS Member, Pedorthic Foot Association member Frederick, Md.

Carol C. Frey, MD: There are many conditions, such as hindfoot varus or valgus, that are difficult to control with foot orthoses alone. At what point do you give up on the insert and start to modify the shoe?

Dennis Janisse, CPed: My comment here might be to be sure that the patient even has the correct shoe to begin with. Does the shoe have a counter? Is it a long medial counter? What is the shoe made out of? Is the shoe a laced oxford, slip-on, high-top, etc.? The type of shoe can play a major part in the success of the foot orthosis. The blame shouldn’t be put on the foot orthosis right away. Obviously, if the patient doesn’t have enough support, you can then look at internal reinforcement, like fiberglass or flares and external wedging.

Jeffrey E. Johnson, MD: I use shoe modifications for hindfoot varus or valgus of greater than 10º, especially if it is at least partially passively correctable. In fact, a lateral or medial sole flare or small wedge can exert a much greater force to correct a flexible varus or valgus deformity than a foot orthosis. Here is where the skill and training of the certified pedorthist can really be helpful to fabricate these external shoe modifications appropriately and cosmetically.

David Levine, DPM, CPed: I think it is important to approach this in a stepwise fashion as well. Frontal plane motion is best controlled with functional orthotic devices. However, in order for the functional device to succeed, you need a good foundation and base of support. Starting out with custom-fitted shoes and orthotic devices is important. If this fails to control the foot, then shoe modification is necessary. Although shoe modifications can be successful, patients do not always accept this recommendation.

Pierce E. Scranton Jr., MD: Gait analysis, preferably on a treadmill with the orthosis in place, must confirm efficacy. If there is still abnormal varus or valgus deviation the shoe is the next target, followed by actual surgery if necessary.

Frey: Foot orthoses are useful in the treatment of the diabetic patient, especially after a partial foot amputation or to help avoid plantar ulceration. What advice can you give for the use and fabrication of a foot orthosis, with this patient in mind?

Janisse: When fabricating a partial foot orthosis you need to provide control, redistribution of weight and forces as well as cushioning and shock absorption.

The orthosis should not be tight against the end of the remaining foot; it should fit more like a shoe should fit. The orthosis does not hold the foot back in the shoe, the lacing system and fit of the shoe should control the foot and hold it in place. In addition to the partial foot orthosis, typically we will add a carbon fiber (contoured) plate to the bottom of the orthosis or a rigid, full-length shank to the shoe. The shoe should have adequate rock or a rocker sole added to aid in propulsion and protect the remaining foot.

Johnson: Too often I have observed the use of soft Plastazote alone or with PPT for the patient with diabetes. These are often bulkier orthoses which bottom out rather quickly and do not contain posting to help redistribute weight-bearing loads or correct deformity. I favor a foot orthosis laminated with three thinner layers of foam materials contained by a thermal moldable cork base. The top layer is soft, #1 Plastazote that is very moldable. The middle layer is PPT and is conformable but helps resist bottoming out. The bottom layer is EVA foam, which is moldable but firm enough to redistribute loads and resist bottoming out. The hindfoot portion of the orthosis is then posted with cork, and global metatarsal relief is then built in with an internal metatarsal bar contoured just proximal to the metatarsal heads. All of these moldable type materials will eventually bottom out, and the key to optimal long-term management with the diabetic patient is close follow-up with a foot care professional to periodically examine their feet and a pedorthist to refabricate the orthosis before it bottoms out. Ideally, the orthosis should be replaced every six to 12 months depending on patient’s activity level, body weight and orthosis materials.

Levine: This type of orthotic device would need to be accommodative. If it is a transmetatarsal amputation, a more proximal amputation, or more than two rays are absent, then a toe filler is necessary. It is important to take a semi-weight-bearing impression of the foot. If a nonweight-bearing impression is taken, then the accommodations and/or the toe filler may not be placed accurately. In addition, using pressure mapping such as Fscan is an excellent tool to actually quantify the results. In some cases, when we are struggling with a particular situation, we will have the patient use our gait lab and actually modify the devices during the test to help obtain the desired result.

Michael S. Pinzur, MD: I will tackle this question with two answers as follows:

1. My algorithm for treating diabetic patients is based on risk status. Low-risk patients (ie, those who are sensate to the Semmes-Weinstein 5.07 monofilament, have palpable pulses, and have no deformity) are given instruction of safe footwear. When such patients develop peripheral neuropathy, as measured by insensitivity to the SW monofilament, I then prescribe a pressure-dissipating insole and soft leather oxford shoes. Once they become moderate risk (ie, insensate to the monofilament, deformity, non-palpable pulses), I then prescribe depth-inlay shoes and a custom accommodative pressure-dissipating orthosis;
2. A diabetic partial foot amputee will need a custom accommodative pressure-dissipating custom foot orthosis and a “toe-filler.” When the patient has a partial foot amputation, I will combine the custom foot orthosis with a cushioned toe filler, and modify the depth-inlay shoe to have a cushioned heel and rocker sole.

Scranton: Soft, total contact accommodative inserts.

Frey: For the treatment of metatarsalgia, can an orthosis ever be as good as a rocker sole shoe?

Janisse: I would start with a pre-made or custom-made orthoses before a rocker sole. With a properly constructed orthoses, many metatarsal problems can be addressed. Use a rocker sole if more relief is needed.

Johnson: Yes, especially if the patient has full ankle joint dorsiflexion. However, the combination is often best. Many shoes have a mild rocker sole built into them, and is often all that is needed. A custom-made rocker sole is effective for more severe cases of metatarsalgia or when ankle joint dorsiflexion is limited.

Levine: If metatarsalgia is coming from a single metatarsal head or MTP joint then an orthotic device can sometimes be more effective. First the etiology of the metatarsalgia must be established. This goes back to completing a biomechanical assessment of the patient. Imbalances must be assessed and the etiology of the problem identified. One of the problems in medicine today is increasing specialization. When a patient comes in with foot pain or an asymmetric complaint, there may be an underlying reason for that problem. If only symptomatic treatment is provided, long-term treatment success of treatment will not be possible. For instance, what happens to a patient who has surgery to correct a bunion or even hallux limitus when it is an asymmetric finding? If it turns out that a leg length discrepancy was present, the deformity may recur or never get better. As a result, both rocker soles and orthotic devices can be helpful with treating metarsalgia. In addition, rocker soles are helpful in addressing sagittal plane problems and orthotic devices are helpful in addressing frontal plane problems.

Pinzur: I generally have these patients try a pre-fabricated commercial flexible orthosis that has a metatarsal pad built in. If this works, the patient can continue with this option, or have a custom foot orthosis with metatarsal pad fabricated. If it does not help, they can try a rocker sole.

Scranton: An orthosis can be satisfactory, but the addition of the rocker bottom sole can spell the difference between nonoperative success and surgery.

Frey: What device do you recommend for the treatment of posterior tibial tendon dysfunction (PTTD)?

Janisse: Post tib tendonitis can be addressed with a semi-rigid device, all the way to a rigid University of California Biomechanics Laboratory device. Again, the material selection depends on the severity of the condition and the shoe the patient will be wearing. Often, we use an EVA combination of materials, post it with cork, and have both medial and lateral flanges high and with good medial support. If the attachment of the post tib tendon is too tender to accept this support, you can add a small channel of soft viscoelastic polymer in the painful area to make it more comfortable while still providing adequate support to take tension off the tendon.

A UCBL can be extremely effective in very flexible feet that need a lot of control. Also, a UCBL is useful if someone won’t or can’t wear a shoe with good support. If a UCBL is constructed properly, fitting and wearing can often be accomplished more effectively than a semi-rigid device.

Johnson: The prescription for the foot orthosis depends somewhat on the stage of the posterior tibial tendinopathy and the flexibility and severity of the deformity. For Stage I, a foot orthosis is used only once the acute inflammation along the posterior tibial tendon has resolved. An AFO is often utilized for that purpose, and a foot orthosis can be fabricated as a device to transition into as the AFO is being discontinued. I recommend a medium or firm density orthosis such as EVA posted with cork and that uses a medial hindfoot wedge to correct heel valgus and support the longitudinal arch and a lateral forefoot wedge to elevate the lateral border of the foot and rotate the forefoot out of forefoot varus into a more neutral position.

For Stage II, I typically use a short supra-malleolar type polypropylene AFO (such as a short-articulated AFO or a gauntlet-style AFO rather than a foot orthosis. However, when the patient does not wish to wear the AFO, then a foot orthosis similar to the Stage I orthosis is recommended.

For Stage III when the hindfoot deformity is fixed, a foot orthosis with softer more accommodative materials with cork posting is fabricated. Shoe modifications such as reinforcement of the medial counter of the shoe or a medial flare are helpful to prevent medial roll over of the shoe counter. A gauntlet-style AFO is often used for Stage III as well since I believe it is difficult to control these types of deformities with a foot orthosis alone and the deltoid ligament at the ankle is often attenuated and benefits from support.

Levine: Both frontal plane motion of the foot and the leg must be addressed. The internal rotation of the leg can drive the foot into the floor making an orthotic device uncomfortable or even intolerable. Therefore, sometimes it is necessary to fabricate a device with a deep heel cup and as much longitudinal arch support as possible. Sometimes this requires using an accommodative device or a combination device that is part functional and part accommodative. In addition, an ankle brace may need to be used as well. This is an easy way to implement control of the foot as well as the lower leg. If it proves successful, then a custom device such as a Richie Brace or gauntlet style AFO may be helpful.

Pinzur: For acute posterior tibial tendonitis, I use a removeable fracture boot. For PTTD, I start with a pre-fabricated flexible foot orthosis. If the deformity is beyond the potential for a foot orthosis, I advise the Aircast Air Sport ankle orthosis or the new Aircast PTTD brace. I only advise a custom Arizone brace for patients who receive some benefit from one of the Aircast braces and who are not interested in a surgical correction.

Scranton: Depending upon the stage and the age of the patient, in order of effectiveness: UCBL insert, Arizona Brace, Custom AFO orthosis.

Frey: Although the UCBL is often recommended for the patient with PTTD, I find that most of my patients find it very uncomfortable and do not wear it. How often do you recommend the UCBL (for any diagnoses)?

Janisse: The problems that exist with the UCBL are often that the person taking the cast doesn’t do a good job positioning the foot, or the technician fabricating the device doesn’t understand how to modify the cast and/or fabricate it properly. In my experience, the UCBLs are easier to fit than the more flexible types of foot orthotics, and usually require fewer adjustments. The patient is not going away unsatisfied, we follow-up with everyone, or see them back in clinic with the orthopedic surgeon that prescribed the device.

Johnson: I rarely order a UCBL orthosis for the reasons stated. Where I see a UCBL most effective is for patients who have a flexible foot with normal to low body weight and where muscle control may not be strong enough to stabilize the hindfoot. However, in most cases a short AFO is more effective even for this situation.

Levine: Rarely, if ever, for those same reasons.

Pinzur: Virtually never.

Scranton: In addressing PTTD I use the UCBL in only about 10% of all orthotics prescribed. Most patients are past Stage I and will require greater support.

Frey: There are many specialists who feel they can prescribe and/or fabricate foot orthoses: orthopedists, podiatrists, certified pedorthists, physical therapists, chiropractors, and nurse practitioners. In many cases, there may be a financial incentive to keep the business “in house.” I would like your comments and thoughts on this.

Janisse: My issue here would be anyone can fabricate and dispense orthoses and reap the benefits if they are qualified. The problem is that some don’t understand the concepts, indications, fabrication techniques and are only doing them for financial gain. If someone has the knowledge, skills, and resources to do the job, more power to them.

Johnson: With the proper skills and training, any one of the practitioners listed could provide a very effective orthosis. There appears to be an increase in the number of “in-house” made orthotics by orthopedic surgeons, physical therapists, and chiropractors, whereas traditionally in-house foot orthoses have been done primarily in podiatry offices. For patients who do not require a sophisticated prescription for their problems, such as for mild flexible hindfoot deformities, metatarsalgia, heel pain, etc., these devices usually work well (although a pre-made orthosis may work as well). However, if the patient requires a more sophisticated prescription, my experience is that the devices fabricated in-house often fall short. In a busy office practice, when the orthosis does not solve the problem, it is difficult for the in-house practitioner to take out the time necessary to sort out why the orthosis did not work and to make the necessary adjustments. Some do-it-yourself orthoses companies provide an in-house technician with some training which may or may not be adequate. In my opinion, the best combination of quality workmanship and service is from a certified pedorthist or orthotist under the guidance of a well-thought out prescription from a practitioner who has made a complete exam of the patient and has a thorough understanding of the problem.

Levine: No doubt there is financial incentive to make orthotic devices for those that do. That is also true of surgeons as well. Surgeons get paid for surgery. There are probably podiatrists and orthopods doing foot surgery on patients that, in some cases, would be better served by being treated conservatively. Not only do you get paid for what you do, but like refers like. We can only hope that the majority of those making orthotic devices, and practicing medicine, for that matter, are doing so ethically and with the proper justification for treatment administered.

Pinzur: As in many similar circumstances, there is a potential conflict of interest. I avoid this potential problem, by referring all such patients to a CPed.

Scranton: The ability to effectively and cost-efficiently produce orthotics will vary from region to region and practice to practice. My practice is predominately surgical so I don’t have the ability to devote the necessary time it takes for proper analysis and fabrication. I have excellent relationships with the pedorthists in my area so all orthotic fabrication goes “out of house.”

Frey: Let’s talk about rigidity. There are classifications for rigid, semi-rigid and soft-foot orthoses. Rigid orthoses can be made of stainless steel, rigid thermosetting plastics and thermoplastics. There are many who feel that there is a limited role for the rigid orthosis as it is difficult to mold a rigid orthosis to fit the foot exactly and when in use, it does not allow the intrinsic muscles to function fully and over time may lead to intrinsic weakness. What is your preference and why?

Janisse: When discussing rigidity, there is a very simple rule of thumb: “A rigid foot needs more cushioning or shock absorption and a flexible foot needs more control or rigidity.” I personally am not a fan of extremely rigid, single density foot orthoses. I often incorporate more rigid materials into a foot orthosis, combining rigidity, shock absorption and moldability all in one (synergy). A semi-rigid (cork posted type) foot orthosis can accomplish the same results as a rigid orthosis most of the time, and provide shock absorption that the rigid device will not. The argument for a more rigid device would probably be that it is less bulky and can go into a larger variety of shoes.

Johnson: I prefer a combination of semi-rigid and soft-foot orthosis materials depending on the diagnosis. I rarely if ever use a rigid orthosis since the rigid materials allow very limited shock attenuation, are difficult to modify, and generally have little or no covering material extending into the forefoot to allow metatarsal relief.

Levine: In general, accommodative devices are fabricated from softer materials while functional devices are made from more rigid materials. Softer devices often take up more room inside the shoe and may not last as long. This is because the softer materials compress and deform over time at a faster rate than the thermoplastic materials. A more rigid device can be thinner, take up less room in the shoe and be very durable. However, a patient who needs an accommodative device will not do well with a rigid device. In fact, this may even be contraindicated. Rigid orthotic devices used to be prescribed more often. The thinking has changed and shifted away from making devices with no give to them. I don’t know how one could prove that intrinsic muscle weakness occurs with one type of material and not another. It would seem that supporting the foot to work more efficiently can only help both the extrinsic and intrinsic musculature to work the way they should.

Pinzur: The only time that I recommend a semi-rigid orthosis is for the morbidly obese patient who receives some benefit from a pre-fabricated commercial flexible orthosis. In these patients, eg, usually very large men, I find that flexible orthoses are not sufficiently durable.

Scranton: Except for a hindfoot medial or lateral Kant that might not collapse, I have no place for rigid components in the orthosis itself. The only exception here is the custom AFO – which still will have a sorbothane accommodative pad.

Frey: I hate to pin you down, but what is the average cost (a range is OK) of custom made foot orthoses in your town?

Janisse: Prices can vary greatly. Pedorthists prices for a pair of foot orthoses would probably be $250 to $350. Other disciplines could range as high as $500 to $550.

Johnson: The average cost in St. Louis for a custom foot orthosis fabricated by a certified pedorthist is in the range of $250 to $350.

Levine: Over-the-counter devices can range in price from $10 to $50. There is even a retail store in my town that sells off the shelf arch supports for as much as $250 to $300. Custom devices in my region range from $300 to $370. This cost often includes the casting visit, fabrication of the devices and at least one follow-up.

Pinzur: $400 to $500.

Scranton: I do not know the cost of podiatric custom orthoses. For the certified pedorthotic device, depending upon the needs, between $150-250.

Frey: What is “subtalar neutral?” Is it different in the weight-bearing vs. non-weight-bearing foot? How is the concept used in the fabrication of a foot orthosis?

Janisse: My two cents worth here: Subtalar neutral is a wonderful position to evaluate a foot in (non-weight-bearing); you can identify forefoot, varus and valgus deformities, etc. Not a position to hold a foot in when it’s functioning.

Johnson: A subtalar joint neutral is a helpful reference point for describing and defining a particular foot shape or deformity. I do not prescribe a foot orthosis to necessarily correct a foot back to “subtalar joint neutral” but rather to correct it into whatever position I think will be most functional and biomechanically efficient with the foot. In my hands, when I find “subtalar joint neutral” the heel is usually in neutral and generally in more varus than the most “functional position” for the foot. Posting placed on a foot orthosis would be intended to correct the foot toward “subtalar joint neutral” but not necessary to “subtalar joint neutral.”

Levine: Subtalar neutral is the position of the subtalar joint that is between pronation and supination. One can feel it by palpating the talonavicular joint on both its medial and lateral sides. When it is congruous by palpation, then the foot is in the neutral position. This is in a new open kinetic chain position.

Frey: Just as you need to have your eye prescription changed every few years, how often does a patient who requires a foot orthosis need to be checked — either for material failure or change in prescription?

Janisse: We send out reminder cards to our diabetes/neuropathic patients every six months for a recheck. We need to check for orthosis and shoe wear to identify possible changes in the foot itself. Other patients we recommend a recheck visit every year.

Johnson: I recommend that patients with diabetes and peripheral neuropathy have their foot orthosis and footwear checked every six months by the certified pedorthist or foot care practitioner who has experience in diabetes-related foot problems. For other patients, a once yearly check is sufficient, or earlier if symptoms recur, to check for material failure.

Levine: Prescriptions can change and feet can change. An obvious example of this is the patient with diabetes. Surgery, amputation or development of Charcot arthropathy will change the needs of a patient’s orthotic devices. As far as functional devices, in a patient who is healthy otherwise, there is no set time to change the orthotic or prescription. It should be based on changes in the patient’s anatomy, activity level and complaints. I have some patients successfully wearing the devices for more than eight to 10 years.

Scranton: Orthoses need periodic changing even if there is no visible deterioration. Many of the foams, sponges or device material will compress or crystallize over time and the accommodation is lost. Additionally feet and arch mechanics change as well. I recommend reevaluation at least every two years.

Frey: Many athletes, especially the runner, will come to my office and request foot orthoses. What is the most common reason that a runner many require a foot orthosis? Do you think they benefit? Any pearls on fitting the athlete with a foot orthosis?

Janisse: Common problems would probably include plantar faciitis, post tib tendonitis, sesomoiditis and peroneal problems.

Johnson: The most common reason a runner requests a foot orthosis in my practice would be mild pes pronation or hyper-pronation of a normal foot, or metatarsalgia. Typically, an over-the-counter foot orthosis can be used. In many cases replacing their shoes for a bottomed-out mid sole or switching to a different type of shoe may do as much for the foot symptoms as a foot orthosis. As runners age, or their mileage increases, shock absorption becomes even more important, and I think an orthosis is an effective way to increase the shock absorption in a shoe.

Levine: Runners come in because of chronic injuries that prevent then from training. Runners are usually educated and well informed in the ways of treating foot and other lower extremity injuries. When the over-the-counter devices they have tried fail, then custom orthotic devices are necessary.

Scranton: Most runners requiring orthoses seen in my practice are serious recreational runners. They run competitively in 10Ks, half marathons, marathons and triathlons. Their training is usually on streets and sidewalks, tough unforgiving surfaces. They typically have overuse syndromes: shin splints, plantar fasciitis, sinus tarsii pain or a spectrum of tendonitis from over pronation or the rigid cavus foot. These individuals absolutely benefit from gait analysis and then custom accommodation. The greatest pearl in fitting the serious recreational athletes is to understand what they are training for, their sport, to especially look at limb asymmetry, and then be sure that in follow-up gait analysis that the abnormality has been corrected.

Frey: Many parents request foot orthoses for their children with flat feet. What is your experience in the younger patient who may or may not require foot orthoses?

Janisse: The consensus is that children with flat feet probably don’t need FOs, but we still see kids with Sever’s disease, shin splints and just painful feet. The question is, “Is an arch support going to hurt?” I don’t think so. A properly fitted, semi-rigid type pre-made could actually improve the fit and function of some less desirable footwear the kids are wearing now.

Johnson: Parents who request foot orthoses for their children with asymptomatic flat feet need education about this problem rather than a foot orthosis. Although it is easier to merely prescribe the orthosis, in the long run, the family will be benefited by understanding the natural history of the flexible flatfoot in children. In the young child with a painful flatfoot deformity, a thorough workup with radiographs and possibly a CT scan, and other lab work as needed is important to rule out tarsal coalition, inflammatory disorders, neurologic disease, or some other type of problem that would be treated with other than a foot orthosis. I try to use modified over-the-counter foot orthoses for younger children if needed to reduce the cost and allow the parents to replace the orthoses easily as needed as the child’s foot grows.

Levine: Young children have options just like adults, but there may be even more leeway with what works. Starting with an off-the-shelf device is often successful. There are a variety of ways to provide this even with small feet. An orthotic shell for the right size foot can work wonders without having to go the route of a custom device. In a child, more fat in the foot and more reducibility make the simpler devices effective. However, there is no doubt that there are pathomechanical situations that require orthotic intervention. Proof of this is when off-the-shelf devices don’t work and the custom devices do.

Scranton: The toughest problem in this age group is parental education, to teach patience and to insist on consistent annual follow-up to insure that growth proceeds physiologically.

Frey: How much effect does a foot orthosis have on the distribution of forces under the foot?

Scranton: Work published by me and McMaster clearly showed the alteration of forces under the foot in walking, jogging and sprinting, especially with the various foot types. There is an almost infinite amount of gait variation that can be seen from heel-strikers to the forefoot strikers, to cavus feet, to pes valgus feet, to toe-in toe-out, etc. The repetitive forces each foot is subject to (about 2.5 x body weight, multiplied by the hundreds of thousands of repetitions in a training athlete leads to the described overuse syndromes we’ve talked about. Numerous authors, and especially Cavanaugh, have clearly shown the beneficial effect of accommodative orthoses in altering these repetitive forces. These investigators lead the way in proving efficacy, and it is up to us to put into practice then principle.