Bottom of the Foot Soreness: Think Accommodation

Above is a Spenco insert which has the area of soreness cut out on the right foot. You can mark the sore area with a felt pen or old lipstick on your foot. Then put your foot into the shoe and walk a few feet to see where the mark comes out. Cut an area just bigger than the mark. 2 layers may be appropriate.

Here 1/8 th inch adhesive felt is being used to accommodate a sore big toe joint. Be creative with old shoe inserts that you are not using anymore.

Insole Wear Patterns: A Biomechanical Treasure Chest

These inserts tell a wonderful tale about this athlete. See if you can find all these clues, and find Waldo while you are at it. The foot functions more to the lateral heel (inverted) on the left. The left has a more dramatic push off. The pronation is a little more to the right, but both sides are fairly centered. Pushoff is more explosive on the left. 

When We Push Off the Ground: What is the Ideal Wear Pattern?

When we push off of the ground, the powerful first metatarsal should be free to plantar flex (move downward towards the ground) with most of the weight on the 2nd through 5th metatarsals (2nd the most). As push off continues (aka propulsion), the sign of great push off is strong wear under the hallux (big toe) itself.

In the photo above, the right foot shows the typical signs of great push off (also called a propulsive gait pattern), and the left shows minimal to no active push off (confusingly called an apropulsive gait pattern). The right side shows dramatically more pressure under the first through third metatarsals seen in a good push off.

Overall, however, the left side shows more mid foot and metatarsal area pressure, so that side is bearing more weight. These top covers were put on at the same time, and are only used for walking. The patient does a lot of walking each day.

For those biomechanical afficianodos, this patient has forefoot varus with a Root Balanced Technique. I do not like the first metatarsal pressure on both sides, and would personally convert the orthotic to a Kirby skive with first ray cutout or the Inverted Orthotic Technique.

Heel Pain: Try to Beat the Wear Pattern on these Orthotic Devices

The science of reading shoe inserts for pressure analysis can be as mysterious as reading the tea leaves for some, but not for experienced forensic podiatrists like myself. When this patient stated she was having heel pain, and found great relief from some orthotic devices she only wore occasionally, the wear pattern on the top covers shows the whole story. This may be a fitting blog post for the day the new Sherlock Holmes movie comes out. Can you see where the wear is? Probably more important, can you see the heels have had excellent pressure relief? Elementary my dear Watson!!

Podiatry Video Quiz #5: Which foot insert shows more supination tendencies?

This short video demonstrates the findings seen in over supination.

"25 Common Shoe/Insert Modifications in a Podiatry Practice"

Left Outersole Lift for short leg tapered to the toes and cuts for flexibility.

Flexibility cuts demonstrated in outersole lift to avoid Sagittal Plane Blockade

Sole or Your Sole inserts are much better than Superfeet for adjustments. This is the soft athletic red version. Blue version is much thicker, and grey version for dress shoes too wimpy. For simple mechanical changes, or for biomechanical experimentation, these work great.

Pure plastic orthotics for water aerobics---nothing that can dissintegrate

Here are some wedges used for midsole wedging for pronation or supination (when the shoe and/or orthotic still do not do the whole hot tamale)

After the midsole is cut with a 10 blade about 1/3 way in, Barge cement is used to glue.

1/8 to 1/4 inch grinding rubber is skived and then glued on both sides. After 5 minutes, the glue is dry enough to place into the shoe.

Superglue is used to seal any looseness. Here a 1/4 valgus wedge for supinators is being demonstrated in the lateral heel and midsole area of a left shoe.

Custom Inserts can now be made for alot of sandals with the explosion of ones with removable inserts.

Sole insert with added medial arch with Hapad and additional 1/4 inch varus wedge with grinding runner. If you are unsure if the pronation you see in gait is causing the symptoms in the patient's knee, hip, shin, or back, experiment with Sole and get their response before designed an appropriate custom orthotic device.

Bottom view of the Hapad arch and 1/4 inch varus wedge.

The famous Blue Dot of 1/8th inch Poron or spenco (less easy to skive the edges) to give added cushion to any sore spot that bears weight.

I love Hapads. Began using them in Ballet slippers and Pointe Shoes and the rest is history. Get a supply of small and extra-small Longitudinal Metatarsal Arch Pads. Easy to thin out when too thick.

When I use these Hapads in shoes directly, always use the right in the left shoe and vice versa. Tends to work better with the shape of the curve in the arch area of the shoe.

Also love Hapad Metatarsal pads. Never put under a sore spot, always behind. See the diagram shows it one way and I demonstrate another. Experiment and think outside the box always. Patients should feel whether the pad is in the right spot or not, and should feel free to move around and thin. Get a box of small Metatarsal Pads to start.

Lace Skipping is a simple experiment to discern if bunion or pain at the top of the foot may be coming from tight laces. Here bunion pain with this hiking boot is greatly reduced with simple lace modification. See how you normally do not have to skip the entire front area, so there is less loss of stability.

When using lifts for short legs, I prefer the added stability of full length (or sulcus length) lifts.

This photo just put on emphasis on the flexibility cuts in full length lifts.

Dancer's Pads are made to help protect and off weight the big toe joint (including the sesamoids). It can be multi-layers, but care should be taken to discuss with the patient if they feel the pads off weight the sore area or toss them into the hole.

When you are experimenting with patients and making changes in their biomechanics, it is a good idea too remember to have some humor, and remember if you make any mistakes, I have made them 100 fold before you.

Remember spenco as topcovers and forefoot extensions ---very durable and the best cushion out there. Even with rearfoot posts, consider a softer product if you use plastic. This is birkocork which holds its shape well and much kinder on knees and hips than plastic posts.

Here is an example of a heel lift applied directly to an orthotic for a short leg. I would recommend keeping them separate and going full length with the lifts.

 Here is a combination of Budin Splint for Hammertoe and metatarsal pad. Remember that you can combine anything.

 Severe heel pain, think 1/8 tto 1/4 inch adhesive backed gel padding before you put on the topcover. In these cases, if the orthotic device is plastic, ask the lab to thin the plastic as thin as possible before the rearfoot post is applied.

Here a patient with chronic pain under the big toe joint is having the shoe modified. 1/4 inch hard shoe material will be replaced with 1/4 to 3/8 inch soft material.

See the hole created.

Very soft material, like memory foam, is used to fill in the hole. Normally, you have to use more thickness of soft material since it will compress more than the original material.

Frontal plane instability (excessive pronation and/or supination) can be addressed with medial and lateral buttressing with 1/8 to 1/4 inch grinding rubber. Greatly improves overall feelings of stability on any insole. It can be appropriately skived to minimize the heel lift effect.

1/8 to 1/4 inch plastazote actng as memory foam ia a great material for padding when you want the foam to mold to the foot. Here it is used as forefoot padding.

Here a scalpel is used to create a loop on the tongue of the shoe to help keep the tongue from sliding.

The famous Blue Dot used for extra heel cushioning in plantar fasciitis.

Here a scalpel surgically increases the flexibility of the metatarsals. It is importantt not to cut all the way through to the bottom of the shoe or to the sides of the shoe. Normally, 4 or 5 cuts are made 1/8 inch apart.

Varus or valgus outersole wedges to control pronation or supination forces are commonly used in harder to control shoes like dress shoes or sandals. Shoe Repair Stores are experts in making it cosmetically pleasing.

Vertical Cuts can be made in the heel or forefoot area of a shoe

Skip Laces to avoid pressure in sore areas. This is normally alright in a walker, but too unstable for running or hiking on uneven ground.

Here a cut is made 1 to 1and 1/2 inch deep to place a 1/16 th inch of plastic for Hallux Rigidus.

Tongue Pads can add stability to a shoe and can also accommodate a sore area on the top of the foot. This function of accommodation made be combined with appropriate lace skipping.

Don't forget shoe stretching techniques (shoe repair stores mnormally need to keep the shoe overnight)

Surgery to add more padding can be done in the heel or tongue areas

Insoles can be used for accommodations

Custom Orthotic Devices and Shoe Inserts: They Do Not Coexist

When using a custom orthotic device, it is generally very important to remove the insert that comes with the shoe. Not only are there crowding issues, but the form of the shoe insert can effect the position of the orthotic device within the shoe. Thus, it can either help or hinder the orthotic device from doing it's job. The photo above illustrates this principle. My patient was complaining of 4th toe pain. When I looked at his shoe inserts you could see the 4th toe was overhanging the front edge, thus getting irritated. Had he bought the shoe too short? The solution was found at looking at how the orthotic devices were sitting in the shoe. The photo above shows the orthotic is being pushed forward by the heel cup of the shoe insert. If you push the orthotic forward, the whole foot will go forward, and the length of the toe will not be exact.

Here again you get a full view of the orthotic device sitting forward in the heel cup which would push the whole foot forward. To hedge my bet, I also taught the patient power lacing and gave some tongue pads to hold him back into the shoe heel counter better. I had him replace the shoe insert with a flat spenco insole.