Sketchers: A Modification for Stability

I love the concept behind Sketcher's roll bar. It can be very helpful for many different injuries like Hallux Rigidus/Limitus, metatarsalgia, plantar fasciitis, and others where limiting the bend at the ball of the foot (metatarsals) could be helpful. However, this shoe can produce medial instability, called over pronation as we roll forward. This can be easily treated for a little shoe doctoring. I take a scalpel, but a shoe repair store some other sharp instrument, and cut 1 to 1 and1/2 inches into the shoe from the big toe joint area. The length of the cut is 3 inches long as seen in the photos. The material used can be colored for cosmesis, and is beveled before applying. I use Barge Cement and Superglue or knockoff to secure into the shoe. As the patient rolls forward, the 1/4 inch forefoot varus wedge stops the foot from pronating and should subjectively to the patient feel that it holds the foot centered. I have never had a patient not feel more stable with this technique. 

Shoe Wedging to Stop Supination

Supination following heel strike is one of the most deadly biomechanical problems. The shoe industry is starting to pay attention with a range of mor stable neutral shoes which will work with orthotic devices to stabilize that problem. However, almost weekly I need to do in-office shoe wedging to eliminate this problem even in the face of good orthotics and shoes. When we strike the ground walking or running, our legs must internally rotate from the feet, ankles, knees, hips and pelvis to absorb the shock. This internal rotation of the entire lower extremity allows the foot to pronate, and the foot to adapt to the ground. If our foot supinates at this time, forcing external rotation of the foot and ankle, problems arise in many ways. The foot can no longer adapt to the ground well and sprains can occur. The shock wave of heel strike will intensify potentially causing bone and joint problems. The peroneals and iliotibial band must work overtime at stabilizing the lateral/outside of the foot/ankle/knee/hip and strains occur. 

So, when I watch someone walk and run, I look for over-supination at heel strike. I see if simply the shoe needs changing from stability to neutral. I teach the patient how to perform lateral power lacing. I evaluate any shoe inserts/orthotics to see if I can adjust for anti-supination. And, I may also wedge their midsole as shown in the photos below to see if this helps eliminate supination at heel strike, and ease their symptoms. 

Lateral (baby toe side) of the midsole is opened with a scalpel. This process can be easily done by some shoe repair stores.

In this case, a 1/4 inch wedge of grinding rubber from JMS Plastics is placed into the opening. Both sides of the midsole and both sides of the wedge are initially glued with Barge Cement and let to dry for 10 minutes.

All excess wedge material is cut and ground off and SuperGlue is used to seal any gaps that did not seal completely.

The final product is shown. This patient Vince has chronic medial knee joint compartment disease, and this wedging has allowed him to avoid knee replacement successfully for the last 15 years by eliminating the excessive supination which was causing the medial knee compartment to compress abnormally with every step.

So, when evaluating individuals with various injuries, watching them walk and/or run, can give you great clues to treatment. Gait evaluation should be done in most non-acute injuries to see if gait changes may help. This is one example of this process in action. 

Bunion Pain: Ball and Ringer Stretcher to the Rescue

FootFitter Bunion Stretcher Ball & Ring, Cast Iron

http://www.amazon.com/FootFitter-Bunion-Stretcher-Ball-Ring/dp/B000POHTOG

This is a great product that the podiatrists in my office have been using for years. It can not only be used for bunion areas to produce a gentle stretch, but for other pressure spots also. My patient Lynda last Thursday reminded me that she purchased this several years ago and has been stretching her shoes to alleviate the pressure around her bunions every since. You want to go easy so it may take a few nights. If you push too hard, the bump produced can be cosmetically unappealing.

"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