"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

Gait Video of Pronated Right Foot with Corrective Orthotic Devices

If you check the last post, you will see how pronated Julio's right foot is. He is disabled by severe pain following ankle surgery. The hope is that correcting his pronation will alleviate some or all of his symptoms. You can see how following heel contact the shoes and orthotic devices immediate supinate his foot towards a more normal position. He is in 35 degree Inverted Orthotic Devices.

Now compare to shoes but no orthotic devices in this second video.

Gait Video of Pronated Right Foot

See the pronated right foot. The patient has had lateral ankle surgery and post op the surgeon referred him to me for treatment of the severely pronated foot. Post operative pain is quite severe and the hope is if I can eliminate the pronation there will be less lateral ankle and subtalar joint impingement. You can tell how flat that right arch is, what you can not appreciate is that his heel is in severe valgus position (17 degrees everted). The initial orthotics I made for him were 35 degree Inverted which brought his heel position to 9 degrees everted and the second correction of 50 degrees Inverted with Medical Column Correction and Kirby Skive places him to 6 degrees everted.

     See the second video with shoes on but no orthotic devices.

Foot Bones Anatomy Lesson: See if you can beat my 100% in 12.9 seconds

http://www.purposegames.com/game/foot-and-ankle-quiz/info

Type into search box  "Foot Bones"

Click on game upper left corner called Foot Bones
Click on game second time
Press start when you want to challenge my phenomenal 12.9seconds


Then explore the rest of the web site--looks great!!

When Is Swelling Bad? Answer to an Email

Email sent from Jeff in New Jersey today.

Dear Dr. Blake,

A year ago I fractured the right medial sesamoid bone. I just recently

had an MRI and it says it is completely healed.


Problem is it is still pretty much swollen as when it first was


injured. The orthopedic surgeon referred me to another surgeon

because he is at a loss why swelling is still present. I have been

walking around for a year in home made orthotics and I had to open the

shoes on top to acommodate 2 inserts and a dancer pad. Quite a sight!

Do you have any idea why the forefoot is still swollen even though the


sesamoid is healed ?

Thank you very much.

Jeff

 Plantar Axial xray showing the broken lateral fibular sesamoid, not the one Jeff hurt.

 MRI image of the 2 sesamoids under the big toe. Jeff hurt the one towards the outside, not the one more internal.

Typical Dancer's Pad to float the big toe as mentioned in Jeff's email.

Dear Jeff, Thanks for the question. The biggest question concerns whether the swelling is just excessive, or does it mean something still is wrong? Swelling is a normal part of healing, and healing can continue for months and months after a bone injury is completely healed. The body first heals an injury and then heals it further to make it stronger than it was originally. This can produce normal swelling for 2 to 3 times longer than the time it took to heal the bone in the first place. Ankle sprains are probably the most studied injury. The average ankle sprain takes 6 to 8 weeks to heal, yet the average patient has swelling to deal with for 4 and 1/2 months.

     You, of course, want to assume the swelling is normal, and just hanging around too long for your liking. I am assuming by your description is that you have no pain, just swelling. Pain from swelling alone rarely gets above 2 in a pain scale of 0 to 10.  Please comment on this post and I will respond if any of my assumptions are incorrect. If you have swelling and level 4 or more pain, the MRI is not telling the whole picture. You may want to consider a CT Scan which isolates the bone aspect.

     Before you get too excited, I would follow the KISS rule. What is the most obvious? The most common problem with foot injuries on any type is that they swell too much. Our feet are down all day, you have probably been less active which means the swelling has less ability to move out of your foot, and you have worn tight shoes longer than normal (plus it has been the winter). All this can make our feet collect fluid in general, and we will collect more fluid in an injured area over any other spot.

    So, what would I recommend? As long as the MRI results seem to match up with your pain level, please be aggressive with treating the swelling for one month. Everyday do 5 things to reduce swelling, and after 30 days you have done 150 treatments for the swelling. The common treatments for swelling are:

    1. Contrast Bathing 1-2 times per day
http://www.drblakeshealingsole.com/2010/09/swelling-reduction-video-on-contrast.html

    2.  Ice Packs 10 minutes 3-4 times per day

http://www.drblakeshealingsole.com/2010/04/ice-or-cold-therapy-helps-in-injury.html

    3. Physical Therapy with topical cortisone called iontophoresis (5 times in a 2 week period)
    4. Elevation of the body part 2 hours per day (even if it is only several inches off the floor)
    5. 24/7 Compression with Tubigrip or Coban like wraps (physical therapists usually can guide you and perhaps even 1 PT visit to make sure you are wrapping correctly would be wise)

Here Coban is being used around a toe, but you will need to wrap it around the ball of the foot (all the way around the front of your foot).

   6.  Medicines like Zyflamend and topical anti-inflammatories (start with generic and see what the pharmacist recommends). Just stay away from the prescription anti-inflammatories like Advil and Aleve since they may slow down bone healing (and we are not 100% sure the bone is completely healed).

   7.  Of course, activity modification to avoid pain producing activities (over a level 2 or 3 pain) will reduce swelling by limiting aggravation. Read and understand the post on Good vs Bad Pain.

http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

  8.  5 minutes of painfree massage to the swollen area

  9.  5 minutes of gentle motion of the toe with moving the toe up and down (active range of motion).

      Your doctor can also drain the joint (then they send the fluid to the laboratory for analysis). I have had a few patients develop a huge ganglion cyst after a sesamoid injury that needed to be drained like the one in the photo below.  The first photo is off the patient injured right foot. The second photo shows the difference in the non-involved side. The third photo shows the MRI of the swollen ganglion cyst that I have drained. Jeff, if you can take a similiar photo of the MRI image which shows the swelling the best, email it to me (even 2 or 3 images).

So, dedicate the next month at reducing the swelling. If the MRI shows the swelling this well organized, then you may need it drained. Let me know if this is helping you. Rich Blake

Top 100 Biomechanical Guidelines #43: Sagittal Plane Blockade may Occur with Everted not Inverted Heel Corrections (Forefoot Varus Correction could cause Blockade of Motion)

These are Forefoot Varus Casts. Uncorrected then lean inward and the arch would flatten and foot pronate. Correction of this foot has always been a dilemma for biomechanical experts. If you fully straighten this foot, the heel goes straight up and down, but the correction places too much support under the inside front of the foot (near the big toe). Drs Sheldon Langer, Justin Wernick, and Howard Dannenberg were the first podiatrists to discover and explore how potentially dangerous this support was. Too much pressure under the big toe area (first metatarsal) could block the normal motion of the foot from heel to toe and cause problems in the foot, ankle, knee, hip and back. They coined the phrase "Sagittal Plane Blockade" to describe this problem. When you walk with your orthotic devices, do you feel like you can easily move across them? This is a question I try to ask all my patients, and try to observe in gait evaluation. It is vital for normal foot function and to avoid symptoms.

     When I measure foot biomechanics, and I take a cast capturing over 5 degrees of forefoot varus, I know I will have issues for compromise to deal with. Fully correcting the total amount of forefoot varus would probably lead to problems related to Sagittal Plane Blockade. Correcting less than total could lead to the continuation of symptoms related to the pronation I was trying to treat in the first place. For the biomechanical experts out there, if you sacrifice some of the forefoot varus correction with a modified Root Balance Technique consider Kirby Skives, Inverted Pours, or BiAxial Wedging to get your pronation control without producing Sagittal Plane Blockade. You are basically transferring support from the front of the arch to the back of the arch.