A Closer Look At Orthotic Solutions For Women’s Dress Shoes

Given the challenges of prescribing orthoses in women’s dress shoes, this author addresses biomechanical considerations, device modifications and the five most common mistakes in writing orthotic prescriptions for this growing patient population.

   Terror strikes the hearts of many practitioners when a woman walks into their office with a bag full of dress flats, wedges and pumps. Regardless of gender, the podiatric physician cringes at the thought of dealing with a “shoe” issue rather than a pathological or symptomatic foot.

   The practitioner should not shy away from the professional and educated woman with expensive taste in shoes. The podiatric physician can follow some important yet practical suggestions about fabricating and dispensing custom functional foot orthotics. The patient can use a fashionable woman’s shoe and still receive treatment for her foot and ankle pathology.

   There are a few guidelines to ensure effective outcomes with orthotic therapy as well as adherence in daily wear by the female patient. When treating the female pathologic foot with custom orthotic therapy, one must take into account the variety of functional and fashionable shoes, the biomechanical evaluation, the specific orthotic materials and the unique orthotic modifications.

   The female patient looks to her practitioner for guidance and education about both athletic and dress shoes. The patient needs to understand that the orthotic/ shoe interface plays a significant role in her clinical outcome. It is the podiatric physician’s duty to help these patients make appropriate footwear choices as well as educate them about functional yet fashionable dress shoes.

   The dress shoe can be categorized from the most functional and stable to the least stable. The criteria for categorizing a dress shoe are very similar to the athletic shoe. A stiff heel counter holds the heel in a stable position and allows a functional foot orthosis to increase the stability of the rearfoot. A good test is to squeeze the heel counter of the shoe and make sure it is firm.

   Midshoe stability allows for the midfoot to be held in a rigid position and prevents excessive side-to-side torque at the midtarsal joint. A good test is when a shoe does not bend like a pretzel side to side. Employing a removable insole in a dress shoe allows flexibility with orthotic fit and prevents the patient from having to increase her shoe size.

   The loafer or flat dress shoe represents the most stable shoe with a stiff heel counter and stiff upper. The functional loafer or flat dress shoe comes with a removable insole to allow the custom functional foot orthotic to fit properly without changing the shoe size.

   The ½-inch to 1-inch heeled shoe represents the lesser of the functional shoe yet still incorporates a stable heel counter and a less rigid shoe upper.

   The 1½-inch pump and wedge shoe represents the least stable and functional shoe. The pump-heeled shoe does not have a stable heel counter or a removable insole.

   The female patient needs to understand that the outcome of orthotic therapy will depend on both the orthotic device as well as the proper dress shoe.

Essential Insights On Biomechanical Considerations

   Whether the physician is educating female patients about the necessity and effectiveness of a custom functional foot orthosis for the first time or the 10th time, he or she must review the biomechanical exam for the specific pathology. For the practical purpose of this article, the biomechanics of the foot will be significantly simplified.

   The pes rectus foot type presents a perpendicular heel bisection in stance, which is considered the stable foot. When it comes to the unstable pathological foot type, we can categorize these into four foot types.

   • The pes cavus foot type represents an inverted calcaneus position in stance. Common foot and ankle pathologies associated with the pes cavus foot type are a symptomatic Haglund’s deformity, peroneal tendonitis, lateral ankle instability and metatarsalgia.
   • The mild pes planus foot type represents 4 degrees of eversion of the calcaneus in stance. Common foot and ankle pathologies associated with the mild pes planus type foot are plantar fasciitis secondary to an everted rearfoot and hallux valgus.
   • The moderate pes planus foot type represents 6 degrees of eversion of the calcaneus in stance.
   • The severe pes planus foot type represents at least 8 degrees of eversion of the calcaneus in stance. Common foot and ankle pathologies associated with a severe pes planus foot type are severe hallux valgus, hallux limitus, posterior tibial tendon dysfunction and sinus tarsi syndrome.

Keys To Ensuring Optimal Orthotic Prescriptions For Specific Foot Types

   The biomechanical and gait examination will help with prescription writing for effective dress orthotic therapy. A polypropylene device is the most commonly used material when fabricating a functional foot orthosis. The polypropylene material adapts to curvatures of the patient’s foot or allows one to incorporate curvatures into the orthotic shell. Polypropylene comes in a variety of thicknesses, allowing for adjustment in thickness and flexibility of the orthotic shell.

   A graphite material is a glass resin composite. It allows for better shoe fit but does not conform to curvatures of the foot well.

   A Cobra (ProLab Orthotics) or S-type orthotic shell is a combination of a very thin polypropylene shell with minimal EVA arch fill. The Cobra device does not have a heel cup or a lateral aspect to the orthotic shell.

   The following are useful orthotic forefoot modifications that are recommended in flat loafer shoes and ½- to 1-inch dress shoes for patients with various foot types.

   Mild pes planus. In flat shoes, use polypropylene with a 0/0 rearfoot post. Cast work consists of a 2 mm medial skive with 2 degrees of inversion. The heel cup is 10 mm. The functional foot orthotic (FFO) width is normal.

   In shoes with a ½-inch to 1-inch heel, use graphite. Cast work consists of 2 degrees of inversion. The heel cup is 6 mm. The FFO width is narrow.

   In 1½-inch heels, use Cobra materials with minimal cast fill. The heel cup is 2 mm. The FFO width is S-shaped narrow.

   Moderate pes planus. In flat shoes, use polypropylene with a 0/0 rearfoot post. Cast work consists of a 2 mm medial skive with 4 degrees of inversion. The heel cup is 10 mm. The functional foot orthotic (FFO) width is normal.

   In shoes with a ½-inch to 1-inch heel, use graphite. Cast work consists of 2 degrees of inversion and minimal cast fill. The heel cup is 6 mm. The FFO width is narrow.

   In 1½-inch heels, use Cobra materials with minimal cast fill. The heel cup is 2 mm. The FFO width is S-shaped narrow.

   Severe pes planus. In flat shoes, use polypropylene with a 0/0 rearfoot post. Cast work consists of a 4-mm medial skive with 4 degrees of inversion. The heel cup is 10 mm. The FFO width is normal.

   In shoes with a ½-inch to 1-inch heel, use graphite. Cast work consists of 4 degrees of inversion with minimal cast fill. The heel cup is 6 mm. The FFO width is narrow.

   In 1½-inch heels, use Cobra materials with minimal cast fill. The heel cup is 2 mm. The FFO width is S-shaped narrow.

   Pes cavus. In flat shoes, use polypropylene with a 0/0 rearfoot post and no lateral bevel on the rearpost. Cast work consists of a 2 mm lateral heel skive. The heel cup is 10 mm. The FFO width is normal.

   In shoes with a ½-inch to 1-inch heel, use graphite. Cast work consists of a 2-mm lateral heel skive. The heel cup is 6 mm. The FFO width is narrow.

   In 1½-inch heels, use Cobra materials with standard cast fill. The heel cup is 2 mm. The FFO width is S-shaped narrow.

Other Pertinent Considerations With Forefoot Modifications

   There are several useful orthotic forefoot modifications that are recommended in flat loafer shoes and ½- to 1-inch dress shoes.

   Physicians often prescribe a 1/16-inch Korex Morton’s extension for the short first ray as well as the hallux rigidus etiologies. The 1/16-inch Korex reverse Morton’s extension can accommodate hallux limitus as well as sesamoiditis. One can prescribe a 1/16-inch Poron metatarsal pad for metatarsalgia and fat pad atrophy. Physicians may use a 1/16-inch Poron neuroma pad in a specific interspace to offload the inflamed neuroma.

   It is important to specify to the orthotic lab the thickness of the forefoot extension to prevent tightness in dress shoes. One should send the specific shoe with the cast for the functional foot orthotics in order for the lab to capture the appropriate cant of the dress shoe’s last. At the very least, the practitioner should trace the shape of the insole of the dress shoe on a piece of paper and send it to the lab.

Addressing The Top Five Prescription Writing Mistakes

   Podiatric physicians commonly make five mistakes when prescribing orthoses for dress shoes. One can avoid these by considering both the patient’s foot mechanics as well as the correct orthotic material.

   1. Arch height is too high. The patient usually complains about the tightness on top of the midfoot while wearing a flat or slightly heeled shoe. This indicates that the arch fill in the positive cast work was not the appropriate prescription. The patient with a pes cavus foot type cannot tolerate minimal cast fill with a polypropylene shell or a graphite dress orthotic.

   To avoid this complication, consider a standard arch fill for the semi-flexible pes cavus foot type and maximum arch fill for the truly rigid pes cavus foot type.

   2. The device is too wide. Whenever possible, send the orthotic lab one shoe with the negative cast and prescription form. In lieu of a shoe, the podiatric physician should give the lab as much information about the style and heel height, and send a tracing of the insole of the dress shoe. The lab can add a definite dimension to the width of the shoe.

   3. The device is too thick. This is mostly a complication that occurs with the polypropylene dress device. The most popular device prescribed is a semi-rigid 3/16-inch polypropylene for the patient whose weight averages between 150 and 200 lbs. An alternative for the 3/16-inch polypropylene is a thinner 5/32 inch for the same patient weight but be sure to prescribe minimal arch fill in the plaster cast work.

   One can prescribe a 1/8-inch polypropylene with minimal arch fill and a 2-mm skive with a 2-degree inversion in the cast work for the mild to moderate pes planus foot type. Both will be equivalent to the 3/16 semi-rigid polypropylene devices. The inversion, skive and minimal plaster arch fill introduce additional curvatures to the orthotic shell which, in turn, increase its rigidity.

   4. Too tight in the toe box area. A bulky forefoot extension is usually the main dilemma with tightness in the toe box of a dress shoe. It is important to specify 1/16 inch for any forefoot accommodations.

   A physician should get into the habit of prescribing a vinyl top cover to the sulcus when forefoot additions are necessary. Prescribe a top cover to the toes only in flat dress shoes with a removable insole. Always prescribe a top cover to the metatarsal in a pointy shoe.

   5. Heel slippage out of shoe. The shoe’s heel height and the heel counter height are usually the problems with heel slippage. The more information the lab has about the style, brand and height of the dress shoe, the less likely the heel slippage will occur.

   While the following scenario is rare, when a low profile dress orthotic fails to provide control for a severe pes planus foot type, an abductory twist occurs in the rearfoot, causing the heel to move in the shoe. In these cases, one must educate this patient about a more aggressive and stable functional foot orthotic.

In Conclusion

   With an increase of women in the workforce, there is a corresponding increase in overuse injuries and chronic foot pain. Custom dress orthotics are an essential part of the treatment plan for women’s foot injuries. It takes time, education and patience to deal with women’s dress shoes.

   By considering the type of dress shoe, the biomechanical pathology and the orthotic material, the practitioner can develop a proper treatment plan to help the female patient. It is important to emphasize to the female patient that a dress orthotic may not have as much support as an orthotic fabricated for an athletic shoe. Due to the need for a thinner and low profile custom orthotic device, patient adherence is just as vital for the overall treatment plan.

Dr. Kashanian is in private practice in Los Angeles. She is a Medical Consultant for ProLab Orthotics in Napa, Ca.

For further reading, see “Key Insights On Prescribing Orthoses For Dress Shoes And Sandals” in the August 2004 issue of Podiatry Today.

To access the archives or get information on reprints, visit www.podiatrytoday.com.

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