Current Ppedoedothe Officialrr Publicationtt Ofhihi the Pedorthic Footcarecc Associationss

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AthletesAthletes oror Artists?Artists? WhereWhere BiomechanicsBiomechanics meetsmeets PathomechanicsPathomechanics

Vol. 51, Issue 1 | January/February 2019 | www.pedorthics.org

current Pedorthics

Editorial Staff COVER STORY EXECUTIVE EDITOR(S) Cover Story Christopher Costantini ART DIRECTOR Kristopher P. Gramza DESIGN/PRODUCTION KPG DESIGN

Advertising & Sales Staff CURRENT PEDORTHICS [email protected] MEETINGS AND CONVENTIONS MANAGER Kathie Niesen EXHIBIT AND SPONSORSHIP SALES MANAGER Contact our Integrated Media and Events Manager at: [email protected]

Headquarters Staff MARKETING AND COMMUNICATIONS MANAGER Christopher Costantini MEMBERSHIP AND CONTINUING EDUCATION Tanya Rivers & Jay Zaffater GOVERNMENT RELATIONS DIRECTOR Randy Stevens 42 | Athletes or Artists? Where

Current Pedorthics (ISSN 1552-8111) is published bimonthly by the Biomechanics Meets Pedorthic Footcare Association (PFA), PO Box 72184, Albany, GA Pathomechanics 31708-2184. Telephone: (229)389-3440 Fax: (888)563-0945 Website: www.pedorthics.org By Melvyn P. Cheskin, MBS., Email: [email protected] C.Ped, L.Ped Copyright© 2018, PFA. All rights reserved. No part of this publication may be reproduced in any manner without written permission. There are few sports more demanding on Letters to the Editor and other unsolicited material are assumed the body, especially the foot, than dance. intended for publication and are subject to editing. Both amateur and professional dancers Articles in Current Pedorthics do not necessarily reflect the opinion of subject their feet to extremes of pressure, PFA, its board of directors or its employees. Authors are responsible for impact and position. Mel discusses the validity of their content and credentials. Current Pedorthics’ use of footwear types common to various forms trademarked names is done in an editorial fashion intended to benefit of dance. Mr. Cheskin then details injuries the trademark owner, with no intention of trademark infringement. and pedorthic treatments that you are If you have any questions regarding display advertising, please contact likely to encounter when dealing with these our Sales Manager at (229) 389-3440 or email: clients. [email protected]. To place a classified ad, please email: [email protected]. Please send all product and industry-related press releases to: [email protected]. Cover Photo: @Shutterstock.com/CLIPAREA l Custom media

2 Pedorthic Footcare Association | www.pedorthics.org Full Page Ad

BUSINESS & PRACTICE ISSUE January/February 2019 current Pedorthics Volume 51, Issue 1 Features

14 | O&P Alliance Open Letter on 38 | Your guide to the 2019 FedEx and UPS Harassment & Discrimination rate increases By O&P Alliance Representatives By Harry Centa In our Industry News, O&P Alliance presented an Harry Centa is the PFA PartnerShip shipping open letter to the orthotic, prosthetic and pedorthic program representative. In this exhaustive look at community condemning sexual misconduct, the impending rate increases for 2019, Harry let us harassment and discrimination. PFA agrees with the know what to expect, what to plan for and how to O&P Alliance that these behaviors are illegal and have save money on your freight charges using PFA’s no place in our profession. We have reprinted the valuable member benefit. letter in this issue for review.

18 | Lateral wedges with and without custom arch support for people with medial knee osteoarthritis and pronated feet: an exploratory randomized crossover study. By Michael A. Hunt, Judit Takacs, Natasha M. Krowchuk, Gillian L. Hatfield, Rana S. Hinman and Ryan Chang In the second of a pair of research articles relating foot to knee osteoarthritis, we find evidence that supports the use of custom foot orthoses with a lateral wedge over a lateral wedge alone. While this is a very preliminary study, outcomes-based research, such as this, is critical in proving the value of what we do each day and provides a basis for making clinical decisions about treatment. The work that was done here provides a starting point for future exploration in our field.

Departments

Current Pedorthics | January/February 2019 5 CHRIS COSTANTINI FROM THE Executive Editor EDITOR [email protected]

PEDORTHIC FOOTCARE ASSOCIATION

ABOUT PFA LOOKING FORWARD The Pedorthic Footcare Association (PFA), founded in 1958, is the not-for- profit professional association which Arerepresents You the interests Following of the certified PFAand/or licensedOn Ourpedorthist Social and supports the pedorthic profession Mediaat large. Networks?

ConnectThrough PFA’s efforts,NOW pedorthics with – PFAthe management and Others and treatment in the of conditions of the foot, ankle, and lower Pedorthicsextremities requiring Community! fitting, he holidays are behind us now. fabricating, and adjusting of pedorthic Don’t miss out on the latest TTime to sit back, relax and start devices – is a well-established allied working on plans for next year. For announcements and current health profession which makes an those of you that are mainly retail, topics we’re discussing on social invaluable contribution to public the exhaustion of the season is finally media 24/7. health. starting to lift. Hopefully, the fog of See what the PFA is doing today retail will dissipate to reveal solid on Facebook, Twitter, LinkedIn, profits meaning the whole ordeal was google+MISSION and O and P Social for the latest industry and practice worthwhile. The crew here at PFA is PFA’s mission is to enhance the doing the same. Everyone is sitting Current Pedorthics magazine. This buzz! issue features a follow up article to effectiveness and efficiency of back knowing that the Symposium in Joincredentialed us by clickingproviders on of lowerany icon St Louis, the culmination of a year’s the research article we published in below!extremity pedorthic modalities through worth of hard work, was a rousing the November/December 2018 Issue. education; increase the demand for success once again. For those of This article will give you evidence you that attended, thank you! Your based decision making guidance services through marketing; and participation is what makes the whole when treating knee pain caused by promote the right to practice through thing possible. With the learning, foot malalignment. Harry Centa from government affairs activities. networking with colleagues and the PartnerShip details what to expect in chance to see the latest and greatest shipping costs for the year. The dance Pedorthic Footcare Association from our vendor partners, you made season of the holidays has no doubt this year’s event truly fantastic! left your customers who gave their PO Box 72184 Just like you are no doubt doing, blood sweat and foot health begging Albany, GA 31708-2184 slowing down does not mean stopped. for your help. Mel Cheskin is here phone (229) 389-3440 The PFA Board of Directors is already with suggestions for treating these starting work on next year’s event. athletes. fax (888) 563-0945 This one will be a landmark event, I hope you enjoy spending some of email [email protected]&P PFA’s 60th Anniversary. And where your hard earned downtime perusing website www.pedorthics.org this issue of Current Pedorthics. I better to celebrate than Las Vegas? facebook We have lined up a stellar venue also hope that the holidays were both Pedorthic Footcare Association and can’t wait to unveil the details. wonderful and profitable. Here’s to a NOTE: Often the "From the Editor" fantastic new year! columntwitter is an embedded video. If the They will be coming soon, but mark image above@pfapedorthics has a "red play button", November 7th through 9th on your simply click the "play" button to start the video.linkedIn There is also included a tran- Best wishes to you all! Pedorthic Footcare Association calendar now. You are going to be script below for those that download a busy at your association’s milestone ■ hard copygoogle+ or a printable PDF file. We birthday party! (See: pg.41) Chris Costantini hope youPedorthic enjoy this Footcare addition to Association Current Executive Editor Pedorthics and please let us know what In the meantime, I am happy to you think!youtube Comments or Questions on present the January/February issue of the videoPedorthic email: cpmagazine@pedor Footcare Association- thics.org. Any other inquiries email: [email protected] & p social . O&P Pedorthic Footcare Association Photo: @Shutterstock.com/VluePhoto: 6 Pedorthic Footcare Association | www.pedorthics.org ALL NEW PREMIERE COLLECTION QUALITY DIABETIC SHOES & INSERTS

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Melvyn P. Cheskin, MBS., C.Ped, L.Ped Mel Cheskin MBS., C.Ped is originally from England. Mel attended the University of Colorado at Boulder, CO., The School Podiatric Medicine at Temple University in Philadelphia, PA and Ars Sutoria Shoe Design College in Milan, Italy. As author of "The Complete Handbook of Athletic Footwear" and technical / medical writer for Podiatry Management, Current Pedorthics, World Footwear, Runner’s World and World Sports Activewear magazines, Mel is one of the most experienced shoe professionals in the Footwear and Pedorthic fields. In his career as a Designer and Consultant, Mel has worked for Nike (Cole-Haan), Adidas, Puma, Reebok, Brooks, Bata and Spenco Medical Corp. Mel is a Licensed Pedorthist in South Florida, residing in Boca Raton. Mel is also a member of the Bioelectromagnetic Society in Frederick, MD. and Associate member of the American Academy of Podiatric Sports Medicine. L V Michael A. Hunt, Judit Takacs, Natasha M. Krowchuk, Gillian L. Hatfield, Rana O S. Hinman and Ryan Chang This study was promoted in part, by a grant from the Pedorthic Research Foundation of Canada: The purpose of this study was to evaluate whether lateral wedge insoles with custom arch support are more beneficial than lateral wedge WHAT MOVESe insoles alone for knee and foot symptoms in people with medial tibiofemoral knee osteoarthritis (OA) and pronated feet. YOU

Harry Centa Mr. Centa is a program manager at PartnerShip, PFA's source and connection to simple and affordable shipping. Mr.Centa acts as the PartnerShip Program Representative for PFA.

Consider Writing an Article for Current Pedorthics! For more details, contact Current Pedorthics magazine at (229) 389-3440 or by email at: [email protected] for additional upcoming special interest topics, guidelines and other From footwear to foot care, no one protects foot health like New Balance. ideas you may want to discuss as topic ideas beneficial to health care, patient care and all We developed the NBRx network of retailers to deliver all your fit and areas of interest in the pedorthics practice and other associated industries. performance needs. Find the 1080 and an NBRx-certified retailer near you at newbalance.com/findastore.

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Current Pedorthics | January/February 2019 9 PFANEWS NEWS AND HAPPENINGS FROM THE PEDORTHIC FOOTCARE ASSOCIATION

PFA Announces 60th Subscribe to ABC CredCast now:

Annual Symposium in iTunes: Las Vegas! https://itunes.apple.com/us/podcast/abc-credcast/ id1447506521?mt=2

For Immediate Release: Google Play: https://play.google.com/music/listen#/ps/ Join us in celebrating PFA’s 60th year of high-quality Imm5n77mkugkslbkyis24cvfen4 pedorthic health care education. Share your knowledge and expertise with pedorthic professionals attending the PFA Symposium & Exhibition at the M Resort-Spa- Casino in Las Vegas, Nevada. (See: pg.41) PFA introduces "Ask the Symposium Date: Experts" Program Thursday, November 7th through Saturday, November 9th, 2019 TAKE ADVANTAGE NOW: The Pedorthic Footcare Association is Symposium Location: proud to introduce our newest member benefit, our Ask M Resort-Spa-Casino, Las Vegas, NV (visit symposium the Experts program! This program allows our member- event site) ship access to a panel of experts that they can ask questions or advise on a number Pedorthic and clinical topics. Download the CALL FOR SPEAKERS (deadline 02/01/2019): All our experts are experienced business owners and have https://www.pedorthics.org/page/SYMPOSIUM2019 been in the industry for 10 years or more. To access this member benefit, simply call the PFA office at (229) 389- 3440 and select the prompt that best describes your ques- ABC has launched its tion or concern. (See: pg.13) first Podcast — ABC CredCast PFA's 2019 Media Kit - AVAILABLE NOW! IT'S LIVE!: Let ABC CredCast be your source for all things creden- For Immediate Release: tialing from certification, continuing ed, accreditation and more! Each month join host Jim Lawson, ABC's Current Pedorthics Magazine / PFA Outreach Development Manager, as he provides insights 2019 Media Kit will be available soon! and helpful tools for navigating all of ABC’s credentialing PFA offers targeted media outlets to help you reach your programs and recertification processes. audience, maximize your return on investment and communicate with the industry. Choose from Current At work, in the car or at the gym...you're just one click Pedorthics Magazine, PFA E-Blast email announcements away from valuable education to help you get the most out & PFA’s website. of your O&P career. For more information and downlod the current 2018 >> LISTEN NOW TO THE FIRST EPISODE Media Kit (click the link): https://www.abcop.org/news-events/Pages/CredCast. aspx https://www.pedorthics.org/?page=CurrentPedorthics

Understanding Privileging

Privileging can be a powerful resource for ABC credential holders, but it is important to understand what it is, what it isn't, who can be privileged and what kind of supervi- sion is needed. Join host, Jim Lawson as he interviews ABC's Clinical Resource Director, Steve Fletcher on this sometimes-confusing topic.

10 Pedorthic Footcare Association | www.pedorthics.org Full Page Ad INDUSTRYNEWS

DECEMBER 6, 2018: JANUARY 1, 2019:

DME MAC Joint Publication New information for 2019! The 2019 DMEPOS Fee Schedule is available. You can download and new A5514 Facial Prostheses, Knee Orthosis (KO), Lower Limb Pros- HCPCS coding information at the bottom of this page. theses (LLP), Orthopedic Footwear, Refractive Lenses, Surgical Dressings, Therapeutic Shoes for Persons with Items of interest: Diabetes (TSD), and Wheelchair Options/Accessories Policy Articles. • The 2019 Medicare deductible will be $185, which is a $2 increase from 2018. Effective for claims with dates of service (DOS) on or after 3/1/2019, suppliers must bill each item on two separate • K0903 will be replaced with code A5514 beginning on claim lines using the RT and LT modifiers and 1 UOS on claims with a date of service 1/1/19 and after. each claim line. Do not use the combination RTLT modi- • There is an increase in all the A-codes this year. Below fier on the same claim line and bill with 2 units of service is a comparison list and attached is the Medicare fee (UOS). Claim lines for HCPCS codes requiring use of the schedule for all DME codes. RT and LT modifiers, billed without the RT and/or LT

modifiers or with the RTLT on a single claim line, will be 2018 2019 rejected as incorrect coding. HCPCS Description per per per per pair unit unit pair • Refer to the Ankle-Foot/Knee-Ankle-Foot Orthoses A5500 Diabetic shoe for density insert 71.56 143.12 73.21 146.42 (A52457External Website), A5501 Diabetic custom molded shoe 214.65 429.30 219.59 439.18 A5503 Diabetic shoe with roller/rocker 35.27 70.54 36.24 72.48 • External Breast Prostheses (A52478—External Website), A5504 Diabetic shoe with wedge 35.27 70.54 36.24 72.48 Diabetic shoe with metatarsal • Eye Prostheses (A52462—External Website), A5505 35.27 70.54 36.24 72.48 bar • Facial Prostheses (A52463—External Website), A5506 Diabetic shoe with offset heel 35.27 70.54 36.24 72.48 A5507 Modification diabetic shoe 35.27 70.54 36.24 72.48 • Knee Orthoses (A52465—External Website), Multi density insert heat A5512 29.19 58.38 29.86 59.72 molded • Lower Limb Prostheses (A52496—External Website), Multi density insert custom A5513 43.56 87.12 44.56 89.12 molded

Multi density insert, CAM • Orthopedic Footwear (A52481—External Website), A5514 43.56 87.12 44.56 89.12 technology • Refractive Lenses (A52499—External Website),

• Surgical Dressings (A54563—External Website), Revised JANUARY 2019 - Fee Schedule DOWNLOAD EXCEL SPREADSHEET • Therapeutic Shoes for Persons with Diabetes (A52501— External Website) and

• Wheelchair Options/Accessories Policy Article Please let us know if you have any questions! (A52504—External Website) and Contact: [email protected] • Standard Documentation Requirements Policy Article Publication History (A55426—External Website) for additional coding and December 6, 2018 Original Publication documentation requirements.

Publication History December 6, 2018 Original Publication

12 Pedorthic Footcare Association | www.pedorthics.org INDUSTRYNEWS NEWEST PFA MEMBER BENEFIT

ACCESS EXPERTS IN ALL AREAS OF YOUR PROFESSION he Pedorthic Footcare Association is proud interest are important to you, our members. To Tto introduce our newest member benefit, our access this member benefit, simply call the PFA Ask the Experts program! This program allows our office at (229) 389-3440 and select the prompt membership access to a panel of experts that they that best describes your question or concern. Not can ask questions or advise on a number Pedorthic sure who to speak with, simply connect with the and clinical topics. We currently have experts to operator and you will be guided to the appropriate cover the following topics: expert. You will be immediately connected to a LIVE person ready and willing to help you get the • Clinical Practice answers to your questions. Business and Business Development Want to know who your talking too, no problem! • See our list of experts and their area of expertise in • Government Affairs the image above! • Continuing Education All our experts are experienced business owners Marketing and have been in the industry for 10 years or more. • They have a wealth of information to share with • Audit Support you, and in the event they don’t know the answers, have a vast network they can reach out too in We will be adding to our list of experts as we order to find an answer. So, don’t hesitate! Take grow the program and find out what areas of advantage of this new member benefit today!!! Call the PFA office at (229) 389-3440 & Talk to an Expert Today!

Current Pedorthics | January/February 2019 13 INDUSTRYNEWS

HARASSMENT

This letter is being reprinted with the will be treaty with respect and granted permission of the O&P Alliance. due process. PFA will work with the credentialing organizations, employers and While PFA is not a member of the Alliance, law enforcement, as appropriate, to assist we fully support their positions on sexual in their investigation. If allegations are misconduct, harassment and discrimination. substantiated, PFA will subsequently aid in We believe that there is no place in our the enforcement of any disciplinary action profession for actions such as these. Any imposed. allegations of this type of conduct can be reported to any member of the PFA staff -PFA

or Board of Directors. All parties involved @SHutterstock.com/TinnakornPhoto: jorruang

14 Pedorthic Footcare Association | www.pedorthics.org INDUSTRYNEWS

Current Pedorthics | January/February 2019 15 meet mallory Features an adjustable contact closure Full Page Ad for a secure ﬁ t on a timeless classic loafer style

T 800.556.5572 Individual results may vary. Neither DJO Global, Inc. nor any of its subsidiaries dispense medical advice. The contents of 10300 North Enterprise Drive I Mequon, WI 53092 I U.S.A. this sheet do not constitute medical, legal, or any other type of professional advice. Rather, please consult your healthcare drcomfort.com I Copyright © 2018 by DJO, LLC I MKT00-8105 Rev A professional for information on the courses of treatment, if any, which may be appropriate for you. Follow us: @drcomfort Dr.Comfort meet mallory Features an adjustable contact closure Full Page Ad Full Page Ad for a secure ﬁ t on a timeless classic loafer style

T 800.556.5572 Individual results may vary. Neither DJO Global, Inc. nor any of its subsidiaries dispense medical advice. The contents of 10300 North Enterprise Drive I Mequon, WI 53092 I U.S.A. this sheet do not constitute medical, legal, or any other type of professional advice. Rather, please consult your healthcare drcomfort.com I Copyright © 2018 by DJO, LLC I MKT00-8105 Rev A professional for information on the courses of treatment, if any, which may be appropriate for you. Follow us: @drcomfort Dr.Comfort BY MICHAEL A. HUNT1, JUDIT TAKACS1, NATASHA M. KROWCHUK1, GILLIAN L. HATFIELD1, RANA S. HINMAN2 AND RYAN CHANG3

18 Pedorthic Footcare Association | www.pedorthics.org Lateral wedges with and without custom arch support for people with medial knee osteoarthritis and pronated feet: An exploratory randomized crossover study.

ABSTRACT stiffness subscales, and the timed stair climb test. Regression modeling was conducted to BACKGROUND: examine treatment, period, and interaction Pronated foot posture is associated with many effects. clinical and biomechanical outcomes unique to RESULTS: medial compartment knee osteoarthritis (OA). Though shoe-worn insole treatment, including Twenty-two participants completed the lateral wedges, is commonly studied in this study, and no carryover or interaction effects patient population, their effects on the specific were observed for any outcome. Significant subgroup of people with medial knee OA and treatment effects were observed for the timed concomitant pronated feet are unknown. The stair climb, with greater improvements seen purpose of this study was to evaluate whether with the lateral wedges with arch support. lateral wedge insoles with custom arch support Within-condition significant improvements are more beneficial than lateral wedge insoles were observed for WOMAC pain and physical alone for knee and foot symptoms in people function, as well as FFI-R pain and stiffness with medial tibiofemoral knee osteoarthritis (OA) with lateral wedges with arch support use. and pronated feet. More adverse effects were reported with METHODS: the lateral wedges alone, while more people preferred the lateral wedges with arch support Twenty-six people with pronated feet and overall. symptomatic medial knee OA participated in a randomized crossover study comparing CONCLUSIONS: five-degree lateral wedge foot insoles with and without custom foot arch support. Addition of custom arch support to a standard Each intervention was worn for two months, lateral wedge insole may improve foot and separated by a two-month washout period of knee symptoms in people with knee OA and no insoles wear. Main outcomes included the concomitant pronated feet. These preliminary Western Ontario and McMaster Universities findings suggest further research evaluating the Osteoarthritis Index (WOMAC) pain and role of shoe-worn insoles for treatment of this physical function subscales, the revised short- specific sub-group of people with knee OA is form Foot Function Index (FFI-R) pain and warranted.

Current Pedorthics | January/February 2019 19 Lateral wedges - a crossover study

BACKGROUND: has also shown that the presence of foot/ankle symptoms significantly increases the odds of Osteoarthritis (OA), commonly affecting the developing knee OA symptoms and symptomatic knee joint, is one of the most prevalent chronic radiographic knee OA [9]. Additionally, rearfoot musculoskeletal disorders and is a leading eversion during walking has also been shown cause of long-term physical disability affecting to be associated with medial compartment knee adults [1]. While we are unaware of joint specific joint load, as quantified by the external knee indicators of the economic burden of OA, a adduction moment (KAM) [10]. Specifically, more recent report indicates that more than 6.9% of rearfoot eversion appears to be associated the adult population in the Unites States had with lower KAM values. Finally, older adults symptomatic knee OA in 2007-2008 [2] – a with pronated feet are more likely to exhibit number that is expected to rise dramatically in knee pain and medial tibiofemoral cartilage the coming decades. Further, symptomatic OA damage than older adults with other foot (the combination of symptoms and radiographic types [11]. Taken together, these findings evidence of OA) is more commonly found in the indicate that people with pronated feet form knee than in any other joint [3]. Given that there a large, and clinically relevant, sub-group of is no cure for knee OA and the overall economic the population with knee OA. Thus, targeted burden of OA is high, there has been a recent treatment approaches for this subgroup that push towards the identification of non-surgical, considers their unique biomechanical needs non-pharmacological treatments for knee OA may be warranted. However, current methods that can be delivered effectively, safely, and with for the treatment of knee OA symptoms and minimal personnel and economic resources biomechanics has typically failed to directly [4]. Shoe-worn insoles/orthotics are a low-cost address any aspect of foot biomechanics and low-burden self-management option that in general, and in those with knee OA and has widespread appeal for managing knee OA concomitant pronated feet specifically. symptoms. A commonly studied conservative treatment Recent research confirms the link between approach for knee OA is shoe-worn insoles, in knee and foot problems in people with knee OA. particular insoles that are built up along the An examination of data from the Osteoarthritis lateral edge (lateral wedges). There have been a Initiative showed that 25% of individuals with number of studies examining the biomechanical painful knee OA concurrently report foot pain, and clinical changes associated with use of and that the presence of foot pain adversely lateral wedges. Although lateral wedges have affected overall health and function [5]. been shown to provide immediate reductions Individuals with knee OA also tend to exhibit in KAM magnitudes [12, 13] – consistent with more pronated feet compared to those without the reported negative correlation between knee OA [6, 7]. Indeed, a recent study involving increased rearfoot eversion (which would occur 164 people with symptomatic medial tibiofemoral with lateral wedging) and the KAM [10] – the OA reported that 45% had pronated or effects on knee symptoms are less clear [14]. A severely pronated feet [8]. Recent research primary limitation of previous lateral wedges for

20 Pedorthic Footcare Association | www.pedorthics.org Lateral wedges - a crossover study

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"An examination of data from the Osteoarthritis Initiative showed that 25% of individuals with painful knee OA concurrently report foot pain, and that the presence of foot pain adversely affected overall health and function."

knee OA research has been a failure to consider Given the apparent strong link between participants’ foot morphology in the study pronated foot type and disease characteristics design and delivery of treatment. In clinical specific to medial compartment knee OA, and practice, pronated feet are typically managed that biomechanical interventions such as lateral with some form of medial arch support [15, 16], wedges are advocated in clinical guidelines for the use of conservative treatments for knee and while some research shows that beneficial OA in general [22], a better understanding changes in ankle kinematics [17] and foot of the clinical effects of shoe-worn insole pain [18, 19] may be obtained with this clinical treatment for in this specific subgroup of knee approach in people with pronated feet, the OA is warranted. Therefore, the purpose of evidence in this area is sparse [20]. However, the present exploratory randomized crossover there is potential that a combination of lateral study was to compare clinical effects (knee wedges and arch supports may be beneficial for and foot symptoms) of lateral wedges alone people with painful knee OA and pronated feet to insoles that combined lateral wedging with

Illustration: @Shutterstock.com/Tefi [21]. customized arch support in people with medial

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knee OA and concomitant pronated feet. We NCT02234895), gait biomechanics data were were also interested in the safety of these only collected at the initial baseline data interventions and adherence to treatment. It was collection session, rather than at all time points, hypothesized that the combined insole would and are presented elsewhere [24]. produce greater improvements in knee pain STUDY DESIGN and physical function, as well as foot pain and stiffness, and would be more comfortable. This was an exploratory, within-subjects cross-over study. METHODS PROCEDURES Participants: Community-dwelling individuals with medial tibiofemoral OA were recruited via Interested participants were initially advertisements in print media. Inclusion criteria screened for inclusion and exclusion criteria, included: (i) definitive medial tibiofemoral and eligible individuals were referred for a osteophytes on radiograph; (ii) joint space physical screening of foot posture. Individuals narrowing greater in the medial tibiofemoral who passed the foot posture eligibility criteria compartment compared to the lateral described above were referred for radiographic compartment; (iii) history of knee pain longer evaluation. Standing, semi-flexed, postero- than six months; (iv) average knee pain of at anterior radiographs were obtained and graded least 3 out of 10 (using an 11-point numerical for disease severity using the Kellgren and Full Page Ad rating scale (NRS) with terminal descriptors of Lawrence (KL) OA classification system [25]. 0=“no pain” and 10=“worst pain imaginable”) Individuals who met all study eligibility criteria over the one month prior to initial screening; were then referred to a Canadian Certified and (v) pronated feet, defined as +4 or higher Pedorthist, who obtained foot measurements on the Foot Posture Index [23], with at least and made volumetric casts of both feet to inform four items rated as +1 (indicating pronation). manufacture of insoles. Participants returned to Exclusion criteria included: (i) knee surgery the same Pedorthist following manufacture of or intra-articular injection for pain within the both sets of the insoles for final modifications previous six months; (ii) current or past (within and instruction on insoles wear. Insoles were six weeks) oral corticosteroid use; (iii) history made for bilateral wear, even in cases where of knee joint replacement or tibial osteotomy; knee OA was unilateral. Both sets of insoles (iv) any other condition affecting lower limb were then sent directly to the University function; and (v) current, or failed previous (i.e. laboratory, and participants were scheduled premature cessation of orthotic treatment due for their first baseline testing session. Following to adverse effects), wearing of shoe insoles/ baseline assessment of outcomes (month 0), orthotics. The study was approved by the participants were randomly allocated to either Institution’s Clinical Research Ethics Board i) lateral wedges alone or; ii) lateral wedges plus and all participants provided written informed custom arch support. Allocated insoles were consent. In contrast to information provided on worn for a two-month period in their own usual the trial’s registry (Clinicaltrials.gov identifier: shoes, and then participants were reassessed

Current Pedorthics | January/February 2019 23 Lateral wedges - a crossover study

"A commonly studied conservative treatment approach for knee OA is shoe-worn insoles, in particular insoles that are built up along the lateral edge (lateral wedges)."

(month 2). After a two-month washout period of design of the insoles. Both pairs were provided no insole wear, participants were re-assessed to participants upon study completion. again (month 4) and then underwent a second INTERVENTIONS two-month period of intervention with the alternate insole condition, after which they were For both types of insoles, polypropylene sheets re-assessed for the final time (month 6). of 34 mm thickness were vacuum formed or The randomization schedule was produced milled directly to produce a sulcus length insole. before study commencement by a researcher For both conditions, the lateral wedges consisted not involved with data collection or analysis. of a 5-degree ethyl-vinyl acetone (EVA) (Shore Random permuted blocks of 4 or 6 were A hardness of 55) sulcus-length posting. For developed and randomization codes were sealed the lateral wedges plus arch support insole, the in consecutively numbered, opaque envelopes same lateral wedges were used in combination that were opened after baseline testing for each with a custom arch support across the foot to participant. To prevent cross-contamination match the negative of the volumetric cast. Both of insole wear, the unused pair (in the case insoles (Fig. 1) were finished with the same of active treatment periods), or both pairs (in neoprene cover and modified as necessary to the case of the wash-out period) of insoles maximize comfort and fit. Participants were were kept onsite at the University. Further, instructed to wear the insoles as much as the participants were unaware of the study possible and no other instructions regarding the

hypotheses as well as the justification for the intervention were provided. from:https://www.braceability.com/products/medial-lateral-heel-wedges adapted Photos

24 Pedorthic Footcare Association | www.pedorthics.org Lateral wedges - a crossover study

OUTCOME MEASUREMENT applicable” is a potential response for some questions, questions rated as “not applicable” Outcome assessments were conducted by the were removed and the remaining scores within same blinded assessor. Testing sessions at the that subscale were summed. Subscale scores University included completion of self-report were then converted to a percentage of the questionnaires and objective assessment of maximum potential score for that particular physical function. subscale with 25% indicating no pain or Self-reported knee and foot symptoms were stiffness and 100% indicating severe pain or the clinical outcomes of interest. Participants stiffness. completed the Western Ontario and McMaster Universities Arthritis Index (WOMAC) Likert Objective physical function was assessed using version, from which the pain and physical the timed stair climb test, where participants function subscales were calculated [26]. The were instructed to ascend 12 stairs “as quickly WOMAC contains 24 items that quantify pain (5 as possible” and the fastest time from two items), stiffness (2 items), and physical function attempts was recorded [28]. Adherence to each (17 items) that has been used in numerous knee insole intervention was self-reported in daily log OA studies. Foot symptoms were assessed using books. Participants reported the total number the Foot Function Index (revised - short form) of hours of shoe wear each day as well as the (FFI-R). This self-report questionnaire consists total number of hours wearing the insole. Wear of 34 items that provide the ability to quantify time was then calculated by the research team aspects of foot pain, disability and activity following the intervention, and expressed as limitation [27]. For the purposes of this study, total number of insole wear hours, as well as a the pain and stiffness subscales were used. Each percentage of total shoe wear time. Participants question is rated from 1 (no pain or stiffness) also recorded perceived adverse effects of the to 4 (severe pain or stiffness). Given that “not insoles, and changes in treatment regimens

FIGURE 1: Intervention insoles. Left: the lateral wedge only condition consisted of a sulcus- length 5-degree lateral wedge. Right: the lateral wedge plus custom foot arch support involved the 5-degree sulcus length lateral wedge built into a negative of the volumetric cast that provided the support across the entire foot. Photo: Provided the by authors

Current Pedorthics | January/February 2019 25 Lateral wedges - a crossover study

during the active treatment periods (months 0 STATISTICAL ANALYSIS to 2 and 4 to 6) in their daily log books. At the All statistical analyses were conducted using month 2 and month 6 assessments, participants Statistical Analysis Software (SAS, v 9.4; SAS rated comfort during the intervention using Institute Inc.: Cary, NC, USA) and p values <0.05 an 11-point NRS with terminal descriptors of were considered significant. For WOMAC, 0=“maximum discomfort” and 10=“maximum FFI-R and timed stair climb outcomes, change comfort”. Participants also rated their perceived scores were calculated as follow-up minus overall change in symptoms at follow-up (month baseline values for each intervention period. As 2 and 6) compared to baseline (month 0 and 4) comfort data were only acquired at the follow- using a 5-point Likert scale (1=“much worse”, up assessments, these were treated as raw 2= “slightly worse”, 3= “no change”,4=“slightly data rather than change scores. Mixed effects better”, and 5=“much better”). Finally, at the regression models predicting change variables month 6 assessment, participants indicated against fixed effects for intervention period and which pair of insoles (“first or second”) they treatment type, and a random subject effect preferred. were developed for each outcome variable.

TABLE 1: Participant characteristics at baseline based on order of intervention. Values are mean (sd) unless otherwise noted

Wedge to Wedge plus arch support Wedge plus arch support to Wedge All participants (n = 12) (n = 14) (n = 26)

Age (years) 66.3 (10.2) 62.1 (5.0) 64.0 (7.6)

Sex (F:M) 9:3 13:1 22:4

Foot Posturea 5 (4,8) 5 (4,9) 5 (4,9)

Body Mass (kg) 65.3 (9.8) 75.0 (15.3) 70.5 (13.8)

2 BMI (kg/m ) 25.2 (3.0) 28.9 (4.5) 27.2 (4.2)

Disease Severity (n)

KL 2 9 7 16

KL 3 3 7 10

a As quantified by the foot posture index (FPI). Values are reported as median (minimum, maximum)

26 Pedorthic Footcare Association | www.pedorthics.org Lateral wedges - a crossover study

Interactions between intervention period completed their first allocated treatment period, and treatment type were initially included as and of those, 22 completed month 6 assessment. predictors in a second model, then dropped Of the four participants who did not complete from the models if non-significant (this was true the study, three were lost-to-follow-up (one for all models). prior to the month 2 follow-up assessment, one after the month 4 baseline assessment, and one RESULTS prior to the month 6 follow-up assessment), Between July 2014 and June 2015, 127 while the fourth withdrew prior to the month individuals underwent eligibility screening, 2 follow-up assessment due to health issues of which 26 were enrolled. Participant unrelated to the study. Mean (sd) intervention times were 2.2 (0.2) months for the lateral demographics are summarized in Table 1. wedges and 2.1 (0.2) months for the lateral Fourteen individuals were randomized to wedges plus arch support, with a washout receive the lateral wedge plus arch support period of 2.1 (0.3) months. in the first iteration (months 0-2), while 12 participants received the lateral wedges alone Table 2 provides results for clinical outcomes in the first iteration. Twenty-four individuals across test conditions. The lateral wedges

Table 2: Outcomes data. Mean (sd) baseline and follow-up outcome data for all variables, as well as model adjusted differences (follow-up minus baseline; difference (95% confidence intervals)) within each condition as well as between conditions. Model estimate values represent the within- and between-condition least-square mean differences adjusted for period and random subject effects from the regression modeling

Lateral wedges (n = 24) Lateral Wedges plus Arch Support (n = Between 22) conditions comparison

Variable Baseline Follow-up Difference Baseline Follow-up Difference Difference

-0.7 (-1.8, -1.9 (-3.1, -1.2 (-2.9, WOMAC Pain (0-20) 5.9 (3.0) 5.2 (2.9) 6.3 (3.4) 4.0 (2.5) 0.5) -0.6)* 0.5)

20.2 -2.5 (-6.2, 21.4 -6.1 (-9.9, -3.6 (-7.9, WOMAC Function (0-68) 17.6 (8.9) 14.0 (8.8) (11.0) 1.1) (12.5) -2.3)* 0.8)

41.0 -2.7 (-8.9, 43.6 -7.0 (-13.5, -4.3 (-12.0, FFI-R Pain (25-100%) 38.4 (11.9) 33.0 (9.3) (17.4) 3.5) (16.2) -0.6)* 3.4)

39.2 -2.1 (-7.3, 42.8 -6.3 (-11.7, -4.1 (-11.0, FFI-R Stiffness (25-100%) 37.1 (13.7) 32.3 (9.4) (15.7) 3.0) (19.5) -0.9)* 2.7)

0.04 5.32 6.57 -0.69 (-1.3, -0.73 (-1.36, Stair climb (seconds) 5.35 (1.54) (-0.55, 5.58 (2.29) (1.68) (4.04) -0.08)* -0.11)* 0.63)

* p < 0.05

Current Pedorthics | January/February 2019 27 Lateral wedges - a crossover study

F ea au ed ea

OMA Pain Score

Mont Mont Mont Mont

F ea au ed ea

OMA Function Score

Mont Mont Mont Mont

FIGURE 2: Assessment of treatment and period effects for Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain a and physical function subscales b. Lower scores indicate less knee pain and physical dysfunction. Dotted lines indicate mean values for participants receiving the lateral wedges alone first, followed by the lateral wedges plus arch support; solid lines indicate mean values for participants receiving the lateral wedges plus arch support first, followed by the lateral wedges alone.

28 Pedorthic Footcare Association | www.pedorthics.org Full Page Ad Lateral wedges - a crossover study

plus arch support resulted in significant than their “second” (9/22), which translated improvements in all parameters, whilst the into more individuals preferring the lateral lateral wedges alone did not significantly wedges plus arch support (17/22; of these 17, change any clinical outcome. However, these 10 participants were randomized to the lateral differences generally did not translate into wedges plus arch support first, while the other significant treatment main effects (between 7 received the lateral wedges plus arch support conditions), with the exception of timed stair second). When asked to report overall change in climb, where improvements were significantly symptoms compared to baseline, 15 individuals greater with the use of the lateral wedges with reported improvement with lateral wedges arch support compared to lateral wedges alone alone (7=“much better”, 8= “slightly better”) (p=0.02). In addition, a significant period effect while 18 individuals reported improvement with (Figs. 2 and 3) was seen for WOMAC Pain scores the lateral wedges plus arch support (9=“much (p=0.04). There were no intervention by period better”,9=“slightly better”). interactions. A total of 16 unique, yet minor, adverse events Using a minimal clinically important were self-reported during the study, 11 of which improvement of 17% for WOMAC pain and 12% occurred during lateral wedges wear and five for WOMAC function [29], use of lateral wedges during lateral wedges plus arch support wear. alone resulted in improved pain in 13 (54%) With lateral wedges alone, the most common participants and improved function in 14 (58%) complaint was onset of foot pain or discomfort participants. When using the lateral wedges (n=3), which lasted between one and three plus arch support, 14 (64%) participants had weeks. There were two reports of increased improved pain while 17 (77%) participants had bunion pain, one lasting two weeks and the improved physical function. other for the duration of the intervention. Other Wear times were similar between the two complaints included: five weeks of toe cramping treatment periods, whether expressed as (n=1), three weeks of lateral ankle pain (n=1), absolute or relative time values. The mean (sd) one week of calf tightness (n=1), generalized number of hours that participants self-reported lower leg pain lasting three days (n=1), and one insole wear was 150.7 (86.5) hours for the lateral report each of lower back and knee pain lasting wedges and 152.5 (121.0) hours for the lateral one and ten weeks, respectively. During lateral wedges plus arch support over the two-month wedges plus arch support wear, five individuals intervention periods, which equated to 72.5 reported foot pain or discomfort ranging from (19.2)% and 75.8 (24.4)% of total shoe wear two days to two weeks. Finally, three individuals time, respectively. There were no differences underwent additional treatment during lateral (p=0.55) in self-reported comfort between the wedges use (two instances of topical pain relief two conditions (lateral wedges=6.4 (2.6) out gel and one instance of foot and lower leg of 10; lateral wedges plus arch support=6.9 massage), while the same two treatments were (2.5) out of 10). More participants indicated completed by another two individuals during that they preferred their “first insole” (13/22) lateral wedges plus arch support wear.

30 Pedorthic Footcare Association | www.pedorthics.org Lateral wedges - a crossover study

F ea au ed ea

FF Pain Score

Mont Mont Mont Mont

F ea au ed ea

FF Stiness Score FF Stiness

Mont Mont Mont Mont

FIGURE 3: Assessment of treatment and period effects for Foot Function Index (FFI-R) pain a and stiffness subscales b. Values are presented as percentages of the maximum scores for each subscale, and lower scores indicate less foot pain and foot stiffness. Dotted lines indicate mean values for participants receiving the lateral wedges alone first, followed by the lateral wedges plus arch support; solid lines indicate mean values for participants receiving the lateral wedges plus arch support first, followed by the lateral wedges alone.

Current Pedorthics | January/February 2019 31 Lateral wedges - a crossover study

DISCUSSION "Taken together, these studies Findings from this study indicate that the show the potential for greater addition of custom foot arch support to improvement in knee pain with 5-degree lateral wedges may result in clinical improvements in knee and foot symptoms, and a combined insole than with a timed stair climb, in people with medial knee lateral wedge alone in people OA and pronated feet. However, these changes with knee OA." were generally not statistically significantly better than those observed with treatment by improvement in WOMAC pain was observed lateral wedges alone. Further, more participants with our combined insole, compared to only 12% subjectively preferred the supported lateral with the lateral wedges alone. Similar findings wedges overall, compared to lateral wedges have been reported elsewhere, with Jones et alone. Data from this study provide important al showing more immediate improvement in preliminary clinical information regarding knee pain with a combined insole compared to safety and efficacy of combined insoles for the a standard lateral wedge alone in people with treatment of an important sub-group of patients knee OA [21]. Taken together, these studies show with knee OA, namely those with concomitant the potential for greater improvement in knee pronated feet. pain with a combined insole than with a lateral Although no other research has specifically wedge alone in people with knee OA. evaluated effects of insoles in a subgroup of Although the combined insole resulted in people with knee OA and concurrent pronated clinical improvements across all measured feet, our findings are consistent with the limited parameters, and we observed no significant research investigating combined lateral wedge effect on outcomes when participants were insoles with arch supports in heterogeneous treated with lateral wedges alone, there was samples of people with knee OA. Indeed, a generally no statistically significant difference previous uncontrolled study investigating a in outcomes when comparing between insole similar insole design showed improvements in conditions. A larger sample size may have pain and function in 42 individuals with medial produced statistically significant differences, knee OA and varus knee alignment. Skou et al and results from this study can now be used showed that an insole that combined a custom- to guide sample size calculations for future made arch support with an individualized clinical trials. Importantly, though the lateral amount of lateral wedging produced significant wedges plus arch support produced more improvements in pain, function, and quality symptomatic benefits over a two-month of life after an average of 7.75 months of wear period, biomechanical data from the current [30]. Specifically, they found greater than 40% cohort taken at the initial baseline assessment improvement, on average, in knee pain intensity indicates that both insoles produced similar (measured using a visual analog scale) with the KAM reductions (albeit slightly larger reductions combined insole. In the present study, a 30% in the lateral wedges alone) compared to a

32 Pedorthic Footcare Association | www.pedorthics.org Lateral wedges - a crossover study

no insole walking condition [24]. Thus, the or foot symptoms obtained with the combined differences in clinical outcomes in the present insoles which then translated into perceived study cannot be attributed solely to the changes at the knee. Further research is needed biomechanical effects of the lateral wedges. to better elucidate the relationship between foot Indeed, a direct relationship between changes mechanics and knee symptoms in this patient in KAM magnitudes and pain levels with population. foot-based interventions has not been shown It was clear that participants preferred the in the literature [31, 32], suggesting that the lateral wedges with arch support. Indeed, 17 relationship between measured external loads of 22 participants (78%) indicated an overall and knee pain magnitudes is complex. Rather, preference of that insole condition and reported it is likely that the addition of the custom arch that the combined insole was slightly more support played a role in reducing self reported comfortable under the feet. Any difference in knee pain in the present study. The reasons for comfort with the combined insole may partially this are unclear, but may include indirect effects explain why we observed clinical improvements of the insoles, such as psychological factors with the combined insole but now with the on overall benefits based on insole preference lateral wedges alone. However, as there were no

Current Pedorthics | January/February 2019 33 Lateral wedges - a crossover study

"Since recent research has identified a link between foot symptoms and development of knee OA, and the fact that shoe-worn insoles evoke change directly at the feet, measurement of foot and ankle symptoms with foot-based treatment for knee OA is necessary."

statistical differences when comparing group higher risk of developing knee pain and medial mean comfort ratings, any effect of perceived tibiofemoral cartilage damage [11], this subgroup comfort would have occurred on an individual in particular represents an important target for basis. Jones et al also reported slightly more the study of shoe-worn insoles for the treatment perceived foot comfort with a combined insole of knee OA. More research with a homogeneous compared to a lateral wedge alone, though the sample of pronated foot posture is warranted. differences were also not statistically significant This is also the first study, to our knowledge, to [21]. Given that 19/26 individuals reported at assess the impact of insoles on foot symptoms least some foot pain (values >25% on the FFI-R in people with knee OA. Since recent research pain subscale) at the initial baseline assessment, has identified a link between foot symptoms assessment of changes in foot symptoms was and development of knee OA [9], and the fact important. Within-condition assessment of that shoe-worn insoles evoke change directly change in these symptoms from the current at the feet, measurement of foot and ankle study would indicate that the lateral wedges symptoms with foot-based treatment for knee plus arch support were able to improve foot OA is necessary. Indeed, given that more self- symptoms. Finally, while not statistically reported adverse events (especially lower leg, tested, more self-reported adverse events were ankle, and foot issues) were reported in the recorded during lateral wedges use (n=11) than present study with the lateral wedges alone, during the combined insoles (n=5). While these this finding provides important information reports were relatively minor and short-term, necessary to inform clinical decision making this finding provides further justification for the in this particular subgroup. However, given the need to comprehensively assess the feet when potential cost difference between the two types providing any insoles treatment to people with of insoles (potentially in excess of $300 per pair knee OA to primarily target knee symptoms. depending on the provider), a cost-effectiveness analysis of any symptomatic benefits of the Our study is novel, and an important combined insole must be conducted to assist in contribution to the literature for a number of the justification of prescribing this addition to a reasons. First, this is the first study evaluating standard lateral wedge. shoe-worn insoles in people with knee OA that has considered foot type as an inclusion or There are some limitations to this study. exclusion criterion. As noted above, given that First, although within-condition changes were pronated foot posture is common in people observed, our relatively small sample size for with knee OA [6], and is associated with a this exploratory study likely impacted our

34 Pedorthic Footcare Association | www.pedorthics.org Lateral wedges - a crossover study

ability to detect significant between condition that shoe-worn insoles that attempt to evoke differences. In addition, certain limitations of a biomechanical changes at the knee may be less randomized crossover study in general (such as effective at improving knee symptoms in people the potential for carryover and learning effects) with mild disease. Further research in samples must be considered. However our findings with more advanced radiographic knee OA provide justification for larger studies in this and pronated feet is required to determine the area. Second, the two-month intervention was effectiveness of shoe-based intervention in this shorter than previous similar studies which cohort. utilized 6- or 12-month (or longer) intervention CONCLUSIONS periods [33–35]. Although we did observe improvements in pain and function with the In conclusion, we found that the addition of combined insole over this timeframe, it is custom arch support to standard lateral wedge unknown if these benefits would be maintained shoe insoles resulted in improvements in foot over the longer-term. Further, we relied on pain and function in a group of individuals with self-report data to examine outcomes such as knee OA and pronated feet. However, changes usage and adverse events. Future research in symptoms were not statistically different from would benefit from more objective outcomes those observed when participants were treated of wear time such as instrumented insoles that with lateral wedges alone. Given that shoe- more accurately measure usage and would worn insoles represent a relatively inexpensive include some form of assessment of load during treatment option with little patient burden, dynamic movement. Finally, more than half findings from the present study suggest further of our sample was comprised of individuals research is required to evaluate the role of with mild radiographic disease severity. combined insoles in managing knee and foot Recent research suggests that the relationship symptoms in these patients. between biomechanics and knee symptoms in individuals with knee OA is stronger in more —END advanced radiographic disease [36], suggesting

ABBREVIATIONS: AVAILABILITY OF DATA AND MATERIALS: EVA: Ethyl-vinyl-acetate; FFI-R: Foot function index revised The datasets used and/or analyzed during the current version; FPI: Foot posture index; KAM: Knee adduction study available from the corresponding author on moment; KL: Kellgren and Lawrence; NRS: Numerical reasonable request. rating scale; OA: Osteoarthritis; WOMAC: Western AUTHORS’ CONTRIBUTIONS: Ontario and McMaster Universities Osteoarthritis Index. MH was involved in study design, data analysis, as FUNDING: well as drafting and approval of the manuscript. JT was This study was funded, in part, by a grant from the involved in study design, data collection, and approval Pedorthic Research Foundation of Canada. The funding of the manuscript. NK was involved in participant body had no role in any aspect of this study. RSH is recruitment, data collection, and approval of the supported by an Australian research Council Future manuscript. GH was involved in data collection and Fellowship (FT130100175). The funders had no role in any approval of the manuscript. RH was involved in study aspect of this study. design, data analysis, and approval of the manuscript. RC

Current Pedorthics | January/February 2019 35 Lateral wedges - a crossover study

was involved in study design, data analysis, and approval AUTHOR DETAILS: of the manuscript. 1) Department of Physical Therapy, University of British ETHICS APPROVAL AND CONSENT TO PARTICIPATE: Columbia, 212-2177 Wesbrook Mall, Vancouver, BC V6T 1Z3, Canada. 2) Department of Physiotherapy, This study was approved by the University of British University of Melbourne, Melbourne, VIC, Australia. 3) Columbia Clinical Research Ethics Board (approval Human Performance Engineering Laboratory, Reebok number: H14-01313). International, Canton, MA, USA. COMPETING INTERESTS:

The authors declare that they have no competing interests.

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Current Pedorthics | January/February 2019 37 MEMBERSERVICES

by Harry Centa PFA PartnerShip Program Representative

38 Pedorthic Footcare Association | www.pedorthics.org MEMBERSERVICES

A CLOSER LOOK AT THE 2019 FEDEX AND UPS RATE INCREASES

ith the New Year approaching, it’s time FedEx and UPS increases so PFA Members can W to look at the UPS and FedEx rate accurately prepare for the new year. Download increases for 2019 and how they will affect your the free white paper to see a breakdown of where costs. There are three Major Takeaways from the you’ll find the highest increases and get a simpli- 2019 FedEx and UPS Rate Increases. fied explanation of the complicated changes you need to be aware of. Here are some quick facts:

1. FedEx and UPS small package rates are Link: http://www.pedorthics.org/ increasing an average of 4.9%—effective resource/resmgr/currentpedor- January 7, 2019 and December 26, 2018 PDF thics/2019_Rate_Increases_ respectively. Paper.pdf 2. Your actual costs will vary. Depending on the service you use and your package When you enroll in the PFA Shipping Program, characteristics, you could see increases you receive exclusive discounts on select FedEx® above or below the average. services – helping to offset the 2019 rate increas- 3. Many common surcharges are also es. For more information or to enroll today, visit: increasing. On top of the base rates, you Link: PartnerShip.com/57pfa need to be aware of the charges that apply to your shipments and how they’ll affect Or call: 800-599-2902 your total costs. This is one of the most valuable benefits of PFA PartnerShip®, the benefit provider that manages membership! the PFA Shipping Program, has analyzed the

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42 Pedorthic Footcare Association | www.pedorthics.org Athletes or Artists? Where Biomechanics meets Pathomechanics

By Melvyn P. Cheskin, MBS., C.Ped, L.Ped

To state that professional dancers are prone to overuse injuries is an understatement. In fact, many merely treat pain as an occupational hazard. A thorough understanding of the categories of footwear available for the various dance forms can help pedorthists be aware of the dancer’s shoe requirements in order to better protect the feet, and when consulted, be more effective with treatment.

Current Pedorthics | January/February 2019 43 Athletes or Artists?

Normally we associate biomechanics and footwear are manufactured in such diverse countries as Russia, with athletes, where the study of the science relates to Australia, U.S.A., Germany, Italy, Japan, Spain, Brazil movements and interaction of the lower anatomy with and England. shoes during sports performance. Pathomechanics is often the extreme of athletic movement. It is the term The biomechanics applied to footwear is not used in sports medicine that determines the etiology, exclusively dominated by the sport shoe industry. diagnosis and treatment of overuse injuries. However, An increasing number of dance shoe makers, along this terminology frequently refers to another athletic with orthopedic and comfort shoe manufacturers, endeavour where foot and ankle injuries are often are paying more attention to biomechanical footwear career threatening – professional dancing. Injuries testing and new materials. The Freed family is still incurred by dancers have much in common with deeply involved in improving its English ballet shoe sporting injuries, but they are usually not identical. business and Eliza and John Minden of Gaynor Minden Inc. in New York City have both added When an avid runner is diagnosed and treated for a biomechanical design features and new materials typical overuse injury, such as progressive tibial stress to their ‘en Pointe’ models. Italian-born Salvatore syndrome, it is not uncommon for the pedorthist to Capezio, the founder of the New York dance shoe inquire as to the brand of footwear currently being company that bears his name, actually took a worn. Running shoe brands such as Nike, New ballerina for his wife. Now that’s really being married Balance, Asics, Adidas and Brooks have become to the job. household names. Certainly, most of the major sports categories, such as court, turf shoes, hiking Almost as specialized as sport shoes, dance shoes must and skating have features that are familiar to footcare have the same unique performance characteristics as professionals. Not so in a comparative evaluation of in most sports disciplines to cushion and withstand specialized ballroom, ballet, tap or show dancing strenuous athletic movement. However, unlike shoes. Even Capezio, the largest and best-known sport shoes, dance shoes must be aesthetically dance shoe brand – based in New York City, is little pleasing to the eye and/or subtly disguised as known outside of specialized dance suppliers and everyday or character footwear to fit the scene. dance studios. There is a choice of at least fifteen The major categories of dance are: ballet, jazz/ ballet shoe makers in the U.S. alone, the most popular swing, tap, ballroom, Flamenco, clogging, modern, being, Bloch, Gaynor Minden, Sansha, Grisko, Leo’s, lyrical and character or specialized show models and Capezio. As in the specialized sports, such as (think Cat’s paws, as in the Broadway show “Cats”). tennis or soccer, where major brands offer specialized Cheerleading and aerobic footwear are probably the categories of shoes, dance shoe categories also vary from ballroom to jazz, ballet to tap and Flamenco to closest crossovers between sport and dance shoes. clogging. The standard for the aerobic dance model has been developed with a split-sole, high-cut design with Unlike sports shoes that are predominantly flexible midfoot waist (first introduced by Capezio). manufactured in China and distributed worldwide, Both Nike and Capezio make shoes for cheerleading dance shoe makers are truly international. With and specialized niche brand Nfinity from Atlanta GA limited production quantities in demand, dance shoes has built its brand solely on the category.

44 Pedorthic Footcare Association | www.pedorthics.org Athletes or Artists?

"Almost as specialized as sport shoes, dance shoes must have the same unique performance characteristics as in most sports disciplines to cushion and withstand strenuous athletic movement."

Photo: @Shutterstock.com/Lorraine Swanson @Shutterstock.com/Lorraine Photo:

Current Pedorthics | January/February 2019 45 Full Page Ad

MOVABL RE E

T FOOTBED Athletes or Artists?

Specialized shoes made for dance may be as simple as aerobic exercise. Will ballroom dancing ever become a soft nappa leather gymnastic turn shoe construction, an Olympic event? The International Olympic as used in ballet slipper, or rugged full-grain 1.5 mm Committee (IOC) has recognized competitive pairs leather Flamenco high-cut boots with metal shank dancing as dancesport, so it may only be one step and taps on toe and heel. In modern dance and away from a recognized medal event. The best lyrical there is a piece of footwear used that can best choices in footwear for dancing at this level are shoes be described literally as a foot glove. It is a piece of designed especially for the ballroom and even more intricately cut soft chamois suede that fits between the specifically, for the exact dance style such as a strappy toes and under the ball of the foot to give the dancer Latin shoe with Cuban heel for the cha-cha or rumba, an optimal feeling of the dance floor and at the same or a sequined covered high-heel for the elegant waltz. time prevent blistering. Irish or Highland dance beginners and intermediate In most traditional dance categories, such as jazz dancers in this category wear soft shoes known as or tap, everyday dress shoes have been adapted by ghillies, pumps, or slippers that are made from soft craftsmen into lightweight, flexible designs using black nappa leather that conforms to the foot. The leather, synthetic poromeric or fabric materials in the design of the upper wraps around the foot and is upper. Specific soling materials are added to meet secured by long laces or elastics. Once the dancer the requirements of the dancer and particular dance becomes stronger and more experienced, they are Full Page Ad floor surface. For example, thin side split-suede or trained in routines using hard-shoe techniques. This bend leather is commonly used for soling on shoes type of shoe may have a fiberglass tip and heel to used in ballroom dancing for the optimal amount achieve the famous” clogging” sound with which of glide. This is combined with patent, nubuck and we have become familiar in the popular “Lord of soft full-grain leather uppers. Men’s upper styles for the Dance” routines. The rule here seems to be the ballroom dancing shoes are still relatively basic and higher the level of the dancer – the tighter the slipper. follow a CVO (circular vamp overlay) or one-piece This makes thin, protective padding, such as Poron® plain toe cap design on semi-pointed lasts. This is the essential to avoid heel and metatarsal bruising. look that inspired the original Reebok aerobic design in the early 1980’s. Ladies ballroom shoe styles are Harder materials such as wooden heels with more varied with closed toe or peek-a-boo toe, Mary leatherboard, thermoplastic or expanded rubber for Jane, T-Strap or sling-back designs being the most soling on shoes is used for tap or clogging with or common. Ballroom or swing dancing, like most other without a variety of metal heel and toe plates added. ‘sports’ has its own variety of footwear depending on Clogging incidentally is not dancing in clogs. It is a whether the dancer is in a class, studio rehearsal or dance category encompassing several sub-categories of competition. dance such as square dancing, Nordic, Irish, Scottish and English folk dance. Two of the most famous Ballroom pair’s dancing has become increasingly European clogging styles would be the ever-popular athletic and competitive in the past few years. Spanish Flamenco style dancing and the German Popular television shows such as ‘Dancing with Schuh Plattler. These traditional steps are blended the Stars’ has rekindled interest in the ‘sport’ and with American flatfooting, buck dancing, or in its many older athletes have turned to ‘the dance’ for most popular form, tap dancing, which owes its roots

Current Pedorthics | January/February 2019 47 Athletes or Artists?

to traditional African steps. In addition to wooden Cha. Surprisingly, width fittings are more common in heels and metal taps, acrylic soles may also be used to dance shoes than in athletic footwear (New Balance maximize the resonance on wooden flooring. Another excluded) and at least one company – Toe-to-Toe Inc., traditional family business is known for its specialty offers separate-size feet fittings, which is virtually footwear in this category – Steven’s Stompers from unknown outside of orthopedic footwear. Many of Pennsylvania. American Country and Western style the features on women’s dance shoes - viewed as (square dancing) is traditionally performed in Western aesthetic, have practical purposes. The ankle straps boots for both genders. Luckily, most “cowboy boots” on ladies dance heels add stability and control to have leather soles making them suitable for spinning the shoe. Similarly, elasticized gore panels in the and twirling on various flat surfaces. upper construction help to hug the foot for a more anatomical fitting. Women’s dance heels typically range from 1 to 3 inches in height. Men’s heel heights are up to 1.5 Cushioning is important in most dance shoe inches. Midsole shanks and firm heel counters are categories because many wooden dance floors are mandatory in ballroom with a shorter shank being built directly on top of concrete, making landing preferred in conjunction with the Cuban heel for and clogging a bruising experience. Many dance Latin dances such as the Rumba, Samba and Cha categories tend to emphasize the “feel of the

"We all understand the importance in fitting normal footwear correctly, however, fit is even more critical in pointe shoes due to the choices available and the extreme foot and ankle movements required in this discipline." Photo: @Shutterstock.com/DenisProduction.comPhoto:

48 Pedorthic Footcare Association | www.pedorthics.org Athletes or Artists?

ground” at the expense of cushioning the foot. In ‘demi-pointe,’ to the full-pointe position, where the the past decade however, shock-absorbing materials foot is at an extreme angle of plantar-flexion. Once such as Poron®, EVA and Sorbothane® have been en pointe is achieved, a contraction of the muscles of incorporated into dance footwear from athletic shoe the feet, ankles, legs and torso are required to pull the designs. dancer up out of the shoe. Without proper technique and practice an attempt at toe-dancing can cause Street shoes, with the exception of full leather soles, injury to the foot and ankle. Children with growing are not acceptable on the dance floor and should feet should not be encouraged to dance en pointe, nor be avoided, along with sandals and flip-flops. Most should anyone lacking adequate strength and training. street shoes will not slide properly on a wooden dance We all understand the importance in fitting normal floor and open shoes offer little to no protection. footwear correctly, however, fit is even more critical Athletic footwear is not a good choice for ballroom in pointe shoes due to the choices available and the and traditional forms of dancing, although for extreme foot and ankle movements required in this unstructured dancing such as jive, break dancing and discipline. all the derivations under the Rock ‘n Roll umbrella – athletic shoes work. Options in fitting a pointe shoe

To the pointe 4In the overall length, in pointe shoes sizes usually run ½ to a full size larger than American The category of dance that requires the most street shoe sizing. A small ¼ inch pinch at the athleticism and engenders the most injuries by far is highest part of the heel, up by the drawstring is pointe in ballet. From the beginning of their extensive desirable. The shoe should not fit too tightly. training, ballerinas are schooled in an increasingly challenging physical vocabulary, including multiple 4To avoid bruising, subungual hematoma pirouettes, jumps and leaps. In the modern pointe and ingrown toenails select the correct toe box shoe, the foot is supported from underneath the configuration and midfoot width selection. longitudinal arch by a stiff insole or shank. The box of the shoe tightly encases the toes, so that the dancer’s 4The correct amount of shank support depends of weight rests on an oval-shaped platform. The shank the dancer’s level or competency. Gaynor Minden, has varying degrees of flexibility and the toe box may for example offers six levels of stiffness from have different configurations. The outer material is flexible to hard. usually satin and lined with cotton (or a thin denier nylon lining) for added strength. Surprisingly, until 4Vamp depth may vary from shallow to deep and broken in, pointe shoes will fit either foot; there is fit at the heel (the rake) may vary in angle and usually no left or right. Except in rare cases, pointe width. shoes are worn only by women. Pointe shoes have come a long way from their Although it is the shoe that enables the dancer to humble beginnings using such materials as burlap, poise indefinitely on tiptoe, it is her strength and paper saturated with glue, and lamb’s wool. Amongst technique that bring her from the normal standing the most progressive makers of ballet shoes today is position in the sagittal plane through mid-position or Gaynor Minden. Using modern materials throughout

Current Pedorthics | January/February 2019 49 Athletes or Artists?

the shoe, the shank and toe boxes are made of an Various overuse injuries are common amongst unbreakable elastomeric resin lined with Roger’s professional and serious amateur dancers due to Corporations’ Poron® 4000, which carries the repeated rehearsals and performances. Although American Medical Podiatric Association’s Seal of overuse injuries at the highest levels of dancing are Acceptance. Using modern cushioned materials in typical, dancers do not always seek out trained doctors the toe and midsole areas of the shoe help to make and clinicians. The pedorthist must understand the the shoe less noisy on landing. A wide selection of mind-set of dancers and be aware of their special shanks and boxes vary in stiffness and styles from needs in order to be more effective with treatment. soft and pliable to firm and extra-supportive to Dancers have the mentality that they don’t want to accommodate both the professional and the beginner. stop dancing, because in many cases they are used Unbreakable shanks can be adjusted by simply heating to pain, they tend to dance through injuries. Often them to perfectly conform to the longitudinal arch of dancers don’t seek medical help for a minor injury the foot. Additionally, the upper material made from and then the condition becomes chronic and harder satin is specially lined to wick perspiration away from to resolve. A thorough evaluation, which should the dancer’s feet. include observing dance technique, can help the pedorthist understand the causes behind a specific Due to the extreme athleticism of ballet and its injury. Approximately 50 percent of all dance injuries techniques, no pointe shoe or toe pad can be are foot and ankle related. The majority of dance guaranteed to eliminate the risk of injury in the injuries, 60–70 percent – can be classified as overuse lower extremities. However, by understanding the injuries. biomechanics of the art, shoemakers can increasingly use innovation and space-age materials to build better A repertoire of typical injuries to dancers with footwear in an attempt to alleviate the problems appropriate shoe advice: associated with pathomechanics in ballet. As we move further into the 21st century, perhaps the traditional Achilles Tendinitis: show business expression to wish good luck, break a Many dance shoes have little to no heel elevation. leg, will literally become a redundant phrase. This is often a factor in the development of Achilles

4Achilles Tendinitis 4Anterior Ankle Osteophytes 4Blisters

50 Pedorthic Footcare Association | www.pedorthics.org Athletes or Artists?

tendinitis. A heel pad or lift will help elevate the shoes may rub at the heel causing a friction blister to foot and reduce tension on the Achilles tendon. Soft occur. If the dance aesthetics allow, synthetic socks padding around the Achilles will help, if the shoe act as a cushion and barrier for the skin. Many dance allows, and a firm heel counter can reduce medial shoes are made from stretchable materials or contain / lateral heel movement inside the shoe. Pain in the stretchable panels in the quarter and vamp. Also, posterior aspect of the ankle is often misdiagnosed in changing into dry socks after many hours in the same dancers as Achilles tendinitis instead of flexor hallucis shoe will also help to prevent blisters. Cushioning longus (FHL) tenosynovitis. under the metatarsal heads and calcaneous, along with good arch support to help control the foot inside Anterior Ankle Osteophytes: the shoe will help prevent friction blisters on the Common in ballet dancers, due to extreme plantar surface of the foot. The less seams in the plantarflexion required en Pointe, small ossicles may upper, the better. break off of the front of the lower tibia. Conservative treatment may consist of strapping the ankle or rest. Bunions (hallux abducto valgus): If the resulting osteophyte does not stabilize and Dancers, with ballet being the extreme, subject the becomes symptomatic, there is little that will help hallux to pressure and forces not usually encountered other than surgery to remove the osteophyte. in everyday movements or in most sports. This constant pressure causes an enlargement of the hallux Blisters: and forces the great toe to abduct towards the second As in long-distance running and tennis, where the ray. The bunion is the result of an overuse type foot is subjected to many hours of excessive movement of injury common in the dancer. Toe spacers and within a shoe, blisters are common in many dance bunion shields help to mitigate the enlargement of forms and disciplines. From a shoe perspective, ill the hallux. The correct width and shape of the shoe fitting shoes are often the cause of blisters. Fitting is important to keep the dancer active. Stretchable shoes too tightly may give adequate support but as uppers or using a ball and ring stretching device (or the foot swells during activity, the toes in particular, balloon patch in extreme cases) can help. Many types may cause irritation resulting in blisters. Loose fitting of dance shoes will not accommodate an orthotic due

4Bunions 4Calcaneal Bursitis 4Calluses & Corns

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to their form- fitting nature However, if a thin rigid this condition. Cutting the topline at the back and orthotic is applicable, a Morton’s extension can be reinforcing the split with addition stitching will help helpful to support the hallux. Conservative treatment relieve the pressure at the back of the heel. Rest, anti- in the young dancer will help to avoid surgical inflammatory medication and gentle stretching will Ladies’ intervention in later life. help. More serious cases may require excision of the bursa for relief. Calcaneal Bursitis: Another typical overuse injury common to dancers. Calluses and Corns: Choice!Canvas Classics The main complaint is pain in the lower part of the Familiar words to dancers that need further Achilles tendon, often with localized swelling. The explanation to be defined correctly. Corns as well as Reimagined cause is friction on the lower part of the Achilles calluses appear as thickened areas of skin especially tendon between the tendon and the calcaneus, on the on the feet in response to continual mechanical calcaneal bursa. Any pressure from the topline of the stress. There are five subtypes of corn of which the shoe or backstay can be painful and will eventually hard corn (heloma durum) and the soft corn (heloma result in Haglund’s deformity if left untreated. An molle) are the most common in dancers. Hard corns Achilles notch design at the posterior of the shoe present as translucent smooth yellow patches with a was originally incorporated in athletic shoes to help core that presses inward into softer tissue. Soft corns INTRODUCING LIV & ELLEN Four new timelessly fashionable styles: pink, Fullwhite Page and Adnavy canvas, 4Flexor Hallucis Longus (FHL) 4Haglund’s Deformity 4Hallux Rigidus Ellen or black leather. Perfect summer footwear for women on the go! Model: A401W

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Current Pedorthics | January/February 2019 53

180626_Apex_Current_Pedorthics_Lev&Ellen_Ad.indd 1 6/27/2018 12:59:23 PM Athletes or Artists?

have an indented center and are white and spongy; of the ankle. Elasticized strapping of the ankle and they are only found between the phalanges. good shank support in the shoe may keep the dancer active. If the great toe continues to “lock” when the Corns form on the outermost layer of epidermis on dancer is en pointe, surgery may be necessary to the feet as a result of increased friction or pressure repair the tendon. upon the skin. In dancers, corns are not only common, but sometimes necessary to offer protection Haglund’s Deformity (pump bump): and support in areas of repetitive stress. Corns, as Distinct from retrocalcaneal bursitis, which is an distinct from calluses (hyperkeratotic tissue) are inflammation of the bursa between the posterior

4Nails 4Patella Femoral Syndrome 4Plantar Fasciitis

sensitive to pressure when applied to their cores. In and superior portion of the calcaneus and Achilles addition to debridement or enucleation, if the corn is tendon, Haglund’s deformity is a bony exostosis at painful, offloading within the shoe will help to reduce the posterior, medial or lateral aspect of the heel pressure on sensitive areas. Corn sleeves and sponge below the Achilles tendon attachment. Both these or silicone spacers between the toes can help and conditions are associated with tight fitting shoes custom orthotics prescribed to offload the metatarsals and aggravated by footwear causing friction around or prevent overpronation can prevent excessive callus the posterior calcaneal tuberosity. As footwear build up. causes this condition, it is usually footwear that can conservatively reduce swelling and pain. If possible, Flexor Hallucis Longus (FHL) Tenosynovitis suggest an open-heeled shoe (mule) or sandal, at (trigger toe): least when the patient is not dancing. When active, Commonly, following prolonged overuse, a nodule elevating the heel with a lift inside the shoe can may develop on the medial side in the FHL tendon reduce tension. Soft padding or a thin gel strip around near the ankle. This causes a clicking and forces the the topline of the shoe will ease discomfort but may hallux to stick in the plantar-flexed position. Due to end up compromising the fit. Look for a shoe with an the basic movements required in ballet, the dancer Achilles tendon notch, a common feature in athletic may complain of pain and crepitus on the medial side shoes. A donut-shaped pad adhered to the posterior

54 Pedorthic Footcare Association | www.pedorthics.org Athletes or Artists?

counter inside the shoe around the bony prominence spread naturally. A good arch support and metatarsal can offload the pressure on the Achilles tendon. In pad changes the relative position of the metatarsals to severe cases a silicone elastomer shield can be custom help relieve pressure on the metatarsal heads. A more molded to further reduce shear resistance. specific neuroma pad placed immediately proximal to the affected web space will lift the metatarsal thus Hallux Rigidus: relieving pain as well as changing the biomechanics This is a major problem for dancers. Again, due to of the foot. the extremely demanding movements in ballet, this condition often restricts the dancer from achieving Medial Tibial Stress Syndrome: en pointe as the hallux becomes increasingly stiffer. This condition, which has been sub-classified into Several in-shoe devices can help in the early stages three types, is quite common in running and jumping and add life to the dancer’s career. A softer recessed sports, hence it is also frequently diagnosed in pad under the first metatarsal phalangeal joint (1st dancers. Dancers suffering from MTSS complain of MPJ) helps to lower the metatarsal head and release recurrent exertional pain along the posterior border of the hallux. Dr. Clough’s ‘Cluffy Wedge’ added to the the middle and distal tibia. The pain usually presents insole under the hallux has been shown to improve itself as a dull ache, but may become intense focal range of motion in the first metatarsal phalangeal pain during toe-off. Rest, adequate cushioning in the joint. If the dance discipline allows, a midsole rocker shoe and dancing on a layer of softer mat will help. with stiff forepart in the shoe will give greater range of Changing to a different shoe with increased padding motion and relieve pain in the joint. may help with additional support from an orthotic.

4Posterior Impingement 4Sesamoiditis 4Shin Splints

Interdigital Neuroma: Metatarsalgia: Due to the pointed or semi-pointed toe boxes This term refers to general pain experienced in the traditionally worn in many dance categories, metatarsal region, hence the name matatarsalgia. compression of the interdigital nerves between the Perhaps more of a constant in dancing than in second and third, and third and fourth metatarsals most sports, the foot is subjected to pounding, high may cause pain during toe-off. If possible, a wider toe tensile stresses and shearing on hard surfaces often box in the shoe is recommended to allow the toes to without adequate cushioning under the metatarsals.

Current Pedorthics | January/February 2019 55 Athletes or Artists?

Conservative pedorthic treatment and the use of well direct collision with the toe box of the shoe. A custom padded footwear, at least during rehearsals and long orthotic will help to hold the foot in position inside hours of practice, are recommended. If plantar surface the shoe to prevent the foot from sliding forward. If, as gait analysis is available, off-loading in the form of in ballet, nail pressure is unavoidable during certain custom orthotics or underfoot padding is effective in dance movements, a wad of soft lamb’s wool or a low relieving specific pressure and pain. Custom orthoses density silicone pad or sleeve in the toe box will help will help reduce pressure on the metatarsal heads, as to protect the nails from excessive abuse. will a metatarsal pad. Properly fitted shoes, which is a basic recommendation in all categories of footwear, is Patella Femoral Syndrome: particularly important in dance to reduce shear inside Misalignment of the patella and femoral trochlea the shoe and restrict excessive metatarsal phalangeal can be greatly influenced by rearfoot and forefoot joint motion. pronation. It has been proven that foot mechanics can be changed by using a custom-made or total contact Nails: orthotic that limits overpronation of the foot. Dancers It is essential for the professional or serious dancer are often off balance, or when wearing high heels, to receive regular podiatric nail care and inspection. severely plantarflexed. Because pronation is dynamic, Particularly in ballet, when the dancer’s weight is it is more difficult to control the entire gait cycle in largely on the hallux and tips of the lesser digits, a typical heeled dance shoe or classical ballet slipper. pressure on the distal tips of the nail pushes the nail Externally, a broader medial base of support in the back into the nail bed. As a result, over time, nails shoe will help to shore up the medial arch. Internally, may become thickened or discolored and eventually a semi-rigid ¾ length custom orthotic will help deformed. Subugunual hematomas and even loss control the rearfoot. If the shoe allows, a full-length of the nail is common and often accepted as an Q-angle stabilizing orthotic has been developed to occupational hazard amongst ballet dancers. Ingrown help this condition. toenails necessitate immediate attention due to the resulting intense pain and swelling that accompany Plantar Fasciitis: this condition. Again, properly fitting shoes with Along with ankle sprains and toe nail issues, dancing adequate toe room helps to protect the nails from on hard surfaces with the foot under severe pressure

4Sprained Ankle 4Stress Fracture

56 Pedorthic Footcare Association | www.pedorthics.org Athletes or Artists?

inside the shoe for long periods of time is also the caused by excessive pivoting or pounding on the first perfect etiology for plantar fasciitis. Dancers, more metatarsal head or from poor technique when landing so than other athletes, are usually unwilling to take from jumps. In athletic shoes used on hard court time off from their activity to let overuse injuries such surfaces, the incorporation of the “pivot spot” design as plantar fasciitis heal. Pedorthic treatment for this in the sole under the first metatarsal head has become syndrome, and heel pain, is primarily to decrease a standard feature. Most shoes used in dance, other pronation and off-load pressure on the heel with than for practice, will not allow this design feature elevation. Due the variance in dance footwear, it is on the bottom of the sole. Most of the recognized more difficult to modify the dancer’s shoe in order pedorthic modifications that help this condition, such to facilitate treatment. An orthosis can be fabricated as a good toe rocker to reduce dorsiflexion and reduce with a horse-shoe concavity at the heel to specifically weight off the first MPJ, or a well cushioned midsole, relieve heel pain. A good longitudinal arch support may not be possible in dance shoes. When the space and a forefoot post will help control pronation on the in the forepart of the shoe is limited, a thin silicone medial side. A cuboid lock (support pad) can prevent or Poron® pad under the first metatarsal head will the foot from sliding off the device laterally. The help. Cutting the pad to off-load the sesamoids bones firmer the shoe, the less stress will be placed on the specifically creates the “dancer’s pad.’ foot as it tries to flex. As a result, stress on the plantar fascia is limited. Shin Splints (Posterior tibial stress syndrome): Dancers are vulnerable to shin splints as a result Posterior Impingement Syndrome of the Ankle: of hyperpronation due to leaps and jumps on hard Dancing often necessitates jumping. In posterior surfaces, improper shock absorption or weakness of impingement syndrome of the ankle, pain is felt at the tibialis posterior muscle. Pain at the insertion the back of the ankle when the toe is pointed. This of the tibialis posterior usually indicates tendinitis is due to a piece of bone that occupies space behind or inflammation of the tibialis posterior tendon. A the ankle, leading to compression of the soft tissues. rearfoot varus wedge controls pronation and reduces As this condition is related to pointing the foot, any stress on the tendon and muscle. Running shoes additional pressure on the Achilles tendon will cause with an overpronation control device on the medial pain. An Achilles notch at the back of the shoe or aspect of the shoe would be good advice for everyday cutting the backstay of shoe at the top line to relieve wear to relieve pain. For dancers, in most cases, a pressure on the Achilles tendon insertion may help. custom-made orthosis is the most effective method Any cut made at the back of the shoe may need to be of controlling excessive motion in the foot. Most bar tack stitched to stop the cut from tearing too far categories of dance shoes will accommodate at least down the backstay. a ¾ length orthotic. In ballet shoes, a stiff shank and arch support is all that can be offered conservatively Sesamoiditis: within the shoe. If a dancer already uses an orthotic, Here’s a condition that has been long recognized in they should always include the orthotic in any new dancers. So much so that an off loading pad in the shoe fitting, as with any other type of shoe. region of the two sesamoid bones that lie beneath the head of the first metatarsal, is called a “Dancer’s Sprained Ankle: Pad.” Pain that develops in the sesamoids can be Recognized both in sport and dance (particularly

Current Pedorthics | January/February 2019 57 Athletes or Artists?

in ballet), the inversion injury of the ankle with A good counter in any shoe helps to align the foot subsequent strain of the lateral ankle ligaments is correctly and control lateral and medial movement the most frequently treated sports injury. Medial inside the shoe. ankle sprains are much less common. If diagnosed as such, a medial ankle sprain is a sprain of the Stress Fracture: deltoid ligament. Most sprained ankle injuries are Stress fractures below the knee are common in dancers involved in high impact pounding and treated, depending on their severity, with one or landing from jumps on hard wooden flooring. A more of the following – rest, crutches, strapping or stress fracture is another type of overuse injury. It is a cast. A surgical boot with midfoot or toe rocker, classified as a spontaneous fracture of normal bone along with crutches may be advised. Except for ballet as a result of stress applied to the bone. Typically slippers, most other categories of dance shoe will stress fractures in dancers occur in the neck or base accommodate strapping or bracing, once the dancer of the second metatarsal, the lesser metatarsals and is fit for activity. The key point in the shoe is stability. lower fibula. Stress fractures in the feet occasionally In sport shoes, a high-top over the ankle shoe, such as are diagnosed in the tarsal bones, calcaneum and a basketball shoe, may be used, likewise in American navicular. Shoes with extreme cushioning and shock football. Adidas experimented with a specially absorption can relieve the pain and pressure during designed stability shoe to aid rehabilitation some everyday activities. If the dancer insists on performing, years ago, but this was available only for elite athletes. padded insoles will help to reduce impact. Impact Dance shoes are more specific and other than a high- reduction and the risk of further injury can be top training shoe, only strapping or an elasticized achieved by dancing on a “sprung floor” as opposed to brace will help to stabilize the foot and ankle inside an unyielding surface. the shoe. On certain shoes, an outside flange may be added on the lateral side for stability during rehab. —PFA

PHOTO CREDITS: 12) Metatarsalgia - @Shutterstock.com/p_saranya 1) Achilles Tendinitis - @Shutterstock.com/catinsyrup 13) Nails - @iStock.com/Cunaplus_M.Faba

2) Anterior Ankle Osteophytes - http://footandankleinstitute. 14) Patella Femoral Syndrome - http:// be/disorders/ankle/anterior-impingement-syndrome/ angelasimpsonphysio.ca/patella-femoral-pain-syndrome/ 3) Blisters - @Shutterstock.com/Cristian Dobre 15) Plantar Fasciitis - @Shutterstock.com/TANAPAT LEK. JIW 4) Bunions - @Shutterstock.com/vasara 16) Posterior Impingement Syndrome of the Ankle - http:// 5) Calcaneal Bursitis - @Shutterstock.com/BlurryMe footandankleinstitute.be/wp-content/uploads/2010/08/ 6) Calluses and Corns - @Shutterstock.com/kunanon Fig-33.jpg 7) Flexor Hallucis Longus - @Shutterstock.com/In The 17) Sesamoiditis - https://images.radiopaedia.org/ Light Photography images/5506848/b04416fbb0acf5e6360e4f92f4b27a_ jumbo.jpeg 8) Haglund’s Deformity - @Shutterstock.com/Levent Konuk 18) Shin Splints - @Shutterstock.com/namtipStudio 9) Hallux Rigidus - http://rydepodiatry.com.au/wp-content/ uploads/2015/11/Halluxrigidusxray.jpg 19) Sprained Ankle - @Shutterstock.com/Luis Santos 10) Interdigital Neuroma - https://mortonsneuroma.surgery/ 20) Stress Fracture - https://www.michiganpodiatry.com/ mortons-neuroma/mortons-neuroma/about-mortons- wp-content/uploads/2015/06/stress-fractures.jpg neuroma/ 11) Medial Tibial Stress Syndrome - @Shutterstock.com/ comzeal images

58 Pedorthic Footcare Association | www.pedorthics.org Athletes or Artists?

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Current Pedorthics | January/February 2019 61 PRODUCTS&SERVICES

This reference guide is intended solely to make it easier our readers, Current Pedorthics has noted the year the company for individuals, facilities and companies to locate pedorthic joined PFA in parentheses after the company’s name. Inclusion products. Companies listed in the guide are PFA vendor/ in this list does not suggest or imply PFA endorsement of manufacturer members. Companies may produce additional companies or products. Vendor/Manufacturer members are products beyond those listed, and most companies are pleased encouraged to keep their listing up-to-date. To arrange changes to provide additional information on request. As a courtesy to in your company’s listing, email: [email protected].

of Akaishi products is able to Wheaton, IL afford wearers with unsurpassed Arizona AFO, Inc. (2003) Phone: (800) 235-8458 comfort and support. Following Arizona AFO manufacturers a Fax: (630) 653-5077 Acor (1979) overwhelming success in Japan, line of medical ankle braces for Email: [email protected] Custom Inserts, AFO Gauntlets, AKAISHI aims to bring comfort the treatment of foot disorders. Website: www.bintzco.com Materials, Accessories and and health to the feet of women The Arizona AFO line is used by Supplies. Originator of Tri-Lam, throughout the world. physicians and practitioners as P-Cell and Microcel Puff. a way to increase mobility, avoid Gardena, CA pain, avoid surgery and provide a Cleveland, OH E-mail: kurato.sato@akaishiusa. better quality of life. Phone: (800) 237-2267 com Fax: (216) 662-4547 Mesa, AZ Website: www.akaishiusa.com Phone: (480) 222-1580 Birkenstock USA, LP (1990) Email: [email protected] U.S. distributor of Birkenstock Website: www.acor.com Fax: (480) 461-5187 Email: [email protected] sandals, shoes, clogs and arch Website: www.arizonaafo.com supports, and also representing Footprints shoes and Birko Orthopadie arch supports. Novato, CA Amfit Inc. (1996) Phone: (800) 949-7301 Since 1977, Amfit has elevated Fax: (415) 884-3250 Aetrex Worldwide, Inc. (1973) custom foot orthotics in the Bestsole, Inc. (2010) Email: [email protected] Aetrex Worldwide has been a computer age. From diabetic Website: www.birkenstockusa. supplier of footcare products for care to professional athletes We manufacture and distribute com 60 years. Aetrex’s brands include and beyond – Amfit 3D contact a glycerine-filled, therapeutic, Aetrex® and Apex Footwear, technology offers innovative, massaging insole. Our insoles Lynco® Orthotics, iStep® and raw user-friendly tools to create the will massage your feet and materials. exact results you desire. From increase circulation to your feet. small scale operations to large They are also excellent shock Teaneck, NJ labs. Where technology fits. absorbers for your feet, knees, Brooks Sports, Inc. (2001) Phone: (800) 526-2739 Perfectly. Amfit is your custom hips and back. One pair fits in all Brooks Sports, Inc., is proud of Fax: (201) 833-1485 foot orthotic partner. shoes. Our insoles are machine our hard-earned reputation for Email: [email protected] washable. We offer a two-year Vancouver, WA engineering footwear that provides Website: www.aetrex.com replacement warranty. Our Phone: (800) 356-3668 the perfect ride for every stride. insoles have always been made Fax: (360) 566-1380 Brooks works to ensure that all of in the USA. Visit our website for Email: [email protected] our footwear products meet the additional products. Affinity Insurance Services, Website: www.amfit.com biomechanical needs of runners, Inc. (1998) enhance comfort, and aid in the Boynton Beach, FL Affinity Insurance Services prevention of running-related Phone: (866) 301-3338 administers the PFA product injury. We’re dedicated to reducing Fax: (561) 547-4684 and malpractice liability running injury risk and have aligned Email: [email protected] insurance program. Designed for ourselves with some of the top Website: www.massaginginsoles. pedorthists, insurance protection researchers around the work to Apis Footwear Company com can be customized for each‑PFA (2000) tackle this. member. Mt. Emry therapeutic line - Bothell, WA Chicago, IL accommodate, never correct! We Phone: (800) 2-BROOKS Phone: (800) 544-2672 have the shoes to accommodate Fax: (425) 483-8181 Fax: (312) 922-9321 charcot, edema, hammer toes, com Email: [email protected] bunions & RA. Whether for depth, Website: www.brooksrunning.com width or even for shape, select Akaishi (2013) from our variety of styles to fit that special foot of your patient. Akaishi strives to provide an unfailing level of comfort and Bintz Company, Inc. (1991) S. El Monte, CA satisfaction to each customer. Phone: 626-448-8905 Distributor of pre-molded After years of research into the orthotics, comfort foot products, Fax: 626-448-8783 Bunion Bootie (2014) structure of women’s feet and E-mail: [email protected] fitting aids and sheet goods. legs, AKAISHI has discovered Products from Birkenstock, Birko Web site: www.bignwideshoes. Say good-bye to painful rigid the key to long term foot care com Orthopadie, Pedag, Powerstep, and health. Through rigorous Spenco, Pedifix, Knit-Rite, Hapad, splints, pads that do not stay functional testing, each line Rieckens PQ and more. in place, and spacers that are

62 Pedorthic Footcare Association | www.pedorthics.org PRODUCTS&SERVICES

difficult to walk in. Bunion Bootie footbeds. Hand-crafted in is the complete bunion treatment Germany. Goodhew, LLC (2012) Honeywell Safety Products Goodhew, a leader in the (2013) package; protective, supportive, Thousand Oaks, CA ModernCraft movement, NEOS overshoes provide a comfortable, and not to mention, Phone: (805) 375-0038 tough barrier between everyday discreet. Truly one-of-a-kind in Fax: (805) 375-0848 spins fresh designs, natural the world of bunion treatments. performance yarns, and footwear and the harsh elements Email: [email protected] of nature. Wear over your favorite, The newest in bunion treatment Website: www.finncomfort.com the heritage of American to help manage your bunion pain craftsmanship to create high comfortable shoes or boots and best of all - it doesn’t involve performance socks for the with confidence that feet and surgery! everyday world. Goodhew: a sock footwear will stay warm and dry. Foot Solutions (2012) for every walk in the walk of life. NEOS are extremely lightweight San Luis Obispo, CA Feet are your foundation and easy to get on and off. With different heights, insulation and Phone: (877) 208-4540 for life. At Foot Solutions, Chattanooga, TN traction to offer the right amount Email: [email protected] we use the most advanced Phone: 423-643-0821 Website: www.BunionBootie.com technology combined with a full of protection, NEOS has you Fax: 423-643-0825 covered. understanding of biomechanics E-mail: eeckardt@goodhew. of feet and gait, along with the us.com Smithfield, RI C.N. Waterhouse Leather Co., highest quality footwear on Web site: www.goodhew.us.com Phone: (401) 757-2503 Inc. (1998) the planet to fit your unique feet. Through our customized Fax: (401) 233-7641 Manufacturer and distributor of E-mail: jennifer.stritzinger@ fine leathers, woolskins, suede solutions, we will improve your comfort and body alignment and Guard Industries, Inc. (1996) honeywell.com pig-skins, sheet goods and Website: www.overshoe.com adhesives for use in the pedorthic help you achieve better health Components for shoe care, footwear and orthopedic through your feet. foot comfort, orthotics and industries. prosthetics. Complete listing of Marietta, GA available products will be sent Hyannis, MA Phone: (888) FIT-FOOT upon request. Fax: (770) 953-6270 Phone: (800) 322-1177 St. Louis, MO Fax: (508) 771-2300 Website: www.footsolutions.com Phone: (800) 535-3508 ING Source, Inc. (2013) E-mail: info@waterhouseleather. Fax: (314) 534-0035 com ING Source, Inc. is a consumer Email: [email protected] Website: www. health and medical device Frankford Leather Company, Website: www.guardmfg.com waterhouseleather.com Inc. (1997) manufacturer selling products Frankford Leather Co., Inc., is world-wide. Our origins were in your single source supplier for design, development, sourcing Dr. Comfort (2004) your pedorthic shoe repair and Haflinger/Highlander and marketing consulting. ING (Gerda Hoehm) (1999) Source holds several patents, and Dr. Comfort manufactures, shoe store supply needs. In stock, more than 8,000 products Boiled wool slippers, latex is the creator of the innovative warehouses and distributes the OrthoSleeve Branded products finest quality extra-depth shoes are available for immediate arch support, felt and leather shipment. Representing major clogs, cork molded footbed. of FS6 Compression Foot Sleeve; for diabetics or patients who CS6 Compression Calf Sleeve; brands and lines like Vibram, Highlander is Gerda Hoehm’s need quality comfort shoes. KS6 Patella Knee Sleeve; ES6 Soletech, Spenco, Powerstep, new high-quality comfort line Mequon, WI Compression Elbow Sleeve; and Pedifix, Pedors, Orthofeet, with a removable footbed. Both Phone: (800) 992-3580 the DermaSox Foot Treatment Kiwi; shoe care, adhesives, Fax: (262) 242-9300 Haflinger and Highlander are System. ING Source also offers leather and more. Free catalog Email: [email protected] made in Germany. OEM for compression wear and available. Website: www.drcomfort.com New York, NY orthopedic support in sports, Bensalem, PA Phone: (212) 949-6767 rehabilitation and Diabetic Foot Phone: (800) 245-5555 Fax: (212) 949-8833 Care to numerous premium Fax: (215) 244-4411 Drew Shoe Corporation Email: [email protected]. brands. Email: sales@frankfordleather. (1968) net com Hickory, NC Men’s and women’s depth Website: www.frankfordleather. Phone: (828) 855-0481 and comfort footwear in over com Fax: (877) 635-1521 150 sizes. Hapad, Inc. (1988) E-mail: [email protected] Lancaster, OH Hapad is a leading manufacturer Website: www.ingsource.com Phone: (800) 837-3739 Gadean Footwear (2010) of 100% natural wool felt foot Fax: 740-654-4979 products and sports replacement Gadean Footwear is the largest Email: customerservice@ insoles used for conservative orthopaedic shoemaker in J.H. Cook & Sons, Inc. drewshoe.com management of common, painful Australia. Gadean Footwear (2004) Website: www.drewshoe.com foot complaints. Correctly skived provides retailers with washable Shoe modification components, and adhesive backed for a quick slippers, motion shoes, fashion foot comfort products and shoe and easy fit, Hapad products shoes, depth shoes, removable repair supplies. Products from insole sandals and many more are an affordable alternative to Aetrex, Spenco, Vibram and products. custom made devices or they Soletech. can be used to make custom Malaga, Western Australia, modifications. Granite Quarry, NC Australia Phone: (704) 279-5568 Finn Comfort (1993) Phone: 61-8-92486533 Bethel Park, PA Fax: (704) 279-5261 Phone: (800) 544-2723 Luxury comfort footwear. Men’s Fax: 61-8-92486711 Email: [email protected] Fax: (800) 232-9427 and women’s walking shoes, Email: info@gadeanfootwear. Email: [email protected] sandals and boots featuring com.au removable/modifiable orthopedic Website: www.gadeanfootwear. Website: www.hapad.com com.au

Current Pedorthics | January/February 2019 63 PRODUCTS&SERVICES

Canadian manufacturer and FOOTWEAR, was founded For over forty years National distributor of orthopedic and more than 40 years ago by Shoe has taken pride on shoe repair machineries, is Martin Michaeli. Mephisto has providing exceptional service to the undisputed leader and the a loyal following and a strong our customers by offering: Industry’s main supplier for international reputation for • Leading, Reputable and North America and Australia. comfort and quality. Its high- Premium Quality Brands Landis International offers JMS Plastics Supply (1992) quality handcrafted footwear • A Knowledgeable and new and reconditioned quality styles include sandals, boots, JMS is the first U.S. company Professional Sales Team equipment, tools, as well as the clogs, dress and classic walkers, to have Silpure in our nylon top • Unparalleled Customer Service necessary parts required for the as well as the ergonomic brand, cover on our Neolon. Silpure Our relationships are built on a maintenance of equipment built Mobils. In recent years, the is an advanced anti-microbial foundation of trust, respect and a to last a lifetime. company also introduced the protection that provides proven desire to partner in the continued more athletic inspired brand, anti-bacterial properties of silver. 800, Rossiter success of our customers and Allrounder by Mephisto and their Available in 1.5 mm and 3.0 mm Saint-Jean-sur-Richelieu vendors through innovation latest collection with superior sheets. Our Neolon with Bamboo (Québec) Canada J3B 8J1 and continuous improvement. is also deodorizing and anti- Phone: 1-450-359-8800 toning technology, Sano by At National Shoe we offer an bacterial and comes in sheets Toll-free: 1-800-634-0806 Mephisto. extensive material & footwear 40” x 48” or 48” x 80”. Our new Fax: 1-450-359-9619 selection for the Pedorthic/ J-fab line of prefabs are thin, heat Email: [email protected] Franklin, TN Orthopaedic/Prosthetic, Shoe moldable and they come in three Website: http://landisusa.com Phone: 800-775-7852 Store and Repair channels of styles and three colors. Fax: 615-771-5935 business across Canada and the E-mail: [email protected] United States Neptune, NJ Web site: www.mephisto.com Phone: (800) 342-2602 Lord Custom Molded Shoes, Inc. (1994) Fax: (732) 918-1131 Toronto, ON E-mail: [email protected] Fashionable custom-molded Phone: 800-387-5246 Miami Leather Company Website: www.jmsplastics.com shoes for men, women, and Fax: 800-568-8930 (2001) children. Guaranteed fit and Websites: www.nationalshoe.com service. Wholesaler to the orthopedic, www.biotimefootwear.com Bohemia, NY prosthetic, retail shoe and shoe Phone: (800) SHOES11 repair trades. Wide variety of Justin Blair & Company Fax: (516) 471-3090 products. (2001) Website: www.lordshoes.com Miami, FL Manufacturer of Ralyn Shoe Care Phone: (305) 266-8328 and Backroom Supplies and Fax: (305) 266-8728 NightCare Foot Care. Distributor Email: [email protected] New Balance (1990) for Aetrex, Acor, Darco, Herbal Website: www.miamileather.com New Balance, headquartered in Concepts, Pedifix, Swede-O, Boston, MA supports a family of Silipos and Therafirm. brands including New Balance, Chicago, IL mediUSA, LP (2013) Aravon, Dunham, PF Flyer, Phone: (800) 566-0664 Warrior and Brine. All brands Fax: (773) 523-3639 Our company slogan “medi. I feel better.” reflects our view specialize in sizes and widths Email: [email protected] across a number of categories Website: www.justinblairco.com of ourselves as a partner to everyone who operates in the including running, walking, medical aids market training, kids, comfort casual, With our products and lifestyle, team sports and apparel. technologies, we would like to Boston, MA make people’s lives easier, better Phone: (617) 783-4000 and more comfortable. We aim to Nolaro24, LLC (2015) Fax: (617) 783-7050 do this by meeting the different Nolaro24, LLC is the Maker of Website: www.newbalance.com needs of all our customers, every Quadrastep and littleSTEPS foot KLM Laboratories (2006) day and throughout the world. orthotics - the first Patented An industry leader in the “I feel better” is therefore a custom to foot type prefabricated new manufacture of foot orthotics promise that becomes a reality foot orthotics for adults and kids, and insoles, specializing in with medi, because we offer the Next best thing to Custom! custom orthotics, pre-fabricated indication-specific and effective step orthotics, orthotic insoles and product solutions to the highest 80 Turnpike Drive, Unit 2B orthortic lab, inc. orthotic materials. standards, which, with the help Middlebury, CT 06762 Valencia, CA of our pioneering, individual Phone (Toll Free): (877) 792-4669 New Step Orthotics (2015) Phone: (800) 556-3668 concepts and dense customer Website: www. At New Step Orthotics our Fax: (800) 556-3338 service network, can be provided thequadrastepsystem.com mission is to provide quality Email: [email protected] wherever they are needed. Email: info@ orthotics and services that Website: www.klmlabs.com thequadrastepsystem.com reflect our effort to a quality Whitsett, NC product with excellent customer Phone: (800) 633-6334 service. We offer a 7 day in house Fax: (888) 570-4554 turnaround on all custom foot E-mail: [email protected] orthotics. We offer free in-bound Web site: www.mediusa.com shipping to our customers and a 1 year product warranty. Family owned since 2004. Mephisto (1998) National Shoe Specialties & Landis International (2014) With worldwide headquarters in Biotime Footwear (2014) Phone: 866-798-7463 Website: www.newsteporthotics. Landis International Inc., a Sarrebourg, France, MEPHISTO National Shoe Specialties & - the WORLD’S FINEST Biotime Footwear (2014) com

64 Pedorthic Footcare Association | www.pedorthics.org PRODUCTS&SERVICES

orthotics, secure closure and relief and prevention of any new STS Company (1997) maximum customization. pains or deformities. Medical Resin-impregnated tubular and practitioners must first be Kent, WA fitted socks made to take foot certified to order from us because Phone: (800) 877-6738 and ankle impressions for custom we offer a completely different Fax: (800) 597-8668 shoes and foot/ankle orthotic type of support than the ones for PartnerShip (2000) Email: customerservice@ devices. which they were trained in school The PFA Shipping Program, propetusa.com Mill Valley, CA and because we must have the managed by PartnerShip, features Website: www.propetusa.com Phone: (800) 787-9097 best possible cast of your foot to discounted shipping rates with Fax: (415) 381-4610 make the best support. FedEx®, UPS Freight® and YRC. Email: [email protected] PFA members can enroll in this Lyles, TN Website: www.stssox.com free member benefit and take P.W. Minor, Inc. (1968) Phone: 931-670-6111 advantage of savings on every P.W. Minor is the premium brand Fax: 931-670-6008 E-mail: [email protected] shipment – inbound, outbound, that provides pedorthically Website: www.solesupports.com business to business, business superior, precision-fit footwear to consumer, express, small for discriminating consumers package ground, tradeshow and unwilling to compromise style LTL freight - all with no shipping when preventing or caring Spenco Medical Corporation minimums or requirements. (2013) For more information or to for their foot-health needs. Shoe Systems Plus, Inc. Delivering foot-health through (2003) Spenco is an innovative enroll today please visit www. healthcare company whose precision fit shoes is a brand Complete line of orthotic and partnership.com/57PFA, call mission is to help people mission that remains as true and prosthetic equipment including 800-599-2902 or email sales@ everywhere achieve more finishers/grinders, vacuum pans, partnership.com. relevant today as it was back in comfortably. While Spenco’s pumps, presses, industrial sewing Cleveland, OH 1867. core business revolves around machines, fume busters and Phone: (800) 599-2902 producing high quality insole more. Fax: (800) 439-8913 Batavia, NY and footcare products, Website: www.partnership.com Phone: (800) 796-4667 Goshen, NY Spenco also provides the most Fax: (585) 343-1514 Phone: (800) 354-6278 advanced sports medicine E-mail: [email protected] Fax: (845) 291-7097 and first aid products. Above Website: www.pwminor.com Email: shoesystemsplus@hvc. all else, customer service is rr.com Spenco’s focus and we are Website: www.shoesystemsplus. 100% committed to providing com outstanding service as we help PediFix, Inc. (2001) Remington Products (2000) you find the solutions for all of Foot specialists since 1885, Insoles and sheet packages, rigid your health and footcare needs. PediFix is the only fourth arch supports, viscoelastic heel generation, family-owned cups, 3/4 and full insoles. Waco, TX business in the pedorthic Phone: (800) 877-3626 industry. Choose from more Wadsworth, OH SoleTech, Inc. (1994) E-Mail: [email protected] than 150 quality foot treatment Phone: (330) 335-1571 SoleTech Inc., established in Website: www.spenco.com products, including a unique OTC Fax: (330) 336-9462 1946, has a full line of cushioning line guaranteed to generate cash Email: [email protected] and fabrication materials for sales, keystone profits and doctor Website: www.remprod.com the pedorthic footcare industry. referrals, an assortment of both Soletech introduced its registered traditional and exclusive Visco- brand Cloud EVA and Soleflex GEL foot pads and cushions, new EVA in the early 1980s and is now dermatology products, GelStep Renia GmbH (2001) recognized as the industry leader Spira (2004) silicone insoles and orthotics, Specially designed adhesives for materials for the fabrication of El Paso, TX Diabetic Solutions Socks, and components for the shoe custom foot orthotics and AFOs Phone: (866) 838-8640 PediPlast and more. 15 new industry, shoe repair trade, and O and components for build-ups Fax: (915) 838-8641 products are being introduced & P industry. and modifications to extra-depth Website: http://spira.com this year. and custom footwear. In addition Cologne, Germany Contact PediFix today for a free to its presence in the orthopedic Phone: 49-221-6307990 color catalog. market, SoleTech is also a leading Streifeneder USA (1997) Fax: 49-221-63079950 supplier of footwear components Brewster, NY Preformed insoles, diabetic Email: [email protected] and materials to the shoe Phone: (800) 424-5561 shoes and materials in different Website: www.renia.com manufacturing and shoe repair Fax: (845) 277-2851 hardnesses, especially for industries. Email: [email protected] diabetics. Website: www.pedifix.com Claremont, NH Tampa, FL Phone: 603-542-8905 Phone: (800) 378-2480 Toll Free: 877-625-9494 Fax: (813) 246-5998 Fax: 603-542-8909 E-mail: [email protected] Email: [email protected] Website: www.eurointl.com Website: www.soletech.com SAS Shoemakers (1992) Propet USA, Inc. (2000) Comfort walking shoes for Leading manufacturer in men’s women and men in a wide range Sole Supports, Inc. (2012) and women’s comfort walking of widths and sizes. shoes. Available in up to 5 widths, Sole Supports is an innovative, San Antonio, TX sizes 5-13 in women’s, 7-17 in medical-grade foot orthotics Superfeet Worldwide LLP men’s. Propet features a vast Phone: (210) 924-6561 manufacturer. We make custom (2003) selection of Medicare A5500 Fax: (210) 921-7460 foot supports that follow your Ferndale, WA coded footwear with removable Email: [email protected] doctor’s prescription in order Phone: (360) 384-1820 Website: www.SASshoes.com to provide both immediate pain

Current Pedorthics | January/February 2019 65 PRODUCTS&SERVICES

Fax: (360) 384-2724 line of contemporary, fully the last rubber soling plants in the Email: [email protected] accommodating custom-molded USA - the Quabaug Corporation in Website: www.superfeet.com shoes, including the Thera-Medic North Brookfield, MA. Shoe package – the most flexible, highest value shoe package for Concord, MA TechMed 3D (2011) Medicare-eligible patients with Phone: (978) 318-000, ext. 136 diabetes. E-mail: [email protected] TechMed 3D is an easy to use, UniStyle Footwear (2017) accurate, and portable solution Buffalo, NY Website: http://us.vibram.com/ for the digital acquisition of Phone: (800) 843-6653 Since 2003, UniStyle Footwear images and measurements Fax: (716) 881-0406 has been manufacturing of human body parts, giving Email: [email protected] fashionable comfort, orthopedic orthotists, prosthetists and Website: www.trumold.com and custom footwear. UniStyle pedorthists access to very reliable Footwear provides quality handcrafted footwear according Ziera Shoes N.Z., Ltd. and consistent measurements. (Formerly Kumfs Shoes N.Z., Tru-Mold Shoes, Inc. (1980) to rigorous quality standards and Levis, Quebec, Canada use the best natural materials, Ltd.) (1998) Tru-Mold Shoes offers a complete Phone: (418) 836-8100 quality leathers, and breathable Ziera Shoes, formerly Kumfs line of contemporary, fully Fax: (418) 836-1589 lining. Shoes, are women’s shoes, Email: [email protected] accommodating custom-molded sandals and boots that are truly Website: www.techmed3d.com shoes, including the Thera-Medic North York, ON M3J 2R8 Shoe package – the most flexible, Phone: (416) 638-7000 orthotic friendly. Ziera Shoes highest value shoe package for Fax: (416) 638-7627 come in a wide range of heeled Medicare-eligible patients with Email: [email protected] fashion and walking footwear. diabetes. Website: www.unistyleshoes.ca We have widths in stock from M through XXW in sizes 34 through Buffalo, NY 45. Therafirm (A Division of Phone: (800) 843-6653 Value Foam, Inc. (2014) Fax: (716) 881-0406 Knit-Rite, Inc.) (1999) Value Foam Inc. is devoted to Email: [email protected] Port Orchard, WA. Quality medical-grade offering our customers high Phone: 877 717 0588 compression hosiery and diabetic Website: www.trumold.com quality, low cost materials Fax: 877 717 0589 socks. commonly used for orthotic and Email: craig.taylor@zierashoes. prosthetic devices. Bring us your Ellerbe, NC Trufit Orthopedic Labs com current invoice, we will be happy Phone: (800) 562-2701 (2013) Website: www.zierashoes.com Fax: (910) 652-2438 to offer you the same type of Website: www.therafirm.com Trufit Biomechanics Labs is a materials at 10 percent less. Our full service biomechanics and product lines include high quality podiatric company. We manufacture EVA, AccuZote (a more economic individually engineered CAD/CAM substitute of plastazore) and PPT/ Tekscan, Inc. (1994) corrective foot orthotics in the USA. SBR materials at various density Broad range of pressure We operate multiple chiropractic and and thickness. assessment and clinical/research podiatric patient-care facilities across evaluation tools for use in Europe. In addition to operating South El Monte, CA orthotics, brace evaluations, joint several patient clinics in Europe, Phone: (800) 788-1358 biomechanics, and gait analysis. we continuously engage in highly Fax: (800) 788-1358 Boston, MA funded research and development E-mail: [email protected] Phone: (617) 464-4500 projects in conjunction with several Web site: www.valuefoams.com Fax: (617) 464-4266 European government laboratories Email: [email protected] as joint ventures that have become Website: www.tekscan.com very successful in developing new patient care evaluation techniques and innovative medical corrective Thor-Lo, Inc. (2001) devices, grounded in science. Statesville, NC Our commitment to Research, Phone: (704) 872-6522 Development and Innovation is a Vibram USA (1998) Fax: (704) 838-6323 foremost goal, and we only employ Since 1937, Vibram has stayed true Website: www.thorlo.com medical, engineering, and computer to its heritage by building products science professionals who share that focused on quality and performance vision. while keeping the end user in mind. Each sole, heel or rubber component Orlando, FL is built with proprietary compounds Phone: 855-910-2525 and endless quality control. We are Treadlabs (2017) Fax: 321-202-2819 also proud to say that we produce Tru-Mold Shoes offers a complete E-mail: [email protected] millions of soles each year in one of Website: www.trufitusa.com

66 Pedorthic Footcare Association | www.pedorthics.org ADVERTISERINDEX

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ABC (American Board for Certification in Orthotics, ICF abcop.org Prosthetics and Pedorthics, Inc.)

Acor pg. 27 acor.com

Amfit pg. 3 amfit.com

Apis pg. 7 apisfootwear.com

Apex pg. 40 apexfoot.com

Bintz Company pg. 11 bintzco.com

Comfort Products pg. 37 comfortoandp.com

CuraFoot3D pg. 29 curafoot3d.com

DJO / Dr. Comfort pg. 20 drcomfort.com

JMS pg. 4 jmsplastics.com

Kiwi pg. 52 kiwiorthoticservices.com

New Balance pg. 9 newbalance.com

New Step pg. 33 newsteporthotics.com

Orthofeet pg. 59 orothfeet.com

OS1st pg. 26 os1st.com

Revere pg. 46 revereshoes.com

Spira pg. 1 spira.com

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