Unique Orthotic Strategies for Low-Volume Footwear
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Unique orthotic strategies for low-volume footwear The low-volume shoes “Orthotics are all about alignment.” Anecdotally, many practitioners prefer full- worn by cyclists, figure length orthoses for treating foot-related injuries skaters, and others can or pain, but low-profile shoes—designed for anything from rock climbing to dance—of- make orthotic manage- ten don’t allow for a full-length solution. So, ment of these patients practitioners working with such cases have to challenging. So, lower ex- get creative—using tape, felt, or super-thin rigid inserts—to find ways to support feet and align tremity practitioners have joints. had to develop creative The challenges differ from one type of shoe to the next. strategies for achieving the desired biomechanical ef- Cleated sports On the face of it, cleats may seem an easy fit for fects while working within foot orthoses. Roomier than many other athletic a limited space. footwear (ie, cycling shoes, figure skates, or dance shoes), cleats present their own unique By Jill R. Dorson challenges, particularly when athletes have a Manolo Blahniks, soccer cleats, and an elegant preference for cleats that are too small. It is well new pair of figure skates might seem to have known among clinicians that both soccer players little in common. But—whether it’s stylish high and football kickers, for example, wear their heels, cleats that allow an athlete to truly to cleats extra-tight to improve feel on the ball. feel the ball, or a boot balanced atop a narrow Multiple studies1-3 have shown cleats are Therapy Faculty Clinic in Hillsborough, recently blade—form-fitting shoes do a job on the feet. associated with increased pressure on the heel, relocated to Southern California to focus on And, with little room to negotiate, low-volume lateral midfoot, and fifth metatarsal when ath- research, writing, and her consulting firm, styles of footwear can make it a challenge to letes are running or turning. San Diego-based FootCentric. insert foot orthoses to relieve or prevent pain pedorthist and physical therapist Patricia Pande, For cleated sports, Pande favors carbon and injury. PT, MCLSc, CPed, CSCS, has found tight cleats fiber inserts, which she said can be semicus- But, experts say, regardless of how much can also be associated with forefoot injuries. tomized for each athlete. Pande said the carbon room is available in a shoe, the goals of orthotic The range of potential injuries associated with fiber allows practitioners to increase the rigidity management are consistent. cleats is wide, and includes plantar issues, ankle of cleats to make the foot and shoe more stable, “Whether for a women’s dress shoe, skate, sprains, and other soft tissue or bone injuries. and fits well into low-profile shoes. The material or a soccer cleat, the key is the biomechanical Pande, formerly of Kinetic Physical Ther- can be heated and shaped, allowing for tweaks. fit of the orthotic,” said Robert Weil, DPM, a apy in North Carolina and a faculty member However, while carbon fiber lasts longer than podiatrist based in the Chicago suburban area. at the University of North Carolina Physical 16 lermagazine.com the felt or foam favored for dance-shoe inserts, Regardless of how much issue of the International Journal of Sports Pande said its life span is about a year or two— Physical Therapy, a review of interventions at which is shorter than the polypropylene used for room is available in a the foot-shoe-pedal interface in cyclists reached other specialty insoles. shoe, lower extremity a similar conclusion.9 Since soccer shoes are, overall, bigger than The goal in using an orthotic device in many other athletic shoes, practitioners are able clinicians say, the goals cycling shoes typically is to better distribute to fit a full insert into the shoes. of orthotic management plantar pressure while the cyclist’s shoes are “When I do injury profiling, I try very, very clipped to the pedals. Results of the German hard to put in a full-length insert,” Pande said. remain focused study showed a decrease in pressure using “Think about the excursion of the orthotic in the custom carbon fiber insoles. shoe. The shearing plays such a role in plantar on alignment and The most common injuries in cycling often fasciitis4 and can cause skin issues.” biomechanics. relate to overuse, according to the American As with other athletic shoes, the goal is to Academy of Podiatric Sports Medicine.10 Knee alleviate pain, redistribute pressure, and reduce pain, shin splints, Achilles tendonitis, sesamoid- the risk of injury. However, Pande is quick to itis, and numbness can often be traced back to point out that if the cleat is the “culprit,” she the fit of the cycling shoe. A custom insert may recommends orthoses for the cleat only, but help to solve these problems. if there is a more pervasive issue, the athlete Custom orthoses for cyclists may be stiff should have inserts made for each pair of shoes (eg, carbon fiber or polypropylene) or more he or she wears. forgiving (eg, ethylene vinyl acetate [EVA]) depending on the nature of the injury or pain Cycling being treated. The only consistency in cycling Few studies exist to test the use of orthotic de- inserts is size. Similar to dance shoes, the in- vices in cycling shoes, which are typically made serts are small and the focus is on the ball of the of rigid materials and are often attached directly foot due to the limited amount of space inside to the pedal of a bike with toe clips. These shoes the shoe. are not made for walking. An April 2014 LER article11 explored in 7 A March 2012 investigation in the German In a November 2011 JSMS study, a different more detail the contradictions that arise when publication Sports verletz Sportschaden5 found group of Australian researchers found no overall prescribing orthotic devices for cyclists and the that, compared with the standard insoles that kinematic effects of custom foot orthoses in a lack of meaningful research on which to base come with cycling shoes, carbon fiber insoles for group of 12 cyclists, but did find subject-specific this aspect of clinical practice. Experts inter- cycling shoes were associated with lower plantar effects. viewed in that article suggested that high-per- pressures in all foot regions except the toes. Such studies tend to have small numbers formance road cyclists may benefit from rigid In an Australian study of 12 cyclists published of participants and other methodological limita- inserts, while recreational cyclists may get relief in January 2013 by the Journal of Science and tions, making it difficult to identify the clinical from more flexible options. Medicine in Sport (JSMS),6 contoured prefab- implications. A May 2014 systematic review 8 ricated orthoses were associated with greater in the Journal of Foot and Ankle Research Dance shoes foot contact area and greater perceived midfoot concluded there is limited evidence supporting Of all the challenges involved in getting foot support than flat inserts of similar hardness. the use of insoles in cycling. In the August 2016 orthoses into specialty shoes, dance shoes may lermagazine.com 17 present the toughest. Putting aside the fact that to stabilize the big toe, though she often sees modern dancers go barefoot, leaving taping as tendinitis (anterior tibial, posterior tibial, and the only real alternative, dance shoes often don’t Achilles) as well as plantar fasciitis. Climbing allow for a full-sized insole, according to Jeffery only once a week is enough to create foot issues, A. Russell, PhD, AT, FIADMS, an assistant pro- she said. fessor of athletic training and director of science Rock-climbing shoes are made for a snug and health in artistic performance (SHAPe) at fit to allow the climber to better feel the surface Ohio University in Athens. He noted a modified, he or she is climbing. Soles are generally stiff smaller insert is usually the solution. and may be thin, and the shoe can be down- Like many other athletes, dancers often ex- turned, forcing the foot into a plantar flexed perience pain in other areas—such as the ankle, position that is more conducive to climbing. knee, or Achilles tendon—that can be related to Sanders said fit is critical to the sport, but sug- foot issues. Pain associated with hyperpronation, gests her patients go for a wider, if not longer, according to a 2013 Journal of Dance Medicine shoe to alleviate some issues. insole, which may require alterations to move- & Science study,12 is a common issue in dancers Although the authors of the JAPMA article ment, Russell said. that can be alleviated with foot orthoses. The listed foot orthoses among the potential options “We’re not using a full orthotic, so we’ll study found orthosis use was associated with a for preventing and treating foot issues in rock often craft them ourselves,” he said. “If you’ve decrease in pain, as well as in the static medial climbers, Sanders said she prefers to tape her been a dancer for years and years, it’s going longitudinal arch angle. patients. change the sensation of the entire foot and that According to Russell, dancers often present “There’s not a lot to talk about that because can throw them off quite a bit. … The biggest with pes planus or pes cavus, both easily climbing shoes are incompatible with orthotics. thing is them getting used to it.” managed conditions. High arches can be treated They’re even incompatible with socks,” Sanders with a simple D-shaped support in the center Rock climbing said. “Taping is great for climbing shoes and of the shoe/foot.