Unique orthotic strategies for low-volume

The low-volume “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 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 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 kickers, for example, wear their heels, cleats that allow an to truly to cleats extra-tight to improve feel on the . feel the ball, or a 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 , skate, sprains, and other soft tissue or bone injuries. and fits well into low-profile shoes. The material or a soccer , 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 . 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 Sports­verletz 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 ,” Sanders with a simple D-shaped support in the center Rock climbing said. “Taping is great for climbing shoes and of the shoe/foot. A donut-shaped orthosis can really the only option.” Like athletes who wear cleats, rock climbers be used to alleviate pain from a heel spur or a tend toward wearing specialty shoes that are teardrop-shaped pad can be inserted behind the Skates smaller than their regular shoe size to get better metatarsal arch to absorb some of the shock to Weil has decades of experience with foot feel. Perhaps not surprisingly, rock climbers are the metatarsal bones. orthoses and has worked with some of America’s prone to neuromas, bunions, and other foot Unlike athletes wearing more rigid shoes, top figure skaters. When it comes to putting issues caused by shoe pressure and rubbing. insoles for dance shoes are usually made of orthoses into any kind of skates, Weil said, there A March 2013 Journal of the American Po- orthopedic felt (a thicker, more durable cousin really is no downside. diatric Medical Association (JAPMA) article13 re- of art felt), closed-cell rubber foam, leather, cork, “Balance, edging, propulsion, and stability ported 86% of rock climbers sustain sport-spe- or a variety of soft and firm plastics. In Russell’s are all enhanced with proper orthotics,” he said, cific foot injuries, ranging from nail disease to experience, he has found that some of these noting joint malalignment can cause skaters to Achilles tendinitis. Anecdotally, experts say, the orthoses require regular replacement (every experience back pain, knee pain, or foot pain. most common chronic injury is toe pain. few weeks) versus the longevity of a more rigid “Alignment becomes a very, very big deal, espe- Jenny Sanders, DPM, principal podiatric insert. cially when you are really starting to jump.” physician at the Financial District Foot & Ankle Among the biggest challenges is the ability Weil says there is little that is unique to Center in San Francisco, specializes in hiking of the dancer to become comfortable with the fitting orthoses in skates, even tight-fitting figure and running issues. Sanders said her goal is

18 lermagazine.com skates. The boot of a is rigid—it of long-lasting polypropylene with an EVA filler may have up to three layers of leather—to pro- and a light topcover of either vinyl or leather. vide ankle support, and the result is that other Overall, the device is rigid, but the cobra style parts of the foot don’t conform to the pattern allows for some flexibility in the heel. Because of the leather. Most often, Weil said, the skater the orthoses are not truly full-sized, Huppin experiences foot problems before the skate itself said, they won’t last as long as a polypropylene wears out. version made for roomier shoes, but should last The durable materials most often used in several years. making orthoses for skaters—polypropylene Jill R. Dorson is a freelance writer based in San and sometimes graphite—are the same mate- Diego, CA. rials often used in other sports and for nonath- letes. Unlike his counterparts in other sports, References Weil said he rarely uses topcovers with orthoses 1. Nunns MP, Dixon SJ, Clarke J, Carre M. for skates. To that end, Huppin, who practices in Boot-insole effects on comfort and plantar “Polypropylene is great because you’re Seattle, favors a cobra-shaped insole, which loading at the heel and fifth metatarsal during never going to break it,” Weil said. “And there helps relieve pain in the ball of the foot but running and turning in soccer. J Sports Sci are different kinds of graphite that can be made nearly eliminates the heel cup of a conventional 2016;34(8):730-737. razor thin.” foot orthosis. The cobra design provides support Weil’s anecdotal experiences are backed 2. Kaalund S, Medeleine P. Effects of shock-ab- for the ball of the foot and the arch, but the up by an August 2016 Journal of Sport sorbing insoles during transition from natural heel cup is replaced by a piece that looks like a Rehabilitation study,14 which reported notable grass to in young soccer players: curved tail. improvement in postural stability after skaters a randomized controlled study. J Am Podiatr “The goal is to make or get [patients] into used custom insoles for six weeks. The study Med Assoc 2014;104(5):444-450. a prefabricated orthotic to grab the arch and found center of mass sway and ankle sway were 3. Carl HD, Pauser J, Swoboda B, et al. Soc- transfer pain off the ball of the foot,” Huppin reduced, leading to improved balance. cer elevate plantar pressures in elite said. “You’re very limited in what you can fit into male soccer professionals. Clin J Sport Med a dress shoe … so if I can get a cobra device that Dress shoes 2014;24(1):58-61. attaches really well to the arch of the foot, then I High-heeled shoes can put exceptional pressure think I am doing the best I can do.” 4. Ekstrand J, Nigg BM. Surface-related injuries on the ball of the foot, causing capsulitis, callus- Huppin noted that women may experi- in soccer. Sports Med 1989;8(1):56-62. es, Morton’s neuroma, or sesamoiditis, according ence pain in the forefoot, as well as overall foot 5. Baur H, Hoffman J, Reichmuth A, et al. Influ- to Larry Huppin, DPM, clinical professor of fatigue, when wearing heels.15-17 Such issues ence of carbon fiber foot orthoses on plantar podiatric medicine and surgery at Western Uni- can be prevented by fitting an orthoses before pressure distribution in cycling. Sportsverletz versity of Health Sciences’ College of Podiatric pain arises, but Huppin also said that insoles, Sportschaden 2012;26(1):12-17. Medicine in Pomona, CA. possibly in concert with other treatments, often While the height and tightness of the shoe 6. Bousie JA, Blanch P, McPoil TG, Vicenzino B. resolve the issue. He is quick to point out that often contribute to pain or injury risk, experts Contoured in-shoe foot orthoses increase mid- inserts “can take pressure off, but won’t get rid say a shoe’s elevation is not critical when devel- foot plantar contact area when compared with of inflammation.” oping an insert. Rather, as with other low-vol- a flat insert during cycling. J Sci Med Sport Whether custom or prefabricated, Huppin ume footwear, it is space. 2013;16(1):60-64. said foot orthoses for dress shoes are often made

lermagazine.com 19 7. O’Neill BC, Graham K, Moresi M, et al. Cus- 2016;6(1):e010053. tom formed orthoses in cycling. J Sci Med 17. Ko PH, Hsiao TY, Kang JH, et al. Relation- Sport 2011;14(6):529-534. ship between plantar pressure and soft tissue 8. Yeo BK, Bonanno DR. The effect of foot or- strain under metatarsal heads with different thoses and in-shoe wedges during cycling: a heel heights. Foot Ankle Int 2009;30(11):1111- systematic review. J Foot Ankle Res 2014;7;31. 1116. 9. FitzGibbon S, Vicenzino B, Sisto SA. Inter- vention at the foot-shoe-pedal interface in competitive cyclists. Int J Sports Phys Ther 2016;11(4):637-650. 10. American Academy of Podiatric Sports Medi- cine/American Podiatric medical Association. Cycling and your feet. AAPSM website. http://www.aapsm.org/cycling.html. Accessed May 6, 2017. 11. Daniel PK. Cyclists and foot orthoses: A unique set of challenges. LER 2014;6(4):33- 40. 12. Nowacki RM, Air ME, Rietveld AB. Use and effectiveness of orthotics in hyperpronated dancers. J Dance Med Sci 2013;17(1):3-10. 13. Buda R, Di Caprio F, Bedetti L, et al, Foot overuse diseases in rock climbing: an epi- demiologic study. J Am Podiatr Med Assoc 2013;103(2):113-120. 14. Grewal GS, Baisch R, Lee-Eng J, et al. Effect of custom foot insoles on postural stability in figure skaters while on ice. J Sport Rehabil 2016;25(3):255-262. 15. Borchgrevink GE, Viset AT, Witso E, et al. Does the use of high-heeled shoes lead to forefoot pathology? A controlled cohort study comprising 197 women. Foot Ankle Surg 2016;22(4):239-243. 16. Barnish MS, Barnish J. High-heeled shoes and musculoskeletal injuries: a narrative systematic review. BMJ Open

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