Treating patients who rapidly deform their shoes

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I have several patients, adults and children, who have come in with great concern over their tendency to rapidly deform the lateral heel counters and uppers of their shoes, often with excessive corresponding lateral heel wear on the sole. They literally hang over the lateral sides of their shoes, However when standing barefoot they usually have a medially deviated STJ position. Is this just a result of heel striking with the foot in an abducted position? and how can it be prevented? Also if the patient has no symptoms -other than a pain in the wallet re rapid shoe turnover, is it reasonable to intervene?

 

Hi Penny,

People with a tibial varum will heel strike more laterally so the bigger the varum, the more significant the deformation. They are always going to heel strike like this so firm heel counters and a sole material that resists compression is the go. Lawn bowling shoes and others with the cushy soles can wear in weeks.

Rebecca

 

Hi Penny,

An old fashioned remedy to slow the lateral shoe wear down during heel strike is to send the client's shoes to a cobbler/shoe repairer who can add a steel roll cap to the lateral edge.

I have seen a couple of clients who wear their entire lateral sole down to the inner sole. They have found this to be the only method that preserves their shoes.

Good Luck!

Melanie

 

Penny, Rebecca, and Melanie, i am considerably bow'legged with a charlie chaplin abducted foot gait (a pretty picture i'm a'painting for you ladies), I wear my lateral heels atrociously and i'm not comfortable until they're worn down to a degree such that everyone (not just my podiatric peers) comment. My joints ache whilst i 'break in' the shoes, relief only after the 'deformation' has been attained. Biomechanically why should this modification be 'corrected' or prevented (in me or patients)?, mark c

 

hi markjohconley

I'm a little similar in that I have a large tibial varum which is only partially compensated ie: I stand with calcaneus inverted to the ground mildly but with no further pronation available. I'm comfy in my old joggers that are worn into inversion. My foot spews over the lateral aspect of the sole at the rearfoot and forefoot. It doesn't look so great so I replace my joggers when it goes a bit too far. When I buy shoes, they last longer with a firm heel counter and upper and when the sole isn't too soft.

I have orthotics that hold my rearfoot inverted to keep me away from maximal pronation and thankfully my STJ axis must be such that I don't go over on my ankle ie: inversion sprain.

So to my thinking, you just have to get your patients to understand why the shoes deforms, what shoe properties to look for so they are not replacing them every two weeks and keep the STJ away from max pronation. I'm always going to heel strike inverted and orthotics are not going to change that.

Rebecca

 

Hi Rebecca, and all,

I understand that you will always have an inverted heel strike despite orthotic intervention. I often draw similarities between wearing spectacles and wearing orthoses. For example, in a person who is short sited, spectacles can enable him to see long distances more comfortably. However, when he removes his spectacles, he is still short sited.

However, I don't understand why you must have footwear with lateral wear. From my perspective, the angle of wear in your shoes, is acting like an extrinsic post to increase the angle of support under your foot. If for example your shoe wear when you are most comfortable wears into 6 degrees of inversion, and your orthoses are inverted by 6 degrees, then your feet are being inverted by a total of 12 degrees. Is this not the same angle of support as a 12 degree inverted orthotic and a new pair of unworn shoes?
The unfortunate side to this perspective is that once those shoes do wear out laterally, your feet would be overcorrected and lateral instability may become an issue. This problem could only be prevented by a perfect pair of shoes that never wears out (If anyone finds or invents such perfect shoes let me know!).

Melanie

P.S. Rebecca, Can you please suggest a Brand of running shoe which you find is most comfortable for your foot type?

 

Hi Melanie,

Well I don't know about your 6 degrees inverted etc etc. But with a significant tibial varum, heel strike is more lateral. And with a MTJ that can't fully compensate to get 1st MPJ weightbearing enough for propulsion ie: toe off is more mid-lateral MPJs, my thinking is that the lateral sole and upper of the shoe have a big job to do and this is the area of the shoe that is going to wear first.

As for a brand of shoes, if you find out, let me know. Unfortunately I have a size 5 foot and most ladies shoes start at size 6, so I am usually limited to kids shoes which is great because they cost heaps less but which is bad because they aren't as sturdy etc as adult shoes.

Rebecca

 

Given that those whose angular positions of the tibia and calcaneum are so in varum or inverted that shoes are most comfortable when worn in I use a minimal change in orthosis prescription that:

- Allows for the comfort factor to be retained
- Provides a stability in gait when there maybe a tendency to increased
and prolonged lateral column loading

The minimal change is simply a lateral heel skive. This has shown itself very affective both in the comfort and stability stakes. I have described this to patients as providing resistance to lateral drift but the biomechs will likely say we are producing a supination moment instead.

I have further found that although a person may not exhibit a stiff or fixed plantar flexed 1st ray (do frequently find this to accompany many of these feet though) the inclusion of a 1st ray cut out seems to be useful as well. My suspicions about this are another conversation.

It would not be unusual for me to get a physio to examine the hips to look at muscle inbalance contributors once the devices are fitted. The person has a pattterned gait, the devices may allow a chance for positive change in this patterning and so physio input here can be great jam on the bread!

It is not until such measures are applied that a person realises the level of instability they have been accomodating

Ian

 

Hi Ian

Just trying to get my head around this ... I would think that a lateral heel skive would be contraindicated as it produces a larger STJ pronation moment on a foot that is either maximally pronated or at least pronates to a large degree. I have always thought a medial heel skive to be the go to increase the STJ supination moment and keep away from max pronated / reduce pronation. But thanks for your insight, I might have to try it and see what happens.

Pronation moment??

Rebecca

 

hi Rebecca

Just driving home now and thought to myself "plonker, its a pronation moment". You are right.

With these situations I tend to go for a intrinsic posting so that I end up with a vertical heel, rarely more than a 2 degree forefoot varus post and a lateral heel skive of approx 3mm. I ask for the apex of the medial arch to come close to the navicular (When I made my own devices I brought the apex of the arch beneath the navicular which ussually brought some level of comfortable control to the MTJ). The net effect is that the foot appears to be cradled upon the device. ( I might occassionally place a 3mm heel raise in as well just to see what happens and if it helps)

For me these situations are one of the times when we look to balance things out and as a consequence may well apply a technique that seems contrary.

Be it a pronation or supination moment they are simply tools for us to balance the foot in function and nothing more. Its surprising the ways you can apply them to achieve such balance. Add some good peripheral joint and soft tissue mobs as well, can aid in encouraging potential for a fresh pattening of muscle function and it gets better still. Works most of the time very occassionally not.

Cheers
Ian

 

My Pedorthic view

“tendency to rapidly deform the lateral heel counters and uppers of their shoes, often with excessive corresponding lateral heel wear”

This sometimes can be exaggerated by the sole shape of the shoe, as some of the new styles can tend to be cut in rather sharply from heel to the midfoot whilst not having a Shank which destabilize the shoe transversally giving little if any support.
The other thing to look at is the “flare” of the sole, is it under cut?

“can you suggest a brand of running shoe which you find is most comfortable for your foot type?”

This is something l hear often, if you are going to suggest a “Brand” could you also state the “Style” please.
So many people walking into our store and say they where told to get a shoe Brand “X” sadly brand “X” does not produce all of its products on the same style last or sole unit that was found to be so good in the first place.


“send your client's shoes to a cobbler/shoe repairer who can add a steel roll cap to the lateral edge”

Wow, people still do that ? Try referring to your cobbler for some advice first, l am sure if asked he/she would suggest some hard rubber or better still Nylon, the edges of which will not damage polished floors, catch on carpet and rugs and make very little noise if any whilst walking

For myself l would add a slight flare to the lateral aspect of the shoe, from heel to midfoot of about 6 at the ground level, hard to notice and will stabilize the whole structure.
l would also ask the client to seek some advise on shoe selection, even if after the purchase they take it to their Podiatrist for approval, there are some great products out there that offer firm and extended heel counters with a sole that does not finish at the edge of the upper

Just a thought !