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Ski boot fitting question

Discussion in 'Biomechanics, Sports and Foot orthoses' started by scott63, Jan 19, 2012.

  1. scott63

    scott63 Welcome New Poster

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    Hello, I am a ski boot fitter of 20+ years and have a unique circumstance I need an opinion on. I have a client who is in a pretty tight fit. I have shaped the boot for him to accomodate any pressure points that I knew he would have. I do believe he is still getting instep pressure as he has some pretty decent knobs on his instep. My question pertains to the balls of his feet. When he gets out of the boots the ball of his foot is white from under the 1st met head to nearly under the 3rd met head. He experiences numbness which I do think could be caused by instep pressure but I'm mostly concerned about the whiteness. I do believe the whiteness is possibly due to the instep pressure and it will be hard to give him more room over the instep. I've thought of putting a met head spreader on the footbed but haven't yet. I'd love some thoughts. I think the boot now has adequate width after the work I've done so I'm a little puzzled. Any help would be appreciated.
  2. Admin2

    Admin2 Administrator Staff Member

    Related Threads:
    Other skiing related threads
  3. Scott:

    Sounds like your skier needs a boot with more volume to accommodate his foot better. I would be more concerened with numbness than with "white skin", whatever that means.
  4. scott63

    scott63 Welcome New Poster

    Thanks Kevin but I should have given you more info. Just wanted to start a thread for ideas. First off a boot with more volume is not an option as it needs to be very tight for racing purposes. I have worked with this style of fit many times before and have shaped this particular boot to match his foot very well. The challenges with fitting a boot this way is that any little spot can cause numbness and a millimeter or two can make all the difference. This style of fit is for elite athletes. This is a whole different world from fitting a ski boot for the recreational masses. That is why I pose this question.
    So numbness is my main concern but I'm trying to locate the source of pressure. The foot in question has 2 large knobs on top of each "cuboid"? Is that right? One feels a bit filled with fluid, the other like solid mass build up. I'm sure this is contributes to his numbness when pressure is applied to his instep. I've worked on alleviating that pressure and have a bit more room to go but still I am very intrigued by the white area underneath his 1st - 3rd met heads. What ever is causing that lack of blood flow is probably associated with the numbness. This is just the well educated bootfitter with no medical degree talking. That's why I started this thread. Hopefully you can give me a detailed analysis of your thoughts. Not trying to cheat the medical world. Just trying to educate myself and solve this problem.
    Thanks, Scott
  5. Scott:

    It would probably be best if you could send in some photos of the foot you are dealing with since your foot anatomy knowledge isn't sufficent for me to be able to understand which anatomical structures you are talking about.

    Here is a paper I coauthored on the subject quite a few years ago.
  6. Dananberg

    Dananberg Active Member


    Could be one of two problems. First, your client may be experiencing deep peroneal nerve compression from the top of his boot. The deep peroneal nerve is between the bases of the 1st and 2nd mets as they articulate with the cuneiforms. Solving this problem (if possible with a racer boot fit) is to try to adjust the foot bed. You may consider dropping the 1st ray as this can relieve a bit of pressure superiorly (rather than a dorsal jamming compression) which can occur when the 1st ray is elevated. Skiing a passion of mine and find that without proper foot bed construction, I can get a similar effect (but more numbness in the 1st and 2nd toes vs. blanching). Second, he may also have Raynaud's phenomena, which is a vasospastic disease and can result in white blanching of the skin from exposure to the cold. Either a boot heater (doubtful for a racer) or prehaps 100mg of CoQ10 daily, which can be purchased from any health food store works terrific for this condition. Ask him if this ever happens to his fingers (white blanching)....if so, a professional referral would be appropriate as this may represent a systemic issue and not be a boot fit problem.

    Good luck with this problem and please let us know the outcome.

  7. scott63

    scott63 Welcome New Poster

    Thanks Howard. The client does have a boot heater. I've learned a bit more since my last post. When in the boot buckled looser in the store for 30 min. there is no sign of whiteness in the mets area. Only when he comes in from the snow and now confessing he buckles much more tightly on the lower two buckles when racing do I notice the whiteness under the foot. I have snapped 4 photos to look at. Two are from the top and the "knobs" on his medial cuneiform (if I have my bones straight) is worse on his left foot. The other two pics are the bottom of his foot immediately after he got out of the boot. I have put a met head spreader bump in the footbed but that seems to have no effect although comfortable. The footbed is very thin but supportive. It is a Conformable Ski Race molded in a semi weighted process. I hope I can figure out how to attach these photos as I am new to this forum. Thanks for you help.

    Attached Files:

  8. Dananberg

    Dananberg Active Member


    Sure looks like a Raynaud's type issue. Check out the end of the 2nd toe.....I could understand the overload to the met heads....but with the toe in that color, this is a vasospasm....and does not appear biomechanical to me.

    Raynaud's can be just what you see, or a precursor to autoimmune type diseases. A complete physical exam by his primary care doctor would be a really good idea.

  9. Scott:

    The "white spots" plantar to the first and second metatarsal heads and hallux most likely represents the areas of highest plantar pressure during skiing with the boot clamped down during racing. These "white spots" are caused by the high plantar pressures pushing the subcutaneous blood away from these areas of the skin and these areas will pink back up within a few seconds to a few minutes in most individuals. There is little risk of vascular damage as long as the skier unclamps their boots intermittently to allow normal arterial inflow into the plantar skin to occur.

    The dorsal erythema (i.e. pinkness) is also like caused by a high pressure area from the dorsal aspect of the boot pressing down firmly on a dorsally prominent first metatarsal-medial cuneiform joint and second metatarsal-middle cuneiform joint. This is also not an uncommon finding in those skiers that have more high medial arches (i.e. cavus-type feet) since they may have dorsal prominence in this area of their foot that the boot will press down on when clamped on more tightly for racing.

    My guess is that you could do a much better job at making a foot orthosis for him that transferred some of the boot reaction force plantarly into the whole medial arch of the foot to give a greater surface area of contact which would, in turn, then decrease the high pressures plantar to the 1st and 2nd metatarsal heads (Pressure = Force/surface area). Look at how white the plantar arch is in your photos....think of trying to make these areas at least "a little pink" after ski racing. Increasing the surface area of contact especially in the distal medial arch will undoubtedly decrease the first and second metatarsal head pressures during skiing and may help the "white spots".

    As far at the erythema on the dorsal medial midfoot, you could try putting a "doughnut pad" over that area in the liner or modify the boot shell to increase the surface area of contact with these prominent "knobs", as you call them. Even simpler, have your skier not ratchet his boots so firmly down onto his feet. You will likely find that once you get a better fit of the orthosis into the medial arch, the added plantar stability that the foot orthosis provides will allow the skier to feel that they won't need to clamp down their boots quite so hard while skiing to attain the edge control that they desire.

    Hope this helps.
  10. Dananberg

    Dananberg Active Member


    When one removes a pair of ski boots, and then the socks, more than a "few seconds" passes. He seems to have had time to remove his boots and socks, and then "pose" for 4 different photographs without this "pinking up" except in the 2nd toe.

    For safety sake, I would continue to include Raynaud's in the differential diagnosis. Mistaking this for a purely pressure related issue may result in the loss of a digit or two. I always like to err on the side of caution.

    Living in Northern New England, this is something I see regularly. Cold exposure does promote Raynaud's.

    Scott....how long before the blanching resolves?

  11. CEM

    CEM Active Member


    what model of boot is your client in, with most race shells the pictured foot will require extensive work to get comfort and reduce the loading

    just looking at the pictures the medial and lateral sie of the boot should be ground out to accommodate the 1st /5th metatarsal heads, the toe box of most race models will also need to be expanded to deal with such a square forefoot. you say the problem does not happen when in the shop but does occur after skiing, this may be something to do with ski set up and binding delta angles, too much binding delta will force the skier into the back seat and the forefoot into the front of the boot, or if the ankle joint ROM is not as good as it should be there may be excessive loading of the metatarsal heads as the skier flexes the boot (more likely in certain boot models with high levels of forward lean or with skiers with tight gastroc-soleus complex)

    normally for a tight calf a small heel lift inside the boot solves the issue but for a racer who as to comply to FIS regulations it is generally not possible to get anything into the boot barring the foot and a very thin footbed before you are over height and looking at a DSQ from any event he enters, the best solution in this case is to gas pedal the boot or the binding to make the boot cuff functionally more vertical

    the exostosis on top of the cuneiform also needs the shell to be punched upwards or the tongue materials to be ground away to accommodate it, i am assuming that this has been done in the "shaping of the shell for his foot"

    i would also be referring this client out to his GP to have a check for raynauds as although there may not be any long term damage being done you want to be very sure

    good luck getting him sorted

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