On Your Feet: Pedorthic Solutions for Stressed Out Feet

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Feet aren't just a built-in mode of transportation-they can be critical to a person's professional success. For a professional athlete, for example, foot wellness can translate into fame and a million-dollar salary. But there are a multitude of other professions that also place heavy demands on workers' feet: healthcare, education, retail, industrial, food service, and performing arts, just to name a few.

For those whose careers involve repeated foot-impact stress or require hours of standing, walking, or climbing, an injured or aching foot can sometimes mean more than just a tough day at work-it can mean loss of income or losing a job all together.

The O&P EDGE asked several pedorthic professionals how they have helped people with "feet-demanding" professions put their best foot forward every day. The solutions they shared combine a solid understanding of foot biomechanics and highquality, well-fitting footwear.

Foot Type First

Hayes

Shane Hayes, CPed, has seen it all. His pedorthic patients include ice hockey players, members of the Seattle Mariners, Olympic athletes, Boeing workers, and even skaters from Disney on Ice. The mix of customers keeps the owner of Shane's Foot Center, Shoreline, Washington, and past president of the Pedorthic Footcare Association (PFA), on his toes.

He is the only pedorthist to have research on diabetes published by the Journal of the American Medical Association (JAMA). He also is a consultant to several shoe companies and has taught courses for a number of pedorthic education programs.

The best way to treat people with high demands on their feet, he says, "regardless of the sport or the job, is to look at the foot type first. Once you understand the foot type, you know where the stresses are going to be. Then you add in the specific movements or repetitive movement that [the patient] would be making because of his or her job or sport, and that leads you where you need to be."

There are some pedorthists, however, who "look at 'this is where it hurts' and work backwards. I think that's a disservice to the patient."

According to Hayes, there are two basic extremes in foot types: highest and lowest arches. Each extreme creates predictable complications.

"What you are trying to do with those two extremes is simply nudge them back more to the middle range and let them operate in that middle range," he says. "The patients are instantly going to be more comfortable."

Among Hayes' most challenging patients was a female Olympic weightlifter with a leg-length discrepancy. He had to figure out how to put a lift into a high top, stiff-soled weightlifting shoe.

"It was a matter of picking the right durometer of materials that would withstand the various weights and make it properly fit the shoe," Hayes says.

Developing a pedorthic solution for the leg-length discrepancy was only half the battle. Once he designed the lift, he had to convince the athlete to wear it. "At first, she was resistant to it," Hayes recalls. "She came to me a year after she had already blown her knee, a referral from the other side of the United States. I said, 'If you do not put this lift in this shoe, you are going to blow out your knee again." He knew that a person standing with a large weight overhead with a short leg on one side would force the opposite knee inward.

"She was training for the [Olympic] team at that time. Once we got the lift on the shoes, she never had another problem with that."

Germany and America: A Good Fit

Goodhart

Douglas Goodhart's, CPed, pedorthic solutions are so far out of the box-or at least out of this country- that he has written his own book. The majority of his treatment plans are informed by German pedorthic practices. He also gets many of his tools from Germany, a country that he says leads the way in foot care. "German knowledge added to American pedorthic knowledge is really the key," says Goodhart, owner of Goodhart Shoes and Footcare, Overland Park, Kansas.

In his professional view, standing in the same place for long periods of time is the most injurious to foot health. "The pressures don't change, or change less often, and the unwanted pressure builds up faster," he says. "When we walk, the pressures change constantly."

This pressure build-up often results in plantar fasciitis. "It's rampant in [U.S.] culture," he says. "That's because of ignorance and inadequate footwear. Instead of providing complete freedom for the foot, the public is still choosing footwear that places compression on the foot. For a person to be healthy in their feet, the shoe environment has to allow the foot to exist as if it were barefoot. That simply is not happening."

When people whose jobs demand that they be on their feet come to Goodhart with foot problems, he recommends wider shoes for zero compression, socks without compression, and German-designed shoes and/or orthotics.

"There has been a running dialogue over the past few decades about wider shoes," he says. "But it's more specific than that. I am defining it more, which is zero compression on the foot and...shoes [that are wider] than anything people are thinking about right now."

Socks, he says, need to be thin enough not to add girth to the foot in order to retain proper volume within the shoe and fit correctly. They must not make a mark on the calf when removed or pull on the toes. "We don't want the sock to push away blood from the calves and small capillaries in the foot and calves," Goodhart says. It all has to work together. "If a person does everything right but wears the wrong socks, their plantar fasciitis won't really go away. It will be less problematic, but [it] won't go away. It's an all-or-nothing solution."

He points out differences in German and American AFO fabrication as well. For example, there is an AFO fabricated in Germany that is made of titanium and is 0.9mm thick, while a more typical American-made AFO is an eighth of an inch thick (just over 3mm), he says. "It takes up so much space in the shoe, and it's a nightmare to fit," Goodhart says.

Fit the Shoe to the Work Environment

The waiting room at Sobel Orthotics & Shoes, New Paltz, New York, is often filled with teachers, so Robert Sobel, CPed, owner, and vice president of PFA, is well-versed in the challenges these professionals face-or at least stand on. "If you think about it, teachers [stand] on really horrible surfaces," Sobel says. "It's all concrete, and even if there's a rug, it's really thin. It's bad because they have to wear dress shoes and they are on their feet a lot."

Creative Pedorthic Solutions for Industrial and Military Workers

In an industrial or military setting, custom shoes or shoes with foot orthotics can pose complexities that other custom shoes do not. There are specific standards that have to be met, such as those established by the Occupational Safety and Health Administration (OSHA).

"One of the biggest challenges...is steel toes," says Shane Hayes, CPed, owner of Shane's Foot Center, Shoreline, Washington. Hayes is also a past president of the Pedorthic Footcare Association (PFA). "Essentially, there are two [types of] steel-toed shoes," he says. "One tends to be a little more narrow, the other one a little wider and more square. The problem with steel toes is that the toes themselves do not come in widths, so if you have a person with a wide foot, the boot itself will come wide, but the actual steel toe isn't necessarily any wider."

To compensate for the narrow toes of the boots, employees will buy boots that are too long so the steel does not squeeze their toes or will use a composite fiberglass stiff toe they can strap onto their existing shoes, Hayes explains. "It's not acceptable in all jobs, but it's certainly okay for some."

The most common teacher foot complaint, he says, is metatarsalgia and plantar fasciitis. To solve these problems, he first tries to get these individuals into shoes that are better designed for their work environment-something with a cushion that still has a dressy appearance to meet their professional attire requirements.

He does the same thing with foot orthotics for teachers, providing cushions that ease the stress on their feet while not taking away from the appearance of their shoes. "Rather than just putting them in a vinyl [foot orthotic], a lot of times what we will do is give them something that has neoprene and a fabric cover so it gives them a light cushion," he says.

When recommending foot orthotics, Sobel likes brands such as Volara, which has a microsuede cover and good cushioning, and he likes Aetrex brand shoes, which has a "nice line of shoes that are dressier. Women can get a wedge if they want, and the men's shoes are very comfortable. Instead of a leather sole with a stack leather heel, they can go with something that looks really nice but has a softer, cushioned sole...."

Sobel has seen his share of healthcare workers as well. One of Sobel's pedorthic patients who works in healthcare has suffered from Charcot-Marie-Tooth disease for most of her life. By the time she was in her 30s, her feet were in such bad shape they looked like club feet.

"She was in sheer misery," Sobel says. "We wound up getting her some really nice, custom-molded shoes that include a rocker. They changed her life."

During a follow-up appointment, the patient's husband told Sobel that for the first time his wife had completed her Christmas shopping at the local mall without having to stop midway to go home because of her feet.

"It's the same thing with teachers-when they are plagued with plantar fasciitis, they can get hobbled," he says. "I literally have a box of tissues in my treatment room because many of these people break down."

Bigger Shoes, More Support

Like many of his pedorthic colleagues, the most common foot ailment Robert Schwartz, CPed, president and CEO of Eneslow Pedorthic Enterprises, New York, New York, sees among people who are on their feet all day is plantar fasciitis.

He recommends that his patients perform warm-up stretching exercises to reduce tightness in the Achilles tendon and plantar fascia. He then recommends they purchase supportive shoes in a larger size.

Shoes, says Schwartz, "are the ultimate base, the interface between the floor and body. Orthotics would be adjunctive to the shoe formula.

Schwartz

"We find that 80 percent of adults are in shoes [that are] smaller than their feet," he continues. "Their feet flatten out over time, they get bigger, gravity pulls everything down, and they are still wearing the shoes that they wore when they were 20." Schwartz takes into consideration not just the patient's job, but his or her lifestyle before fitting or modifying shoes. One patient came to him with a collapsed arch on one foot. That was easy enough to remedy. The other foot was normal.

However, when Schwartz balanced the collapsed foot, that leg became longer, so he had to elevate the other leg. "We did a post orthotic device for extra support [on one side], and on the other side we had to provide a lift to balance them out," he says.

Many of Schwartz's patients are office workers, who present a unique set of foot care challenges. He says that the attire expectations for women in an office environment are particularly problematic. "They wear sneakers walking to and from work and then pumps at work," he says. "They are walking on a concrete planet."

The abrupt change from the office to recreation is another big issue he sees. "They sit in an office environment and then they go on a hiking trip. They come back with plantar fasciitis or other conditions."

The solution, Schwarz says, is to buy bigger, more supportive shoes with some heel height. The added heel height prevents the foot from flattening, which Schwartz says happens when a person regularly wears flat shoes.

Athletic Demands

LaFontsee

Dane LaFontsee, CPed, works with many pedorthic patients whose feet are the base for lucrative careers. One of his patients recently signed a multi-year, multi-million dollar contract with the NBA.

LaFontsee, owner of Orthletek, Waterford, Wisconsin, and past president of the PFA, began to treat this professional basketball player when he was a promising young player with extremely highly arched feet. The young athlete had seen about seven physicians, none of whom were able to provide him with relief.

"No one had any solutions for him," LaFontsee says. "He would blister out under the big toe at every game to the point [that] it was just a bloody mess."

LaFontsee "went completely out of the box, which is what I do with all my athletes," he says, "and completed a device where all the relief was on top of the orthotic instead of underneath."

To do that, LaFontsee watched his patient play ball. He realized he would have to come up with a semi-rigid device that would eliminate shock. The first two iterations failed. The third one was a slam-dunk.

"I have...the original cast that I made for him when he was a freshman in college," he says. "We're not trying to change the biomechanics; we're just trying to change the way he hits the ground."

A retired ballet dancer, LaFontsee says he sees athletes differently. "I see how the body works," he says.

To find optimal solutions for his pedorthic patients, LaFontsee has been known to hit the road with them. For a professional baseball pitcher with a severe case of peroneal tendinitis, for example, he traveled to spring training to see how an orthotic with a lateral post that a physician had previously prescribed was working.

When LaFontsee arrived at camp, the pitcher said his pain was tolerable with the device and planned to pitch.

"The first pitch went into the dirt," LaFontsee says. "The second, in the dirt. The third pitch, in the dirt and out came the expletive."

So LaFontsee wandered out to the mound and told the pitcher to take off the shoe, remove the orthotic, and then pitch. The pitch was perfect.

The final solution? The pitcher still uses the foot orthotic, but not during games.

"The device was forcing him to fall medially, so the ball went to the ground," LaFontsee says. "I solved his medical problem but he couldn't pitch, so what good is that? Now he wears it as a protective thing when he's practicing.

"People who need to make a living need our services as pedorthists and orthotists as much as elite athletes," LaFontsee says. However, he adds, "There will be times when I look at somebody and say: 'I know your doctor made you a prescription for orthotics, but I don't think you need them. I think you just need better shoes.'"

Garrison Wells is an award-winning freelance writer and author based in Colorado Springs, Colorado. He has written for newspapers and magazines nationwide and authored five books on martial arts. He can be reached at garrison.wellscreative@gmail.com

Extreme Shoes for Military Personnel

Members of the military wear what some might consider the least attractive shoes in the world-bland, black, camouflage, functional-but those shoes can be lifesavers. A soldier with a major foot issue faces a major dilemma. If that soldier wears an extreme shoe size, there are even more problems. "We have ladies in the military with size 1.5 shoes. We have men with size 22 shoes. We know the ramifications of all that, because the military wrote standards for military shoes," says Mark Grundman, CPed, owner of Grundman Shoe, Vincennes, Indiana.

A size 1.5 ladies' shoe...is not in the military manual. "That's a child's size, and they don't do that," Grundman says. A size 22 is equally unheard of, and yet these extremes in shoe size do exist, and these soldiers also must have military-grade footwear.

For one military base, Grundman made six pairs of size 22 safety oxfords. Safety toe caps in these extreme sizes are difficult to incorporate because they also do not exist, Grundman says. He's working on such a project right now. The question is, he says, "Do you build the same bridge over the Mississippi River as you would a small creek? According to the [military] standards, you do. It requires special machinery to cut and stretch the steel." In this case, he will create a model. Then he will send it to a company in Minnesota to see if a cap can be developed. If not, he may have to go with a composite.

Safety toe or not, foot injuries in industrial and military settings still abound, says Meredith Crary-Johanson, CPed, vice president of Crary Shoes, Portland, Oregon.

One patient put his hand on a crane and 400,000 volts of electricity grounded in his feet. Crary-Johanson created a heavy-duty custom workboot with an extended, custom-molded steel shank integrated to create strength where the patient had damaged or missing toes. The steel shank and increased toe spring create rigidity and help the patient with walking. A custom orthosis made with a blend of polyurethane created a soft, durable bed. He's still working today at the age of 60. "We have made him shoes every single year for the last 30 years," Crary-Johanson says.

Not all complexities are quite so difficult to handle. For instance, another patient had his ankle fused so he couldn't get his foot down into the boot. "We put a zipper up the back of the boot so he can slide [his foot] in from behind," Crary-Johanson says.