The single most important step in making a custom-molded shoe is the cast. A good cast takes patience and is all important to determine the correct fit and function of the shoe.
The choices on a shoe order form can often seem limiting and confusing. Our goal is to describe the best shoe that meets the original prescription and the patient's biomechanical, therapeutic, and lifestyle requirements. With a good cast and a clear description of the shoe, we are able to fit almost every molded shoe right the first time, making the whole process more pleasant and efficient.
Shoe style -Generally, the higher the counter of the shoe, the more control it will provide. Most patients want low-top shoes for aesthetic reasons. Examine what they are wearing currently and determine if their shoes are working for them. Low-top shoes are easier to sear, but there is a greater chance of slippage and looseness at the heel. Patients with any midfoot medical problems, such as Charcot or PTTD, or those patients wearing AFOs, braces, or bandages, will do much better in shoes with higher counters i.e., chukkas or high-tops.
- Shoe upper-The normal opening of a shoe goes across the ball of the foot. A surgical opening occurs more distally, almost over the toes. Surgical openings will make the shoe look a little more orthopedic, but they are very useful whenever the patient may have difficulty putting on or taking off the shoe, such as when there is limited ankle range of motion.
- Velcro closures are quick and easy for people who have limited use of their hands, such as arthritis patients or those who have difficulty bending over to tie laces.
- Padded collars are a good addition to help ensure a snug heel fit and also to reduce the possibility of the heel pistoning out of the shoe. Patients with fluctuating edema can also benefit from padded collars and padded tongues.
- Cast modifications-The typical molded shoe comes with a standard 1/2"-3/4" toe elongation. This extra plaster is added to the last and then checked against the weight-bearing tracing. If the original cast and tracing are good, there should be no problems with the fit of the shoe. Often patients will feel they are "swimming" in the new shoes. This is usually because they are used to tight and ill-fitting footwear.Each cast gets a 1/4" addition of plaster over the toe box area. Specifying an extra-high toe box will provide even more room for those patients with severe hammer toes.
- Shoe weight-This will depend on the patient's weight and activity level. Molded shoes are normally designed to be more accommodative to the foot, providing protection rather than being rugged. If the patient is heavy and/or is a heavy-duty user because he works outdoors or does a considerable amount of walking, the shoes can be made tougher by choosing a stronger, heavy-duty upper, adding sole stiffeners, using firmer soling materials, etc.
- Insole-The insoles can be made from a variety of materials, depending on the patient's needs. Plastazote offers the most protection, but EVA insoles tend to last longer. If the patient is wearing a brace, AFO, or gauntlet inside the shoe, it is best to make a cork insole that will hold up longer. Just as with any custom orthotic, depressions, pads, and postings can be built into the insole. As an excellent insurance precaution I always recommend a spacer under the insole. This separate 1/8" piece can be quickly and easily removed if the shoe is a little tight.
- Lifts-Shoe lifts can be added to the inside and/or the outside of the shoe. Often patients will have their own preference based on the look. Lifts up to 1/2" are not usually noticeable to the untrained eye. It is often better to put a lift on the outsole of the shoes as the height can easily be adjusted later without affecting the internal fit of the shoe.
- Outsole - A great deal of the biomechanics of the shoe can be controlled by selecting or altering the outsole. A standard shoe will have 3/4" of pitch from heel to ball. Rocker soles are very useful for off-loading met heads or aiding ambulation in patients with limited gait cycles. Flares and wedges can be incorporated to improve stability or alignment. In cases where the final balance of the shoe depends on how the patient adapts to the new support, it is often best to request that the outsole be left off. This will allow you to modify the pitch and wedging in the presence of the patient.
- Fitting - It may sound elementary, but the first rule of success in fitting custom shoes is that the person who cast the patient should fit the shoe. If you have shown the patient a sample of a molded shoe, pre-sold him/her on the benefits of proper fitting, therapeutic footwear, and developed trust and rapport, then there should be no surprises when the patient sees the shoes.
- Check the shoes for fit and function, and, in particular, look at the length and width. Patients will certainly feel that the shoes are different from anything they have had before. Feeling looseness at the heel is not uncommon. This is often due to a stiff outsole that does not yet bend. Once the shoe has been worn a little, the outsole will flex, and the heel will not feel so loose. If the shoe is a little tight, you can remove the extra spacer below the insole and/or adjust the insole.
- Adjustments - Unless the shoes are obviously incorrect, regardless of how they feel-good or bad-patients should break them in slowly over a period of about two weeks, checking their feet daily. We start them with one hour the first day and build the time up gradually. After two weeks, patients will have had time to adapt to the shoes and, if they need an adjustment, they will be able to tell you exactly what is required.
- (source: Séamus Kennedy, BEng (Mech), CPed, OandP.com)
MODIFYING A PLASTER MOLD OF A PATIENT FOR CUSTOM MOLDED SHOES CUSTOM MADE ATHLETIC CHUKKA SHOE CUSTOM MADE HIGH-TOP BOOT CUSTOM MADE SHOES WITH STITCHED DESIGNS ON THE UPPER