Check the Patient’s Shoes
There are two reasons for taking a good look at the patient’s shoes. 1] To determine if the patient is a bracer and 2] To make sure the patient has shoes that are in good shape (not worn out, or strictly “fashionable”). Shoes that are worn all day have too significant an impact on foot mechanics and posture to be selected just for fashion.
Checking Shoes for Bracing and Releasing Patterns
When scheduling a patient for fitting, always ask them to bring in a pair of well worn shoes.
As mentioned before, bracers are hyperpronators in disguise. A characteristic of bracers is that even though they may measure for a 6.0mm PCI, many of them will not tolerate that amount initially. Bracers are often so muscularly bound they need a conservative start - 3.5mm.
Bracers can be clearly identified by checking the wear pattern on their shoes.
Bracers will almost always wear the lateral side of the heel, and the amount of wear is often dramatic because bracers often have a harder heel strike. The forefoot will indicate even (mild bracing) or significant lateral wear. Typically the harder the lateral wear, the more significant the bracing pattern.
A person with a mild bracing pattern (even wear in the forefoot) may be able to start with a 6.0mm pair of PCIs if the First Metatarsal Deficit (FMD) calls for a 6.0mm pair.
If the bracing pattern is severe or if the patient is sensitive to change, for sure start conservatively with a 3.5mm pair.
Releasers will wear their shoes either on the lateral or medial side of the heel. The forefoot will show most significant wear from the middle to the medial side, often with the heaviest wear underneath the second metatarsal head.
Unless other factors dictate a conservative approach (see contraindications), releasers may start with the amount of ground force indicated by the First Metatarsal Deficit (FMD).
Shoe Wear and Fit
Before fitting the PCIs, make sure the patient is wearing shoes that will facilitate the PCIs and work effectively.
Six aspects of the patient’s shoes are vital:
- Room (height) in the toe box
Because the PCI requires vertical space in the toe box, make sure that the patient is wearing shoes that will facilitate the amount of ground force. It is important that the patient does not feel the upper of the shoe rubbing on the top of the big toe. The discomfort of this experience will quickly cause non-compliance.
Many people (especially women) tend to wear shoes that are too short. Determine where the end of the patient’s longest toe is relative to the tip of the shoe. There should be approximately 3/8” between the end of the toe and the tip of the shoe.
Shoe width is a debated issue. Shoe manufactures often make “comfort shoes” wider. As a result many people wear shoes that are too wide. The shoe should fit snuggly across the foot and the foot should not be able to slide from side to side in the shoe.
Have the patient stand normally and squeeze the upper in the area of the ball of the foot. If the foot is not snuggly filling the shoe from side to side, it is too wide.
If you fit the PCIs in shoes that are too wide, you risk the patient twisting off the ground force causing blisters and calluses.
Also look out for shoes that are too curved. The PCI’s work better with a straight last.
We recommend a good flat flexible shoe. Do not fit PCIs in shoes with insoles that have all kinds of toe grips and odd shapes. Some running shoes are posted heel to toe on the medial side to counteract hyperpronation. Do not fit PCI’s in these shoes.
Extra cushioning may be added inside the shoe, or you may look for shoes with extra cushion built into the heel.
If you want to fit insoles in sandals or open shoes, it is best to find a shoemaker with the right adhesives to place it permanently.
Do not fit PCIs in shoes that have no remaining lateral support, and have disintegrating mid soles.
It is important to impress upon the patient that you cannot fit them with PCIs unless they are willing to invest in a suitable pair of shoes. Many people believe that orthotics will require them to purchase orthopedic shoes. With PCIs, most regular shoes with normal height in the toe box will do fine.