The document discusses shoes and orthopaedics. It provides details on the normal anatomy of a shoe, including the upper, sole, heel, linings and reinforcements. It describes different shoe styles and discusses surgical footwear. The document outlines how to check if a shoe fits correctly and discusses various modifications that can be made to existing footwear to relieve pain, such as heel pads, metatarsal bars, and rocker bars. It also covers compensating for leg length discrepancies using heel raises.

1. Shoes in Orthopaedics
Moderator: Dr.(Prof) R Maheshwari
Presenter: Dr.Tejasvi Agarwal

2.  A shoe is an item of footwear intended to protect and comfort
the human foot while doing various activities.
 The most important requirement of any footwear is that it fits
correctly. If it fits correctly it will be comfortable and will not
cause any pain and deformity in future.
 Any attempt to accommodate normal feet within incorrect
footwear will result in pain, formation of callosities, bursae and
skin ulceration from localized areas of excessive pressure, and
occasionaly growth abnormalities.

3. The Normal Shoe
 Parts of Normal shoe
are:
1. The upper
2. The sole
3. The heel
4. The linings
5. The reinforcements

4. Types of Shoes:
 The Gibson Style: the quarters are stitched on top of
the vamp so that the lace stays open freely to allow the
foot.
Comparable type: Derby

5. • The Oxford Style: The vamp overlies the quarters
which meet at the front and are laced together.
Comparable type: Balmoral

6. The Sole
 There are 2 sole, the
outer and the inner
 Outer is seperated
from inner by a
compressible filter by a
compressible filter, the
shank.
 The shank reinforces
the waist of the shoe,
part which lies
between heel breast
and the ball(broadest
part of the sole)

7. The outer sole can be
attached in two ways–
indirectly or welted, or
directly.

8. The Heel
The anterior surface of the heel is called the heel breast.
The shape of the heel may vary.
It should have straight sides and be broad enough to
provide firm support and prevent the ankle from rolling
over .
The height is measured in front of the centre of the heel,
in line with the medial malleolus.
For orthopedic purpose its should not exceed
1⅝inches(4.2cm). Heels higher then this ,force the
weight of the body forwards onto the metatarsal head.

9. Different types of heel

10. The Linings
Those parts of the shoe which
make contact with the foot are
lined. The vamp is lined with
cotton and the inner sole and
the quarters with either leather,
or cotton reinforced with
leather.
The Reinforcements
 The vamp is reinforced by the
toe box , and the quarters , in
the area of the anatomical heel
by the counters.

11. SURGICAL FOOTWEAR
The manufacturer of special footwear, or alteration or addition
to existing footwear, may be necessary to
 Accommodate deformed feet
 Relieve pain
 To compensate for shortening of the lower limb
 To provide foundation of an orthosis

12. Surgical footwear is made on a last constructed from
accurate measurements or from plaster cast of the
deformed foot.
Shoes are prescribed when the deformity is limited to the
forefoot, and
Boots if the foot is grossly deformed, if the hindfoot is
involved ,if scars are present around the ankle, or if
large raise is required.

13. VAMP of surgical shoe and boots is commonly plain as
this gives a smooth inner surface
SIZE OF THE OPENING through which foot is inserted is
also considered when prescribing a surgical shoe.
OXFORD STYLE can not be opened widely over the
forefoot , whereas GIBSON STYLE can be.
LACING is extended distally to the toes to provide an
larger opening for a rigid or flail foot.

14.  PIEDRO and EAGLE lace-to-toe bootees are suitable
for children and some adults with small feet , suffering
from spina bifida and other neurological disorder of the
feet.

15. CLOSURE is important. The most common method of closure by
laces or eyelets allows the snugness of the vamp to be adjusted
to accommodate swelling of the feet.
EYELETS may be replaced by hooks, thus enabling the patient to
don and doff the boots more rapidly, if hand action is impaired.
ELASTIC LACES,STRAPS AND VELCRO FLAPS
The use of elastic laces or slip on variety can be of great help in
patients with impaired hand function or limitation of the elbow,
knee or hip movement.
Strap and buckle and Velcro flaps afford other methods of easily
adjustable closure.
Shoe or boot may be fitted with Zip-Fasteners or elastic webbing
inserts.

16. How To Check That Footwear
Fits Correctly
 Excessive pressure must not be exerted on the foot by the
upper or the inner sole.
 The fit must be snug enough, that the shoe does not fall off
the foot, but loose enough to allow movement of the foot.
 There must be adequate clearance over the dorsum of the
toes, as well as adequate space at the sides of the heads of
the first and the fifth metatarsal heads.
 There must be a gap between the ends of all the toes and
the toe of the shoe or boot.
 The patient must be able to move all his toes freely.

17.  The metatarso-phalangeal joint of the hallux must be
level with the inner curve of the sole, where the sole
starts to curve laterally under the arch.
 The counter must fit snugly around the back of the
heel.
 The quarters must not gape excessively.
 The waist of the shoe or boot must grip the foot firmly
enough to prevent the foot from slipping forward or
backward.
 The quarters must be high enough medially over the
instep to prevent impingement or irritation at or near the
region of the first metatarso-medial cuneiform joint.

18. MODIFICATION TO EXISTING
FOOTWEAR
 Although surgical footwear as described , may be required
for the management of painful feet , particularly in case of
severe deformity
 Much foot pain can be alleviated by prescribing various
addition or alteration to existing footwear.
 A shoe suitable for modification , is preferably of leather and
welted construction and laces. The heel should be broad,
and only of moderate height i.e. not exceeding 1⅝
inches(4.2cm)
 Pain in the foot is considered to arise from on or more of the
following sites (a)ankle and subtalar joints (b)heel (c)medial
longitudinal arch (d) metatarsal arches and (e)toes

19. ANKLE AND SUB-TALAR JOINTS
1. ANKLE STIFFENER
Restriction can be obtained by adding
an ankle stiffener. It is made from
plastic or metal. It extends upwards
from the heel on the medial and/or
the lateral aspect of the ankle.
Commonly it has to be added on
the outside of the upper boot ,its
lower end being riveted to the
existing counter.
Pain arising from ankle and subtalar joints may be relieved by
limiting or preventing movements at the affected joints. This can
be achieved by :

20. 2. ROCKER BAR
The apex of the rocker
bar lies just behind and
parallel to the line joining
first and fifth metatarsal
heads. It differs from the
metatarsal bar in that its
anterior extension is
longer , its overall length
being up to
2½inches(5.6cm)

21. Rocker bar & Rocker bottom
 Rocker bar: located proximal to metatarsal heads;
improves weight shift onto metatarsals
 Rocket bottom: builds up the sole over the metatarsal
heads and improves push off in weak or inflexible feet.
May also be used with insensitive feet

22. 3. OUTSIDE HEEL FLOAT
The lateral ligament of the ankle may be partially or completely
ruptured following a severe inversion injury.
In the absence of radiological evidence or increased talar tilt either
with or without general anaesthesia, or if the patient declines
operative repair, inversion injuries can be prevented by floating out
the lateral side of the heel of the shoe.
In muscle imbalance, when the peroneal muscle are weak, an outside
heel float with possibly the addition of an outside heel wedge, an
ankle stiffener or an ankle foot orthosis can be used to correct the
varus deformity which occur.

23. Indications:
• Excessive or inadequate
supination
• Peroneal paralysis (stroke;
polio)
• Extreme genu varum
• Posterior tibial tendon
dysfunction and rupture
• Poor stability caused by
conditions such as Ankle
sprains
• Extreme lateral instability
• Peroneal muscle atrophy
(Charcot Marie Tooth)

24. HEEL
Pain under the heel may be relieved by fitting a horse shoe
shaped sponge rubber heel pad inside the shoe on a
leather insole.
Pain over the back of the heel can be relieved by
removing the counter from the back of the shoe and
inserting two thick sponge rubber pads covered with
chamois leather, one on each sides of the exostosis.
Indication:
-Heel Spur
-Heel Ulcer
-Plantar Fasciitis/heel pain

26. MEDIAL LONGITUDINAL ARCH
Pain arising from medial longitudinal arch of the foot may be due to foot
strain or degenerative changes in the tarsal and tarso-metatarsal joints.
It is usually associated with flattening of the medial longitudinal arch and
can be relieved by supporting that arch.
 Indications
— Excessive or inadequate pronation
— Peroneal paralysis (stroke; polio)
— Extreme Genu valgum
— Posterior tibial tendon dysfunction and rupture
— Ankle sprains
— Extreme medial instability
— Peroneal muscle atrophy (Charcot Marie Tooth)

27. This support can be obtained by the following ways
1. Insoles
2. Shoe alteration

28. 1. INSOLES
 VALGUS INSOLES
These are constructed commonly from felt or sponge
rubber covered with leather mounted on a firm leather
insole. Occasionally rigid arch supports made from
metal or plastic as prescribed.

29. The support extends from the middle of the heel forward under
the medial longitudinal arch to half an inch(1.25cm) behind
the metatarsal head. The height of the arch support must be
correct.
A combined valgus and metatarsal arch support may be
prescribed also for pes cavus, so that the body weight is
evenly distributed and pressure on metatarsal head is
relieved.
Insoles may be either of full or three quarter length. A full length
insole is less likely to shift within the shoe with moment of
the foot. But should not be prescribed if there is any
tendency to hammer toe or claw toe deformity

30. 2. SHOE ALTERATION
 THOMAS HEEL
The front surface of the normal heel is slightly concave
and runs transversely across the sole. The medial part
of the heel is extended forward at least 1 inch (2.5cm),
at which point the front of the heel lies under the
navicular bone. This gives support to the median
longitudinal arch.

31.  MEDIAL SHANK FILLER
Heavy patients sometimes depresses the longitudinal
arch of their shoes. This can be prevented by adding a
medial shank filler which fills in the gap between the
ground and the undersurface of the longitudinal arch of
the shoe on the medial side.

32.  MEDIAL HEEL AND LATERAL SOLE WEDGES
This combination of wedge produces a tendency to invert the
heel and to evert the forefoot, which result in the elevation of
the medial longitudinal arch.

33. METATARSAL ARCH
Pain arising from metatarsal arch region of the foot is
usually due to the prominence of one or more of the
central three metatarsal heads in the sole of the foot ,
associated with dorsal subluxation or dislocation of the
respective metatarso-phalangeal joints .
It can be relieved by relieving pressure on the plantar
aspect of the metatarsal head by
1. Insoles
2. Shoe alteration

34. 1. INSOLES
 METATARSAL ARCH
SUPPORT
It consist of a pad of sponge
rubber mounted on a firm
leather insole and covered
with leather.
A single dome support will
provide support for one or
two of the middle metatarsal
heads.

35.  METATARSAL PAD AND GARTER
This consist of a pad of sponge rubber mounted on a broad elastic
band , which is slipped over the foot
It must be of adequate thickness and must be positioned correctly
. They must lie behind the metatarsal heads.

36. 2. SHOE ALTERATION
 METATARSAL BAR
Pressure on the metatarsal head can be relieved also by
placing a raised bar of leather or rubber across the sole of
the shoe directly behind and parallel to the line between
the first and fifth metatarsal heads. The average height of
the bar for adults is ⅝ inch(1.5cm)

37. TOES
1.CLAWS , HAMMER AND
MALLET TOES
Deformed toes may give rise to
pain due to pressure upon
them by the shoe. This
pressure may be relieved by
 Wearing longer and wider
shoes with plain vamp
 Ensuring that the toe box is
of adequate height
 Stretching the shoe over
deformed toe

38.  Inserting a balloon patch in the vamp where
necessary
 Providing a metatarsal arch support .
It may be necessary, however, to prescribe surgical
footwear to accommodate the deformities.

39. 2. HALLUX RIGIDUS
The pain may be relieved by
advising thick, relatively stiff,
soled pair of shoes or by
modifying the footwear so that
dorsiflexion at the metatarso-
phalangeal joint of the hallux or
eliminated. This can be done by
 Addition of a rocker bar to the
sole of the shoe
 Stiffening the medial side of the
sole of the shoe.

40. 3. HALLUX VALGUS AND
BUNION
The pain can be relieved by inserting
a balloon patch in the vamp at the
first metatarso-phalangeal joints,
or by prescribing a pair of surgical
shoes.
4. TOE BLOCK
Occasionally for multiple deformities,
gangrene or infection, all the toes
have to be amputated.
Following this procedure a toe block
is prescribed. It is made of sorbo
rubber or Plastazote.

41. TRUE AND APPARENT DISCREPANCY
IN LENGTH OF THE LOWER LIMB
TRUE DISCREPANCY: It is present when there is a
decrease in the distance between the upper surface of
the head of the femur and the lower surface of the
calcaneus, compared with the other limb.
APPARENT DISCREPANCY: It is due to the
presence of a fixed adduction or abduction deformity at
one hip.

42. COMPENSATION FOR A
SHORTER LIMB
A short leg gait can be ungainly and tiring. In addition it
can increase the stress imposed upon the hip joints
and lumbo-sacral spine and therefore contribute to the
occurence at pain at these sites. Compensation for
inequality in length of the lower limbs, whether true or
apparent, can improve function.

43. CALCULATION OF
THE AMOUNT OF
RAISE REQUIRED
It is rarely necessary to
compensate for the first half an
inch(1.25cm) of shortening, as
this can be accommodated
easily by tilting the pelvis.
The height of the heel raise for
any length can be calculated by
subtracting 1.25cm from the
difference in length of the lower
limb measured with the patient
supine.

44. All patients who require
compensation for
shortening must be
measured in the standing
position , in this position
the height of the heel
raise, and the degree of
allowable equinus of the
ankle and forefoot
necessary to compensate
for any true or apparent
shortening, which is
comfortable to the patient
can be determined.
The comfort of the patient
is much more important
than any theoretical
calculation.

45. The height of the heel raise is measured anterior to the centre
of the heel of the shoe , in line with the medial malleolus.
When a raise is added to the heel of the shoe, the thickness of
the posterior border of the heel must be greater than that of
the anterior border.
It is necessary to provide rocker action for walking, the height
of the raise must decrease toward the toe. The height of the
raise at the toe will depend upon that at the tread, if this is
large the tapering must be more.

46. TYPES OF RAISES EMPLOYED
 OUTSIDE RAISE
 INSIDE RAISE

47. 1. OUTSIDE RAISE
If the footwear is normal, the raise can be added to
ordinary footwear. Sensible footwear is essential.
Certain type of footwear are unsuitable, for example:
 Court shoe
 Shoe with welded rubber sole or heel
 Soft suede shoes or boots
 Shoe with heel exceeding 2 inches(5cm)

49. When the required raise is ¼-¾ inch(0.6-2.0cm)
The heel and if necessary sole can be raised by adding to
the surface of the existing heel and sole.
Microcellular rubber is used for the raise.
When a heel raise of more than ¾inch(2.0cm) is required
the existing heel and sole are removed and layer of cork
is are added to obtain the required height.

50. 2. INSIDE RAISE
When the foot is deformed or of
an odd size, surgical
footwear must be made.
All or part of raise may be
concealed within the upper.
This is known as inside
raise.
The maximum height is usually
3½inches(8.0cm) at the heel,
with 2 inches(5.0cm) at the
tread and approximately 1
inch(2.5cm)
When the required raise is
more than 3½inches
(8.0cm), the cork raise can
be arched and bridge
waisted.

52. CTEV shoes
 These are modified shoes
used once a child starts
walking.
 Straight inner border to
prevent forefoot adduction.
 Outer shoes raise to
prevent foot inversion.
 No heel to prevent
equinus.
 This shoes are used until
the child is 5 years old.

53. Plantar Fascitis
 Shoe inserts can be used
with existing shoes.
 Patients with low arches
experience increased
stress on the plantar
fascia with foot strike and
have a decreased ability
to absorb the forces that
are generated by foot
strike.

54. Thank You