General Description - Shoes and Foot Orthotics PDF Print E-mail

Shoe components

Shoes are the important foundation of the lower limb orthosis. Shoes are used to protect and warm the feet, transfer body weight while walking, and reduce pressure or pain through redistributing weight. Shoes should be comfortable and properly fitted. They should be at least 1 cm longer than the longest toe and correspond to the shape of the feet.



The shoe can be divided into lower and upper parts. The lower parts consist of the sole, shank, ball, toe spring, and heel. The upper parts include the quarter, heel counter, vamp, toe box, tongue, and throat.


  • Outer and inner soles are separated by compressible filler. Both of them are made preferably of leather for breathability.
  • The ball is the widest part of the sole and corresponds to the area of the metatarsal heads.
  • The shank area is from the anterior border of the heel to the ball. A steel piece may be used to reinforce the shank area.
  • The toe spring is the space between the anterior sole and the floor.
  • Heel
    • Leather with rubber on the plantar surface commonly is used for the heel.
    • A spring heel is one-eighth inch high.
    • An Oxford heel is three quarters to 1 inch high.
    • A military heel is 1 and one quarter inches high.
    • A Cuban heel is 1 and a half inches high.
    • The heel counter is the posterior portion of the upper part between the quarters. This structure is used to reinforce the quarters and support the calcaneus. The heel counter can increase the posterior stability of the shoe.
  • Upper
    • The upper is the portion of the shoe above the sole.
    • The vamp is the anterior section.
    • The quarters are the posterior section.
    • The throat is the base of the tongue.
    • The tongue is a piece attached to the vamp.
    • The toe box is the reinforcement of the vamp to protect the shoe from trauma.

Shoe modifications

A properly fitted shoe should have adequate room for the foot to expand while the patient is bearing weight. The shoe should be at least 1 cm longer than the longest toe, and the widest part also should correspond to the widest part of the foot. Shoes can be modified to reduce pressure on sensitive areas by redistributing weight toward pain-free areas. (See image below.)

Blucher style orthopedic shoe (top); diabetic sho...

Blucher style orthopedic shoe (top); diabetic shoe (bottom).

External shoe modifications

  • Heel modifications
    • A cushioned heel - A wedge of compressible rubber is inserted into the heel to absorb impact at heel strike. This cushion often is used with a rigid ankle to reduce the knee flexion moment by allowing for more rapid ankle plantar flexion.
    • A heel flare - A medial flare is used to resist inversion, and a lateral flare is used to resist eversion. Both flares are used to provide heel stability.
    • A heel wedge - A medial wedge is used to promote inversion, and a lateral wedge is used to promote eversion. The heel counter should be strong enough to prevent the hindfoot from sliding down the incline created by the wedge.
    • Extended heel - The Thomas heel projects anteriorly on the medial side to provide support to the medial longitudinal arch. The reverse Thomas heel projects anteriorly on the lateral side to provide stability to the lateral longitudinal arch.
    • Heel elevation - A shoe lift is used to compensate for fixed equinus deformity or for any leg-length discrepancy of more than one quarter of an inch.
  • Sole modifications
    • Rocker bar - This is a convex structure placed posterior to the metatarsal head. The rocker bar is used to shift the rollover point from metatarsal head to metatarsal shaft to avoid irritation of ulcers along the metatarsal head in patients with diabetes mellitus (DM).
    • Metatarsal bar - This is a bar with a flat surface placed posterior to the metatarsal head. The metatarsal bar is used to relieve the pressure from the metatarsal heads.
    • Sole wedge - A medial wedge is used to promote supination, and a lateral wedge is used to provide pronation.
    • Sole flare - A medial flare is used to resist inversion, and a lateral flare is used to resist eversion. Both flares promote great stability.
    • Steel bar - The steel bar is placed between the inner sole and outer sole. This bar is used to reduce forefoot motion to reduce the stress from phalanges and metatarsals
  • Combination of sole and heel modifications - If heel elevation is more than half an inch, a sole elevation should be added to avoid equinus posture.

Internal shoe modifications

  • Heel modifications
    • Heel cushion relief - This soft pad with excavation is placed under the painful point of the heel.
    • Heel wedge - A medial heel wedge can rotate the hindfoot into inversion. A lateral heel wedge can evert the hindfoot to avoid pressure on the cuboid.
  • Sole modifications
    • Metatarsal pad - This domed pad is designed to reduce the stress from metatarsal heads by transferring the load to metatarsal shafts in metatarsalgia.
    • Inner sole excavation - A soft pad filled with compressible material is placed under 1 or more metatarsal heads.
    • Scaphoid pad - This type of pad extends from one half inch posterior to the first metatarsal head to the anterior tubercle of the calcaneus. The apex of the scaphoid pad is between the talonavicular joint and the navicular tuberosity. The scaphoid pad is used for medial arch support.
    • Toe crest - A crescent-shaped pad is placed behind the second through fourth phalanges. The toe crest fills the void under the proximal phalanges and reduces the stress.

Foot orthosis

The foot orthosis extends from the posterior border of the foot to a point just posterior to the metatarsal heads. This device is used to accommodate the abnormal foot to help restore more normalized lower limb biomechanics.Orthopedic inserts include the following:

  • UCBL (University of California at Berkeley Laboratory) insert - This insert is made of rigid plastic fabricated over a cast of the foot held in maximal manual correction. The UCBL encompasses the heel and midfoot, and it has rigid medial, lateral, and posterior walls.
  • Heel cup - The heel cup is a rigid plastic insert that covers the plantar surface of the heel and extends posteriorly, medially, and laterally up the side of the heel. The heel cup is used to prevent lateral calcaneal shift in the flexible flat foot.
  • Sesamoid insert - This addition to an orthosis is an insert amounting to three quarters of an inch with an extension under the hallux to transfer pressure off the short first metatarsal head and onto its shaft.

In a randomized clinical trial, a Canadian study investigated the effectiveness of custom-made orthoses versus that of prefabricated ones, with both types tested over a 4-week period in patients with lower extremity musculoskeletal pain. The report’s authors determined that although both types of orthoses brought immediate improvement in economy of gait, only the custom-made orthoses enabled patients to maintain such improvement over the entire 4-week period.






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