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The Interplay of Shoes and Orthotics: Strategies for Patient Success

Welcome back to Podiatry Today podcasts where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. Today's orthotics Q and A is with Elizabeth Piselli, DPM and is created in partnership with the American Association for Women Podiatrists. We have the chance to chat with Dr. Piselli about her experience with balancing patient expectations and clinical excellence when advising on shoe gear for patients with custom orthotics. For instance, how do you educate patients on the interplay between shoes and orthotics? How do you manage expectations? And what pearls have been successful that you implement regularly in your practice? Dr. Piselli is a diplomate of the American Board of Podiatric Medicine and Practices in Rockville Center, New York. She's also the first vice president of the American Association for Women Podiatrists. Welcome, Dr. Piselli and thank you so much for being with us today.

What are the top concerns that patients relate to you regarding shoes and orthotics?

Dr. Elizabeth Piselli, DPM:

So usually we're at the point where we've already decided that they need custom orthotics, the over the counters didn't work, so their biggest concern usually is, "Do I have to buy new shoes? Will I be the same size? Will they fit into all my shoes? And do I have to transfer them from shoe to shoe? Then do I always have to wear these?" And in other words, if I can't fit the custom orthotic in a shoe, does that mean that shoe is completely off limits to me?

So how do you counsel patients about this? How do you allay some of those concerns?

Dr. Elizabeth Piselli, DPM:

So what I tell them is, "Wait until the orthotics come in to buy new shoes. Yes, you're going to have to move them from shoe to shoe. More importantly, be honest with me with the types of shoes that you're wearing. If you're only working out an hour a week, then we're not really addressing the pathology with the orthotic because you're not really going to be wearing them. If I'm making you a sneaker device and you're really only wearing a sneaker about 45 minutes, really most of your day is going to be in that work shoe." And sometimes we have patients who are professionals that don't get to work from home and have to wear dress shoes and that's just the culture of their work environment and we have to go with that, especially depending on certain pathologies. So that's something that I ask them to be honest with me because they want to be the person that's working out eight hours a day, but that's just not reality.

What I also try to tell them is, "Yes, the shoes are a big part of the problem for you or a big way to address the issue that you have. So it is important that you give us a shoe that's going to help the device work that much better." Another thing is it may change your shoe size, so definitely wait to buy any new shoes until that comes. The worst is when the patient comes in with boxes and boxes of all new shoes and they say, "But I just got all of these." And I say, "But I told you to wait and that would be really important."

The other thing is, yes, there's going to be times when you're going to have to be out of the device. Let's say you're going to a wedding and you're wearing a shoe that you don't normally wear, for men, it would be a tuxedo shoe. Let's say they're going to a black tie event, then yes, the orthotic might not fit in there, but what I have found especially with certain pathologies, the custom foot orthotic gives us the ability to last a little bit longer in those uncomfortable shoes once you've been nurturing your foot for most of the week or most of the day. That's really what I try to address what their concerns as far as shoes go.

For some of those brief use shoes like the tuxedo shoes or the dress shoes, do you ever try to do anything for these patients with say, an arch pad or an over-the-counter device that works in a dress shoe? Do you ever try to use that as a stopgap method?

Dr. Elizabeth Piselli, DPM:

I do, actually there's some great foam pads that pour on the blue plastazote that you can get. PediFix has them and I've actually outfitted their shoes, I've outfitted my own shoes when I've had to address that. Where it really works for a high heel is that four foot padding when someone has a little fat pad atrophy or maybe a plantarflexed second metatarsal, that's where it can really just make their lives a lot easier. The other thing I've done is taped their feet before. For my sister-in-law, for instance, for her wedding, when I taped her feet I said, "It would just be a big honor if you'd let me make you comfortable for this day."

And she was able to walk around in sky high heels for the whole night and that was a big accomplishment, just even taping. Because you can do a lot with tape and it's low profile, so if the patient can come in that day, that's not always feasible, but a lot of the K-Tapes do last a few days so even if you can get them the day before and tape them in position, that is a really good method.

Well, in that way, sometimes you can even inspire more confidence in your treatment plan too. If you can show that flexibility, the patients may show you that flexibility in return as well. Are there any pearls you'd like to share as far as successful management of how the shoe orthotic relationship impacts your treatment plans?

Dr. Elizabeth Piselli, DPM:

What I try to tell the patients is, "The orthotic is only as good as the shoe you're putting it in." So often they're saying, "But I got these XYZ shoes and they're supposed to be so great or I got these Hokas and they're supposed to be wonderful." And what I try to tell them is, "The shoe has to work for you and it's going to be a trial and error to find out what combination of shoe to orthotic is going to work." A lot of new information and new materials are coming out. So a lot of patients will come in and they will have bought, let's say, the ASICS GT-2000 and they bought it for 10 years in a row and they keep getting the new model, but all of a sudden it's not working for them and that it's not working for them with the orthotic and they come back unhappy with the device. But really it could be that ASICS tried a new foam or tried a new distribution of the way they put their treads.

Or even for me, I have a Tailor's bunion and they've changed where they'll sometimes put the end of their ASICS symbol and that can be really irritating to a Tailor's bunion if you have any bursitis there. So sometimes it's getting that combination where I call it the alchemy of both the device and the shoe and just because it works for so and so down the street who has theoretically the same issue you do, it doesn't mean it's right for you because your biomechanics to be different, you might have more hamstring tightness, you might have some internal tibial torsion or something else going on, even if it's your identical twin, it could be something else that's going on that's a little bit different for you. And at this point, with the array of shoes that we're given, it's important to find that shoe combo that works for you.

On the contrary also, if a shoe has been working and all of a sudden it's not and it's the same shoe, check the bottom because it could be the wear is just too much. The shoes don't have the durability that they used to, that's something I advise patients is you're not going to be able to get the mileage you used to because while they might be more shock absorbing, they don't have that shelf life that they used to have or I should say the street life.

And if they are using these devices for a sneaker, I say, "Try to get one with a removable insole." Most sneakers do have that removable insole and also a nice wide toe box. Sometimes if a patient has a wider four foot, I would recommend something like an Altra which has just a little bit wider of a toe box and not as tapered. But again, even that sometimes isn't right for the patient. So it really is going to be a trial and error, but I give them that talk ahead of time, that, "Be aware that this is going to be a trial and error because this is custom and we are custom fitting this to you, to your life and to your needs."

Is there anything else that you'd like to share that you picked up along the way when it comes to finding that ideal shoe orthotic combination?

Dr. Elizabeth Piselli, DPM:

The biggest thing and I think I've gotten a lot of this from a lot of the experts out there and there's some great podcasts including yours that you can look into, but stay on top of the changes in the shoe world. Someone that does that very well is the Bartold Clinical site, which I really like. The biggest eye opener for me is I had been thinking one way about shoes for so long and then the change in thinking that whatever works for the athlete, if there's no pathology, is what's working. I also try to advise patients that even though you think a shoe is comfortable, if you are in here because you're having pain, then it's not the right shoe for you. Pain is pathology, pain is not normal, that doesn't mean that the shoe is right. So I try to advise them about comfortable versus pathology. So I'm sure a lot of people that are listening have that same aggravation and frustration as well.

I know that many podiatrists hear these same questions on a regular basis and that we can learn from each other as far as where we each find success or challenge in everyday practice. Thank you so much to Dr. Piselli for sharing her insights with us today and also to the American Association for Women Podiatrists for their organizational partnership. To the audience, thank you as always for tuning in. Keep checking out for the latest podcast episodes or follow us on your favorite podcast platform.

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