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09/21/2017    Scott Carlis DPM

Treating Alpine Skiers with Pes Planus (Lawrence Huppin, DPM)

My many years as a ski boot fitter helped steer
me towards my career in podiatry. I wanted to add
a few additional thoughts to the in depth article
by Drs. Huppin and Scherer as well as the
comments by Dr. Steinberg.

For those podiatrist that see skiers or who get
ski boot related questions from patients I want
to provide some basic information on the design
of ski boots and the most common adjustments made
to ski boots by a boot fitter.

As podiatrists, we are asked to make
recommendations about dress shoes, running shoe,
cleats, dance shoes, sandals and the list goes
on. Basic knowledge about ski boot design will
help you look like rock star to your patients who
are lifelong skiers or those just getting into
the sport. Skiing is an expensive sport and you
want your patients to be comfortable and enjoy
themselves while they are chasing their next
powder day.

Are all ski boots the same? The shape of the boot
varies by manufacturer, just the same way shoes
vary by designer. Ski boots are designed with
varying forefoot widths or lasts. Boots also vary
in instep height, leg volume and overall
stiffness. In general boots get narrower in all
areas and have a stiffer flex as they move from
entry level to recreational to racing boots.
Higher end boots are typically stiffer and are
made from more uniform durometer materials.
These points in design are important when it
comes to accommodating deformities in the foot
and ankle. A good boot fitter will want to work
with the best shell to accommodate deformity.
This does mean that your patient may have
additional cost and get a more advanced boot in
order to accommodate their foot shape.

How can a boot fitter make the boot more
comfortable? The most common areas that boot
fitters make accommodations are the forefoot area
for bunions, Taylor’s bunions and people with
history of neuromas. The navicular area and
medial ankle are often stretched for all foot
shapes, not just the pes planus foot. As the
boot narrows into the ankle and heel pocket this
can be the tightest part of the boot. This area
also contains the hinge bolts connecting the
upper and lower shells. This portion of the boot
design can make a ski boot uncomfortable for any
foot or ankle shape. In many cases, the
corrective orthotic is not sufficient to pull the
foot deep enough into the heel pocket or keep the
medial aspect of the foot and ankle from rolling
into the shell.

Will my running or dress shoe orthotics fit into
my ski boots? Ski boots are sized very
differently than running shoes and hiking boots
which often have extra room in the toe box. A
ski boot is often sized down from a running shoe.
I wear a size 11.5 running shoe and a size 9 ski
boot. The smaller the boot the more control you
have over the ski and less intrinsic stress, as
discussed by Dr. Huppin. Clamping the forefoot
buckles tighter will not relieve the intrinsic
stress if the boot is too big. People can be
comfortable in a smaller ski boot due to the
small amount of posterior translation of the foot
while flexing the upper cuff of the boot. This
motion will move the foot deeper into the heel
pocket and pull the toes off the front of the
boot. Due to the sizing and shape of the ski
boot a person’s regular orthotic may simply not
fit into the ski boot.

What materials should I use for the ski boot
orthotic? With regards to the materials of the
orthotic I find that a 1-2mm subortholene or
flexible graphite to be sufficient. You do want
some flex in the device for assistance in loading
the edge of the ski. Rigid running type
orthotics can in a way overcorrect a patient in
their ski boot and keep them from the optimal
knee over the center of the boot position that
Dr. Steinberg mentioned. I have not found an
orthotic heel cup to be a problem with regard to
fitting into the heel pocket of a boot, but I
would likely stay away from deep or extra deep
heel cup. I do like to make full length covers
with an EVA or Ucolite. The orthotic should
replace the insert that comes with the boot, just
as you would replace the insert in a running
shoe. Full length covers allow for heating
devices to be installed as well.

If you see patients who ski, I recommend
establishing a relationship with your local ski
shop just the same way you do with the local
running shoe store. Talking with the head boot
fitter can provide you with great knowledge and
likely some referrals. Dr. Huppin is right that
ski shops are often the first place someone goes
when their feet hurt in their boots but if their
pain does not go away after a few days they need
to be seen by a specialist like us.

Scott Carlis DPM, Renton,WA

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