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Shoe Modifications

Original Editor - Jess Bell based on the course by Donna Fisher
Top Contributors - Jess Bell, Tarina van der Stockt and Stacy Schiurring

Introduction

Footwear has many functions, from providing support and protection to fashion. Regardless of the type of shoe (i.e., sport trainer, work shoe, etc.), a shoe should fit well, be comfortable, functional, and look good.[1][2]

For people with foot conditions or fixed deformities, decisions around footwear can be even more important. Often, standard mainstream footwear will not meet their needs. However, high-street (commercial) orthopaedic footwear can be modified to provide additional features that reduce pain and pressure, optimise movement and enhance biomechanics.[3]

Anatomy of a Shoe

Anatomy of a Shoe.

Shoes can be divided into an upper and a lower part. The upper part covers the forefoot, hindfoot and top of the foot. This is usually made of leather or a synthetic material. The upper part of a shoe includes the vamp, quarter, heel counter, collar, toe box and interior lining. The throat refers to the tongue, the opening of the shoe and the fastening mechanism. The lower part of the shoe is the sole, which consists of the external sole, the midsole and the inner sole. The welt connects the upper part of the shoe to the sole. Modifications can be made to both the upper and lower parts of a shoe.[1]

Shoe Modifications

When modifying a shoe, it is essential to consider fit, comfort, function and aesthetics. Clinicians can also gain information about gait patterns and pressure distribution from the wear patterns on patients’ existing shoes, and should always consider the materials of a shoe when making adjustments.[1]

Upper Modifications (Internal Adaptations)

One of the most common shoe modifications is to modify its width at the forefoot. This modification benefits people with a range of foot conditions, including diabetes,[4] hallux valgus,[5] and rheumatoid arthritis. The circumference and diameter of the metatarsal heads are measured to establish optimal shoe width.[1]

Extra depth can be added or reduced in the forepart region of a shoe to ensure ease of entry and comfortable fitting, not too tight or too loose. Foot circumference behind the metatarsal heads is measured to determine optimal depth. At the time of fitting, it’s important to ensure ease of entry into the shoe and comfortable shoe closure.[1]

The instep circumference can also be increased or decreased to ensure ease of entry into the shoe and comfortable shoe closure. This is especially important for people with oedema or when using an orthosis.[1] Instep circumference is measured at the highest point of the foot (which is typically over the navicular and cuneiform bones).

Toe box depth can be increased or decreased. Conditions such as claw or hammer toes and diabetes can benefit from increased toe box depth.[6] For people with diabetes, it’s important to ensure that there’s no friction, pressure or discomfort over the toes to reduce the risk of skin breakdown.[7]

Specific modifications like medial bunion pockets[8] or bunionette pockets around the fifth metatarsal provide additional space and comfort for people with hallux valgus (bunions) or Tailor’s bunions.[1]

Quarter height can be increased or decreased. This can ensure adequate heel coverage and is beneficial for people wearing orthoses or those with prominent malleoli.[1]

Lower Modifications (External Adaptations)

Shoe raises can be used to address leg length discrepancies.[9] There is a limit as to how much you can raise a shoe—the higher the raise, the more material is required to be added to the shoe, this can result in a heavier, stiffer and more unstable shoe. Raises can run straight through the shoe, or they can be tapered. They can be inserted between the midsole and the outsole. It’s possible to just add heel raises, but this changes the balance of the shoe. In addition, small raises (5-8mm) can be added inside the shoe.[1]

Watch this video to see how shoe raises can be added to a standard trainer:

[10]

As mentioned, the more material added to a shoe, the stiffer it becomes. There are benefits to stiffening a shoe for people with painful foot conditions, such as diabetes, hallux rigidus, hallux limitus and first metatarsophalangeal osteoarthritis.[1][11] [12] There are various internal and external techniques to create additional stiffness. For example, a steel stiffener can be inserted into the midsole of the shoe, or a carbon fibre plate can be added inside the sole to prevent movement. However, simply stiffening a shoe creates a rigid hindfoot to forefoot, which influences gait.[1]

Rocker soles are usually added when a shoe is stiffened with a raise or stiffener to allow a natural roll-over. When adding rockers, we need to determine the apex of the rocker, its position and angle. A rocker can enhance roll over, accommodate foot and ankle stiffness, manipulate ground reaction force,[13] and reduce plantar pressure.[14][1]

This video shows a boot being modified to have a rocker sole:

[15]

Additional material can be added to the inside or outside of the heel or sole (medial or lateral flare). These flares provide additional stability, widen the wearer’s base of support and can influence ground reaction force.[1]

Wedges can be added to the medial or lateral sole and heel. A medial wedge can reduce pronation, while a lateral wedge can reduce supination. For people with fixed deformities, wedging can provide increased stability.[1]

Buttress or counter stiffeners add additional material to the medial or lateral side of a shoe to support the heel counter. However, they can be bulky and are not a cosmetic option.[1]

Toe protectors can be added to the sole and/or toe box. To reduce wear on the front of the shoe. However, it is important to ensure the additional material does not become a trip hazard.[1]

Conventional stirrups can be added to the heel of a shoe. The shoe needs to be stiff enough to support the metal of the stirrup. Positioning is crucial and needs to be measured with the brace and patient.[1]

Key Takeaways

Footwear and shoe modifications are an integral part of orthotic treatment. Shoe modifications are time-intensive and highly technical. There is not always strong evidence to support these techniques, so it’s important to ensure treatment is customised for each person. Success depends on a comprehensive assessment, and to create a shoe that fits well, is comfortable and functional, and looks good.[1]

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 Fisher D. Shoe Modifications Course. Physiopedia Plus, 2025.
  2. ↑ Braam C, Kloprogge S, Schiphof D, van Meurs JBJ, Bierma-Zeinstra SMA, van Middelkoop M. Patients' perspectives on participation in an effectiveness study on footwear modification for the first metatarsophalangeal joint osteoarthritis: a qualitative study. J Foot Ankle Res. 2025 Jun;18(2):e70050.
  3. ↑ Barbara AM, Grobelna A. Orthopedic footwear for people with lower-limb conditions: CADTH health technology review. Canadian Journal of Health Technologies. 2022;2(1).
  4. ↑ Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Hinchliffe RJ, Lipsky BA. IWGDF Guidelines on the prevention and management of diabetic foot disease, 2019.
  5. ↑ Kuhn J, Alvi F. Hallux Valgus. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553092/
  6. ↑ Colò G, Fusini F, Melato M, De Tullio V, Logrieco G, Leigheb M, Surace MF. The effectiveness of shoe modifications and foot orthoses in conservative treatment of lesser toe deformities: a review of literature. Musculoskelet Surg. 2025 Sep;109(3):225-232.
  7. ↑ Ahmed S, Barwick A, Sharma A, Hasan MZ, Kabir MA, Nancarrow S. Examining characteristics of those who receive pedorthic services: A clinical audit. PLoS One. 2024 Jul 1;19(7):e0304443.
  8. ↑ Ying J, Xu Y, István B, Ren F. Adjusted indirect and mixed comparisons of conservative treatments for hallux valgus: a systematic review and network meta-analysis. Int J Environ Res Public Health. 2021 Apr 6;18(7):3841.
  9. ↑ Tirtashi FH, Eslami M, Taghipour M. Effect of shoe insole on the dynamics of lower extremities in individuals with leg length discrepancy during walking. J Bodyw Mov Ther. 2022 Jul;31:51-56.
  10. ↑ ontheballorthotics. External Lift on a Running Shoe. Available from: http://www.youtube.com/watch?v= kM7zOfk2aUM [last accessed 6/11/2025]
  11. ↑ Munteanu SE, Landorf KB, McClelland JA, Roddy E, Cicuttini FM, Shiell A, et al. Shoe-stiffening inserts for first metatarsophalangeal joint osteoarthritis: a randomised trial. Osteoarthritis Cartilage. 2021 Apr;29(4):480-490.
  12. ↑ Martinez-Rico M, Gijon-Nogueron G, Ortega-Avila AB, Roche-Seruendo LE, Climent-Pedrosa A, Deschamps K, Sanchis-Sales E. Effect of different custom-made foot orthotics on foot joint stiffness in individuals with structural hallux limitus: A quasi-experimental study. Clinical Biomechanics. 2025 Feb 1;122:106423.
  13. ↑ Hemmati F, Karimi MT. The effect of rocker sole shoes on ground reaction force in the elderly. Proc Inst Mech Eng H. 2022 Jul;236(7):988-993.
  14. ↑ Malki A, Baltasar Badaya M, Dekker R, Verkerke GJ, Hijmans JM. Effects of individually optimized rocker midsoles and self-adjusting insoles on plantar pressure in persons with diabetes mellitus and loss of protective sensation. Diabetes Res Clin Pract. 2024 Jan;207:111077.
  15. ↑ ontheballorthotics. Rocker Sole Shoe Modification. Available from: http://www.youtube.com/watch?v= OIhHom_TjI4 [last accessed 6/11/2025]
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