How to manage a patient's request for a shoe insert to alleviate leg discomfort?

Management of Leg Length Discrepancy with Shoe Inserts

For a 70-year-old male patient requesting a half-inch shoe insert for the right leg, providing a custom-made shoe insert of 1/2 inch thickness for the right shoe is appropriate, along with physical therapy to address any associated musculoskeletal issues. 1

Assessment and Measurement

When evaluating a patient with suspected leg length discrepancy:

1. Confirm the leg length discrepancy through proper measurement

   • Measure from the anterior superior iliac spine to the medial malleolus bilaterally
   • Consider radiographic measurement for precise evaluation if clinically indicated

2. Assess for associated symptoms:

   • Lower back pain
   • Hip or knee discomfort
   • Gait abnormalities
   • Balance issues

Appropriate Footwear Modifications

The International Working Group on the Diabetic Foot (IWGDF) guidelines provide valuable insights on footwear modifications that apply to leg length discrepancies:

• Shoe insert specifications:

  • The shoe insert should be custom-made to the individual's foot 1
  • For a 1/2 inch discrepancy, a full-length insert is preferable to maintain proper foot biomechanics 1
  • The insert should conform to the shape of the foot, providing cushioning and proper weight distribution 1

• Footwear considerations:

  • The shoe should be 1-2 cm longer than the foot itself 1
  • Internal width should equal the width of the foot at the metatarsal phalangeal joints 1
  • Sufficient height should allow room for both the toes and the insert 1
  • Evaluate fit with the patient standing, preferably at the end of the day 1

Implementation Plan

1. Short-term management:

   • Provide heel cups for immediate comfort as you've done 2
   • Order the custom-made 1/2 inch shoe insert for the right shoe (size 9.5) 1
   • Ensure the insert is full-length to maintain proper foot biomechanics 1

2. Physical therapy prescription:

   • Focus on gait training with the new insert 2
   • Include strengthening exercises for quadriceps and hip girdle muscles 1
   • Add range of motion/stretching exercises 1
   • Incorporate balance training to adjust to the modified gait 2

3. Follow-up evaluation:

   • Schedule a follow-up appointment 2-4 weeks after insert delivery
   • Assess for proper fit and comfort
   • Evaluate gait pattern and any remaining symptoms
   • Make adjustments to the insert if necessary

Potential Complications and Considerations

• Adaptation period:

  • Advise the patient to gradually increase wearing time of the new insert
  • Start with 1-2 hours daily, increasing by 1 hour each day 1
  • Monitor for skin irritation or discomfort

• Biomechanical considerations:

  • Be aware that shoe inserts may alter joint moments and center of pressure during walking 3
  • Individual responses to inserts vary and may not always be as expected 3

• Long-term monitoring:

  • Regular follow-up to assess insert condition and effectiveness
  • Replace inserts when showing signs of wear (typically every 6-12 months)
  • Re-evaluate leg length discrepancy annually to ensure appropriate correction

Special Considerations for Older Adults

• Balance and fall risk:

  • Sudden changes in shoe height can increase fall risk in older adults
  • The physical therapy should include balance training specifically 2
  • Consider a walking aid during the adaptation period if balance is compromised 1

• Comorbidities:

  • Assess for conditions that may be exacerbated by leg length discrepancy (osteoarthritis, spinal stenosis)
  • Monitor for changes in joint pain with the new insert

By following this approach, you can effectively address the patient's leg length discrepancy while minimizing complications and optimizing functional outcomes.