What are the best shoe recommendations and management strategies for a patient with bilateral bunions, Parkinson's disease, and cardiac problems?

Footwear Management for Patient with Bilateral Bunions, Parkinson's Disease, and Cardiac Problems

Primary Recommendation

This patient requires custom-molded orthopedic shoes due to the bilateral bunions representing extreme bony deformities that cannot be adequately accommodated with commercial therapeutic footwear. 1

Specific Footwear Requirements

Custom-Molded Shoes

• Custom-molded shoes manufactured on a positive model of the patient's foot are necessary to accommodate the bunion deformities and redistribute plantar pressure appropriately 1
• Extra-wide or depth shoes are insufficient for bunions classified as extreme bony deformities; full custom fabrication is required 1
• The shoes must have sufficient depth and volume to accommodate both the deformity and appropriate custom insoles 1

Essential Design Features

The custom shoes must incorporate 1:

• Firm construction with appropriate support to compensate for Parkinson-related gait instability
• Rounded toe box with ample room to prevent pressure on bunion prominences
• Flat heel with proper heel support (elevated heels increase fall risk in Parkinson's patients) 2
• Adjustable closure system (laces, velcro, or straps) for secure fit
• Leather or fabric mesh upper rather than synthetic materials to allow air circulation 1

Custom Insoles

• Pressure-redistributing insoles are mandatory and should be designed based on plantar pressure assessment to prevent callus formation over metatarsal heads 1
• Insoles must provide cushioning while redistributing weight evenly across the forefoot 1, 3

Critical Safety Considerations for Parkinson's Disease

Fall Prevention Features

• Avoid backless styles completely as they significantly impair balance control in patients with neurodegenerative disease 2
• Avoid elevated heels which heighten fall risk in older adults with balance impairments 2
• The patient's personal well-fitted footwear is safer than hospital-provided non-slip socks, which lack adequate footwear properties 4

Gait Stability

• Firm construction and proper heel support are essential to compensate for Parkinson-related bradykinesia and rigidity 5, 2
• The shoes must restrict excessive motion that could destabilize gait while allowing necessary flexibility 2

Implementation Process

Referral and Fabrication

• Immediate referral to a podiatrist or orthotist experienced in complex foot deformities is required for custom shoe fabrication 1
• The fabrication process involves creating a positive mold of both feet to ensure precise accommodation of the bunion deformities 1

Patient Education

The patient must be counseled on 1:

• Daily foot inspection using visual examination (compensating for any Parkinson-related motor limitations)
• Wearing shoes and socks at all times—never walking barefoot due to fall risk
• Signs of shoe wear indicating need for replacement
• Monitoring for pressure areas or skin breakdown, particularly over bunion prominences
• Immediate reporting of any new foot problems or pain

Follow-Up Schedule

• Schedule follow-up every 3-6 months to assess footwear condition and make necessary adjustments 1
• More frequent visits may be needed initially to ensure proper fit and function 1
• Any calluses that develop must be debrided by a foot care specialist, not self-treated 1

Common Pitfalls to Avoid

• Do not simply replace with standard commercial therapeutic footwear or athletic shoes—these are inadequate for bunions classified as extreme bony deformities 1
• Do not duplicate the previous prescription without complete reassessment—the foot deformities may have progressed since the last fitting 1
• Recognize that improper footwear leads to pressure ulcers, worsening deformity, and increased fall risk in this high-risk patient 1, 2
• Standard wide-toe-box shoes recommended for mild hallux valgus are insufficient for established bunion deformities requiring custom accommodation 6, 3

Multidisciplinary Coordination

Given the complexity of managing Parkinson's disease and cardiac problems alongside foot deformities, coordinate care with the patient's neurologist and cardiologist to ensure the footwear prescription accommodates any mobility aids or activity restrictions 1