We Care About Feet!: 1st English Edition

www.ostechnik.
de
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We care about feet!

Offizielles Organ des
Zentralverbandes
Gesundheitshandwerk
Orthopdieschuhtechnik
und des
Internationalen Verbandes
der Orthopdieschuhtechniker
Welcome to Orthema
CAD / CAM insole system
Real 3D foot measurements
Precise CNC millings
Orthema group CH - 6343 Rotkreuz Switzerland

www.orthema.com / sales@orthema.com
: Halle 1, Stand G50 und G48
E D ITO R I A L
We care about feet

Specialised knowlegde and skills in the treatment of the foot are needed on a worldwide scale. In almost all developed industrial nations the percentage of older people
has been rising and therefore also the need for suitable shoes and aids
for foot problems. Also the symptoms of diabetes concerning the foot are
known in different countries worldwide not only in industrialized nations.
In some European countries orthopeadic shoemaking has already a very long
tradition. Orthopeadic shoemakers are valued partners of physiscans in the
treatment of all kinds of foot disorders. Health insurance funds take over
the costs for the treatment. However in many other countries orthopedic
shoemaking is hardly known, as opposed to prosthetics and orthotics P&O.
This first English edition of the German orthopaedic shoemakers magazine
Orthopdieschuhtechnik would like to show some aspects of what the
trade of the orthopedic shoemaking the profession around foot and shoe
is able to do in the treatment of foot- and gait-disorders. This special issue
also wants to show how training and professional structures can be built
aiming at a worldwide recognition of a profession.
In this issue we present the German history of the profession and the German model
of education. We are well aware, however, that education and qualification are also
on a very high level in many other countries.
Our aim is to give examples of what is needed and what is possible in the promotion
of the profession as well as in the creation of international standards of education.
We are convinced that orthopedic shoemakers are needed all over the world. Suitable
initiatives in countries where the profession has not yet been known will catch on
quickly, as in countries like Japan or Australia (see page 16).
Therefore we hope that this first English edition will trigger many people from medicine and trade to look into the possibilities of this profession. Already existing initiatives should be encouraged to go on promoting a qualified education and the recognition of the profession.
It is well worth it for ourselves and especially for the patients.
Wolfgang Best
Chief editor
Orthopdieschuhtechnik 1st English Edition 2010
CONTENT
International standards
Welcome to Australia
Custom made shoes
Standards of education and qualification in orthopedic shoe technology are very diverse in different
countries. A new initiative wants to
show the pathway to international
standards to ensure the quality of
treatments and contribute to the development of the trade.
The Australian Pedorthic Medical

Grade Footwear Association
(APMFGA) will host the 18th World
Congress of Orthopedic Shoe Technicians in Sydney in March 2012.
Chairperson Karl-Heinz Schott tells
the story of orthopedic shoemaking
and pedorthics in Australia.
What is the chronological workflow

of manufacturing an orthopedic
custom made shoe? Elena Schumilin,
pupil of the Alice Salomon School
in Hanover, Germany, explains the
details of this royal discipline of orthopedic shoemaking with self
made graphics.
Content
Portrait of a profession
How to reach a masters degree
in orthopedic shoemaking
in Germany
in orthopedic shoe technology
15
Orthopedic shoe technology

and pedorthics in Australia
16
8
The orthopedic custom-made shoe.
A class project between theory
and practise
20
10
International standards are

a big chance for the profession 12
IVO promoting international
cooperation in footcare
IVO Congress 2012 in Sydney
The treatment of the

diabetic foot
14
Imprint
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26
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O RTH O P E D I C S H O E TE C H N O LO GY
Wolfgang Best:
Portrait of a profession
It was at the beginning of the 20th century, when in Germany more
and more shoemakers specialised in the treatment of foot disorders.
Those first orthopedic shoemakers founded their first nationwide association in 1917. From then until today, orthopedic shoemakers have
evolved from specialists for custom-made orthopedic shoes to specialists for all kinds of foot disorders using a wide range of treatment
techniques.
pecial shoes or ortheses for the

therapy of foot deformities and
foot diseases have already existed for centuries. Often shoemakers
or other craftsmen
manufactured
these aids. The development towards
an individual trade specialized in
therapy of foot diseases began in Germany about 100 years ago, when shoemaker masters began to specialize in
medicine.
With the support of orthopedic surgeons they acquired the medical, especially orthopedic knowledge in order
to support the physicians therapy
with aids, produced individually for a
patient. During that time orthopedic
surgeons joined forces in an association in 1901 the German Society for
Orhopedics and Surgery was founded.
In 1906 an inquiry among Germanys
population showed that many children, particularly from poorer classes,
that suffered from a disability, were
not medically treated. In the following
years many institutions were founded
for that reason, like the Annastift in
Hannover or the Friedrichsheim in
Frankfurt. Their aim was and still is
Example of a sensorimotor orthotic.
to provide these children with adequate treatment also with orthopedic aids.
This development promoted the
emerging of independent medical assistant professions in the trade such as
the orthopedic shoemaking and the
prosthesists orthotists.
The first formal union of shoemakers specialized in the orthopedic foot
treatment occurred with the foundation of the Alliance of Orthopedic
Shoemakers in Leipzig on August 8,
1917.
In the following decades the newly
founded organization managed to
establish the work of the orthopedic
shoemaker also with governmental
agencies and health insurance funds.
Prices for services were negotiated and
the entitlement of exercising the profession was linked to specific trainings
and examinations.
According to trade law, orthopedic
shoemakers still were part of the shoemaking trade. This continued until
after world war II, even though the
trade more and more veered away from
purely shoemaking in its field of
activity and in the education with its
own master schools. Only with the
foundation of the German Association
of Orthopedic Technology (Bundesinnungsverband) on February 15, 1970,
complete independence was reached
as an autonomous profession. In 1991
orthopedic shoe technology was accepted in the circle of health trades.
Apart from orthopedic shoe technicians also prosthesists and orthotists,
hearing aid audiologists, dental technicians and optometrists belong to
this circle.
Wide range of qualifications

Since the establishment of the Alliance of Orthopedic Shoemakers in 1917
not only the technology has changed.
The field of activity of the orthopedic
shoemaker has expanded enormously
over the years. Whereas in the beginning mainly custom-made shoes as an
aid for foot problems were focused on,
today orthopedic shoemakers are active
in almost all areas that deal with the
treatment of problems of feet and legs.
Apart from orthopedic custommade shoes orthopedic shoemakers
produce individual orthotics and modify the soles or the inner part of ready-made shoes in order to adjust them
to the needs of the person wearing the
shoe. The production of inner shoes
that can be worn in ready-made shoes
or of forefoot prostheses belongs to
the field of activity as well as the manufacturing of individual ortheses for
ankle joints. Another task of orthopedic shoemakers is the delivery and individual adjustment of ready-made ortheses and bandages for the ankle
joint and the knee. Medical chiropody
and treatment with compression
hosiery also belong to this profession.
Three and a half years of apprenticeship in a company and in a vocational school are concluded by the examination to become an assistant orthopedic shoemaker. The preparation
in a special course at the master
school takes 6 8 months before the
examination for a master craftsmans
diploma, the highest qualification in
the trade. The title of master craftsman entitles to carry out all assignments of the profession and contains
the authorization to train apprentices.
Movement analysis and sports
Today many orthopedic shoemaker offer

movement analysis as a special service for
customers.
New fields of activity

The fields of activity of orthopedic
shoemakers have changed. In the beginning there was mainly the treatment of foot deformities as well as of
orthopedic and neurological diseases.
Also the treatment of war invalids
played a major role after the two world
wars.
There are less and less war invalids
now. The further development of surgery and the operative treatment at an
early stage of defective positions such
as talipes led to the fact that nowadays less serious foot deformities have to treated with shoes. There is still
enough work for orthopedic shoemakers left, however. Widespread diseases like Diabetes mellitus or rheumatic diseases also affect the foot.
Here new, highly specialized skills are
needed in order to prevent the progression of deformities or the occurrence of lesions of the foot. There is
also an increasing demand for solutions that promote comfortable and
pain-free walking. As in all industrial
nations also in Germany the percentage of elderly people has risen, many of
which suffer from foot problems that
may be caused by diseases or by wearing unsuitable shoes for years.
It is an important task for orthopedic shoe technology to keep these persons mobile without pain. The ability
to walk well is the basis for an independent life also later in life; it is the
best insurance against the need of
care.
6
Most of these foot problems can be

treated with orthotics and shoes suitable for the foot. Due to the fact that
orthotics only work when put in the
suitable shoe, many orthopedic shoemakers also sell shoes or cooperate
with specialized shoe shops.
In the last decade many orthopedic
shoemakers also have specialized in
further areas. Many companies specialize in the treatment of athletes
amateurs and professionals. Here running style analyses for athletes are offered that help to find out possible
causes of overloading damages. Other
companies specialize in so-called sensorimotor and neurological orthotics.
This type of orthotics uses specific
stimulation or obstruction of muscles
and muscle chains in order to have an
effect on posture and stride.
So far running style analyses as well
as sensomotor and neurological orthotics are settled privately with customers
or patients. Orthopedic shoes, orthotics,
compression hosiery as well as ortheses
and bandages however are part of the
benefits of compulsory health insurance
funds. The health insurance covers the
costs except for a relatively small own
contribution of the patient.
Health insurances
under pressure
As in many countries, in Germany
health insurance funds however are having big financial problems. Expenditures have risen due to the population
that grows older and to the
occurrence of widespread diseases such
as Diabetes. These costs are in opposition to the declining income from the
declining contributions of the insured
persons. Although for orthopedic shoemakers costs have also been rising
salaries, energy, administration
health insurance funds increasingly demand that they lower the prices or at
least do not adjust their prices: Of
course, the health insurances expect
the quality of work to stay on the same
level. Often this cannot be done with
the prices offered by the health insurance funds. Most of the companies
therefore charge patients further additional fees for high-quality services.
have been possible without the tight

contact to medicine and to science.
There have always been excellent representatives of orthopedic surgeons
that realized that in many cases a
good treatment with orthopedic aids
has to be a permanent part of orthopedic therapy.
On the other hand, orthopedic
shoemakers have always looked for
contacts to medical science. The Advisory Committee for Orthopedic Shoe
Technology of the German Association
of Orthopaedic Surgeons has been in
existence for more than 50 years and
works in an interdisciplinary way with
orthopedic surgeons and orthopedic
shoemakers. This panel meets regularly and develops statements towards
recent issues of treatment or towards
cooperation of medicine, science and
trade.
Physicians and scientists for example from the field of biomechanics
often are welcome guests of conferences of orthopedic shoe technology.
These conferences are organized by
the educational committees of orthopedic shoe technology, developed by
former students of various master
schools of the trade. The fundamental
reason for the foundation and the organization of these annual conferences was the realization that an earlier
earned title of master craftsman is not
sufficient for the whole professional life. Only on-going further education
guarantees a state-of-the-art treatment.
Academic studies
For some years now it has been possible to earn a scientific degree in the
area of technical orthopedics at the
University of Applied Sciences Mnster/Steinfurt. The bachelor study
Further education and Science

The development of orthopedic shoe
technology to become a recognized
medical assistant profession would not
New technologies e.g. CAD/CAM are being integrated into the profession.
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course leads after 6 semesters to the qualification

Bachelor of Engineering
(B.Eng.). Entry requirement is the higher education entrance qualification, the subject-restricted
higher education entrance
qualification, or the advanced technical college
entrance qualification and
a successfully completed
apprenticeship
(trade
test) as orthopedic shoemaker or prosthesist and
orthotist.
The course of studies
offers a diversified educaFoot pressure measurement is an important tion in natural scientific
diagnostic tool , especially in the treatment and engineering scientific
of the diabetic foot.
basic knowledge.
Also
specific knowledge and
skills in the fields of biological science, clinical technical qualification, orthopedic
pathology,
orthotics,
prosthetics and orthopedic shoe technology are taught. Goal of the studies
is to broaden the know-ledge of the
students in those areas and skills that
are not taught during the apprenticeship. With their knowledge of craftsmanship and science, the graduates later predominantly work in research
and development, in product and project management or as scientific staff
at universities. Some of them, however
work in orthopedic shoemaking or prostesists and orthotists companies,
e. g. as technical head of a workshop.
Beginning in fall of 2010, it will also be possible to combine an apprenticeship to become an orthopedic
shoemaker with a bachelor study course in the framework of a dual study
course at the University of Applied
Sciences of Mnster/Steinfurt.
With the studies of technical orthopedics, the trade has found its way to
university. The apprenticeship and the
master skills will however continue to
shape the profession and to be prerequisite for a successful treatment.
With the connection to science it certainly can be expected that the trade
will receive many incentives for its further development and for the scientific
analysis of treatment technology.
hoe.
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E D U C AT I O N
How to reach a masters degree in

orthopedic shoemaking in Germany
In Germany, the education in the field of craftsmanship follows the principle of Dual Education. One part
takes place in the workshop, the other part in college. To receive a Master Craftsmen Diploma one has to
attend a special college after basic training.
he education of a Master Orthopedic shoemaker (OSM) is divided into 3 main stages:
Stage 1
This initial stage is intended to give
the OSM trainee a sound basic knowledge of all aspects of the profession.
The apprenticeship takes 3.5 years during which the trainee is taught in the
Dual Education System. This means
part of the training takes place at a registered laboratory of an OSM and the
other part takes place at a college
(as set down by legislation).
Emphasis is placed on a hands-on
approach (a total of about 4.620 hours
is spent doing practical work under the
guidance of a registered OSM), according to the guide-lines set down by
legislation. A monthly essay must be
submitted to the supervising OSM,
dealing with a particular case-study.
Initially, several hours are spent in
developing the feeling of precision in
the hands to prepare the student for
the more delicate aspects of orthotic,
orthopaedic appliance construction
and podiatry. As the student becomes
more and more competent, his tasks
become more demanding, and on completion of stage one, he undergoes
several days of examinations on the
skills and knowledge he has acquired,
such as independently constructing orthotics and orthopaedic appliances.
In the following you find a list of
subjects that must be covered by the
OSM in the vocational part of his training:
1. Work place safety regulations, environment protection and energy saving
2. Knowledge about the place of education
3. Maintenance of tools and equipment
4. Chosing materials and aids
5. Differentiating foot-shapes, -deformities and diseases
8
16. Casting for orthopaedic footwear,

orthopaedic appliances and orthotics
17. Developing and forming of parts,
functional components, for orthopaedic footwear
18. Shoemaking, lasting
19. Maintenance of orthopaedic footwear, appliances and ready made
footwear (factory made footwear)
10. Orthopaedic alteration of factory
made footwear
11. Construction of orthopaedic appliances and functional parts
12. Construction of orthotics.
In addition to the practical training, students must attend lectures
and classes (totalling 980 hours) at
one of the approved colleges located
in most major cities. Attendance in
courses is compulsory, and subjects
include anatomy, podiatry, applied
mathematics, technical drawing, the
theory of orthotic and orthopaedic
appliance design and construction,
health science, behavioural and social
science, material technology, safety
regulations, environmental protection
and interactive studies. The syllabus is
set down by law.
In the following you find an overview of subjects taught.
1. anatomy - pathology
2. tools machinery materials
3. shoemaking lasting
4. orthopaedic shoe alterations
5. basics of technical drawings
6. applied mathematics
7. form design
8. orthopaedic appliances
9. podiatry (medical foot care)
Assessment examinations are held
bi-annually. Each year an additional
week of intensive instruction, held at
graduate colleges, must be attended
and are part of the continuous assessment. These special courses add up to a
further 120 hours of theoretical and vocational instruction. At the end of the
3.5 years, students have to pass a test

including practical work in order to
gain their professionals certificate.
Stage 2
After completion of stage 1 one is
entitled to enroll in of the specialized
colleges to prepare himself for the
Master Craftsmen Diploma. However,
most of the Gesellen first start working in their profession for a couple of
years in order to apply and improve
their technicals skills. Not everybody
decides to go for the highest degree in
the profession, though. Skilled Gesellen are sought after for the production
of orthotics and custom made orthopedic shoes.
Stage 3
The final stage is a highly specialized
and very intensive 6-8 month program,
which culminates in a Master's diploma,
and qualifies the graduate to register
with the registration board. Each independent laboratory/workshop must have
at least one registered OSM in charge.
There are five Colleges of Advanced
Education which offer the full diploma
course. As well as passing the entrance requirements, applicants should
have undertaken any of a number of
courses offered by the colleges. The
student's own initiative and interest is
taken into consideration. The Colleges
are located in Hanover, Langen, Siebenlehn, Landshut and Dsseldorf.
Total lecture hours about 1500 concentrated on subjects such as anatomy, pathology, physiology, biomechanics, podiatry, behavioural, social
science, education, relevant laws and
business matters.
The student is given a complicated
case study to be completed by himself
for assessment at the end of the program. This involves initial consultation with the patient, assessing and
treating the disorder and presenting
the case to the examination board. In
E D U C AT I O N
the following you find a description of

the responsibilities of an Orthopdieschuhmachermeister.
(1) Field of Activity
1. Design, construction, fitting and
maintenance of orthopaedic appliances, aids and remedies in particular:
a) Orthopaedic footwear, Innershoes
(functional orthopaedic components), foot prosthetics, footbeddings and orthotics - orthoses
b) functional braces, foot correctors and functional shoe components
c) propulsion aids, fixation and relieving elements for the foot and
lower leg (crus) as necessary for
the treatment of the foot.
2. construction of orthopaedic shoe
alteration
3. selection and fitting of therapeutic
prefabricated appliances and blanks
4. to perform medical foot care (podiatry)
5. manufacture and maintenance of
footwear of any kind
(2) the OSM is knowledgeable and

skilled in :
11. knowledge in Anatomy, Physiology
and the Pathology of the support
and propulsion system
12. knowledge of the Psychology of
the disabled
13. knowledge about Bio mechanics
14. knowledge about the function of
remedies and aids
15. knowledge about structure, properties and use of relevant materials
16. knowledge about tools, machinery
and technical equipment
17. knowledge about hygiene, sterilisation, anti and asepsis, preventing of infections. (history of infections)
18. knowledge about relevant regulations concerning the safety of the
work place
19. knowledge about the relevant supply regulations of the social and
health law
10. knowledge about the supply and
use of medication outside the responsibility of a pharmacy as well
as about foot care medication.
11. knowledge about the effect of a prescribed therapy by a medical doctor

12. selection of orthopaedic remedies
and aids in accordance to a medical doctors prescription
13. evaluation of footprints and profile drawings
14. making of plaster casts
15. development and cosmetic design
of orthopaedic remedies and aids
16. technical drawings
17. the use of leather, chemicals, wood,
metals, textiles and other materials
18. construction and fitting of orthopaedic remedies and aids
19. assessment, care and treatment of
skin and nail defects, if required or
according to a prescription of a
medical doctor
20. construction, fitting and fixing of
nail prosthetics and nail braces
21. construction, fitting and fixing of
pressure protection and relief orthoses as well as the selection and
fitting of pressure protection and
relief cushions.
22. maintenance and care of professional
tools, machinery and equipment.
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I N T E R N AT I O N A L S TA N D A R D S
in orthopedic shoe technology
Standards of education and qualification in orthopedic shoe technnolgy are very
diverse in different countries. A new initiative wants to show the pathway to international standards.
f you take a look at the international situation of orthopedic shoe
technology, you will notice how
differently the profession is carried
out in the individual countries and also how different the company structures are. First of all you will notice that
there are only few or no qualified education possibilities at all in this area
in many countries. This is amazing,
because problems with the foot exist
all over the world and are even increasing. The reason for that is the rising
number of elderly people in industrial
states, the occurrence of wide-spread
diseases such as diabetes or the wearing of unsuitable footwear for many
years.
Today there is an infrastructure for
education and further education mainly in Central Europe or in the member
states of the International Association
of Orthopedic Shoe Technology (IVO),
that also has member countries such
as Canada, Japan and Australia. A survey among the European members organized by the office of the IVO showed how education and further education in orthopedic shoe technology is
structured in the individual countries.
In spite of all differences in structure of education there are also a lot
10
of common factors. In almost all countries there is a division between basic

education and further qualification
that entitles the independent exercise
of the profession. With the exception
of England, where the education is
university-based, there is an apprenticeship education that lasts between
three to five years. This education is
recognized by the state, except for
Belgium. The education takes place in
companies and at vocational schools.
It finishes with a final examination
where usually practical and theoretical
skills are required. In Denmark the examination is limited to practical skills.
In almost all IVO-member states there
is an examination for the master
craftsmans diploma or a comparable
qualification. The duration of the education varies strongly, depending on
the type of education, a full-time
schooling or extra-occupational preparation for the examination. It varies
between 6-8 months and up to four
years. The classes for the master examination are offered by specialized
schools, that do not exist however in
every country. In those cases, sometimes qualifications of schools from
other countries are acknowledged.
Yet a comparable education struc-
ture cannot be found in many other

countries. In countries that do not
have a regulated education and that
do not offer corresponding courses,
shoes and orthotics for persons with
foot problems are often produced by
other professions.
It can be said however that in the
last years there has been increasing
interest in orthopedic shoe technology
world-wide and that there are initiatives in many countries to create education possibilities for a qualified treatment of the foot and to aim at an acknowledgement of the state of this
profession.
Often these movements arise from
the trade with suitable shoes, like in
Japan. 20 years ago, shoe dealer in Japan began to employ European orthopedic shoemakers that built shoes and
orthotics. They also shared their knowledge and over the years this way some
private institutes were established
that offered classes for shoe appliances, orthotics and orthopedic shoes.
Finally they succeeded in establishing
a proper school with a two-year wellgrounded education. This very positive
development was honored by the IVO
by assigning the IVO-congress of 2003
to Japan, thus promoting yet again
the further development of the profession in Japan.

Also other Asian countries are
interested in the establishment of an
orthopedic treatment of the foot. In
countries of Eastern Europe such as in
the Czech Republic, in Hungary, Poland
or in Lithuania there are companies
specialized in orthopedic treatment.
In the USA in the last years Certified Pedorthists have developed into
an approved profession for the treatment of foot problems with suitable
shoes and orthotics.
The latest example of how the profession can develop and how structures for education and recognition can
be created is Australia that was awarded the next IVO-congress in the year
2012 (see article on page 16).
Creating international
standards
Different levels of education, but also
different fields of activity of orthopedic shoemakers in different countries
led to an initiative that promotes the

creation of international standards for
orthopedic shoe technology.
In 2007 Belgium and The Netherlands
took the initiative to create international standards for orthopedic shoe
technology on different levels. ISPO
supported the idea and asked the Belgium and Dutch partners to take the
initiative. In September 2009 there
was a first meeting of this working
group with representatives from Belgium, France, Germany, Switzerland and
The Netherlands. At the IVO World
Congress in November 2009 in Den
Haag other countries (Japan, Canada
and Mexico) appeared interested.
It was agreed upon that a working
group of five countries will start working but keep the other countries informed about the developments and
products. The first step was to collect
all documents concerning profiles and
qualifications in order to be able to
analyze and compare the different
levels of education and qualification.
The next activity is to define the profiles and detail the draft outline for international standards. After that competences and profiles will be defined.
With these profiles one can focus on
education (educational institutes,
benchmarking and comparing) and/or
best practices (quality standards, profession institutes).
The process of creating international
standards for orthopaedic shoe technology has just begun. It is already
obvious that these standards will play
a major role in the further development of the profession.
(please also see interview on page 12)
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International Standards are

a big chance for the profession
International standards are necessary for the education of orthopedic shoemakers, says Frank Schievink
from the German Central Association for Orthopedic Shoe Technology (ZVOS). They help to ensure the
quality of treatments and contribute to the development of the trade also in other countries.
Mister Schievink, why do we need international standards for the education of

orthopedic shoemakers?
The inner-European borders are getting less and less important. The colleagues want to select a place of education or work without any barriers. A
comparable education level enables an
assessment of the scope and the quality of skills and knowledge. It answers
questions about the qualification of
the technical heads and the approval
of companies by health insurance
funds.
We need protection against unqualified competitors and would like to
use our opportunities for business especially in the areas close to the border. Patients want to choose suppliers
themselves. Examples are spas or
dental practices in Majorca. We do
not want to and we cannot prevent
this. A globally thinking, informed
society does not want to depend on
suppliers on-site, even if the treatment close to home has the most advantages for all parties involved. The
general regulations should provide
security for everybody involved. Distortions of competition and price
dumping can only be prevented on a
European scale by identical minimum
standards.
What role can international standards
play for the further development of the
profession in other countries?
Orthopedic shoe technology is almost non- existing internationally
apart from few neighbouring countries. Either this work is not offered
there at all or carried out by podiatrists or orthopedic technicians. There
is still a huge potential to improve the
quality of treatment in this special
field and to make our profession
known to physicians and health insurance funds. New markets can arise.
12
The conversations led so far clearly

show that the international exchange
of experience alone can lead to an improved education; everybody wants to
be the best one. Every education system emphasizes different aspects, this
can lead to synergy effects. For all
specialized schools an international
market will be open.
How big is the difference in education
and qualification?
Duration of education and versatility differ. The dual education system
that is very successful in Germany, unfortunately is not very well known internationally. But especially the link
between the practical education content including contact to patients in
the companies and concurrent schooling is very practice-oriented. In some
countries education mainly takes place
at universities. Here excellent theoretical knowledge is conveyed, the practical part has to be learnt and proven
later.
Does a bachelor have advantages or disadvantages over a master craftsman?
I think we will need both in the future. Bachelors will work very closely
to the patient and will focus on research and development. Masters will
be better for implementing individual
solutions with a strong emphasis on
the handicraft part. Many of them will
cooperate in order to make the most
out of possible solutions.
What is the core work or core competence of an orthopedic shoemaker?
The production of orthopedic custom-made shoes as well as the adaption of semi-orthopedic shoes have absolute priority and are the unique feature in all countries participating in the
discussions. In Germany orthopedic
shoe technology is very diversified with
Frank Schievink
the production and adaption of orthopedic custom-made shoes, shoe appliances, orthotics, compression hosiery,
bandages and foot-part prostheses.
There is a strong consensus that advisory skills will be increasingly important. The course from mainly a craftsman oriented company to a service provider with individually adapted solutions cannot be stopped. It is likely that
the companies will continue to specialize within the niche of orthopedic shoe
technology. Every company will select
its main focus and will provide solutions according to its skills, inclination
and environment. This could be movement analysis close to physiotherapy
and sports, specialization in pain patients or diabetic patients or as main
partner in the area of rehabilitation.
Others may have the right touch with
children. Each of them will need their
own area with a lot of experience.
What are the problems of the creation
of international standards?
Every country has its own history
and a different mentality. Different habits are deeply rooted in every days
life and lead to different experiences,

needs and requirements. Different
health insurance systems lead to different perceptions of entitlements of patients.
The job description of orthopedic
shoe technology does not even exist in
some countries, sometimes there is no
state recognition as an occupation requiring formal training. The range of
treatment is as different as the corresponding state of the scientific and
technical knowledge. Just think of the
treatment of diabetic patients to avoid
amputations. Some European countries have experience that is internationally unequaled. They have to talk
about their experience and success before standards will be lowered. The
possible consequences would be disastrous for the patients.
How does the Central Association assess
the efforts towards a standardization?
Is there any danger of a downward leveling, in order to enable other countries to reach the standards faster?
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No, we do not see any danger here.

Standards are agreed upon, that correspond to different minimum requirements. Important for the classification is the competence or responsibility
towards the patient, so to speak the
direct work on the patient.
Three levels were discussed: level 3
(lowest level) work in the workshop in
the so-called back office without
contact to patients. Level 2 means
that work on the patient is possible in
a restricted way, in accordance with
the agreement of a higher qualified
person. This corresponds to the present cooperation between an assistant
and a master. Level 1 enables completely independent customer contact,
comparable with the present bachelor
or master.
In Germany it is still the medical
prescription that is the basis for every
kind of treatment, whereas this is not
the case everywhere. Here German
education still has some catching up
to do. We have to take the task of
lifelong learning more seriously and
Infrared
must not rest on our earlier earned

qualifications. The countries that appear to be backward today, will catch
up. It is up to each of us to take the
opportunity of a harmonization of
education. Those trying to preserve
the current situation will be surpassed
in the medium term.
Overall the ZVOS considers this initiative to have a strengthening effect
on orthopedic shoe technology.
Interview: Wolfgang Best
Frank Schievink is a member of the board of

directors of the Central Association of Orthopedic Shoe Technology (ZVOS). As head of
the educational department he participates
in the initiative on harmonization of the profession and on the creation of international
standards of education.
From 2006 2009 Schievink was chairman of
the ISPO Germany.
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13
IVO
IVO promoting international

cooperation in footcare
Promoting the international cooperation in the technique of orthopaedic shoes that is the special concern
of the International Association for Orthopaedic Footware (IVO). Among the development of international
education standards one of its most important tasks is the organization of congresses, where experts from
all over the world exchange their knowledge.
he history of the IVO dates back
to the fifties of the last century,
as first border-crossing contacts
between colleagues from the orthopaedic shoemaking were established.
These have been intensified over the
years and resulted in first common
specialized events. In 1996 the international work group of orthopaedic
shoe technicians (IAO) was founded,
the precursor of todays international
association. At the conferences of the
international workshop it was decided
in the following years to work even
closer together. In 1973 the International Association for Orthopedic
Footware(IVO), the still existing international association of the orthopaedic shoemaking trade, was finally
founded.
IVO-Office
Katharina Krbes
Bahnhofstrasse 11
D-31008 Elze
koerbes@rascherer.de
www.ivonet.org
IVO-President
Rudolf Jutz
Bankstrasse 12
CH-8400 Winterthur
ivo@jutz-osm.ch
www.ivonet.org
14
The IVO was founded at a meeting

of members of the IAO in Salzburg in
1973 by the members Germany, England, Belgium, Holland, Luxembourg,
Norway and Sweden with 2 400 companies in the consenting countries. The
creation goes back to an application
from Holland. Walter Schievink from
Germany, who became the first president, suggested at the same time the
renaming of the IAO into IVO.
Today 14 associations from 13
countries from all over the world belong to the IVO. The IVO is represented
in Australia, Asia, North America and
Europe. Due to an amendment of the
statutes in 2006, now also more than
one association from the same country
can become member of the IVO. Members Countries are: Australia, Austria,
Belgium, Canada, Denmark, France,
Germany, Japan, Luxembourg, Netherlands, Portugal, South Tyrol, Switzerland.
Tasks of the IVO

The goals expressed at the foundation
have remained the same until today.
The IVO sees its tasks mainly in the
following areas:
The organisation of international
trade conferences, specialized exhibitions and competitions.
The promotion of professional contacts beyond the borders.
IVO-Congresses
1973 Salzburg, Austria,
foundation congress
1975 Gent, Belgium
1977 Norkwijkerhout, Netherlands
1979 Versailles, France
1981 Berlin, Germany
1983 Copenhagen, Denmark
1985 Davos, Switzerland
1987 Vienna, Austria
1989 Paris, France
1991 Amsterdam, Netherlands
1993 Qubec, Canada
1995 Berlin, Germany
1997 Bruxelles, Belgium
2000 Friedrichshafen, Germany
2003 Tokyo, Japan
2006 Basel, Switzerland
2009 Den Haag, Netherlands
2012 Sydney, Australia (in preparation)
2015 France (in preparation)
IVO
The common efforts toward a close

cooperation with orthopaedic specialists, paramedical associations as
well as with national and international institutions for the prevention
and rehabilitation in the field of orthopaedics.
The common efforts toward adjustment of training and examination
systems and for a standardization of
the profession.
The exchange of experience in the
specialized area.
The promotion of the exchange of
colleagues.
Measures for transcending language
barriers.
The establishment of contacts with
professionals associations throughout the world.
The support of the third world in all
questions of the supply of orthopaedic aids, and in particular, of the
education and further education of
young professionals of the trade.
Organization of congresses
An important part of IVOs work are
the congresses, that took place every
second year from 1973 until 1997 and
that have been organized every third
1 Since its foundation the IVO has had 8

presidents. The three last ones have been:
Raymond Massaro, France: 1995 1999 (r.)
Robert Srensen, Denmark, 1999 2006 (l.)
and the current president Rudolf Jutz, Switzerland, since 2006 (m.).
year from the year 2000 on. The congresses are assigned by the chair of
the IVO to different member associations that apply for the organization.
The IVO-congresses have the aim,
apart from the promotion of further
education and the professional contacts beyond the borders, to arouse
2 Even the numerous different languages

are not a barrier to the international
exchange of expert knowledge. Robert
Srensen at the IVO Congress in Tokyo
2003.
interest in the profession. Especially

countries, in which the profession is
not very well known, can promote the
profession for consumers as well as for
government agencies and the specialist medical fraternity by the importance of the congress and the number
of foreign visitors.
IVO Congress 2012 in Sydney

Thursday 29 Saturday 31 March 2012
uilding on the success of IVO
2009 Congress, The Australian
Pedorthic Medical Grade Footwear Asscociation are delighted to
bring the 18th World Congress of Orthopedic Shoe Technicians to Sydney,
Australia in March 2012.
Organised under the auspices of The
Australian Pedorthic Medical Grade
Footwear Association, this exciting
event is expected to attract more than
400 delegates from all over the world.
This Congress will provide an opportunity for professionals and specialists in
Orthopaedics and Pedorthics to gather together to share new ideas and
innovations, while at the same time
strengthening international networks
within the industries associated with
the area. The Congress program will be
designed to promote interaction, emphasise practical experience and explore ways to support positive change.
More Information
ICE Australia has been appointed as
the official Professional Conference Organiser (PCO) for the IVO 2012 Congress. Specialising in managing Conferences and Exhibitions, ICE Australia
are committed to ensuring you receive
the maximum value on your sponsorship and exhibition presence.
Contact:
IVO Congress Secretariat
C/ ICE Australia
183 Albion Street
Surry Hills Sydney NSW 2010
P: +61 2 93 68 12 00
F: +61 2 93 68 15 00
E: info@ivo2012.org.au
W: www.ivo2012.org.au
Sydney is Australias largest city and the nations

number one destination for visitors. The citys focus is its magnificent Sydney Harbour, home to
the famous Harbour Bridge and Sydney Opera
House. Sydneys beauty, warm climate and friendly
people entice visitors from around the world.
15
E D U C AT I O N
The 1st certification training course.

First row (seated): Dr. George
Carter, orthopeadic surgeon, Jodie
Morrison, Daniel Raffaele. Second
row (standing): Karl-Heinz Schott,
Ron Henson, Paul Galey, N.N.,
Andreas Reimann, Stewart Levey,
Dragomir Paven, Alfredo Roldan
(from left to right).
Karl-Heinz Schott:
Orthopaedic Shoe Technology and

Pedorthics in Australia
The Australian Pedorthic Medical Grade Footwear Association (APMFGA) will host the 18th World Congress
of Orthopaedic Shoe Technicians in Sydney in March 2012. Chairperson Karl-Heinz Schott tells the story of
orthopaedic shoemaking and pedorthics in Australia.
t is reasonable to assume that
shoe makers in a European sense
were among the early settlers in
Australia to provide and maintain
footwear for the colony. It is also reasonable to assume that they were responsible for the provision of special
footwear to individuals with special
needs. Up until the mid 1800s all
footwear was custom made. The global
introduction of shoe factories altered
that perspective dramatically.
Orthopaedic footwear, more commonly referred to as surgical footwear,
has been custom made by surgical
boot makers in one form or another
until the present day. Surgical boot
makers established themselves as the
primary providers for those with special needs, illness, deformities or other
medical conditions. This often covered
the spectrum of including children
with deformities from charitable organisations. Hospitals and institutions
also fell under the umbrella of widespread footwear requirements. The
needs of children from both government and the private sector have been
met by surgical boot makers for centuries, this trend still exists to the present day.
16
The Australian Surgical Boot Makers

Association was founded in 1972. It
was established by boot makers across
the nation. Annual conferences were
organised in various states and territories nationwide.
The education program

of Australia
The form of educating the surgical
boot maker initially began with an apprenticeship in a private company or
state wide institution. Hospitals and
government institutions also played a
role in providing training in their own
footwear and orthotic department.
Training was on par and often alongside the artificial limb and splint maker
in public hospitals or private institutions. They worked cohesively to achieve
the best outcome for their patients.
The form of training was initially as
boot makers however over time it progressed to specific surgical boot maker
courses. A surgical boot maker trade
certificate was issued at the conclusion of this course.
The education program varied from
state to state across Australia, although essentially it was an apprenticeship system enhanced by attend-
ance at college. The college education

system covered both surgical footwear
training including general footwear
industry standards. The surgical footwear course however offered the
highest degree of recognition.
Over the years the general footwear
industry in Australia diminished and
with it the footwear college system.
Due to the closure of the education
centres surgical courses were no longer available resulting in surgical boot
makers deprived of enhanced training
and educational opportunities.
Concurrently during this time, the
artificial limb and splint maker evolved
into the Prosthetist & Orthotist with
a university based education. This
development was typical in providing many paramedical professionals,
including podiatrists, physiotherapists
and nurses with the initiative to steer
towards university level education.
This further devalued the college system, resulting in the diminishment of
the role of the surgical boot maker,
boosting the initiative of the association to heighten both standards and
reputation. This was indeed a task
beyond the capabilities of the association, which contributed to its decline.
E D U C AT I O N
It was during this time that the association split into two groups with opposing views, leaving the profession
disoriented and disorganized.
In mid 1990 the Australian Federal
Government embarked on a competency based training program. The intent
was to ensure that training provided
was actually the appropriate training
needed for the work place environment. This involved the establishment
of meetings for various industries and
professions nationwide.
This included surgical footwear however it was renamed Medical Grade
Footwear. The program heralded the
introduction of meetings and visits to
companies which resulted in rising
awareness of levels of competency in
the general work place environment.
Dennis Janisse during

an examination.
Dr. Janisse was guest
lecturer during the
course at Latrobe
University.
Australian Medical Grade

Footwear Association (AMGFA)
This prompted an injection of invigoration within the Australian Surgical
Boot Makers Association. It broadened
its scope to include prefabricated medical grade footwear, and changed its
name to the Australian Medical Grade
Footwear Association (AMGFA) under
the brief presidency of Mr. Paul Galey.
This development enhanced AMGFA
with a new leadership team and a new
approach with the 1997 incoming presidency of Mr. Karl-Heinz Schott. Much
of the ground work and hard yards was
as a result of the work done by Mr.
Philip Brownrigg, Physiotherapist and
Prosthetist & Orthotist. The AMGFA triumphed as the peak national body representing the profession at countless
meetings, initiating much of the input
for the competency standards.
Out of those competency standards
the national training package for Medical Grade Footwear evolved. New
training courses were based principally on that national training package.
This was not achieved without
obstacles. As yet no college or university was available to provide the
courses based on the national training
package so far. AMGFA had many meetings with various colleges in various
states, however the general pre-emptive at the time was that the training
establishments felt that student levels
were too low, further distancing themselves from providing courses which
were much needed. Opportunities for
apprenticeships were indeed slim in
various states however it further en-
Examination of a
patient, supervised by
Dr. Carter.
hanced the need for national recognized qualification.

Health funds and other funding bodies were increasingly questioning a
system that they could use in the future being occupied by suitably qualified professionals to provide medical
grade footwear.
This was further problematic since
the market became congested with
pre-made comfort footwear, claiming
orthopaedic applications. Difficulties
were heightened when health funds
found they needed clarification on valid medical grade footwear providers
and specialised shoe store proprietors.
As a result of the closure of many
footwear factories, the market was further peppered with shoe makers claiming to be orthopaedic footwear specialists, but essentially lacking the medical training and education required.
For Medical Doctors and other referrers as well as for Patients there was
no guidance as to who may have some
level of training, education and qualification. Clarification was necessary to
help referrers, patients and to align
the health funds and other funding
agencies to support those in need of
medical footwear services.
The personal certification

system of AMGFA
Since no college or university undertook medical grade footwear courses
that could lead to a national qualification, the AMGFA developed a personal
certification system as a benchmark
under the presidency of Mr. Karl-Heinz
Schott. The AMGFA stipulated that a
system needed to be established providing a national register of those that
had completed training, with commitment to further education in medical
grade footwear.
This system is based on the national training package and certifies the
competency of the individual. This is
entirely based on a voluntary system
as there is no requirement in place
whereby qualification or certification
to work in Australia in the field of medical grade footwear is necessary.
This standard is not unusual, a personal certification program of this
kind is common practice along with
other professions in Australia, including certified accountants.
The Australian program was developed under the guidance of the AMGFA
by the independent consultancy of Mr.
Peter Reeves, of Rims Consultants.
17
E D U C AT I O N
The Australian Orthopaedic Foot

and Ankle Society (AOFAS), a specialist society of orthopaedic surgeons for
the foot and ankle, took an increasing
interest in the work of the AMGFA. The
members of the AOFAS supported the
certification system, and their involvement as lecturers, and panel members was well received. Dr. George Carter provided much of the certification
training. His role was extended further
as a certification panel member.
Certification involved meeting entry requirements, successful completion
of the pre-certification training, including written examination, practical
competency test and presentations of
their work to the certification panel.
The content of the exam was developed by the educational committee,
reviewed by an orthopaedic surgeon
and was updated over the years
through the educational committee of
the association. It is based on the national training package.
The certification process and the
register are managed independently of
the AMGFA by the MGF register. The
AMGFA provides training and education but has no influence on applications for certifications.
This is managed independently and
all those that meet the full criteria can
be applied to the register. The register
consists of those that have passed the
certification process successfully. No
exemptions apply, all applicants are
required to have completed their training, pass their exams and present to
the panel. Applicants are registered as
medical grade footwear practitioners.
The Medical Grade Footwear Register
consists of three respective levels of

registration. To remain on the register,
practitioners must participate in continuous education and training, compile a work log and adhere to the certification criteria. Over the years the
AMGFA offered training in several states and a number of practitioners gained certification across the country.
Many existing practitioners undertook the challenges and achieved certification, therefore supporting the system with further strength and growth.
Over the years the certification system
has gone from strength to strength
and is now widely used by health funds
and government agencies alike. The
system has been recognised as a
bench mark to give provider numbers
to practitioners wanting to access funding for their medical grade footwear
and orthoses.
The certification has undergone
change and review over the years partly due to changes in legislation, combined with community expectation.
There are significant levels of Australian medical doctors and paramedical personnel who further their individual education in other areas across
the globe. North America has long
been established as a destination for
Australians intent on extending their
education. Medical grade footwear
practitioners are identified as pedorthists in the US. This exposed Australian medical practitioners to further
developments in pedorthics.
The AMGFA recognized the global
contribution in pedorthic terminology
and cohesively fostered the system
with the Australian counterpart. The
Since 2000 the APMGFA has

established a qualification structure. The pictures on this page
and the opposite page give an
impression of the practical work
in the courses. The pictures were
shot at a certification course at
Latrobe University in 2006 and at
a two-week course in preparation
of the certification.
18
association was renamed the Australian Pedorthic Medical Grade Footwear

Association (APMGFA). This was an indication that pedorthics was well and
truly established in Australian terms.
In 2006 and 2008 Mr. Denis Janisee
was invited by the APMGFA to present
in Australia a series of training and
education sessions. He is recognized
as an undisputed talent in the field of
pedorthic education. Australia is indeed in a unique position since it has
the benefit and expertise of the German OSM system, since the then president of the APMGFA Mr. Karl-Heinz
Schott is a recognised OSM. It has the
added benefit and cohesive co-operation of the US based pedorthic
methods.
Three levels of pedorthic

certification
The certification criteria were updated
to reflect the changes to pedorthics in
Australia. The register has three levels
of pedorthic certification. It commences with the certified pedorthic retailer who provides pre-fabricated medical grade footwear and related appliances. The second level is the certified
pedorthist who like their American
counterparts are eligible to provide
custom made foot orthoses including
modifications made to footwear. The
third tier is the certified pedorthist
CM, qualified to provide custom made
medical grade footwear along with orthotic appliances, this is more in adherence with the German OSM system.
The certification system is in accordance with current Australian standards. Recent legislation has been introduced in which health funds are required to only deal with non regulated
health care providers providing they
adhere to a set of standards. Our certification system pre-empted these
standards and consequently all certified personnel on the register are compliant to current legislation.
Pedorthics and medical grade footwear falls under the umbrella of this
legislation. This has led to an increased percentage of health funds in accommodating their provider status to
pedorthic practices registered with the
MGF register.
A substantial proportion of pedorthic practices are privately funded, however health funds and government
support have ensured that pedorthic
services are more widely available to
E D U C AT I O N
Hands on practise during a certification course at Latrobe university.
those most in need.

The involvement and sheer hard
work that has been achieved by the
APMGFA has been boosted by increased membership over the years. It currently has more than 80 members. Its
annual symposia extend to between
70 90 participants, a significant
achievement indeed.
There has been serious interest expressed by a university which may endeavour to include pedorthics as a degree program. APMGFA is in close discussion with the university with a view
towards better education.
This would provide scope for further
educational opportunities within Asia,
Australia and the Pacific nations since
much of the region remains untapped.
Australia has proven to be further along
in the chain with prospects for enhancement to training and education, potentially targeting overseas students
from our region within the field of
pedorthics and pedorthists CM training.
The APMGFA hopes to continue to
breathe new life into what was formerly an ailing profession. Pedorthist professionals continue to heighten their
training levels and skills. Improvements to facilities are in place with

more qualified certified personnel integrating further into the open market
place, further enhancing the profile of
pedorthics in Australia.
Trademark protection was introduced in early 2010 by the APMGFA.
This ensured through the appropriate
legal channels that only registered
personnel can be associated with the
title of certified pedorthist including
certified pedorthist CM.
The acquisition of the said legal
protection is another milestone achieved by the long term APMGFA secretary Mr. Casper Ozinga APMGFA under
the associations current president, Mr.
Ernest Tye. The future looks more promising indeed.
The next scheduled IVO conference
will be held in Sydney in March 2012.
The APMGFA is extremely proud to
host the international pedorthics/orthopaedic shoe technology symposium, which is held every three years.
APMGFA expect more than 600 participants to attend the conference. It
holds further significance since it is
the first time the conference will be

hosted by a nation in the southern hemisphere, thus placing more emphasis
on the strength of the profession in
Australia. It is also the 40th anniversary of the APMGFA.
Karl-Heinz Schott holds a german degree

as Orthopdieschuhmacher-Meister and
Podologe as well as Cert. Ped. CM.
He owns and operates ShoeTech Pty Ltd,
an Orthopaedic Laboratory located in Dee
Why NSW, Australia.
Karl-Heinz Schott is also a leading adviser
and trainer to the Medical Grade Footwear
Industry in Australia and in Japan. He
has a family background in this field
going back to 1888. Schott is Chairperson
of the IVO-Congress 2012.
19
C U STO M - M A D E S H O E S
Timo Borchers, Elena Schumilin:
The Orthopedic Custom-Made Shoe.

A Class Project between Theory and Practise
Explaining chronologically the workflow of manufacturing an orthopedic custom-made shoe that was the
task of the pupils of the Alice-Salomon-School (vocational school for health and social studies in the region
Hanover) within the context of a class project. In the following article the paper of the pupil Elena Schumilin
is presented as an example whose excellent graphical design shows the elaborate examination of the discipline of orthopedic shoemaking.
Workflow of manufacturing an
orthopedic custom-made shoe
20
context of an anamnesis. He examins

the foot (inspection and palpation)
concerning the function and indication and forms his own opinion about
the limitations or dysfunctions of the
foot. After that the orthopedic shoemaker talks about all other aspects,
such as the preparation of a cost estimate for the compulsory health insurance fund of the customer, that guaranties the assumption of the costs by
its approval. After the assessment and
approval by the compulsory health insurance fund, the orthopedic shoemaker invites the patient again in order to
discuss the manufacturing of the orthopedic custom-made shoe.
The orthopedic custom-made shoe is a

special footwear solely adjusted to the
customer or patient, manually manufactured based on a medical prescription. The task of an orthopedic custommade shoe is to compensate, suitably
for the impediment, or treat in the
best possible way individually defined
diseases and dysfunctions of the customer so that he can participate in
social life with as little restrictions as
possible.
The customers compulsory health
insurance claim does not only cover
the first equipment but also its modification and, if need be, a required
substitute.
2. Determining the measuring data
1. Customer consultation
After the reception of the customer in
his shop and the information about
the customers disease concerning the
aid catalogue, the orthopedic shoemaker asks the customer questions in the
Measuring up
The first step for the manufacturing of
a custom-made shoe is the measuring
(joint measure (ball girth), oblique
joint measure (joint girth), measure of
the lower instep, instep measure,
short heel measure, ankle measure, leg

measure and top measure of the upper). Here each foot with its individual shape is measured by the orthopedic
shoemaker.
The footprint
With a kind of a stamp pad the customers foot mark (footprint) is taken,
in order to make visible the distribution of the pressure on the sole.
3. Plaster mould
4. Last construction
After taking and documenting all relevant foot measures a further step is
the production of a plaster mould. This
gives the orthopedic shoemaker an
exact, three-dimensional picture of
the foot for the manufacturing of the
individual shoe last. They are decisive
for the accuracy of fit and the wear
comfort of the shoe and this way the
central part of the orthopedic
care/treatment. Lasts are still the
most important tool for the shoe manufacturing in spite of the latest production technologies.
tured with the help of individual measures and according to the desired
shoe form. They make visible individual dysfunctions of the customer that
have to be treated.
5. Footbed construction
Functionally the footbed corresponds
to an insole. It is adjusted accurately
to the form and the position of the
foot. Due to its functional purpose it
is called for example compensation
bedding (because it compensates the
plantar foot sole plastic) or correction
Classical lasts are made of wood or

plastic. These can be separated in different ways to get them out of the
shoe safely at the end of the production. The desired shoe model is already
taken into consideration when the last
is being produced. Lasts are manufac-
Rapid presses Orthopaedic presses

Adhesive workstations Workshop equipment
Custom products of any kind
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Wilh. Brocksieper GmbH
Postfach 61 45
D-58486 Ldenscheid
fon +49 (23 51) 70 62

www.brocksieper-gmbh.de
fax +49 (23 51) 7 85 80 info@brocksieper-gmbh.de
21
bedding (because it corrects a defective position). Concerning the individual dysfunctions of the customer different orthopedic shoemaking measures are taken for the footbed production. With the help of drawings we
would like to clarify some examples of
these individual measures.
Orthopedic roller bars
Orthopedic roller bars are orthopedic
shoemaking measures that influence
the unrolling of the gait with the creation of rolling curves. Their task is to
facilitate or substitute limited or lost
movements of the unrolling of steps.
Usually they are made as internal roller
bars (at the underside of the compensating insole). Further possibilities are
concealed bars between the welt and
the outsole or directly on the sole as
fitted roller bars. For all roller bars it is
important to add the corresponding
heel adjustment.
22
The advanced rocker bar has a stabilizing function of the knee (unrolling obstacle) that is increased by
sole stiffening. Here the apex line of
the roller bar has to lie beneath the
proximal phalanges of the toes I to V.
The metatarsal bar (only effective

with sole stiffening) causes a relief of
the tarsal joint and of the upper anklejoint. The apex line lies proximally to
the metatarsal heads. Here you have
to pay attention to the fact that the
mechanical foot length is reduced.

The rocker bar relieves the metatarsophalangeal joints, as for example in
the case of hallux rigidus or toe stiffening. Here the apex line is in the area
of the metatarso-phalangeal joints
(ball tread area). It also enables depending on the apex line a correction of the unrolling of the foot towards the inside or the outside.
sary corrections and to take them into

consideration accordingly when manufacturing the shoe. Furthermore the
orthopedic shoemaker discusses the
shaft model with the customer.
7. Production of reinforcing aids,
toe-puffs and stiffeners
6. Rough shoe
In order to check the accuracy of fit, a

walking test model, made of transparent foil, is made with the help of the
individually produced last (trial bedding with transparent foil shaft). This
way it is possible to recognize neces-
Reinforcing aids connect the toe-puffs

and the stiffeners. They are built-in
elements that are fixed between upper
leather and sole leather: the shoe is
supposed to keep its shape laterally.
Toe-puffs consist of sole leather,

plastic or metal (compare work safety
shoes). Their task is to protect the
toes and to maintain the form of the
toe-cap. The toe-puffs are inserted
between the upper leather and the
lining of the vamp.
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nora Lunatec combi is the ideal basis for the manufacture of foot beddings and inserts made of certified quality products.
Benefits thanks to an efficient insert manufacture and time and cost savings:
No gluing
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a higher retention of volume
No displacement
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between the upper leather and the

lining. It causes a functional immobilization of the upper ankle-joint and
the tarsal joint, this way easing the
pain.
Stiffeners on the contrary are only

made of sole leather or plastic. Stiffeners stabilize the shoe at the backfoot and support the heel laterally in
the shoe. Under consideration of different dysfunctions of the customer, we
distinguish different cap types shown
in the following.
8. Production of the upper

An upper is the upper part of the
shoe. It consists of several glued together or sewn together parts (interior upper = lining, mid upper = mid
lining, exterior upper = upper leather)
that give the shoe its look and its
designated use. Here special attention has to be paid to a fashionable
esthetic design, so that the customer
feels good in his shoe. The upper has
to be adjusted to the individual form
of the foot.
4. Molding, rounding, skiving and

scouring of toe-puffs and stiffeners
5. Molding, lasting and drying of
stiffeners on last
6. Loosening of stiffeners
10. Lasting
The actual construction of the shoe
consists of the insertion of the upper
(upper part of the shoe) together with
the stiffener and the toe-puff between
the upper leather and the lining and of
pulling it over the last crease-free with
a nipper and of fastening it to the insole with nails or tacking clips.
The peroneal cap
These are the manufacturing steps:

Making and adjusting of a last copy
Drafting and drawing of a shoe mo-
del
Cutting according to prototypes
Skiving of the upper leather and
The peroneal cap is a stiffener made of

leather, plastic or combined. It is used
in case of an atonic paralysis of the
footelevating muscles (e.g. due to a
damaged Nervus peronaeus): the foot
in a talipes equinus position. The cap
holds the foot mechanically in a rectangular position so that the paralysis
is functionally balanced.
lining
Folding of skived surfaces
Rubbing of inversed seams
Sewing up of lining in the upper
leather upper
Beading of upper leather and lining
Mounting and stitching of upper
The fastening of the upper to the shoe

bottom and the various bottom parts
to each other is carried out by using
different manual bottom fastening methods (workmanship), as for example
sewing, nailing and glueing.
leather
11. Fixing of the welt
The arthrodesis cap
The arthrodesis cap is an inserted orthopedic shoemaking element fitted

24
9. Ranging preparation for the

lasting
1. Preparing of last for the lasting
(removing of clips and nails)
2. Reinforcing aids, molding and
manufacturing
3. Construction of insole, rounding
and fastening to bedding with
nails
After fastening the upper to the insole, the welt is sewed, glued or pinned to the upper and the insole. The
welt can consist of leather, plastic or
rubber. It is especially important for
the form and the look.
12. Bottom filling
The shoe lacks material at the bottom

between the welt and the insole. This
space has to be filled in. This way it
is possible to balance warpings and
to smooth it for the mounting of the
outsole. Also there is a joint tongue
(wood or metal) or a shank (leather or
plastic) inserted. Due to the joint tongue and the shank the shoe does not
push through heel and ball of foot.
The front part of the shoe is filled in
additionally with cork, thus increasing
heat insulation, cushioning as well as
flexibility of the shoe bottom.
13. Soles
Depending on the shoe model the shoe
bottom consists of one or more soles.
Underneath the insole (shoe base) a
midsole is inserted, if indication and
designated use require it.
plastics. The outsole can have sole

treads that depend on the usage (compare orthopedic sports shoe).
14. Heel
A further and important functional
part of the shoe bottom is the heel. It
elevates the heel area opposite the
ball of foot area, apart from different
orthopedic shoemaking functions. In
the following the most common kinds
of heels are briefly described, depending upon shoe model and indication.
We will not focus on the production of
the heel, though.
Dragging heel
The dragging heel is used for patients

that only strain the heel when walking, since the muscles of the calf are
paralyzed. It is used for example for
the treatment of a (paralyzing) talipes
calcaneus. The dragging heel makes
the rear lever of the foot longer.
fered due to the use of different elastic materials, relieving physiologically

the joints. A buffer heel can be used
for example if the customer suffers
joint pains in the area of the tarsus
pedis, of the knees as well as of the
hip. A cushioning of the heel tread is
also recommendable in case of endoprosthetic treatments as well as in
case of various damages to the spine.
The orthopedic shoemaker can dose
the cushioning effect by using different sizes of cushioning areas and of
the used elastic materials.
Thomas heel
Thomas heels provide a heel prolongation in the shank of the shoe. They are
used for stabilization in case of cor-
recting insoles as well as for treating

valgus feet (inside) and club feet (outside).
Wedge heel
The wedge heel goes from the ball of
foot to the heel and strengthens this
way the complete joint part of the
Buffer heel
The midsole
The midsole effects the durability / solidness , the cushioning ability as well
as the security (steel sole) of the shoe.
It is mostly made of sole leather, rubber, plastic or metal and is inserted
between welt and outsole. The outsole, which has direct contact to the
environment, is fixed to the welt and
the midsole.
The outsole
The outsole is the top layer of the shoe
regarding the manufacturing process
and it is the tread area later. It is
made of different materials such as for
example leather, rubber or different
For normal ready-made or custommade shoes the tread is often hard.

With the buffer heel a cushioning of
the heel area during the gait can be
reached. Consequently the compression effect of the heel tread is buf-
shoe. With a wedge heel it is possible

to design the shoe in a firmer and
more rigid way (by using firmer materials like leather or wood) as well as in
a springy way (by using elastic materials like cellular crpe). The wedge
heel can be used in case of severe foot
deformities or for fashion purposes.
25
Roller heel
The normal hard tread of the foot in
the first phase of the step development often is very uncomfortable for
15. Trimming
pared for delivery with the help of the

finish. It describes the preparing of
the shoes through cleaning, impregnating and polishing.
18. Delivery
The delivery means the handing over
of the goods to the customer. The customer tries on the finished custom
After having finished all manufacturing steps, adjusted individually to the

customer, some finishing touches have
to be added. Trimming here means to
work on the soles and heel edges, milling, scouring and polishing them.
16. Removing of the last
the customer due to the tread of the
heel. The rounding of the rear edge
(roller heel) parallel to the tread area
causes a shortening of the rear foot lever and thus a reduced strain of the
upper ankle joint when stepping on
the heel, facilitating the step development of the customer and relieving the
ankle joints.
Bar heel
After the trimming the shaping last is
removed from the finished shoe with
the help of a last hook. Doing this,
special care has to be taken, otherwise
the shoe can still be damaged at the
end of the manufacturing process.
made shoe supervised by the orthopedic shoemaker and gives feedback concerning the aid.
Concluding the orthopedic shoemaker informs the customer about the
safe putting on and off of the shoes,
the care and the maintenance of the
custom-made shoe. Also an appointment is made for the end control about
8-14 days after the delivery of the custom-made shoe. This is important,
since problems related to fit and functions might only occur after a certain
period of wear.
17. Finishing
At the end of the shoe production the
orthopedic custom-made shoe is pre-
The Project:
The bar heel is a kind of heel that has

the heel elongated in the middle under
the shank of the shoe. It stabilizes the
shank of the shoe due to the pulling
forward of the heel and improves the
load capacity of the shoe in the longitudinal arch. Optically it is less noticeable than the wedge heel (i.e. in
case of foot collapse).
26
The teaching unit is preceeded by the development of all important theoretic contents in connection with orthopedic custom-made shoes in class. Within the context of an extensive work assignment the
apprentices have the task to explain the
manufacturing of an orthopedic custommade shoe from the first contact to the
customer until the delivery. For this the
pupils create an operation product (photo
documentation) within a limited time frame. Here the corresponding manufacturing steps for the production of an orthopedic custom-made shoe regarding the
orthopedic shoemaking, medical and
craftsmanship-related functions are
being planned, carried out and finally

checked. Concerning the indication of
the customer or patient, the various steps
and the used materials have to be explained in writing and documented with the
help of photos and pictures. At the end of
the teaching unit the work results are
presented in class and evaluated.
The aim of this teaching idea is to
communicate the job-related theoretical
teaching content in an activity-based and
comprehensive (school and company)
way. As a consequence it ought to be
guaranteed that the pupils recognize the
combination of theoretical and practical
skills as important and fundamental for
the exercise of their profession.
DIABETES
The diabetic foot less amputations

through adequate footwear
Introduction:
The diabetic foot is one of the most
devastating complications of diabetes
mellitus. The risk of suffering an amputation is 30 40 times higher than in the population without diabetes. 10 15 percent
of the diabetes patients with foot ulcers
will suffer a major amputation.
Foot problems are the most preventable of all the long-term complications of
diabetes. Early identification of high risk
patients followed by proper education
and foot-care effectively reduce the amputation rate. Footwear plays a major role
in the prevention of foot injuries and the
reduction of amputations.
In 2005 a interdisciplinary working

group elaborated criteria for the treatment of the diabetic foot with shoes, footbeds and orthoses, which you find on this
douple page spread. Members of the
working group were: Dr. Armin Koller, orthopedic surgeon, Dr. Christoph Metzger,
diabetologist, Michael Mller, orthopedic
shoemaker, Jrgen Stumpf, orthopedic
shoemaker, Dr. Karl Zink, diabetologist.
The criteria for the prescription and
production of orthopedic footwear are intended to serve as guidlines for medical
doctors, health insurance fund an for or-
thopedic shoemakers. The treatment is

divided into 8 risk groups. For each stadium the suitable treatment is being
described.
In 2008, the Advisory Committee for
Orthopedic Shoe Technology of the German Association of Orthopaedic Surgeons, where orthopedic surgeons and orthopedic shoemakers work together, published a commentary, which gives advice how the diagnoses according to the
risk group can be transferred to practical
work.
Treatment according to risk classes

Risk group 0
Diabetes mellitus without polyneuropathy (PNP)/peripheral artery occlusive disease (PAOD).

Treatment: suitable ready-made shoes
The definition of suitable shoes is
without any doubt very subjective and
is interpreted differently for example
by the orthopedic shoemaker and by
the patient himself. Here often the
esthetic sensation of the patient, formed by fashion demands without any
functional knowledge of the foot, clashes with the expert opinion of the
treating team on the form of the shoe
that is suitable for the foot. In this
risk group the recommendation of

footwear suitable for the foot primarily is a prophylactic recommendation
for the avoidance of foot deformities
caused by the shoes, that may lead to
a bigger risk of diseases of the foot in
the course of diabetes with a potential additional combination with PNP.
Thus the patient does not necessarily
have to wear shoes suitable for the
foot and it can be learnt slowly.
Comfort-shoe (Picture: Finn Comfort).
Risk group I
Diabetes mellitus without PNP/PAOD with foot deformity

Treatment: orthopedic shoes according
to orthopedic indication.
The causes of foot deformities are as
varied as their characteristic forms. As
long as there is no occurrence of

PNP/PAOD, the treatment can be carried out exclusively according to orthopedic criteria. However with the limita-
tion that regular check-ups have to be

carried out absolutely to see if PNP or
PAOD has already developed requiring a
corresponding higher-grade treatment.
Risk group II
Diabetes mellitus with loss of sensibility through PNP/PAOD

Treatment: diabetes protection shoe
with loose soft cushion insole according
to orthopedic indication, if need be,
with orthopedic appliances.
The diabetic foot that developed a loss

of sensibility or a peripheric disturbed
blood flow should be protected against
increased pressure, plantar as well as
dorsal. Industry meanwhile offers special shoe models, that have to fulfill certain minimum requirements: Sufficient
space for toes in length and height,
27
DIABETES
Example of a diabetes-protection-shoe
(Picture: Finn Comfort).
enough width, avoidance of pinching

seams, soft materials over pressure-susceptible movable foot areas, no toe-puff
reacting on the foot, loose ready-made
cushion sole with pressure peak reduction in ball area by 30 percent, possibility of orthopedic appliances.
Although a big part of feet belonging
to this risk group can be treated well
with protective shoes offered by the industry, it leads to problems with special
foot types. Among other things, these
shoes often do not fit at all if feet are
very narrow or if the feet have a relati-
vely wide forefoot in connection with a

narrow heel. The treating team consisting of the prescribing physician and
the orthopedic shoemaker have thus to
act in a responsible way when they adjust diabetic protection shoes. If the
proportions of the feet do not fit the offered ready-made shoes, it has to be
considered if the desired fit can be reached by an additional alteration of the
ready-made shoe, for example with the
help of an orthopedic appliance. Here
the expanding of the shoe in certain
areas, such as the area of the hammer
toes for example, is a small but effective
modification. We must not forget appliances that are necessary according to
orthopedic additional indications (such
as a shortened leg etc.).
If the goals of the treatment, the
protection of the at-risk feet, for example due to local plantar pressure increase cannot be reached for example with
standardized soft cushion soles, a individually diabetes adapted footbed has
to be considered. This individual diabetes- adapted footbed can then be worn
complementarily to the ready-made protection shoe in this shoe. Only in exceptional cases will the production of an orthopedic custom-made shoe be necessary. These exceptions can be for example extreme width of feet through
strong adiposity or through too narrow
feet, too narrow heels or similar disproportions.
Further criteria for a higher-grade
treatment are:
Contralateral major amputations.
Arhropathy hip/knee/upper anklejoint or joint implant with functional impairment/contraction.
Amputation of the big toe/resection
of ossis metatarsalis I.
Motor functional limitation/paresis
of one or both legs.
Higher-grade gait- and stance instability.
Extreme adiposity (BMI > 35).
Kidney insufficiency requiring dialysis.
Job with predominant standing and
walking exertion.
Significant vision limitations.
Risk group III
Condition after plantar ulcer

Treatment: Diabetes protection shoe,
normally with diabetes-adapted footbed, if need be with orthopedic appliances
The first appearance of a plantar ulcer
is a decisive occurrence within the
course of a diabetes foot according
to most experts and requires an adequate treatment to avoid reccurrences.
This is the reason why in this risk
group frequently a diabetic protection
shoe is used together with a diabetesadapted footbed. The basic principle
of a diabetes-adapted footbed is a
pressure reduction in at-risk areas
through small-area pressure distribution and large-scale pressure redistribution (macro-relief). The micro-relief is
reached by using soft, possibly permanently elastic cushioning material. The
macro-relief is reached by moulding
anatomically the footbed to regions of
the foot that are still loadable. A soft
insole alone is not sufficient. The foot
would swim without sufficient support, there would be even more pinched parts. Accordingly completely dispensing with possible supports in the
sense of diagonal supports or small
pads does not entirely make sense,
28
since this way areas that need to be

relieved cannot be sufficiently relieved.
Supporting pads or supports must
not lead to pinched parts at all. This
effect is intensified through a differentiated material sandwich, the material characteristics of which depend on
the goals of the treatment and of the
personal circumstances of the patient.
The material sandwich can be arranged
vertically (layer construction) or horizontally (punctual relieving zones).
In order to locate the regions to be
relieved, the plantar electronic pressure distribution measurement has
proven to be an excellent instrument.
With this measuring technique it is
possible to quantify and localize the
plantar pressure peaks during walking.
These data can be used together with
two- and three-dimensional footprints, taken manually with the help of
footprinting and stepping foam or
using a special scanner for the construction of a footbed. Based on these
construction data, an individual foot
model (if need be, CNC-supported) is
made. The subsequent sandwich production is carried out on the basis of
Diabetes-adapted footbed, individually molded with the use of different materials.
this model.
The design of a diabetes-adapted
footbed depends on the requirement
profile of the patient and may vary
strongly in spite of given minimum
standards. In the end the aim of the
treatment, the loading reduction of atrisk foot areas, has to be guaranteed.
The evidence of the loading reduction
with individual patients can only be
made through a pressure distribution
measurement in the shoe between the
foot and the diabetes adapted footbed
using an electronic pressure measuring
sole.
The material thickness of the diabetes adapted footbed is very important
and should be 6 mm, preferably 10
mm, requiring sufficient space in the
shoe. Some applied materials wear off
DIABETES
very fast. A footbed that is too thin

does not have the desired effect and
hard insoles are frequently used in order to correct functional problems
with patients without neuropathy.
(Ulbrecht, Cavanagh and Caputo, 2004).
For the avoidance of the diabetic
foot syndrome the diabetes-adapted
footbed has been established as standard procedure. However there are few
studies proving that an individual
footbed is superior to a standardized
footbed concerning pressure reduction
and pressure redistribution. The magazine Clinical Biomechanics publis-
hed a paper in 2004 presenting this

comparison. In most cases better results were achieved with individual
treatments as with a standard treatment (Bus, Ulbrecht, Cavanagh,
2004).
In contrast, for the evidence of permanent elastic characteristics, serial
measurements with simulators, for example with a so-called impactor, are
necessary. PU-foams proved to be especially permanently elastic, contrary
to EVA-foam materials they resist the
quasi thermoplastic conditions that
occur while walking, considerably bet-
ter (Natrup, Fischer 2004; Jahn 2004).

Special attention has to be paid to
previous plantar ulcer regions, that
can be relieved by a so-called additional ulcer bedding or complemented by
orthopedic appliances measures, such
as for example punctual relief zones in
the shoe or additional roller bar support at the midsole with sole stiffening. Especially the last-mentioned orthopedic shoe adaption mainly has the
effect that pressure impact time on
the at-risk foot regions can be reduced
by approximately 12 percent (Drerup
and Wetz, 2000).
Risk group IV
As II with deformities or disproportions

Treatment: Orthopedic custom-made
shoes with diabetes-adapted footbedDeformities and disproportions are a
risk for diabetic patients with PNP
/AOD that should not be underestimated. The causes for that are manifold
and range from degenerative changes

and congenital diseases to foot positions typical for motor neuropathy.
All these changes have in common
that a shoe that does not consider
these changes adequately necessarily
leads to foot lesions. This is the reason

why the shoe has to correspond to the
foot exactly in its three-dimensional
forming. If this is not possible with
ready-made shoes currently on the
market, orthopedic custom-made
D I R E C TO RY
Contact our business partners for further information about their products and services!
Arch supports
Heels, part-finished
components
Orthema Sales Ltd.

Riedstrasse 1
CH-6343 Rotkreuz
Phone +41 41/7 98 04-34
Fax +41 41/7 98 04-35
sales@orthema.com
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shoe components
D-69469 Weinheim
Phone +49 (0) 6201/ 80-77 16
Fax +49 (0) 6201/ 80-46 83
info-shoe@nora.com
www.nora-shoe.com
CAD/CAM system for arch

support, supplies
shoe components, certified

quality products made of EVA
and rubber
Page 2
Page 23
Comfort shoes
Machinery
HARDO Maschinenbau GmbH

Postfach 3 20
D-32065 Bad Salzuflen
Mr. Ingo Hausdorf
Phone +49 (0) 5222/ 930-170
Fax +49 (0) 5222/ 930-16
hausdorf@hardo.eu
www.hardo.eu
RENIA-Gesellschaft mbH
Ostheimer Strae 516
D-51109 Kln
Phone +49 (0) 221/ 63 07 99-0
Fax +49 (0) 221/ 63 07 99-50
info@renia.com
www.renia.com
Orthopaedic machinery
Adhesives, chemical utilities
Page 9
Page 32
Machinery
Waldi Schuhfabrik GmbH

Postfach 16 53
D-97433 Hafurt
Phone +49 (0) 9521/ 92 33-0
Fax +49 (0) 9521/ 92 33-233
info@finncomfort.de
www.finncomfort.de
Wilhelm Brocksieper GmbH

Eininghauser Weg 20
D-58515 Ldenscheid
Phone +49 (0) 2351/ 70 62
Fax +49 (0) 2351/ 78580
info@brocksieper-gmbh.de
www.brocksieper-gmbh.de
Comfort shoes, golf shoes,

hiking boots
Machinery for orthopaedic

shoemakers, workshop
equipment
Page 7
Page 21
Raw/ancillary materials,
factory supplies
Machinery
Peter Witzel
Vacupress - Apparatebau
Max-Keith-Strae 66
D-45136 Essen
Phone +49 (0) 201/ 6462-284
Fax +49 (0) 201/ 6462-852
info@vacupress.de
www.vacupress.de
Infrared-ovens, hot air-ovens,
vacuum aggregates, supplies
Page 13
Do you want to see

your company here?
Contact us:
Verlagsbro Sibylle Lutz
Phone +49 (0) 511/ 35 31 98 30
Fax +49 (0) 511/ 35 31 98 40
kontakt@verlagsbuero-lutz.de
www.ostechnik.de
29
DIABETES
Custom-made orthopedic shoes.
shoes have to be made. The production

methods for these have been changing
strongly. Apart from scanner-based
CAD/CAM-technologies for the production of orthopedic shoe lasts with subsequent part-industrial manufacturing,
modular systems for shoe production
are offered by the supply industry. All

these systems aim at reducing the considerable costs that occur when producing custom-made shoes. Without corresponding quality assurance measures
the desired cost-cutting effect may
quickly change to the opposite. Ulceration, caused by an orthopedic custommade shoe that does not fit, costs a
multiple of the possible cost-cutting
effect, that can be reached by using
new manufacturing procedures.
In order to check the future fit of
an orthopedic shoe the so-called walking test model made of plastic wrap
or leather-like material has proven to
be an important tool.
In connection with the plantar electronic pressure distribution measurement the fit of the last and the pressure reduction effect of the diabetes-adapted footbed can be tested also when
walking before the final finishing of
the custom-made shoe, thus reducing

considerably possible fitting risks.
The final orthopedic custom-made
shoe is then produced over the last, optimized by the interim testing. Due to
the individual last design, orthopedic
built-in elements (diabetes-adapted
footbed, roller bar sole, sole stiffening,
etc.) can largely be designed according
to the function. The only limitations
come from the cosmetic demand of the
patient. These however are often challenged because orthopedic custom-made shoes first have to be medically effective, being a medical product, and
cannot focus on the cosmetic clothing
aspect. The tightrope walk between
stigmatization and a compromise that
can still be agreed to medically remains
a permanent challenge for the interdisciplinary team and requires first of all
from orthopedic shoemakers a lot of
creativity and design skills.
Risk group V
DNOAP (Levin III)
Treatment: Ankle-overlapping orthopedic custom-made shoes with diabetesadapted footbed, inner shoes, ortheses.
If the previously describes risk group
sometimes allows mid-high footwear,
feet after DNOAP normally require an
ankle-overlapping treatment. The stabilization of the foot that is highly atrisk in its bone structure has absolute
priority. If the measures for reducing
the strong deforming forces like corresponding orthopedic built-in elements
such as heel conducts, roller bar measures and exact moulding of the diabetes-adapted footbed to the foot arch,
fail a repeated collapse is impending.
Localizations in the sense of Sanders
II and III usually require a stabilizati-
on of the lower ankle joint through

ankle-fixing rear caps. At the latest
from a deformity with localization after Sanders IV or V with corresponding
perpendicular deviance on, usually
there is only the possibility left of a
treatment with the help of so-called
splint shoes with rocker bar or with
the help of a leg inner shoe orthesis
combined with an orthopedic custommade shoe. Due to the bone alterations and the involved higher ulcer risk,
a so-called special last according to a
plaster cast should be made in any case. Special attention has to be paid to
the exact moulding of the cast with
corresponding elaboration of the bony
protrusions on the last. Only with such
Ankle-overlapping custom-made shoes.
an extremely painstaking procedure

the permanently described complications with these high-risk feet can be
avoided.
Risk group VI
Condition after amputation of part of the foot

Treatment: as IV plus prostheses.
Amputation of part of the foot cause
on the one hand a functional loss with
involved disturbance of the unrolling
of the foot, on the other hand the loading area of the foot is reduced, increasing the pressure beneath the remaining foot areas. In case of diabetic
patients with PNP/AOD the disturban30
ce of the unrolling of the foot, mostly

leading to a reduction of the step
length, is not very important. Decisive
for therapy however is the preservation of the footpart stump, normally
now considerably less loadable. Relatively uncomplicated is the treatment of
amputations of individual or more toes
with aids described in risk group III.
Starting with transmetatarsal amputations mostly a treatment with orthopedic custom-made shoes is necessary.
The decisive question that has to be
discussed at large with the patient, is
how long the footpart substitute
should be made. Basically a footpart
substitute fulfills cosmetic needs and
increases the stance security only in
DIABETES
the statics. While walking the footpart

substitute however has a negative effect due to the elongation of the lever
in the push phase. The elongation of
the lever leads to an increased force
effect on the foot stump, that may
cause places of high pressure on the
stump tip and the foot sole area and
rubbing areas on the rear foot. For
that reason the use of forefoot substitute prostheses with excellent cosmetic effect for example according to
Bellmann or in very elaborate silicone
technology is only recommended in
case of especially loadable foot
stumps. In all other cases treatment
should follow the guidelines of optimum pressure reduction effect and reduction of shear forces. This means for
the practice an excellently moulded
diabetes-adapted footbed, an effective roller bar sole with an apex line
that is far back as well as, if need be,
additional, foot-fixating upper stiffenings such as a stiffened tongue and
short peroneal cap. If the tarsus pedis
stump is very short or if the loading
capacity of the foot stump is extremely poor, treatment until the knee, for
example modified according to Botta,
should be carried out.
Forefoot-prostheses with footbed for an

amputated foot to be used in a custom-made orthopedic shoe.
Risk group VII
Acute lesion / florid DNOAP

Treatment: Off-loading shoes, bandage
shoes, provisional shoes, ortheses, Total-Contact-Cast (TCC), if need be with
diabetes-adapted footbed and orthopedic shoe appliances.
In the last years a big variety of all
kinds of aids for the treatment of feet
from this risk class has been developed, so that a conscientious selection
according to functional but also to
economic criteria for each individual
case is necessary. Since the so-called
TCC (Total-Contact-Cast) only is used
in highly specialized treatment facilities with corresponding cast teams, in
the following the manifold alternatives will be discussed. In case of nonplantar foot lesions usually bandage
shoes with a light roller bar sole are
used. These enable the patient to walk
short distances without damaging the
bandage. At the same time the foot is
protected against outside influences.
In case of plantar lesions in the forefoot with good healing prospects,
forefoot off-loading shoes have proven
to be excellent. Due to the danger of
Off-loading-shoe.
osteoarthropathic complications by
the longer wearing of these off-loading shoes, the version with the long
sole is to be preferred to the original
form in short version. Additionally
crutches to avoid falling should be
prescribed, because these shoes bear
an increased risk of stumbling. A mixture of bandage shoe and forefoot offloading shoe are special off-loading
shoes with individually adjustable offloading zones.
With these off-loading shoes also
lesions beyond the forefoot can be relieved selectively and punctually. In
case of smaller lesions in the heel
area, also heel off-loading shoes can
be used. In case of plantar foot lesions, that predictably heal slowly and if
the foot is not deformed too extremely, a ready-made leg orthesis often in
connection with a diabetes-adapted
footbed with ulcer relief can be applied. The advantage of this more expensive treatment is the protection
against overloading of bones and joint
structures.
Deformed feet with plantar foot lesions require either an individual
therapy off-load shoe or in case of
corresponding large-area lesions an
individual leg off-load orthesis for example using plastic cast techniques. If
the foot should be relieved extensively
or if the pumping effect through the
up- and down movement should be
avoided in the orthesis, there is an excellent alternative, the double shelled
leg orthesis. With the comprehensive
containing of the leg with possible
compression of soft parts, a part of the

loading can be transferred from the
foot to the leg. This method is also especially well suited for the off-loading
of lesions in the heel area.
In exceptional cases in extremely
unfavourable foot positions such as for
example the position in club foot, offloading ortheses can additionally be
made with knee-condyle frames. This
technique enables the complete offloading of the entire foot. Nevertheless it only should be applied with
greatest care, because under no circumstances the blood supply of the
leg and of the foot must be affected.
Whereas in the above mentioned examples the off-loading or the pressure
redistribution was focused, in the treatment of osteoarthropathies usually
in stage II of Eichenholz the elimination of the foot flexibility is important.
According to Sanders-localization here
either single shelled or double shelled
therapy off-loading ortheses can be
applied. The corresponding diabetesadapted footbed should be constructed in an accordingly firm version. If
the foot is not yet deformed, also a
ready-made leg orthesis in connection
with a diabetes-adapted footbed can
be considered. However too extreme
experiments with these feet usually do
not pay off, since feet that are modified due to osteoarthropathy can
quickly get foot lesions.
The pictures were taken from the new book
Orthopdieschuhtechnik bei Ren Baumgartner, Michael Mller, Hartmut Stinus.
(more at: www.ostechnik.de).
31
VKB
Always the right Stuff in Focus

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We care about feet!

Orthema group CH - 6343 Rotkreuz Switzerland

: Halle 1, Stand G50 und G48

We care about feet

Orthopdieschuhtechnik 1st English Edition 2010

Custom made shoes

The Australian Pedorthic Medical

What is the chronological workflow

Orthopedic shoe technology

International standards are

IVO Congress 2012 in Sydney

The treatment of the

Orthopdieschuhtechnik 1st English Edition 2010

Anzeigenleitung: Sibylle Lutz

pecial shoes or ortheses for the

Example of a sensorimotor orthotic.

Wide range of qualifications

Orthopdieschuhtechnik 1st English Edition 2010

Movement analysis and sports

Today many orthopedic shoemaker offer

New fields of activity

Orthopdieschuhtechnik 1st English Edition 2010

Most of these foot problems can be

have been possible without the tight

Further education and Science

course leads after 6 semesters to the qualification

ISPO May 2010

More than shoes: Attractive. Comfortable. Healthy.

Orthopdieschuhtechnik 1st English Edition 2010

How to reach a masters degree in

he education of a Master Orthopedic shoemaker (OSM) is divided into 3 main stages:

Orthopdieschuhtechnik 1st English Edition 2010

16. Casting for orthopaedic footwear,

3.5 years, students have to pass a test

the following you find a description of

(2) the OSM is knowledgeable and

11. knowledge about the effect of a prescribed therapy by a medical doctor

HARDO Everything from one source

HARDO Router TF5

HARDO Maschinenbau GmbH

Tel. +49(0)5222- 93015

Orthopdieschuhtechnik 1st English Edition 2010

of common factors. In almost all countries there is a division between basic

ture cannot be found in many other

the further development of the profession in Japan.

led to an initiative that promotes the

Its faster by fax: +49 (0)73 31/9 30-1 90

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