Podiatrist and pedorthist Angus Brewin shares the story behind the development of Australia’s updated Pedorthic Footwear Standards. Podiatry has been central to the creation of these standards which are shaped deliberately to be practical and inclusive. Now updated, the standards aim to support real‑world clinical decision-making for podiatrists, pedorthists, patients and a broad range of clinicians across different care settings.
The need for updated Pedorthic Footwear Standards came about at our Pedorthic Conference in Melbourne in September 2024.
I ran a presentation where I put up a range of footwear and asked the audience to give feedback. I asked, ‘is this medical graded footwear or not?’ During that conference, we had Professor Hilton Menz and Talysha Reeve, both podiatrists, in the audience – who were both instrumental in helping us to update the standards.
It was amazing to see how many different answers we received when we asked that question. Some people thought regular athletic footwear qualified as medical graded footwear. Others only considered footwear commonly prescribed through the Department of Veterans’ Affairs (DVA) or similar schemes. The variability in opinion among clinicians in the same room was eye-opening – and the catalyst for the need to update these standards.
From that discussion, it became clear that we needed to put a committee together and properly define what medical grade footwear is, as well as a range of other standards to support clinicians and patients. The standards are not about restricting practice. They are about supporting safe, informed and consistent decision-making.
From the very beginning, podiatry had a strong influence on this project. I am a podiatrist and a pedorthist, and we also had podiatrist Michael Sutton involved. As mentioned earlier, Professor Hilton Menz and Talysha Reeve were also interested in the project early on. Right from the start and throughout its creation, podiatry has been central to the development of these standards.
There was a lot of debate about what should and should not be included. Reviewing older standards was revealing. Some were extremely rigid and unfamiliar to many clinicians, which meant they were rarely used.
These standards were never meant to be theoretical. They needed to reflect real clinical practice and real prescribing decisions. One of our core goals was to make sure this document would be freely available, easy to use and referenced regularly in day-to-day practice.
All that said, we were very conscious that this document should not only apply to pedorthists – or only to podiatrists. In regional, rural and remote areas, we also have trained clinical nurses, occupational therapists and other clinicians involved in footwear decisions. We wanted those professionals to also be able to refer to the document.
One of the document’s biggest goals from the very start was consistency of terminology. Part of this process included reflecting on the term ‘medical grade footwear’, which is a default term. It is overused and potentially abused.
By moving away from the umbrella term ‘medical grade footwear’ and using defined subcategories, we can all use the same language in reports and correspondence.
This helps clinicians, funding bodies and the public understand exactly what is being prescribed. When everyone is talking the same language, decisions become clearer and fairer.
With the advent of different funding sources like home care packages, and with existing schemes like Enable New South Wales and the DVA, it became clear that we needed a much clearer definition. Otherwise, the confusion affects everyone. It affects funding bodies, consumers, podiatrists who are prescribing footwear; and pedorthists who are supplying them. This is one of the reasons we deliberately steered away from using this term in the standards.
The decision to avoid using the term ‘medical grade footwear’ led to one of the most important pieces of work, which was to define the categories.
The most known type of medical grade footwear is extra depth footwear, so that is where we started. Extra depth footwear sounds simple, but it is quite difficult to define. Given shoes are made over lasts – and those lasts can vary significantly in depth – how do you objectively say a shoe is extra depth?
We went back to existing documents and standards, and determined that a six-millimetre minimum removable footbed was essential for this category. That requirement places the prescription element back with the health professional, where it belongs.
A common question podiatrists hear is: Why can’t a patient just buy a shoe from a standard athletic retailer?
You can buy a certain shoe off the shelf, but when you remove the insole and measure it, it may only be four and a half millimetres thick. If the patient requires a thicker insole for pressure relief, that shoe does not meet the standards.
At the same time, we did not want the standards to be so exclusive that readily available footwear could not qualify. There are shoes in retail outlets with a six-millimetre removable footbed, a reinforced heel counter, a stable sole, durability and multiple width fittings – this meets the criteria in the standards.
Another major focus was modernising how we think about pedorthic footwear. There are new technologies, new materials and new use cases emerging all the time.
One example is balance-enhancing footwear. Through the work of Professor Hilton Menz, there has been a strong focus on identifying evidence-based features that enhance balance. On a similar basis, we were careful not to use the term ‘falls prevention’, because we cannot guarantee that any shoe can prevent a fall. What we can do is identify measurable features that contribute to balance enhancement.
That is why this category is grounded in research rather than assumptions, and why we leaned heavily on Professor Menz’s work when defining it.
One of the biggest struggles we face clinically is convincing patients to wear footwear indoors. Many patients remove their prescribed footwear at home and switch to very low support, flimsy footwear.
This footwear often cannot accommodate orthoses, and it can be dangerous for people with diabetes or neuropathy. It can also increase falls risk.
To address this, we included an indoor footwear category. The intention is to support safer footwear use in the home, while recognising that indoor footwear does not need to meet the same durability requirements as outdoor footwear. For example, the durability of the upper and sole can be relaxed, while still maintaining key safety features.
We also included an activity-specific category. This is intentionally open and places the clinician firmly at the centre of decision-making.
We are seeing more aqua therapy, bath/shower and sport-specific footwear being prescribed. Some patients require a specific tread or shoe type for an activity but still need to accommodate an insole or orthotic because of a medical condition.
This category acknowledges those real-world scenarios and allows clinicians to apply their judgement rather than forcing footwear into an unsuitable box. The clinician assessing the patient ultimately has to decide whether a product is safe and appropriate. Activity-specific footwear is a good example of where clinical judgement is essential.
The standards are there to support clinicians, particularly when advocating for funding, not to override professional decision-making.
Funding considerations played a role in the creation of the standards. Funding agencies are often crying out for this type of guidance because they are regularly asked to make judgement calls without seeing the patient and without understanding footwear.
When a funding request comes in, they may lack the evidence needed to confidently approve or refuse it. The people making those decisions are frequently not trained in our profession. They do not know the terminology or the functional importance of footwear.
If a report is not interpreted correctly, funding can be refused. That helps no one. The standards allow clinicians to explain why a particular shoe is required and how it meets defined criteria. This should help to reduce disputes and improve the likelihood of appropriate funding decisions.
Footwear modifications are another section we focused on. This section provides a frame of reference for commonly prescribed modifications. It is not a textbook, and it does not list every possible option, but it covers many of the modifications that podiatrists regularly prescribe.
These include limb length adjustments, buttresses, relasts and rocker soles. A newer modification is low dexterity lacing systems. These systems are not only about reach difficulties. They also support independence and autonomy with donning and doffing footwear. This section should particularly help to support clearer report writing and funding requests.
We also briefly defined semi-custom, modular and custom-made footwear. These definitions are included to provide clarity about the full range of options available in the Australian context. Again, these are reference points rather than exhaustive descriptions.
Throughout the standards’ creation, the response from endorsing organisations was fantastic. The Australian Podiatry Association was immediately supportive. The board provided written feedback, and we worked hard to incorporate that feedback into the final document.
In addition to thanking Professor Hilton Menz and Talysha Reeve, I want to also thank , who provided us with some feedback on the document. Thank you also to our other endorsing partners – we had a very quick and supportive response from the Australian Physiotherapy Association and from the National Association of Diabetes Centres, who endorsed our document.
I would also like to thank Dr Vivienne Chuter who – through the Diabetes Feet Australia Board – provided feedback on the document. We also had great interest and support from the International Association for Orthopaedic Shoe Technicians (IVO) – and the International Pedorthics Association who are keen to implement versions of this document for overseas markets, including the developing world, where access to pedorthic services is very limited or emerging.
Last but by no means least, I want to thank the Pedorthic Footwear Standards Working Group for their efforts and donated time in creating this document.
Ultimately, this document is about clarity. Patients get frustrated when there is confusion about who pays for what. Clinicians get frustrated when prescriptions are questioned without clear reasoning.
If responsibilities are clearly defined, it helps to remove this conflict and support better outcomes for patients. That is what these standards are designed to do, and I encourage all podiatrists to use them.
Don’t miss the webinar* with Angus Brewin (or catch up on it in the library if you are an APodA member): From standards to specialisation
*Free to APodA members, $110 for non-members
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