Insole for an orthopedic device

Abstract

An insole for an orthopedic device includes a top portion including at least one top layer. The top layer defines a top surface arranged to be substantially adjacent a plantar surface of a user's foot. A bottom portion is connected to and arranged opposite the top portion. The bottom portion includes at least one bottom layer. At least one removable element is arranged for removal from at least the bottom portion for defining at least one opening below the top surface. The top surface continuously spans over the at least one opening arranged for off-loading one or more affected areas of the plantar surface of the foot.

Claims

1. An insole for an orthopedic device comprising: a first layer defining a foot engagement surface of the insole configured to face and engage with a plantar surface of a foot of a user, the foot engagement surface continuously extending between a toe edge portion and a heel edge portion of the insole; a second layer defining a bottom surface of the insole configured to face away from the plantar surface of the foot, the second layer extending between the toe edge portion and the heel edge portion of the insole; a third layer connecting and extending between the first layer and the second layer, the third layer being resiliently compressible such that the third layer compresses and rebounds between the first layer and the second layer as the user walks on the insole; a plurality of removable elements formed from at least the second layer and the third layer and each extending downwardly from the first layer to an unattached lower end that is independently movable within the bottom surface of the insole relative to the first layer, at least one of the removable elements arranged for removal from the bottom surface of the insole for defining at least one opening below the foot engagement surface of the insole so that a thickness of the first layer extends over the at least one opening, the first layer extending over the at least one opening being continuous and covering an entirety of the foot engagement surface from the toe edge portion to the heel edge portion of the insole and from a medial side of the insole to a lateral side of the insole to enhance comfort and protection to the plantar surface of the foot, wherein the removable elements surrounding the at least one opening define an outer periphery of the at least one opening and move the foot engagement surface of the insole extending over the at least one opening to reduce shear stress on a plantar surface of the foot and accommodate lateral foot motion; and an adhesive bond between the first layer and the third layer, and an adhesive bond between the second layer and the third layer, wherein the adhesive bond between the first layer and the third layer is arranged to fail or break before the adhesive bond between the second layer and the third layer so the removable elements do not fall apart at the interface between the second layer and the third layer, the first layer having a tear strength between about 7 times to about 12 times greater than a tear strength of the third layer, the second layer having a tear strength between about 2.5 times to about 3 times greater than the tear strength of the third layer.

2. The insole of claim 1, wherein the first layer is heat formable such that the first layer is configured to match a shape of the plantar surface of the foot.

3. The insole of claim 2, wherein the second layer is heat formable such that the second layer is configured to match a shape of the plantar surface of the foot.

4. The insole of claim 1, wherein a combined thickness of the second layer and the third layer is greater than about twice the thickness of the first layer such that the foot engagement surface continuously spanning over the at least one opening remains vertically above the bottom surface of the insole as a user walks on the insole.

5. The insole of claim 1, wherein the second layer includes a high density resilient material such that the second layer is configured to maintain the foot engagement surface a distance from the bottom surface of the insole as a user walks on the insole.

6. The insole of claim 1, wherein the removable elements comprise only the second layer and the third layer.

7. The insole of claim 1, wherein the removable elements are arranged to move independently of one another.

8. An insole comprising: a first layer defining a foot engagement surface of the insole configured to face and engage with a plantar surface of a foot of a user, the first layer extending between a toe edge portion and a heel edge portion of the insole; a second layer defining a bottom surface of the insole configured to face away from the plantar surface of the foot, and a third layer connecting and extending between the first layer and the second layer, the first layer, the second layer, and the third layer being formed of different materials, the third layer being resiliently compressible such that the third layer compresses and rebounds between the first layer and the second layer as the user walks on the insole; a plurality of removable elements formed from the first layer, the second layer and the third layer and each removable element extending downwardly from the first layer to an unattached lower end that is independently movable within the bottom surface of the insole relative to the first layer, at least one of the removable elements arranged for removal from the bottom surface of the insole for defining at least one opening below the foot engagement surface of the insole so that a thickness of the first layer extends over the at least one opening, the first layer extending over the at least one opening being continuous and covering an entirety of the foot engagement surface from the toe edge portion to the heel edge portion of the insole and from a medial side of the insole to a lateral side of the insole to enhance comfort and protection to the plantar surface of the foot, wherein the removable elements surrounding the at least one opening define an outer periphery of the opening and move with the foot engagement surface of the insole extending over the at least one opening to reduce shear stress on a plantar surface of the foot and accommodate lateral foot motion; and an adhesive bond between the first layer and the third layer, and an adhesive bond between the second layer and the third layer, wherein the adhesive bond between the first layer and the third layer is arranged to fail or break before the adhesive bond between the second layer and the third layer so the removable elements do not fall apart at the interface between the second layer and the third layer, the first layer having a tear strength between about 7 times to about 12 times greater than a tear strength of the third layer, the second layer having a tear strength between about 2.5 times to about 3 times greater than the tear strength of the third layer.

9. The insole of claim 8, wherein the first layer is heat formable such that the first layer is configured to match a shape of the plantar surface of the foot.

10. The insole of claim 9, wherein the second layer is heat formable such that the second layer is configured to match the shape of the plantar surface of the foot.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

(1) These and other features, aspects, and advantages of the present disclosure will become better understood regarding the following description, appended claims, and accompanying drawings.

(2) FIG. 1 is an isometric view of an orthopedic device in which the exemplary embodiments of an insole may be implemented.

(3) FIG. 2 is an isometric view of another orthopedic device in which the exemplary embodiments of an insole may be implemented.

(4) FIG. 3 is a top isometric view of an insole according to an embodiment.

(5) FIG. 4 is a bottom isometric view of the insole in FIG. 3 showing some of the removable inserts removed from the insole.

(6) FIG. 5 is an isometric view of the walker of FIG. 1 partially disassembled for ease of reference.

(7) FIG. 6 is a cross-sectional view of the insole in FIG. 3.

(8) FIG. 7 is another cross-sectional view of the insole in FIG. 3 showing some of the removable elements removed for ease of reference.

(9) FIG. 8A is a cross-sectional view of an insole according to another embodiment.

(10) FIG. 8B is a cross-sectional view of the insole in FIG. 8A showing some of the removable elements removed for ease of reference.

(11) FIG. 9 is a cross-sectional view of an insole according to another embodiment showing some of the removable elements removed for ease of reference.

(12) FIG. 10 is a cross-sectional view of an insole according to another embodiment showing some of the removable elements removed for ease of reference.

(13) FIG. 11 is a bottom isometric view of an insole according to another embodiment.

(14) FIG. 12 is a bottom isometric view of an insole according to another embodiment.

DETAILED DESCRIPTION OF VARIOUS EMBODIMENTS

(15) A better understanding of different embodiments of the disclosure may be had from the following description read with the accompanying drawings in which like reference characters refer to like elements.

(16) While the disclosure is susceptible to various modifications and alternative constructions, certain illustrative embodiments are in the drawings and described below. It should be understood, however, there is no intention to limit the disclosure to the embodiments disclosed, but on the contrary, that the intention covers all modifications, alternative constructions, combinations, and equivalents falling with the spirit and scope of the disclosure.

(17) For further ease of understanding the embodiments of an orthopedic device as disclosed, a description of a few terms is necessary. As used, the term dorsal has its ordinary meaning and refers to the top surfaces of the foot, ankle and foreleg or shin. As used, the term plantar has its ordinary meaning and refers to a bottom surface, such as the bottom of a foot. As used, the term proximal has its ordinary meaning and refers to a location closer to the heart than another location. Likewise, the term distal has its ordinary meaning and refers to a location further from the heart than another location. The term posterior also has its ordinary meaning and refers to a location behind or to the rear of another location. Lastly, the term anterior has its ordinary meaning and refers to a location ahead of or to the front of another location.

(18) The terms rigid, flexible, and resilient may be used to distinguish characteristics of portions of certain features of the orthopedic device. The term rigid should denote that an element of the device is generally devoid of flexibility. Within the context of support members or shells that are rigid, it is intended to indicate that they do not lose their overall shape when force is applied, and that they may break if bent with sufficient force. The term flexible should denote that features are capable of repeated bending such that the features may be bent into retained shapes or the features do not retain a general shape, but continuously deform when force is applied. The term resilient is used to qualify such flexible features as returning to an initial general shape without permanent deformation. As for the term semi-rigid, this term is used to connote properties of support members or shells that provide support and are free-standing; however, such support members or shells may have degree of flexibility or resiliency.

(19) The exemplary embodiments of an insole can be used in various orthopedic devices, including, but not limited to, configurations of walkers or walking boots, post-surgical shoes, diabetic shoes, or any other suitable orthopedic device.

(20) For instance, exemplary embodiments of an insole can be implemented with an orthopedic device comprising a walker 11, as shown in FIG. 1. An exemplary walker 11 can include a base shell 13 and a dorsal shell 15, such that that the lower leg is generally fully enclosed and supported by the walker 11. An outsole 17 can be provided along the distal plantar surface of the walker 11. The dorsal shell 15 can be moveable away and towards the base shell 13 to open and close the walker 11. In this exemplary device 11, an insole 19 can be arranged in a foot bed of the walker 11. The insole 19 can be configured to provide protection and relief to affected areas on the plantar surface of a user's foot. While a circumferential walker is shown, it will be appreciated that other walkers (e.g., a strut walker) may utilize similar insole configurations.

(21) Further, exemplary embodiments of an insole can be implemented with an orthopedic device comprising a diabetic shoe 21, as shown in FIG. 2. The diabetic shoe 21 can include an outsole 23, an upper portion 25, and straps 27 for holding the shoe closed. The straps 27 can be mounted on a first closure flap 29 of the shoe 21, extend through openings 31 in a second closure flap 33 and then can be held in a closed position by a closure system on the straps 27 and the first closure flap 29. An insole 35 according to an exemplary embodiment can be arranged in a foot bed of the shoe 21.

(22) Referring now to FIGS. 3-7, a first exemplary embodiment of an insole 200 comprises a top portion 202 and a bottom portion 212 connected to and arranged opposite the top portion 202. The top portion 212 includes a first or top layer 204. The top layer 204 can define a top surface 210 arranged to be substantially adjacent a plantar surface of a user's foot. The bottom portion 212 can include a second or bottom layer 208 and a third or intermediate layer 206. The intermediate layer 206 can be attached to the top layer 204, and the bottom layer 208 can be attached to the intermediate layer 206. The bottom layer 208 can define a bottom surface 213 of the bottom portion 212. While the top portion 202 is shown including one layer and the bottom portion 212 is shown including two layers, the top portion 202 and/or the bottom portion 212 can include one, two, four, or any other suitable number of layers.

(23) FIG. 4 shows a plurality of removable elements 216 can be cut or otherwise formed in the bottom portion 212 of the insole 200. The removable elements 216 can be cut or formed in substantially the entire bottom portion 212 of the insole 200. The removable elements 216 can be cut or formed in select or discrete portions of the bottom portion 212. While a plurality of removable elements 216 are described, it will be appreciated that the insole can include at least one removable element 216.

(24) One or more of the removable elements 216 can be arranged for removal from at least the bottom portion 212 for defining at least one opening 218 below the top surface 210. For instance, some of the removable elements 216 can be removed from the bottom surface 213 of the bottom portion 212 to define the opening 218 below the top surface 210. The opening 218 can be arranged for off-loading one or more affected areas (e.g., a foot ulcer, a sore, a wound, a bruise, a fracture, etc.) of the plantar surface of the user's foot. At least one element 216 can be removed from the bottom portion 212 of the insole 200 to define the opening 218 below the top surface 210, providing relief or off-loading to one or more affected areas on the foot 220, while the top surface 210 of the insole 200, next to the skin or sock, protects the plantar surface of the foot from the opening 218, reducing the likelihood of pressure points along the plantar surface of the foot. While the opening 218 is shown, it will be appreciated that the removable elements 216 can be removed from the bottom portion 212 to define two, three, four, five, or any other suitable number of openings for off-loading one or more affected areas of the plantar surface of the foot.

(25) As seen in FIG. 5, the plantar surface of the foot 220 can be supported on the top layer 204 and the removable elements 216 (shown in FIG. 4) surrounding the opening 218 (shown in FIG. 4). Relief can be provided to an affected area 222 on the plantar surface of the foot 220 by placing the affected area 222 on a relief zone 224 on the top surface 210 of the top layer 204. The relief zone 224 can correspond to the opening 218 formed below the top layer 204 and defined by removed removable elements 216.

(26) As seen, the top surface 210 continuously spans over the opening 218. This means that the top surface 210 forms an uninterrupted protective barrier between the plantar surface of the foot 220 and the opening 218, reducing the likelihood that the edges of the openings 218 will form pressure points on the affected area 220, which can be both uncomfortable and harmful. This is important because conventionally, off-loading insoles have included removable shapes cut into and removable from the upper surface of the insole, creating edge pressures and/or pressure points on the plantar surface of the foot, which in turn, aggravate and/or even cause foot or pressure ulcers.

(27) The top surface 210 continuously extending over the opening 218 can also distribute edge pressures from the opening 218 across and through the top layer 204 and away from the affected area 222. Such an arrangement also can limit or prevent window edema. Window edema occurs when an area of the body under low pressure is surrounded by an area of higher pressure. Body fluids build up and become trapped in lower pressure. Distal parts of the body, such as the hands and feet, are prone to window edema because the cardio-vascular system rarely does a good job of retrieving fluids far from the heart. The trapped fluids become excellent media for bacteria to grow, causing infections.

(28) Window edema can be especially problematic for diabetic users or patients using conventional insoles. For instance, fluids may build up and become trapped in the openings cut into and removable from the upper surface of the insole. Since the patient's foot is far from the heart, the cardio-vascular system has trouble carrying away the fluids that build up in the openings. As bacteria grow in the fluids, the patient may be subject to dangerous infection that can threaten the well-being of the foot and/or life of the patient.

(29) The top surface 210 of the insole 200 continuously extending over the opening 218 reduces window edema by preventing the collection of fluids and/or exudate in the opening 218 rather than allowing the fluids and/or exudate to collect in the opening, as in the prior art. This also has the effect of limiting or preventing distended wounds because any exudate coming out of the affected area 222 generally cannot collect in the opening 218.

(30) A user, a clinician, or medical professional can remove one or more of the removable elements 216 from the bottom portion 212 to define the opening 218, off-loading the affected area 222, without disrupting or breaching the contact area between the top surface 210 and the plantar surface of the foot 220. This allows the insole 200 to both comfortably support the foot 220 and offload the affected area 222. This also prevents the edges of one or more openings 218 rubbing against the plantar surface of the foot, reducing friction and shear forces.

(31) Referring again to FIG. 4, the removable elements 216 can be arranged adjacent to one another in a grid pattern. The removable elements 216 can be configured to move laterally and/or vertically relative to one another in response to forces applied by the foot. The removable elements 216 can be configured to bend and compress relative to one another. The removable elements 216 can be deformable such that they sway and/or bend relative to one another.

(32) The removable elements 216 can comprise independent pieces that work collectively to adjust and react to lateral foot motion. This has the effect of reducing shear stress on the plantar surface of the foot 220, which reduces the aggravation or creation of foot ulcers due to shear stress. Conventional insoles resist lateral foot motion, inducing shear stresses on the plantar surface of the foot, which can cause or aggravate ulcers. The top layer 204 can move with the underlying removable elements 216, helping to reduce shear stress on the plantar surface of the foot.

(33) The removable elements 216 can be generally hexagonal in transverse cross-sectional configuration and can exhibit any other suitable construction. For instance, the removable elements 216 can be constructed in a similar configuration and function as described in U.S. Pat. No. 6,792,699 or U.S. Pat. No. RE 40,363, which are incorporated herein, in their entirety, by this reference. Each removable element 216 can have the same shape or different removable elements 216 can have different shapes.

(34) The removable elements 216 can be removably attached to the insole 200 in any suitable manner. For instance, the top surfaces of the removable elements 216 can be lightly adhered to the bottom surface of the top layer 204 such that to remove elements 216 from the bottom portion 212, a user can selectively pull on the removable elements 216 to break the adhesive bond between the top surface of the removable elements 216 and the bottom surface of the top layer 204.

(35) An adhesive bond between the top layer 204 and the intermediate layer 206 may be smaller than an adhesive bond between the intermediate layer 206 and the bottom layer 208. This can allow the adhesive bond between the top layer 204 and the intermediate layer 206 to fail or break before the adhesive bond between the intermediate layer 206 and the bottom layer 208 so the removable elements 216 do not fall apart at the interface between the intermediate layer 206 and the bottom layer 208.

(36) The removable elements 216 can be removable from the bottom portion 212 by tearing the removable elements 216 out of the bottom portion 212. To remove one or more of the removable elements 216 from the bottom portion 212, a user, clinician, or medical professional can selectively twist or pull on the one or more elements 216 such that the intermediate layer 206 forming a portion of the removable elements 216 tears to remove the removable elements 216 from the bottom portion 212. The top layer 204 may have a tear strength about 1.2 times to about 20 times, about 5 times to about 15 times, about 7 times to about 12 times, or about 8 times to about 9 times greater than the tear strength of the intermediate layer 206. The bottom layer 208 may have a tear strength about 1.2 times to about 10 times, about 1.5 times to about 8 times, about 2 times, to about 6 times, or about 2.5 times to about 3 times greater than the tear strength of the intermediate layer 206.

(37) The removable elements 216 can be removably attached to the insole via a hook-and-loop type system. For instance, the removable elements 216 can have a layer of hook type material on their top surfaces. This hook type material can engage a loop type material on or within a bottom surface of the top layer 204. The resultant securing action being of the hook-and-loop type, similar to Velcro.

(38) As seen in FIG. 4, the bottom portion 212 can include a continuous peripheral rim 226 at least partially enclosing the removable elements 216. The peripheral rim 226 can be configured to provide additional rigidity to the insole 200, reducing the likelihood that the insole 200 will sag along the peripheral edges of the insole 200. In particular, support provided by the peripheral rim 226 in combination with the removable elements 216 can help reduce the chance that an affected area of the user's foot will bottom out.

(39) The peripheral rim 226 can have a higher density than at least some of the removable elements 216. The peripheral rim 226 can include one or more rigid or semi-rigid materials such as metals, composite materials, plastic materials or any other suitable material. The peripheral rim 226 can include one or more separate reinforcement members that can be inserted within the peripheral rim 226 to provide additional rigidity to the insole 200. The reinforcement members can include metal, plastic materials, composite materials, or any other suitable material. While the peripheral rim 226 is illustrated being continuous, in other embodiments, the peripheral rim 226 can be arranged along only portions of the insole 200. For instance, the peripheral rim 226 can be arranged along only a discrete portion of the bottom portion 212 to create at least one zone of additional support to the foot.

(40) It will be appreciated that the layers of the top portion 202 and/or the bottom portion 212 can be attached to one another in any suitable manner. For instance, the intermediate layer 206 can be attached to the top layer 204 and/or the bottom layer 208 via one or more adhesives, hook-and-loop type systems, chemical bonding, mechanical bonding, or any other suitable technique. Optionally, the top layer 204 can include a piece of fabric or other material attached to its top surface, providing additional cushioning and/or friction reduction.

(41) The top layer 204, the intermediate layer 206, and the bottom layer 208 together can define a total thickness T of the insole 200. Each layer 204, 206, 208 can include a layer thickness L defined between its top surface and bottom surface. The total thickness T of the insole 200 can be between about 13 mm and about 22 mm (e.g., about 18 mm). For instance, the top layer 204 can have a layer thickness L between about 3 mm and about 6 mm (e.g., about 5 mm), the intermediate layer 206 can have a layer thickness L of about 2 mm to about 4 mm (e.g., about 3 mm), and the bottom layer 208 can have a layer thickness L between about 8 mm and about 12 mm (e.g., 10 mm). In other embodiments, the total thickness T of the insole 200 and/or layer thicknesses can be more or less.

(42) The total thickness T of the insole 200 can help ensure that the insole 200 is in substantially total contact with the plantar surface of the user's foot. For instance, if a user has a high arch, the insole 200 having a total thickness T of about 18 mm can be contacted substantially all the plantar surface of the foot, including the arch, without bottoming out. Conventional insoles for orthopedic devices can include five or more layers. The layers 204, 206, 208 can have the same total thickness T and support as a conventional insole, but with fewer layers, providing a more efficient and simpler insole construction.

(43) The bottom portion 212 and/or the bottom layer 208 can also be oversized relative to the top portion 202 to help ensure that the removable elements 216 have an adequate height to create effective off-loading of an affected area. For instance, the layer thickness L of the bottom layer 208 can be greater than about 1.5 times, about 1.7 times, or about 2 times the layer thickness L of the top layer 204. The layer thickness L of the bottom layer 208 can be between about 1.2 times and about 2.2 times, about 1.5 times and about 2 times, or about 1.6 times and about 1.8 times greater than the layer thickness L of the top layer 204. In other embodiments, the relationship between the layer thicknesses L of the bottom layer 208 and the top layer 204 can be greater or smaller.

(44) The bottom layer 208 can have a layer thickness L oversized relative to the top layer 204 such that the bottom layer 208 is arranged to provide the primary cushioning to the insole 200. It should be appreciated that the bottom layer 208 is a single layer providing the primary cushioning to the insole rather than multiple layers connected together as in the prior art. This allows the construction of the insole 200 to be simpler and less likely to fall apart due to weak or weakened connections between multiple layers.

(45) The bottom layer 208 can have a layer thickness L oversized relative to the intermediate layer 206 such that the bottom layer 208 is arranged to provide the primary cushioning to the insole 200. The layer thickness L of the bottom layer 208 can be greater than about 1.5 times, about 1.8 times, about 2.2 times (e.g., about 2 times), or about 3 times the layer thickness L of the intermediate layer 206. The layer thickness L of the bottom layer 208 can be between about 1.5 times and about 3.5 times (e.g., about 3 times), about 2 times and about 3.2 times, or about 2.4 times and about 2.8 times greater than the layer thickness L of the intermediate layer 206. In other embodiments, the relationship between the layer thicknesses L of the bottom layer 208 and the intermediate layer 206 can be greater or smaller.

(46) The intermediate layer 206 may be sized and arranged relative to the other layers to help cushion the insole 200. For instance, the intermediate layer 206 can have a layer thickness L arranged and sized to allow the intermediate layer 206 to compress and rebound between the top layer 204 and the bottom layer 208 as the user walks on the insole 200, providing greater cushioning and comfort. The layer thickness L of the top layer 204 can be greater than about 1.1 times, about 1.3 times, about 1.5 times, about 1.6 times, or about 2 times the layer thickness of the intermediate layer 206. The layer thickness of the top layer 204 can be between about 1 time and about 3 times, about 1.2 times and about 2 times, or about 1.4 times and about 1.7 times greater than the layer thickness L of the intermediate layer 206. In other embodiments, the relationship between the layer thicknesses L of the top layer 204 and the intermediate layer 206 can be greater or smaller.

(47) FIG. 7 illustrates a cross-sectional view of the insole 200 with some of the elements removed for ease of reference. As seen, the removable elements 216 can extend through the intermediate layer 206 and the bottom layer 208, but not the top layer 204 (leaving at least the top surface 210 continuously extending over the opening 218 defined by the removed removable elements 216). The removable elements 216 are formed from a portion of the bottom layer 208 and a portion of the intermediate layer 206. Such an arrangement allows the top surface 210 and/or the top layer 204 to form a protective barrier between the plantar surface of the foot and the opening 218 and the removable elements 216, providing cushioning and/or reducing potentially harmful pressure points along the edges of the openings 218.

(48) Alternatively, as seen in FIGS. 8A and 8B, one or more of the removable elements 216A can be arranged for removal from the bottom portion 212 (including the bottom layer 208 and the intermediate layer 206) and at least part of the top layer 204 to define an opening 218A below the top surface 210 of the top layer 204. The removable elements 216A can be formed from a portion of the bottom layer 208, a portion of the intermediate layer 206, and a portion of the top layer 204. In other embodiments, the removable elements 216 can be arranged for removal from the bottom layer 208 and at least part of the intermediate layer 206 to define the opening 218 below the top surface 210. In other embodiments, the removable elements 216 can be arranged for removal from the bottom layer 208 to define the opening 218 below the top surface 210.

(49) Each removable element 216 can have a height H (shown in FIG. 4) defined between a top and bottom surface of the removable element 216. The height H of the removable elements 216 can be arranged to facilitate removal of the removable elements to create off-loading of an affected area without the affected area bottoming out or displacing vertically below the bottom surface 213 of the bottom portion 212, which could negatively affect the affected area and potentially further injure the foot. At least one of the removable elements 216 can be arranged for removal from at least the bottom portion 212 such that the element 216 has a height H about 0.6, about 0.66, or about 0.7 times the total thickness T of the insole 200. In other embodiments, the height H of the removable elements 216 can be more or less. The height H of the removable elements 216 can be substantially the same. The height H of different elements 216 can be different.

(50) The construction of the top portion 202 and the bottom portion 212 will now be discussed in greater detail. The top portion 202 and the bottom portion 212 can be configured to work together to provide greater comfort and support. The top layer 204 of the top portion 202 can be arranged to distribute pressure and/or to minimize friction by substantially conforming to the shape of the plantar surface of the foot. The top layer 204 can be heat-moldable. For instance, the top layer 204 can include one or more heat formable materials including, but not limited to, closed cell polyethylene foam (e.g., Plastazote LD45), heat formable cork material, or any other suitable heat formable material.

(51) To shape the top layer 204 to the plantar surface of the foot, the insole 200 may be heated to a temperature between about 90 C. and about 130 C. (e.g., about 110 C.) or above a softening temperature of the top layer 204, and the patient's foot or a mold of the user's foot applies to the insole to deform the top layer 204, so the shape of the upper surface of the top layer 204 substantially corresponds to the plantar surface of the foot. With this arrangement, the insole 200 can distribute forces from the foot to larger areas of the top layer 204 avoiding higher pressure points, with the lateral action of the removable elements 216 further reducing shear forces applied to the foot as the patient walks or stands on the insole 200. It will be appreciated that a broader range of operable temperatures for heat moldable materials are possible. In addition, instead of activating the molding by heat, other forms of activation may be employed such as, but not limited to, LED light, chemicals, or sound.

(52) The bottom layer 208 of the bottom portion 212 can be sized and configured to provide additional support and/or comfort to the insole 200. The bottom layer 208 can include any suitable material. The bottom layer 208 can include a high density resilient material. The bottom layer 208 can be arranged to prevent the plantar surface of the foot 220 from bottoming out. For instance, as the bottom layer 208 is compressed under the weight of the user, the layer thickness L and compressive strength of the bottom layer 208 can be arranged to maintain the plantar surface of the foot 220 at a distance from the bottom surface 213 of the insole 200. The resiliency of the bottom layer 208 can also provide impact absorption and comfort.

(53) The bottom layer 208 can be oversized relative to the other layers. This can allow the bottom layer 208 to create the primary cushioning in the insole 200. In addition, the oversized bottom layer 208 can help give the removable elements 216 adequate height H to create off-loading of an affected area without bottoming out. The bottom layer 208 may be heat formable such that the bottom layer 208 can be formed to substantially conform to the bottom of the user's foot. The top layer 204 and the bottom layer 208 can be formed to substantially conform to the shape of the plantar surface of the foot 220 in the same or separate processes.

(54) The intermediate layer 206 of the bottom portion 212 can be configured to provide greater cushioning in the insole 200. The intermediate layer 206 can comprise a urethane foam (e.g., Poron 4701-30), neoprene foam, silicone, rubber, or any other suitable material. The intermediate layer 206 can comprise a soft and resilient layer that provides impact absorption as the user walks on the insole 200. The intermediate layer 206 can comprise a compressible and resilient layer arranged to compress and rebound between the top layer 204 and the bottom layer 208 as the user walks on the insole 200, enhancing cushioning and comfort.

(55) The softness of the insole 200 may vary from layer to layer. For instance, a harder top layer 204 and a harder bottom layer 208 can support the foot of the user and a softer intermediate layer 206 can compress and rebound between the top layer 204 and the bottom layer 208, providing an insole that is both strong and durable, while very comfortable for the user.

(56) The top layer 204 can have a Shore durometer that is about 1.2 to about 30 times, about 1.5 times to about 25 times, about 8 times to about 20 times, or about 5 times to about 14 times greater than the Shore durometer of the intermediate layer 206. The bottom layer 208 may have a Shore durometer that is about 1.1 to about 10, about 1.2 times to about 8 times, about 2 times to about 6 times, or about 2.5 times to about 4 times, greater than the Shore durometer of the intermediate layer 206. The intermediate layer 206 can have a Shore durometer between about 3 and about 12 (e.g., about 5). The bottom layer 208 can have a Shore durometer between about 20 and about 80 (e.g., about 60), and the top layer 204 can have a Shore durometer between about 30 and about 70 (e.g., about 50). The bottom layer 208 can have a Shore durometer greater than about 60 and the top layer 204 can have a Shore durometer greater than about 50. In other embodiments, the hardness of the layers 204, 206, 208 can be more or less.

(57) The materials and construction of the respective layers described are to be exemplary only, as any suitable materials and/or properties that can provide comfort and/or support to the insole 200 may be envisioned. For instance, the intermediate layer 206 can include heat deformable materials configured to be permanently deformed or contoured to the plantar surface of the foot.

(58) The insole 200 can be any suitable shape and can be configured to fit a size, or size range of orthopedic devices or feet. For instance, the insole 200 can be made in extra-small, small, medium, larger and/or extra-large size.

(59) The top portion 202 can include the top layer 204 and the bottom portion 212 can include the bottom layer 208 and the intermediate layer 206. In other embodiments, the top portion 202 can include the top layer 204 and the intermediate layer 206 and the bottom portion 212 can include the bottom layer 208.

(60) FIG. 9 illustrates a second exemplary embodiment of an insole 300. The insole 300 is similar to the insole 200 except that the insole 300 does not include an intermediate layer. The insole 300 has a top portion 302 and a bottom portion 312 connected to and arranged opposite the top portion 302. The top portion 302 includes a top layer 204 arranged to be substantially adjacent a plantar surface of a user's foot. The bottom portion 312 includes a bottom layer 308. The bottom layer 308 can define a bottom surface 313 of the bottom portion 312.

(61) A plurality of removable elements 316 is arranged for removal from the bottom portion 312 for defining at least one opening 318 below the top layer 304, leaving the top layer 304 continuously spanning over the opening 318 and reducing the likelihood that the opening 318 will create pressure points on the plantar surface of the foot.

(62) The bottom layer 308 can be substantially thickened or oversized relative to the top layer 304 to facilitate removal of the removable elements 316 of an adequate height to create off-loading of an affected area without the affected area bottoming out. For instance, the top layer 304 can have a layer thickness between about 3 mm and about 6 mm (e.g., about 5 mm) and the bottom layer can have a layer thickness between about 10 mm and about 16 mm (e.g., about 13 mm). In other embodiments, the thickness of the bottom layer 308 relative to the top layer 304 can be more or less.

(63) FIG. 10 illustrates a third exemplary embodiment of an insole 400 comprising a top portion 402 and a bottom portion 412 connected to and arranged opposite the top portion 402. The top portion 402 includes a top layer 204 defining a top surface 410 arranged to be substantially adjacent a plantar surface of a user's foot. The bottom portion 412 includes a bottom layer 408 and an intermediate layer 406. The bottom layer 408 can define a bottom surface 413 of the bottom portion 412.

(64) A plurality of removable elements 416 is arranged for removal from the bottom portion 412 for defining at least one opening 418 below the top layer 404, leaving the top layer 404 continuously spanning over the opening 418.

(65) A retaining member 426 can be removably attached to and positioned below the bottom portion 412. The retaining member 426 can be removably attached to a peripheral of the bottom surface 413 and/or the removable elements 416. The retaining member 426 can be arranged to selectively retain the removable elements 416 between the top layer 404 and the bottom surface 413 of the bottom portion 412. This has the effect of maintaining the position of the removable elements 416 within the insole, which limits undesired migration of the removable elements 416. The retaining member 426 can comprise a rigid plastic piece, an adhesive layer, a metallic or composite member, a rubber member, combinations thereof, or any other suitable member.

(66) FIG. 11 illustrates a fourth exemplary embodiment of an insole 500 comprising a top portion 502 and a bottom portion 512 connected to and arranged opposite the top portion 502. A plurality of removable elements 516 is arranged for removal from the bottom portion 412 to define at least one opening below a top surface of the top portion 502 for off-loading one or more affected areas of the plantar surface of the foot. The removable elements 516 can be limited to locations or regions where affected areas on the foot are commonly formed. For instance, the removable elements 516 can be arranged in only a forefoot region of the bottom portion 512 of the insole 500 as shown. The forefoot region is a common area for the formation of foot ulcers. In other embodiments, the removable elements 516 can be arranged in a toe region and/or the forefoot region of the bottom portion 512 of insole 500. The removable elements 516 can be arranged in the toe region, the forefoot region, and/or a heel region of the bottom portion 512 of the insole 500. If a user has Charcot foot and the user's arch is collapsing the removable elements 516 can be arranged in an arch region on the bottom portion 512 of the insole 500, allowing the insole 500 to provide relief to the user's malformed arch.

(67) While the removable elements are shown and described being generally hexagonal in transverse cross-sectional configuration, in other embodiments, the removable elements can be generally square, generally diamond, generally elliptical, combinations thereof, or any other suitable transverse cross-sectional configuration. For instance, FIG. 12 illustrates a fifth exemplary embodiment of an insole 600 comprising a top portion 602 and a bottom portion 612 connected to and arranged opposite the top portion 602. A plurality of removable elements 616 is arranged for removal from the bottom portion 612 to define at least one opening below a top surface of the top portion 602 for off-loading one or more affected areas of the plantar surface of the foot. As seen, the removable elements 616 can have a generally square cross-sectional configuration.

(68) While various aspects and embodiments have been disclosed, other aspects and embodiments are contemplated. The aspects and embodiments disclosed are for illustration and are not intended to be limiting. The words including, having, and variants thereof (e.g., includes and has) as used, including the claims, shall be open-ended and have the same meaning as the word comprising and variants thereof (e.g., comprise and comprises).