Goals Footwear and Objectives Assessment and Management CME.pdf · upper and the sole. • Linings—Linings are the in-side of the vamp and quarter and can be softer material than

Understanding shoe construction and materials aids in properly fitting patients.

FootwearAssessment andManagement

OCTOBER 2007 • PODIATRY MANAGEMENTwww.podiatrym.com 165

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Following this article, an answer sheet and full set of instructions are provided (p. 176).—Editor

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Goals and Objectives

After completing thisCME, should have:

1) Knowledge of foot-wear construction andmaterials.

2) Skills to accuratelyassess the fit and suitabili-ty of footwear.

3) Current knowledgeof the footwear optionsavailable to better treatpatients.

leading to lower extremity ulcer-ation and amputation in peoplewith diabetic neuropathy.1-5

The benefits of appropriatefootwear in pat ients withrheumatoid arthritis are reduc-tion in pain, and increased mo-bility.6-8 In the elderly population,it is recognized that inadequatefootwear such as badly wornshoes or slippers contribute to

Continued on page 166

Editor’s Note: This CME was origi-nally published by The Society of Chi-ropodists and Podiatrists, and isreprinted by permission.

IntroductionFootwear plays an important

role in the maintenance of foothealth in the healthy population,and has a vital role for people

with systemic diseases affectingthe health status of the lowerl imb. Pat ients with diabetes ,rheumatoid arthritis, connectivetissue disorders, peripheral vascu-lar disease and other conditionsassociated with compromisedneurological status and poor tis-sue viability benefit from appro-priate footwear. It is known thatfootwear has been found to be aprecipitating cause of trauma

By Anita Williams

cluding leather, man-made mate-rials, or, in the case of safetyfootwear, steel and high densityplastics. The tongue of the shoeis attached to the vamp. This isseen mostly in lace-up shoes andthose with fas tenings at thethroat where the fit of the shoe isnarrowest.

• Quarte r s—The s ides andback of the upper are termed thequarters and the top edge i stermed the topline of the shoe.The inner and outer sections ofthe top line are often joined in

the center at the back of theheel. The inside of the quarter isusually reinforced around theheel with a stiffener called the‘heel counter’ and has the pur-pose of stabilizing the rearfoot(particularly important in peoplewith excessive foot pronation—flatfeet). In lace-up shoes theeyelets for the laces are at thefront of the quarter. This part of

the quarter coversthe tongue, whichis attached to thevamp or formspart of the vamp.

• Throat—Theposi t ion of thisarea of the shoe isdependent on thestyle. It is formedby the seam join-ing the vamp tothe quarter . Alower throat line(ex. lace-to-toe)wi l l provide awider opening

and is particularly useful in footproblems which require ease ofaccess to the shoe, e.g., rheuma-toid arthritis, rigid ankle defor-mities, etc. Also, the seam willnot stretch and therefore dictatesthe maximum width of the shoe.

• Toe cap—This is a reinforc-ing cover stitched over the frontof the vamp. It can be decorative,as in certain styles of shoe suchas a strong oxford shoe, usuallywith ornamental perforationsand wing tips..

• Insole—This is the flat insideof the shoe, which covers themidsole and filler between theupper and the sole.

• Linings—Linings are the in-side of the vamp and quarter andcan be softer material than theupper, and hence provide morecomfort and add to the durabilityof the footwear. The lining in thebottom of the shoe is sometimestermed the insock (or sock lin-ing) and can be full length orthree quarters long.

• Shank—The shank reinforcesthe middle or the waist of theshoe from underneath to preventit from collapsing or distorting. It,therefore, needs to be completelyrigid or only slightly flexible.Shoes with a wedge sole, or veryflat shoes, do not need a shank.

• Outer so l e (outso l e )—Theunder surface of the shoe can bemade from a variety of materialsand is joined to the upper in sev-eral different ways, e.g. welted,stitched, or adhesive applied.There should be a small amountof toe spring at the front part ofthe sole so that the foot doesn’tcatch the ground during walking.Toe spring is the angle betweenthe flat surface and the heightthe toe is off the ground in rela-tion to the ball of the shoe.

• Heel—The heel raises the shoeabove the ground. If there is noraise at the heel area or the heel islower than the sole then this istermed a negative heel. The mate-rial covering the area of the heel


166 www.podiatrym.comPODIATRY MANAGEMENT • OCTOBER 2007

Footwear...

the occurrence of falls,9,10

demonstrating the complex in-terplay between footwear, walk-ing, and balance. Inappropriatefootwear can therefore impact onmobility, general health, inde-pendence and lifestyle. Therefore,appropriate footwear should beadvised to these individuals withthe aim of preventing falls andrelated problems, such as frac-tures and loss of mobility.

Footwear Construction andMaterials

Parts of a Shoe

• Vamp—The upper is madeof two main sections which to-gether are molded to form theupper of the shoe. The front sec-tion is termed the vamp and cov-ers the forefoot and the toes. Insome designs of shoes, the vampcan be decorative and made ofmore than one piece, or embel-lished with different materials orstitching. There may be problemswith this area i f there i s toomuch stitching and too manyseams on the vamp. These pre-vent stretching of the vamp ma-terial over the forefoot and toesand may lead to pressure onbony prominences. The vamp isusual ly re inforced in the toearea. This toe box retains theshape of the front of the shoeand prevents it from collapsingonto the toes.

The toe box can be madefrom a variety of materials in-

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There should

be a small amount

of toe spring at the

front part of the

sole so that the

foot doesn’t catch

the ground

during walking.

Figure 1: Shoe last


is an extremely skilled craft. Themeasurements of the last are re-lated to volume in addition towidth and length and, in this re-spect, a last is not an exact im-press ion of afoot . This i s toensure good f i tand a l so takesinto account thechanging dimen-sions of the footdur ing move-ment.

Materials Used inFootwearConstruction

• Upper materi-als—Leather isthe most common material andhas the advantage of being perme-able so that moisture can evapo-

that contacts the ground is calledthe top piece (or top lift) and thiscan be replaced or repaired.

Last Construction in Relation to Shoe Fit and Style

Lasts are the molds on whichshoes are made (Figure 1). Thedesign and shape of the shoe isdependent on the shape of thelast. For example, a last for ahigh heeled shoe needs to beshorter than the foot for which itis being designed to compensatefor the shortened ‘equinus’ posi-tion in which the foot is held. Inorder for a high-heel, pump-styleshoe to stay on the foot its lastwill differ from the last requiredto make a lace-up shoe.

Last design and manufacture

Footwear... rate away from the foot.The advantage to foothealth is that the skin is lessmacerated and therefore lesslikely for fungal infections to pro-

liferate. Leatheralso stretchesand accommo-dates to theuniqueness ofthe foot shape.The advantagesof leather arenegated by theuse of syntheticl inings and/orspecial coatingsoften used top r o t e c t t h eleather.

Some syn-thetic materials are also breath-able, but are less supple thanleather. The use of footwear withsynthetic uppers should not bedismissed as long as they fit welland a suitable period of dryingout is allowed between periods ofuse. Likewise, materials such ascotton corduroy may feel com-fortable but only stretch in onedirection and require reinforce-ment, particularly in the heelcounter.

• Linings—In traditional foot-wear, it is usually soft leather orsynthetic material. This does notgenerally cause a problem as theyare usually confined to the quar-ters and the sock-lining, wherethe loss of stretch and permeabil-ity is not a problem. Some of themodern lining materials can be‘breathable’ or ‘wick’ moistureaway from the foot.

• Soling and heels—The solemust be durable, waterproof andhave sufficient friction to pre-vent slipping. Leather was thetraditional soling material, but ismore expensive and is not asdurable in some condit ions .Man-made soling may be moredurable and resilient to water.Some are designed with bettergrip (traction) depending on thepattern. The soles can be lighter,with cavities in the main solingmater ia l be ing injected withlighter weight foam. Combina-


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Some of the

modern lining

materials can be

‘breathable’ or

‘wick’ moisture

away from

the foot.

TABLE 1Shoe Styles

STYLE DESCRIPTION

Boot Any footwear extending above the ankle.There are numerous designs and types for avariety of uses, and made from a number ofmaterials.

Clog Footwear with no heel counter. The sole canbe leather, synthetic, or wood.

Lace-up Any low-cut shoe fastened by lacings.

Monk Similar to Derby shoes, but with a cross-over section to fasten the quarters with aside buckle.

Moccasin This used to be a simple one-piece hide heldon with rawhide thongs. Today, moccasins can be slippers (with soft suede soles).

Mule A backless shoe or slipper with or without a heel.

Sandal An open shoe with the upper consisting ofany decorative or functional arrangement ofstraps. A sandal is designed for simple utilityor casual wear, or as a fashion shoe.

Court Heeled shoes (various heights) with low-cutfronts and usually no fastening. Those with a low heel are termed pumps.

Shoe StylesThere are eight basic footwear

styles, with the rest made up asvariations on the basic themes

(Table 1). The definition of a shoeis footwear with a mechanism capa-ble of holding the foot in the heelof the shoe to facilitate supportduring push off. Hence there are

two critical aspects of shoes, i.e.,the fastening around the instep andthe section corresponding to theheel. To prevent unnecessary move-ment, these need to be firm and fitthe foot.

There are a variety of footwearstyles that have evolved over cen-turies (for those who have an in-terest in the history of Footwear,visit www.footwearhistory.com orCurtin University websitehttp://podiatry.curtin.edu.au/his-tory.html for excellent informa-tion on the history of footwear).

Although style is dictated bycurrent fashion and the requiredfunction of the footwear, any shoethat is considered suitable for footfunction and protection must havea mechanism for holding the footback into the heel of the shoe.



Footwear...

tions of materials, e.g., amore durable outermost layer,

and a softer, more flexible mid-sole for greater comfort, can beused. This can be a useful combi-nation in patients presentingwith foot pathology, foot painand/or lesions associated withpressure. The heel can be madefrom synthet ic mater ia l or‘stacked’ layers of leather. Theheel is covered with a ‘top piece’(top lift), which can be replacedor repaired as the heel wearsdown with usage. The shank canbe made of steel, wood or syn-thetic material. Toe boxes andstiffeners support the upper ma-terial and prevent it from col-lapsing onto the toe or inwardsat the back of the shoe.

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TABLE 2Footwear Assessment

Checklist

OBJECTIVE ASSESSMENT SUBJECTIVE ASSESSMENT

Easily accessible at the throat or vamp Patient can get the shoes on themselves or their carer can

Strong secure fastening facings 10-12mm apart No feeling of slipping inside the shoe

The heel counter should not collapse when pushed and No excess pressure around the heel, or the heel cradled into the shoe with no pressure on TA conversely, slippageor malleoli

Length i.e., 1 cm. over the length of the longest toe for No pressure on the end of the longest toeelongation during gait

The position of the ball of the foot and ball flex line of the No feeling of cramping at the toesshoe. These must correspond or will cause either cramping of the toes or flexion of the foot over shank > vamp creasing and the shoe will never be comfortable

Adequate width so that there is no pressure on the joints. Comfortable across the joints of the foot Sole must be wide enough so there is no overhang of the (remember patients with diabetic neuropathy upper; takes account of static, dynamic and swollen like tightness so this has to be checked foot > compromise to accommodate all three objectively)

Adequate depth over joints and toes to allow free movement No localized tight spots over areas of and also at toe taper to eliminate pressure over the dorsal deformityaspect of the toes and nails

Width at toes—no side pressure or cramping: good style No pressure over toesis important

Suitable heel height for normal heel-to-toe action. Broad Feel stable when walkingheel for stability/weight redistribution

Without

this fixation, the

foot is allowed to

slip forward in

the shoe.


Footwear AssessmentIt is important to ascertain if

the footwear worn to the consul-tation are thosewhich are usual-ly worn. In fact,for new patients,it is often usefulin the appoint-ment letter to re-quest that theybring a selectionof the footwearmostly worn.

Patient’sHistory ofFootwearUsage and Preferences

As with any assessment, i tneeds to be a structured system-atic approach so that essentialfactors are not left out. It is im-portant to ascertain a patient’sshoe wearing habits. Informationabout when, where, and howoften shoes are bought can bevery useful. It is important to as-certain the footwear history, e.g.,past successes/preferences, likes,dislikes, requirements for em-ployment, e.g., safety footwear,and so on. Other factors that canbe ascertained are financial cir-cumstances and preferences withregards to body image.

Examination of the Footwear

Footwear needs to be evaluat-ed with the pat ient walk ing,standing, and sitting. Once the

Without this fixation, the footis allowed to slip forward in theshoe. This can result in frictionon the sole of the foot and thetoes impact into the front of theshoe, or in the case of sandals, thetoes overhang the front of thesole. The two main importantparts of any style of footwear area band around the instep and cor-responding support at the heelwhich need to be firm and fitclosely to the contours of the footin these locations.

The band around the foot pre-vents it from sliding forward andthe corresponding support at theheel prevents it from slippingbackwards and sideward. There-

fore, mules, clogs, sandals, andcourt shoes may be seen as beingunsuitable.

The suitability of each of themain styles depends on the exactstyling, heel height, materials used,and perhaps most importantly, theuse to which a patient will put thefootwear. For example, high heelcourt shoes may be worn withminimum risks to foot health inhealthy individuals, who wearthem for a very short time withminimal weight bearing. If theseshoes were worn for a long walk inthe countryside, they would notfunction well and the feet wouldcertainly suffer.

Footwear... footwear has beentaken off, it can be in-spected further. The foot-

wear can re -veal clues to aiddiagnosis so it isuseful to s tar twith an evalua-tion of any wearmarks or distor-tions.

• Wear marks—Assessment ofwear patterns ofshoes (inside ofshoe, upper andsoles) may help

confirm a diagnosis or reveal in-formation about foot function.15

Pressure under the sole of theshoe should be even, so no onepart wears out excessively. Nor-mal wear should occur at the lat-eral heel and medial central fore-foot (Figure 2). There may also beslight curvature on the under-surface of the sole at the toe area,which is accentuated by walking.Variat ion from this indicatessome abnormality.

If the tip of the sole is exces-sively worn, then the toe springis insufficient. Conversely, ab-sent wear at the tip of the soleindicates a lack of push-off dur-ing the gait cycle. If the sole cur-vature is absent, asymmetrical orexcessive, this may indicate ab-normal toe function, such as inrheumatoid arthritis. Excessive


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The suitability

of each of the

main styles depends

on the exact

styling, heel height,

materials used,

and perhaps

most importantly,

the use to

which a patient

will put the

footwear.

Pressure

under the sole

of the shoe should

be even, so no one

part wears out

excessively.

Figure 2 (left): Normal sole and heel wear pattern.

Figure 3 (right): Distortion of upper.

border of the heel.Crease marks in the shoe

upper normal ly run s l i ght lyoblique following the line of themetatarso-phalangeal joints. If it

is excessively oblique, this indi-cates fa i lure of f i rs t metatar-sophalangeal joint dorsi-flexion.If there is no crease at all, thenpropulsion is absent, such as ina short stride and/or flat-footedgait. Deformation of the upperis caused by the shoe conform-ing to foot deformities, such ashallux valgus, tailor’s bunion,claw toes or abnormal foot func-t ion, pronat ion, for example(Figure 3). Wear patterns insidethe shoe are l ike ly to mir rorthose found on the heel andsole and the insole and sock lin-ing will often display a print ofthe sole of the foot from whichareas of high pressures can beassessed.



Footwear...

forefoot wear indicatesankle joint equinus.Circular forefoot wear over

the first metatarso-phalangealjoint indicates pes cavus deformi-ty. Normal heel wear spreadsacross the postero-lateral borderof the heel . This re f lects theslightly inverted position of theheel at heel strike during the gaitcycle. Excessive heel wear on theinner border indicates a rigid ev-erted rearfoot, while excessivewear on the outer border indi-cates a rigid inverted rearfoot;however, if the foot is flexibleand excessively pronating duringthe gait cycle, the heel wear maywell be heavy along the outer

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TABLE 3Footwear Suitability Scale

(Nancarrow, 1999)

1) Is the heel of your shoe less As the height of your heel increases, the pressure under the ball of your than 2.5 cm. (1”)? foot becomes greater. Increased pressure can lead to callus and ulceration.

2) Does the shoe have laces, If you wear slip on shoes with no restraining mechanism, your toes must buckles or elastic to hold it curl up to hold the shoes on. This can cause the tops of your toes to rub onto your foot? your shoes, leading to corns and calluses. Secondly, the muscles in your

on feet do not function as they should to help you walk. Instead they are being used less efficiently to hold your shoes on.

3) Do you have 1 cm. (approx thumb This is the best guide for the length of the shoe, as different nail length) of space between manufacturers create shoes that are different sizes. Your toes should your longest toe and the end of not touch the end the shoe as this is likely to cause injury to the toes your shoe when standing? and place pressure on the toe nails.

4) Do your shoes have a well- Shoes should have supportive, but cushioned sole to absorb any shock padded sole? and reduce pressure under the feet.

5) Are your shoes made from A warm, moist environment can harbor organisms, such as those that material that breathes? cause fungal infections.

6) Do your shoes protect your The main function of footwear is protection from the environment. feet from injury? Ensure your shoes are able to prevent entry of foreign objects that can

injure the foot. If you have diabetes, a closed toe is essential to prevent injury to the foot.

7) Are your shoes the same shape Many shoes have pointed toes and cause friction over the tops of the toesas your feet? which can lead to corns, callus and ulceration. If you can see the outline of

your toes imprinted on your shoes, then the shoe is probably the wrongshape for your foot.

8) Is the heel counter of your Hold the sides of the heel of your shoe between the thumb and forefinger shoe firm? and try to push them together. If the heel compresses, it is too soft to give

your foot support. The heel counter provides much of the support of the shoe and must be firm to press.

Perhaps an

obvious thing that

the practitioner

can do is to check

whether the

footwear is the

right size.


and the body weight cannot shiftfrom heel to ball as in barefootwalking, but i s concentratedwholly on the ball.

In a flat-heeled shoe, the shoeand foot are functioning togetherwith the heel lifting with eachstep and moving the weight for-ward onto the bal l . In a low-heeled shoe the vamp will creasewith the flexion of the forefoot.In a high-heeled shoe there willbe no creasing as there is no flex-ion of the metatarsophalangealjoint. The low-heeled shoe re-quires more toe room in the fit-ting because there is more for-ward movement or extension ofthe foot with each step (Figure 5).

• Length—heel-to-ball jointlength—This measurement is veryimportant in successful shoe fit-

Examination of the fit of footwear (Table 2)

Perhaps an obvious thing thatthe practitioner can do is to checkwhether the footwear is the rightsize. There are two primary waysto do this. 1. Shoes on: to assessshoe fit have the patient stand inthe shoes they wore in. Check forlength, width, last, heel height,and balance. 2. Shoes off: with the

shoes off begin by measuring thelength and width of the foot, andalso investigate the heel-to-ballmeasurement and the depth of thefootwear.

• Heel fit—The heel should besnugly cradled into the heel of theshoe to prevent gaping and slip-page. The top edge of the heelcounter should not dig into theAchilles tendon or malleoli. Heelfit also influences the entire fit ofthe shoe because the foot has adifferent stance inside a high-heeled and a low-heeled shoe, andalso functions differently insidethe shoe. When walking barefoot,the heel of the foot is lifted abouttwo inches with each step, withthe ball of the foot working as afulcrum for the step-off.

The amount of heel r ise isproportional to the length of thestep. Therefore, the longer thestride, the higher the heel rise. Ina shoe with a two- inch heel ,there is no rise in the heel, be-cause the shoe i s a l ready ac-counting for that rise. The higherthe heel, the shorter the stride

Footwear... ting. Even if feet are thesame length overall thelength of the heel to ballmeasurement may be longer orshorter (Figure 4). This has majorimplications with regard to shoe fitand the patient’s comfort. The firsttoe joint must fit into the widestpart of the shoe where it is de-signed to bend so that the shoeand foot can bend together.

The practitioner must becomeproficient at determining theexact position of the first jointinside the shoe, because if it istoo far forward, or back, the shoemay appear to fit overall, but itwill never be comfortable. Thepatient can be asked to stand ontip toe and the flex line checkedor, if the shoe has a removablefull length lining, this can be


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The first toe

joint must fit into

the widest part of

the shoe where

it is designed to

bend so that the

shoe and foot can

bend together.

Figure 4: Foot length. A = both feet the same overall length; B = long heel-to-ball jointmeasurement; C = short heel-to-ball joint measurement

Figure 5: Key areas to check the fit of footwear.

• Patte rns and vamps—Pat-terns have a tremendous influ-ence on shoe fit. This applies es-pecially to the ease of gettingthe shoe onto the foo t andkeeping it on securely. There arelong and short vamp lasts andgenerally the rounder the toethe more likely the vamp will beshorter; the more tapered thetoe the longer the vamp. Vamplength i s de te rmined by the

shoe’s design (especially in theretail industry) and correct styleis crucial for forefoot comfortand fit. An example of a longand short pattern would be asix-eyelet tie and a three-eyelettie style, each made on the samelast. The difference in the pat-te rns wi l l a f fec t the way thefoot extends into the shoe andwill also affect the instep free-dom. So, for example, where the

practitioner would be fitting ashoe that is required to accom-modate a large hal lux valgusjoint a six-tie eyelet would be abetter choice as the throat entrywould be larger, enabling easierentry and better adjustment ofthe top l ine around the foot(Figure 5).

Footwear OptionsThere are now many manu-

facturers of retail footwear that isboth appropriate for the foothealth of our patients and is af-fordable. Many foot problemsbenefit from a change in foot-wear style or to a style with dif-ferent features. Some footwearcan be modif ied with rockersoles, which are helpful in reduc-ing forefoot pressures in the dia-betic foot and pain and pressurein the rheumatoid foot.

If patients have major footproblems or deformity then spe-cialized therapeutic footwear canbe provided. Pedorthists and or-thotists are the professionals whohave generally assessed and pro-vided this therapeutic footwearbut increasingly podiatrists areworking alongside their pedorth-ic colleagues or taking on someof the pedorthists’ role, particu-larly in the provision of stockfootwear. Team working in thisarea has demonstrated improvedclinical outcomes and patientsatisfaction compared with work-ing in isolation.16

It is important that podia-trists create good working rela-tionships with their pedorthiccolleagues in the assessment ofpatients, shared information andin the provision of the special-



Footwear...

used against thefoot to check where

the ball flex line occurs.If the ball joint positionis too far forward thetoes will be crowded inthe toe box. If it is toofar back the result is ab-normal tread wear marksand excessive creasing ofthe vamp. These mea-surements can be takenusing a Brannock mea-suring device (for more informa-tion www.brannock.com) whichprovides the practitioner withmore information than the tradi-tional size stick.

• Length—bal l j o in t to toelength—Check the length of allthe toes and don’t assume thatthe first toe is the longest. Gen-erally 1 cm. space at the end ofthe toes is considered sufficient.Also remember toe width andforefoot shape in relation to thestyle of shoe.

• Bal l width—This i s thewidth of the sole (ball tread) andinsole as well as the upper. Theshoe has to adapt to three differ-ent widths at the ball—with thefoot at rest, weight bearing andunder thermal conditions, i.e,swelling. Experience and judg-ment informs the practitionerwhich width will best suit allthese conditions. Subjective feed-back from the patient will alsoaid decisions.

• Throat—This is the entrypoint into the vamp or forepartarea. There must be sufficientroom when the shoe is fastenedonto the foot to allow for thewaist and instep to move duringweight-bearing (a finger width atthe back indicates sufficient roomfor this). A strong secure fasteningto hold the rearfoot against theheel of the shoe prevents forwardslide. The facings (spacing) (wherethe eyelets are) should be usually10-12 mm. apart. If they are over-lapping, the volume of the shoe istoo much, and if they are widerapart than 12 mm., the shoe is toosmall (Figure 5).

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Some footwear

can be modified

with rocker soles,

which are helpful

in reducing

forefoot pressures

in the diabetic

foot and pain and

pressure in the

rheumatoid foot.

Figure 6: An example of ‘stock’ footwear. Figure 7: An example of custom-made footwear.


achieve optimum fit but to thepatient the objective is to achievecomfort and/or style.

It is difficult for practitioners torecommend styles, as there are con-stant changes in fashion. It is betterto recommend certain aspects of

footwear that areimportant fea-tures with regardto fit (Table 3—Footwear Suitabil-ity Scale). Thesefeatures may varyslightly accordingto the specificfoot problems.For example, apatient with anequinus footproblem maybenefit fromwearing a sturdy

but higher heel than those recom-mended withforefoot pain anddeformity.

FootwearSuitabilityAssessmentTools

Footwear as-sessment prac-tices tend to besubjective andtend to focus onthe style of thefootwear ratherthan the suitabil-ity of the footwear for the individ-ual patient and their presentingfoot problems. Non-specialistfootwear assessment rel ies onlength and sometimes width andheel-to-ball measurement, butgenerally ignores the depth. Pa-tients can generally understandwhat is meant by width, but maynot understand the concept of

ized footwear.Stock footwear is therapeutic

footwear that is available in a vari-ety of styles and fittings, for exam-ple, extra deep, and/or extra wide(Figure 6). Cus-tom-made foot-wear (Figure 7) isan option whenthere is major de-formity such asCharcot or ad-vanced rheuma-toid arthritis de-formity (Figure8), if there is ahuge differencein symmetry,fixed equinus ofmore than 20mm., or if thefoot dimensions are outside themeasurements for stock footwear.

Footwear AdviceFootwear can be perceived by

individuals in a variety of waysand this depends on what theshoes are required to offer. Foot-wear can provide a specific func-tion (e.g., toe protection in safetyshoes) but in many people it is in-extricably linked to body image.In this respect fashion trends candictate the style and type of foot-wear worn by individuals. Theachievement of a good clinicaloutcome for the patient relies onmanaging expectations and prac-titioners must recognize that pa-tients may have aims differentfrom their own. For example, thecl inician’s aim might be to

Footwear... depth unless it isdemonstrated by the prac-titioner.

Because of the differencesin the lasts used for differentfootwear and even differences ininternational sizing, there is lackof standardization. This makes itdifficult for patients themselvesto be able to identify footwearthat is suitable for their foothealth and their needs in respectto footwear usage. To address thisproblem a Footwear SuitabilityScale was developed17 specificallyfor patients with diabetes. Thishas proven to be a useful tool inpractice in non-diabetic patientsand as an educational tool in en-suring that practitioners are ableto identify, rationalize and ex-plain the importance of each partof the shoe when providing ad-vice for the patient (Table 3—

Footwear Suit-ability Scale).

I t i s impor-tant for the prac-titioner to knowthe retail trends,and sources offootwear that aresuitable. Havingleaflets on differ-ent footwearm a n u f a c t u r e r smay be useful ineducating andinforming pa-tients about the

sources of good footwear. How-ever, the most important factor ingetting patients to change theirfootwear ‘behavior’ is for the


Continuing

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Footwear can be

perceived by

individuals in a

variety of ways and

this depends on

what the shoes are

required to offer.

It is important

for the practitioner

to know the

retail trends,

and sources of

footwear that are

suitable.

Figure 8: Rheumatoid arthritis foot de-formity requiring custom footwear.

Figure 9: Diabetic neuropathic foot withamputation of the fourth toe. Figure 10: Lack of symmetry.

tients. Diabetes Res Clin Practice. Mar;(1996) 31 (1-3); 109-14.

4 Uccioli L, Aldeghi A, Faglia E et al.Manufactured shoes in the preventionof diabetic foot ulcers. Diabetes Care(1995) 18:1376-8.

5 Chantelau E,Kushner T, SpraulM. How effective iscushioned therapeu-tic footwear in pro-tecting diabeticfeet? A clinicalstudy. Diab Med(1990) 7: 355-359.

6 Chalmers AC,Busby C, Goyert J,Porter B, SchulzerM. Metatarsalgiaand Rheumatoidarthritis—a ran-domised, singleblind, sequential trial comparing 2types of foot orthoses and supportiveshoes. The Journal of Rheumatology(2000) 27: 7 1643-1647.

7 Shrader J.A. (1999). NonsurgicalManagement of the Foot and Ankle Af-fected by Rheumatoid Arthritis. Journalof Orthopaedic and Sports PhysicalTherapy 29 (12): 703-717.

8 Grifka, J K. Shoes and Insoles forPatients With Rheumatoid Foot Disease.Clinical Orthopaedics & Related Re-search. The Rheumatoid Foot. (1997)340: 18-25.

9 Koepsell TD,Wolf ME, BuchnerDM, KuKull WA, LaCroix AZ Tencer AFet al Footwear styleand risk of falls inolder adults Journalof the AmericanGeriatrics Society(2004) 52 (9): 1495-501.

10 Sherrington Cand Menz HB Anevaluation of foot-wear worn at thetime of fall relatedhip fracture 2003Age and Aging; 32:310-314.

11 Disabled Liv-ing Foundation.

Foot wear—a Quality Issue. Provision ofprescribed Footwear within the NationalHealth Service. 1991.

12 Bowker P, Rocca E, Arnell P, andPowell E. A study of the organisation oforthotic services in England and Wales.1992. Report to the Department ofHealth, UK.

13 Williams A. E and Nester C.J Pa-tient perceptions of prescribed stockfootwear design. (2006) Prosthetics andOrthotics International (in print).

14 Vernon, D.W and McCourt, F.J.,Forensic Podiatry—a review and defini-tion, (1999) British Journal of Podiatry,May.

15 Vernon W, Parry A and PotterM. A theory of shoe wear pattern in-

fluence incorporat-ing a newparadigm for thepodiatric medicalprofession. (2004)Journal of theAmerican PodiatricMedical Associa-tion. 94;3:261-268.

16 Williams Aand Meacher KShoes in the cup-board—the fate ofprescribed foot-wear. (2001) Pros-thetics and Or-

thotics International 25:53-9.17 Nancarrow SA Footwear suit-

ability scale:a measure of shoe fit forpeople with diabetes 1999 AJPM 33;2.

18 Prochaska, J . and C. Di-Clemente (1984). The transtheoreticalapproach: Crossing traditional bound-aries of therapy. Homewood, Ill., DowJones-Irwin.

19 Prochaska, J. O. and C. C. Di-Clemente (1982). Transtheoreticaltherapy: Toward a more integrativemodel of change. Psychotherapy: The-ory, Research and Practice 19(3): 276-288.

Additional Reading1) McPoil TG. (1988). Footwear.

Physical Therapy; 68(12): 1857-1865.2) Janisse DJ. (1992). The art and

science of fitting shoes. Foot & Ankle;13(5): 257-62.

3) Rossi WA, Tennant R. Profes-sional Shoe Fitting: Chapter 8, pp.90-105.

4) Merriman LM, Tollafield, DR.Assessment of the Lower Limb: Chap-ter 10, pp.227-47. The D3D Ortho-peadic and Functional shoes are avail-able exclusively from RSscan Lab Ltd,Violet Hill Road, Stowmarket, SuffolkIP14 1NN Tel: 01449 612739, Fax:01449 770025, Email: [email protected], www.rsscan.co.uk


Footwear...

practitioner to understandthat it may take some time. It

is known that knowledge doesn’tnecessarily influence behavior.Having the knowledge may be thestart of a process for patients tothink about change, make thechange, and then maintain thechange.18,19

In situations where clients’shoes contribute to subjectivesymptoms, but there is no appar-ent conscious acceptance of this,then the practitioner may haveto accept that this is the patients’personal decision. Under thesecircumstances negotiated care orcompromise is required.

ConclusionFootwear plays a vital role in

the management of foot prob-lems. Providing patients with thecorrect advice or referral for spe-cialized footwear can impact onthe success of other clinical inter-ventions. Footwear assessmentshould be part of every visit tothe podiatrist. Podiatrists need todevelop skills in ascertaining thepatient’s problems in relation tofootwear, t h epat ient ’s poten-t ial for changeand the solutionsto their footwearproblems. ■

Editor’s Note:We wish to ac-knowledge RobertSchwartz of Enes-low—The FootComfort Center ofNew York for hisassistance in edit-ing this CME.

References1 Baker N, and

Leatherdale B. An audit of prescriptionfootwear. The Diabetic Foot 2002; 100-4.

2 Striesow F Special manufacturedshoes for the prevention of recurrent ul-cers in the diabetic foot. Med Klini.(1998). Dec 93; 12, 695-700.

3 Donaghue VM, Sarnow MR,Giunne JM, Chrzan JS, Habershaw GMand Veves A Longitudinal inshoe footpressure relief achieved by specially de-signed footwear in high risk diabetic pa-

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Anita Williams isLecturer Direc-torate of Podiatryat the Universityof Salford, and amember of theCentre for Reha-bilitation andHuman Perfor-mance Research.

Providing patients

with the correct

advice or referral

for specialized

footwear can

impact on the success

of other clinical

interventions.

Footwear

assessment

should be part of

every visit to the

podiatrist.


6) Excessively oblique creasemarks in the upper indicates

A) absent propulsion such asin a short stride and/or flat-footed gait.B) tailor’s bunion.C) cheap shoes.D) failure of first metatarso-phalangeal joint dorsi-flexion.

7) When measuring the foot, ifthe ball joint position is too farforward the toes will

A) cause abnormal treadwear marks and excessivecreasing of the vamp.B) not reach the end of the shoe.C) be crowded in the toebox.D) be comfortable.

8) For a good fit, the facings ofa shoe should

A) allow for tightening.B) overlap.C) meet.D) have a large gap.

9) It is difficult for practitionersto give advice on footwearstyles because of changes infashion. It is better, therefore,to

A) not bother.B) recommend certain as-pects of footwear whichhave important features withregards to fit.C) wait for the patient tofind a proper style.D) wait for fashion changes.

1) Evidence supports the use ofappropriate footwear in patientswith rheumatoid arthritis, withthe benefits being

A) reduction in pain, and in-creased mobility.B) reduced need for pain-re-lieving medication.C) prevention of deformity.D) increased health statusscores.

2) The upper of a shoe is com-prised of two parts called

A) the insole and linings.B) the vamp and quarters.C) the topline and toe box.D) the shank and counter.

3) The structure which supportsthe waist of the shoe is called

A) the toe box.B) the vamp.C) the heel counter.D) the shank.

4) The purpose of a ‘toe spring’is to

A) prevent catching of thefront of the shoe on the walk-ing surface.B) relieve pressure on thetoes.C) prevent the toe box fromcollapsing.D) improve the fit of theshoe.

5) Excessive heel wear on theinner border indicates

A) a rigid everted rearfoot.B) a rigid inverted rearfoot.C) a flexible and pronatedfoot.D) a severe equinus deformity.

10) What is the main reason forassessing a patient’s footwear?

A) Footwear influences foothealth.B) Patients expect it.C) Patients have to changefootwear stylesD) You need to make surethe shoes are a good value.

11) What is the most importantfitting point?

A) width,B) heel-to-ball and ball-to-toeC) depthD) heel fit

12) The normal shoe wear pat-tern on the heel is

A) centralB) medialC) right across from medialto lateralD) slightly lateral

13) What happens to forefootpressures with an increasein heel height when stand-ing?A) NothingB) It decreasesC) It IncreasesD) It fluctuates

14) What happens if the heel-to-ball joint measurement islong?

A) The foot will not flex.B) The foot flexes in front ofthe flex line of the shoe.C) The shank irritates thefoot.D) The heel slips.

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See answer sheet on page 177.


176 PODIATRY MANAGEMENT

15) Excessive forefoot wear marks indicateA) excessive pronation.B) excessive supination.C) ankle equines.D) rigid toes.

16) It is important to have a firm heel counterbecause it

A) provides support at the heel.B) makes the shoe look good.C) stops the shoe from rubbing.D) stops the foot slipping forwards.

17) Compared to the dimensions of a foot, thedimensions of a high-heeled shoe will be

A) Longer.B) Shorter.C) Wider.D) Deeper.

18) Leather is often used for the uppers of foot-wear as it is

A) permeable.B) non-permeable.C) thermal.D) flexible.

19) To increase the access to a shoe, the follow-ing is required:

A) high quartersB) a stiff heel counterC) a substantial toe boxD) a low opening vamp

20) A well padded sole providesA) increased height.B) extra protection and comfort.C) protection from slipping.D) a good shape to the shoe.

E X A M I N A T I O N

(cont’d)

See answer sheet on page 177.

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LESSON EVALUATION

Please indicate the date you completed this exam

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How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educational objectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

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__________________________________________________

EXAM #8/07Footwear Assessment and Management

(Williams)

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

Documents

Goals Footwear and Objectives Assessment and Management CME.pdf · upper and the sole. • Linings—Linings are the in-side of the vamp and quarter and can be softer material than