May 2014

Clinicians’ shoes can send mixed message to patients

5Footwear-iStock19940141vPatients often look to foot and ankle practitioners for advice about footwear choices. But a recent survey of physicians found that nearly half don’t educate their patients about footwear guidelines, and that only one in five respondents actually wears the type of shoes they recommend.

By Daniel Farber, MD

Although many people choose fashion over function in their daily footwear, those who suffer from foot pain are challenged to find the elusively perfect shoes that balance fit, function, and fashion. These ideal shoes would combine the elements of arch support and cushioning with adequate room for the foot itself, aid in effortless gait, and look good while doing it. In pursuit of this holy grail of footwear, patients frequently query their healthcare providers about the attributes of the perfect shoe. But is there a perfect shoe? How does one answer this common question from patients, who have many different foot types and shapes and different physical demands and limitations?

To approach this question, it’s helpful to briefly consider the origin and development of modern footwear. Evidence suggests humans used shoes almost 40,000 years ago.1 We presume shoes began as a protective covering for the feet, but they have evolved into so much more.

The earliest shoes were made from plant-based materials secured to the foot with vines or grasses. The Greeks introduced advanced fine artistry with leather materials, and the Romans perfected the sandal into a functional and effective form for military use. With the success of the Roman Empire, these sandals made the move from a relatively simple foot covering to a fashion item with decoration and embellishment with valuable materials.2


The medieval period brought further footwear changes, with sandals giving way to enclosed shoes of varying lengths. Some were very long, which was an indicator of social status. This trend in turn gave way to more sensible lengths as well as round and square toe shapes. Throughout the centuries that followed, many changes in shoe styles occurred, including the introduction of heels for men and women around the late 1500s and of buckles in the 1600s. (High-heeled shoes had largely passed out of style for men by the 1700s, but remain popular among women.)

In the 1800s, footwear became even more diverse with the use of buckles and varying toe-box shapes.3 In the 1900s, as hemlines rose, more attention was paid to the fashion of newly prominent footwear. A major change in shoe manufacturing occurred on January 24, 1899,4 when inventor Humphrey O’Sullivan received a patent for a rubber heel as an alternative to leather heels. In 1917, Keds, a canvas-topped rubber-soled shoe, became the first mass-marketed sneaker.4 With this technology came the opportunity for new possibilities in shoe design and construction that has ultimately led to the range of options available today.

footwear-fig1There is a plethora of brands and styles in today’s market and a dearth of literature to guide choice. Much of the shoe industry seems driven by fashion, brand, consumers’ perceived lifestyle, or price point. New technologies are introduced without scientific evaluation of their worthiness. Choosing a shoe can become akin to shopping for a mattress in which there are many options and many claims of scientific superiority but few ways to directly compare the alternatives. There is also confusing pricing, which doesn’t necessarily reflect the quality of the product or its materials.

The public perception of the proper supportive shoe that might be recommended by a physician is the “granny” or orthopedic shoe. This is the drab, low-heeled, wide-toed, clumsy, and awkward-appearing shoe that few patients seem willing to wear to solve their foot comfort issues. Consequently, physicians are often queried about what shoe they recommend.

Surveying surgeons

In a recent study,5 276 orthopedic surgeons in the American Orthopaedic Foot and Ankle Society (AOFAS) were surveyed about their footwear recommendations, as well as their own footwear habits. The results are instructive: Surgeons reported some clear preferences about certain shoe brands for certain indications, but there was far from universal agreement. And one must remember that these findings are based on individual opinions, which may not be based on the science of footwear.

The study also investigated the use of the AOFAS guidelines, “10 points of proper shoe fit.” This set of recommendations is designed to educate physicians so they can guide patients’ selection of proper footwear (Figure 1). More than three quarters (76%) of the responding surgeons were familiar with the 10 points but only 56% educated their patients about these guidelines. Of those, most did so using a face-to-face discussion, but some (38%) used preprinted brochures, and a smaller percentage referred patients to the Internet (20%). Interestingly, only 59% of the responding surgeons followed these guidelines in their own footwear choices. This may reflect the fact that those without acute foot issues—even foot and ankle surgeons—pay little attention to avoiding future problems.

There were several clear winners in some footwear categories. For athletic shoes, 64% of surgeons recommended New Balance. While 23% of respondents recommended Skechers, more than a quarter (26%) did not recommend any specific brand (Figure 2).

In the dress shoe category, more than one-third (33%) of respondents made no recommendations. However, both Rockport and SAS were recommended by 27% and 25% of surgeons preferred Ecco dress shoes (Figure 3).

This study also examined the surgeons’ personal shoe-wearing habits. For athletic pursuits, physicians appeared to follow their own recommendations, with 50% selecting New Balance shoes and 25% selecting Nike. In a casual setting, New Balance was again the predominant choice (36%); Ecco and Rockport were the next-most popular choices, with both selected by 16% of respondents.

footwear-fig2-3Responses were more varied in the dress shoe category. Ecco and Rockport led the way at nearly 24%, with Johnston and Murphy following at 13.5%. Multiple brands made up the remainder of recommendations. For operating room wear, there was little agreement about shoe choice among surgeons, and responses were as varied as old garden clogs, muck boots, cowboy boots, and many other types of shoes.

Despite often being asked about shoes, orthopedic foot and ankle surgeons did not appear to consider themselves role models for their patients. Nearly half (43%) said they didn’t consider patients’ opinions of their own shoes when making general footwear recommendations. Although 38% agreed that patients might be influenced by their surgeon’s choice of shoes, only 19% attempted to wear the type of shoes that they recommend to patients.

In search of evidence

Although there are some clear preferences by surgeons with regard to athletic shoes, and some trends for dress shoes, surgeons seem to ignore those patterns when making decisions about their own footwear. This raises the question of what the medical literature has to say about the subject.

The literature evaluating shoes for the general population is scarce. There are multiple studies examining the use of specialized shoes for diabetes, and a PubMed search of the keywords “diabetic” and “footwear” produced nearly 350 results. At least 69 studies have investigated the effect of footwear on athletic performance. Other studies have focused on contact pressures associated with various footwear types and orthotic devices. Still others have investigated the fall risk associated with some shoes, primarily in the elderly population. There have been a limited number of studies regarding shoe choice in gout and rheumatoid arthritis, among other specific conditions. However, little guidance is available for the average person. This is important, as it has been shown that patients commonly wear improperly fitting shoes,6 which can negatively affect gait.7

Morio et al8 studied 10 healthy male adults and found footwear decreased both torsional and adduction motion of the foot compared with a barefoot condition. Eversion was the most significant motion affected. In children, Wegener et al9 performed a systematic review of 11 studies and concluded that shoes reduce foot motion and thereby increase motion at the ankle and knee during walking, decrease swing velocity during running, and encourage a heel-strike pattern. Some of these changes may be attenuated by increasing the flexibility of shoes, illustrating that footwear can make a difference in performance and, potentially, comfort and stress in the lower extremities. A review by Frederick10 also concluded that specific changes in footwear could have a measurable effect on elements of sports performance.

With the knowledge that shoe design has specific repercussions on shoe function and fit, Barton et al11 attempted to develop a tool to assess these footwear characteristics. Their instrument incorporates fit, general features, structure, motion control properties, cushioning, and wear patterns. Although this tool may be helpful in evaluating a shoe one already owns, it still does not help one choose a shoe de novo.

Krauss et al12 and others have shown there are notable differences between men’s and women’s feet: Men’s feet are wider and higher for the same foot length, necessitating different shoe designs for men and women at similar foot sizes. Customizing shoes may help accommodate some of these differences. Mundermann et al,13 for example, demonstrated that shoe inserts that increased comfort in military recruits also decreased injury rates. Mauch et al took this a step further and performed 3D scanning of the feet of 2867 German children to classify foot shape and allow the creation of specific shoe designs to accommodate their feet. Finally, Grier et al14 replaced the shoes of 112 US military band members with new footwear that had presumed improved cushioning and ventilation, but they saw no decrease in the rate of injury or foot problems over one year.

Basic principles

With limited professional agreement and minimal supporting literature, how does one find the perfect shoe? Like many aspects of the art of medicine, following some basic principles can provide guidance, and it’s useful to consider the following elements: fit, comfort, function, and specific pathology.

Patients and providers must make the effort to achieve and check for proper shoe fit. This includes a wide enough toe box with adequate depth for any toe deformities, proper fit around the heel, and support in the arch without creating undue plantar pressures. The shoes should feel comfortable at the time of fitting. Any pressure points and areas of tightness or slippage need to be addressed and, if appropriate modifications can’t be made, then a different shoe should be tried.

Footwear should be chosen for the appropriate activity, whether that is walking, running, other sports, or work. Finally, for patients with specific conditions, such as diabetes, neurologic conditions, or severe deformity, evidence-based interventions such as diabetic insoles and specialized footwear should be used to prevent problems. In some cases of severe deformity, off-the-shelf footwear may not be appropriate and custom interventions should be sought.

In summary, foot care providers should make an effort to educate their patients about proper shoe selection. This may take the form of a specific shoe recommendation, but more commonly involves teaching patients the proper elements of shoe selection using tools such as the AOFAS 10 points of proper shoe fit. It may also be important for physicians to set a good example to encourage patients to comply with their recommendations.

Daniel Farber, MD, is an orthopedic foot and ankle surgeon and assistant professor of clinical orthopaedic surgery at the University of Pennsylvania in Philadelphia.

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  12. Krauss I, Grau S, Mauch M, et al. Sex-related differences in foot shape. Ergonomics 2008;51(11):1693-1709.
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  14. Grier TL, Knapik JJ, Swedler D, Jones BH. Footwear in the United States Army Band: injury incidence and risk factors associated with foot pain. Foot 2011;21(2):60-65.

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