Footwear Assessment and Management Assessment Footwear ENROLLMENT FORM & ANSWER SHEET & ANSWER FORM ENROLLMENT PODIATRY MANAGEMENT • OCTOBER 2007

Home , Footwear, Mule (shoe), Oxford shoe

MedicalContinuing Education

Goals and Objectives Footwear After completing this CME, should have: Assessment and 1) Knowledge of footwear construction and Management materials. 2) Skills to accurately assess the fit and suitability of footwear. Understanding shoe construction and materials aids in properly 3) Current knowledge fitting patients. of the footwear options available to better treat patients.

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By Anita Williams with systemic diseases affecting leading to lower extremity ulcer- the health status of the lower ation and amputation in people Editor’s Note: This CME was origi- limb. Patients with diabetes, with diabetic neuropathy.1-5 nally published by The Society of Chi- rheumatoid arthritis, connective The benefits of appropriate ropodists and Podiatrists, and is tissue disorders, peripheral vascu- footwear in patients with reprinted by permission. lar disease and other conditions rheumatoid arthritis are reduc- associated with compromised tion in pain, and increased mo- Introduction neurological status and poor tis- bility.6-8 In the elderly population, Footwear plays an important sue viability benefit from appro- it is recognized that inadequate role in the maintenance of foot priate footwear. It is known that footwear such as badly worn health in the healthy population, footwear has been found to be a shoes or slippers contribute to and has a vital role for people precipitating cause of trauma Continued on page 166 www.podiatrym.com OCTOBER 2007 • PODIATRY MANAGEMENT 165 Footwear... cluding leather, man-made mate- and is particularly useful in foot rials, or, in the case of safety problems which require ease of Continuingthe occurrence of falls,9,10 footwear, steel and high density access to the shoe, e.g., rheuma- demonstrating the complex in- plastics. The tongue of the shoe toid arthritis, rigid ankle defor- Medical Education terplay between footwear, walk- is attached to the vamp. This is mities, etc. Also, the seam will ing, and balance. Inappropriate seen mostly in lace-up shoes and not stretch and therefore dictates footwear can therefore impact on those with fastenings at the the maximum width of the shoe. mobility, general health, inde- throat where the fit of the shoe is pendence and lifestyle. Therefore, narrowest. • Toe cap—This is a reinforc- appropriate footwear should be ing cover stitched over the front advised to these individuals with • Quarters—The sides and of the vamp. It can be decorative, the aim of preventing falls and back of the upper are termed the as in certain styles of shoe such related problems, such as frac- quarters and the top edge is as a strong oxford shoe, usually tures and loss of mobility. termed the topline of the shoe. with ornamental perforations The inner and outer sections of and wing tips.. Footwear Construction and the top line are often joined in Materials • Insole—This is the flat inside of the shoe, which covers the Parts of a Shoe midsole and filler between the There should upper and the sole. • Vamp—The upper is made be a small amount of two main sections which to- • Linings—Linings are the in- gether are molded to form the of toe spring at the side of the vamp and quarter and upper of the shoe. The front sec- can be softer material than the tion is termed the vamp and cov- front part of the upper, and hence provide more ers the forefoot and the toes. In sole so that the comfort and add to the durability some designs of shoes, the vamp of the footwear. The lining in the can be decorative and made of foot doesn’t catch bottom of the shoe is sometimes more than one piece, or embel- termed the insock (or sock lin- lished with different materials or the ground ing) and can be full length or stitching. There may be problems during walking. three quarters long. with this area if there is too much stitching and too many • Shank—The shank reinforces seams on the vamp. These pre- the middle or the waist of the vent stretching of the vamp ma- the center at the back of the shoe from underneath to prevent terial over the forefoot and toes heel. The inside of the quarter is it from collapsing or distorting. It, and may lead to pressure on usually reinforced around the therefore, needs to be completely bony prominences. The vamp is heel with a stiffener called the rigid or only slightly flexible. usually reinforced in the toe ‘heel counter’ and has the pur- Shoes with a wedge sole, or very area. This toe box retains the pose of stabilizing the rearfoot flat shoes, do not need a shank. shape of the front of the shoe (particularly important in people and prevents it from collapsing with excessive foot pronation— • Outer sole (outsole)—The onto the toes. flatfeet). In lace-up shoes the under surface of the shoe can be The toe box can be made eyelets for the laces are at the made from a variety of materials from a variety of materials in- front of the quarter. This part of and is joined to the upper in sev- the quarter covers eral different ways, e.g. welted, the tongue, which stitched, or adhesive applied. is attached to the There should be a small amount vamp or forms of toe spring at the front part of part of the vamp. the sole so that the foot doesn’t catch the ground during walking. • Throat—The Toe spring is the angle between position of this the flat surface and the height area of the shoe is the toe is off the ground in rela- dependent on the tion to the ball of the shoe. style. It is formed by the seam join- • Heel—The heel raises the shoe ing the vamp to above the ground. If there is no the quarter. A raise at the heel area or the heel is lower throat line lower than the sole then this is (ex. lace-to-toe) termed a negative heel. The mate- will provide a rial covering the area of the heel Figure 1: Shoe last wider opening Continued on page 167

166 PODIATRY MANAGEMENT • OCTOBER 2007 www.podiatrym.com MedicalContinuing Education Footwear... is an extremely skilled craft. The rate away from the foot. measurements of the last are re- The advantage to foot that contacts the ground is called lated to volume in addition to health is that the skin is less the top piece (or top lift) and this width and length and, in this re- macerated and therefore less can be replaced or repaired. spect, a last is not an exact im- likely for fungal infections to pro- pression of a liferate. Leather Last Construction foot. This is to also stretches in Relation to Shoe Fit ensure good fit and accommo- and Style and also takes Some of the dates to the Lasts are the molds on which into account the modern lining uniqueness of shoes are made (Figure 1). The changing dimen- the foot shape. design and shape of the shoe is sions of the foot materials can be The advantages dependent on the shape of the during move- of leather are last. For example, a last for a ment. ‘breathable’ or negated by the high heeled shoe needs to be ‘wick’ moisture use of synthetic shorter than the foot for which it Materials linings and/or is being designed to compensate Used in away from special coatings for the shortened ‘equinus’ posi- Footwear the foot. often used to tion in which the foot is held. In Construction protect the order for a high-heel, pump-style • Upper materi- leather. shoe to stay on the foot its last als—Leather is Some syn- will differ from the last required the most common material and thetic materials are also breath- to make a lace-up shoe. has the advantage of being permeable, but are less supple than Last design and manufacture able so that moisture can evapo- leather. The use of footwear with synthetic uppers should not be dismissed as long as they fit well and a suitable period of drying TABLE 1 out is allowed between periods of Shoe Styles use. Likewise, materials such as cotton corduroy may feel comfortable but only stretch in one STYLE DESCRIPTION direction and require reinforce- ment, particularly in the heel counter. Boot Any footwear extending above the ankle. There are numerous designs and types for a variety of uses, and made from a number of • Linings—In traditional foot- materials. wear, it is usually soft leather or synthetic material. This does not Clog Footwear with no heel counter. The sole can generally cause a problem as they be leather, synthetic, or wood. are usually confined to the quarters and the sock-lining, where Lace-up Any low-cut shoe fastened by lacings. the loss of stretch and permeabil- ity is not a problem. Some of the modern lining materials can be Monk Similar to Derby shoes, but with a cross- ‘breathable’ or ‘wick’ moisture over section to fasten the quarters with a side buckle. away from the foot. Moccasin This used to be a simple one-piece hide held • Soling and heels—The sole on with rawhide thongs. Today, moccasins must be durable, waterproof and can be slippers (with soft suede soles). have sufficient friction to prevent slipping. Leather was the Mule A backless shoe or slipper with or without traditional soling material, but is a heel. more expensive and is not as durable in some conditions. Sandal An open shoe with the upper consisting of Man-made soling may be more any decorative or functional arrangement of straps. A sandal is designed for simple utility durable and resilient to water. or casual wear, or as a fashion shoe. Some are designed with better grip (traction) depending on the Court Heeled shoes (various heights) with low-cut pattern. The soles can be lighter, fronts and usually no fastening. Those with a with cavities in the main soling low heel are termed pumps. material being injected with lighter weight foam. Combina- Continued on page 168 www.podiatrym.com OCTOBER 2007 • PODIATRY MANAGEMENT 167 Footwear... Shoe Styles two critical aspects of shoes, i.e., There are eight basic footwear the fastening around the instep and Continuingtions of materials, e.g., a styles, with the rest made up as the section corresponding to the more durable outermost layer, variations on the basic themes heel. To prevent unnecessary move- Medical Education and a softer, more flexible mid- ment, these need to be firm and fit sole for greater comfort, can be the foot. used. This can be a useful combi- There are a variety of footwear nation in patients presenting Without styles that have evolved over cen- with foot pathology, foot pain turies (for those who have an in- and/or lesions associated with this fixation, the terest in the history of Footwear, pressure. The heel can be made visit www.footwearhistory.com or from synthetic material or foot is allowed to Curtin University website ‘stacked’ layers of leather. The slip forward in http://podiatry.curtin.edu.au/his- heel is covered with a ‘top piece’ tory.html for excellent informa- (top lift), which can be replaced the shoe. tion on the history of footwear). or repaired as the heel wears Although style is dictated by down with usage. The shank can current fashion and the required be made of steel, wood or syn- function of the footwear, any shoe thetic material. Toe boxes and (Table 1). The definition of a shoe that is considered suitable for foot stiffeners support the upper ma- is footwear with a mechanism capa- function and protection must have terial and prevent it from col- ble of holding the foot in the heel a mechanism for holding the foot lapsing onto the toe or inwards of the shoe to facilitate support back into the heel of the shoe. at the back of the shoe. during push off. Hence there are Continued on page 169

TABLE 2 Footwear 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, slippage or malleoli Length i.e., 1 cm. over the length of the longest toe for No pressure on the end of the longest toe elongation during gait The position of the ball of the foot and ball flex line of the No feeling of cramping at the toes shoe. 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 deformity aspect of the toes and nails Width at toes—no side pressure or cramping: good style No pressure over toes is important Suitable heel height for normal heel-to-toe action. Broad Feel stable when walking heel for stability/weight redistribution

168 PODIATRY MANAGEMENT • OCTOBER 2007 www.podiatrym.com MedicalContinuing Education Footwear... Footwear Assessment footwear has been It is important to ascertain if taken off, it can be in- Without this fixation, the foot the footwear worn to the consul- spected further. The foot- is allowed to slip forward in the tation are those wear can re- shoe. This can result in friction which are usual- veal clues to aid on the sole of the foot and the ly worn. In fact, diagnosis so it is toes impact into the front of the for new patients, Pressure useful to start shoe, or in the case of sandals, the it is often useful under the sole with an evalua- toes overhang the front of the in the appoint- tion of any wear sole. The two main important ment letter to re- of the shoe should marks or distor- parts of any style of footwear are quest that they tions. a band around the instep and cor- bring a selection be even, so no one responding support at the heel of the footwear part wears out • Wear marks— which need to be firm and fit mostly worn. Assessment of closely to the contours of the foot excessively. wear patterns of in these locations. Patient’s shoes (inside of The band around the foot pre- History of shoe, upper and vents it from sliding forward and Footwear soles) may help the corresponding support at the Usage and Preferences confirm a diagnosis or reveal in- heel prevents it from slipping As with any assessment, it formation about foot function.15 backwards and sideward. There- needs to be a structured system- Pressure under the sole of the atic approach so that essential shoe should be even, so no one factors are not left out. It is im- part wears out excessively. Nor- portant to ascertain a patient’s mal wear should occur at the lat- The suitability shoe wearing habits. Information eral heel and medial central fore- of each of the about when, where, and how foot (Figure 2). There may also be often shoes are bought can be slight curvature on the under- main styles depends very useful. It is important to as- surface of the sole at the toe area, on the exact certain the footwear history, e.g., which is accentuated by walking. past successes/preferences, likes, Variation from this indicates styling, heel height, dislikes, requirements for em- some abnormality. ployment, e.g., safety footwear, If the tip of the sole is exces- materials used, and so on. Other factors that can sively worn, then the toe spring and perhaps be ascertained are financial cir- is insufficient. Conversely, ab- cumstances and preferences with sent wear at the tip of the sole most importantly, regards to body image. indicates a lack of push-off during the gait cycle. If the sole cur- the use to Examination of the vature is absent, asymmetrical or which a patient Footwear excessive, this may indicate ab- Footwear needs to be evaluat- normal toe function, such as in will put the ed with the patient walking, rheumatoid arthritis. Excessive footwear. standing, and sitting. Once the Continued on page 170

fore, mules, clogs, sandals, and court shoes may be seen as being unsuitable. 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. For example, high heel court shoes may be worn with minimum risks to foot health in healthy individuals, who wear them for a very short time with minimal weight bearing. If these shoes were worn for a long walk in the countryside, they would not function well and the feet would Figure 2 (left): Normal sole and heel wear pattern. certainly suffer. Figure 3 (right): Distortion of upper. www.podiatrym.com OCTOBER 2007 • PODIATRY MANAGEMENT 169 Footwear... border of the heel. is excessively oblique, this indi- Crease marks in the shoe cates failure of first metatar- Continuingforefoot wear indicates sophalangeal joint dorsi-flexion. ankle joint equinus. If there is no crease at all, then Medical Education Circular forefoot wear over propulsion is absent, such as in the first metatarso-phalangeal Perhaps an a short stride and/or flat-footed joint indicates pes cavus deformi- obvious thing that gait. Deformation of the upper ty. Normal heel wear spreads is caused by the shoe conform- across the postero-lateral border the practitioner ing to foot deformities, such as of the heel. This reflects the hallux valgus, tailor’s bunion, slightly inverted position of the can do is to check claw toes or abnormal foot func- heel at heel strike during the gait whether the tion, pronation, for example cycle. Excessive heel wear on the (Figure 3). Wear patterns inside inner border indicates a rigid ev- footwear is the the shoe are likely to mirror erted rearfoot, while excessive right size. those found on the heel and wear on the outer border indi- sole and the insole and sock lin- cates a rigid inverted rearfoot; ing will often display a print of however, if the foot is flexible the sole of the foot from which and excessively pronating during upper normally run slightly areas of high pressures can be the gait cycle, the heel wear may oblique following the line of the assessed. well be heavy along the outer metatarso-phalangeal joints. If it Continued on page 171

TABLE 3 Footwear 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 toes as 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 wrong shape 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.

170 PODIATRY MANAGEMENT • OCTOBER 2007 www.podiatrym.com MedicalContinuing Education Footwear... and the body weight cannot shift ting. Even if feet are the from heel to ball as in barefoot same length overall the Examination of walking, but is concentrated length of the heel to ball the fit of footwear wholly on the ball. measurement may be longer or (Table 2) In a flat-heeled shoe, the shoe shorter (Figure 4). This has major Perhaps an obvious thing that and foot are functioning together implications with regard to shoe fit the practitioner can do is to check with the heel lifting with each and the patient’s comfort. The first whether the footwear is the right step and moving the weight for- toe joint must fit into the widest size. There are two primary ways ward onto the ball. In a low- part of the shoe where it is de- to do this. 1. Shoes on: to assess heeled shoe the vamp will crease signed to bend so that the shoe shoe fit have the patient stand in with the flexion of the forefoot. and foot can bend together. the shoes they wore in. Check for In a high-heeled shoe there will The practitioner must become length, width, last, heel height, be no creasing as there is no flex- proficient at determining the and balance. 2. Shoes off: with the ion of the metatarsophalangeal exact position of the first joint joint. The low-heeled shoe re- inside the shoe, because if it is quires more toe room in the fit- too far forward, or back, the shoe ting because there is more for- may appear to fit overall, but it The first toe ward movement or extension of will never be comfortable. The joint must fit into the foot with each step (Figure 5). patient can be asked to stand on tip toe and the flex line checked the widest part of • Length—heel-to-ball joint or, if the shoe has a removable length—This measurement is very full length lining, this can be the shoe where important in successful shoe fit- Continued on page 172 it is designed to bend so that the shoe and foot can bend together.

shoes off begin by measuring the length and width of the foot, and also investigate the heel-to-ball measurement and the depth of the footwear.

• Heel fit—The heel should be snugly cradled into the heel of the shoe to prevent gaping and slippage. The top edge of the heel Figure 4: Foot length. A = both feet the same overall length; B = long heel-to-ball joint counter should not dig into the measurement; C = short heel-to-ball joint measurement Achilles tendon or malleoli. Heel fit also influences the entire fit of the shoe because the foot has a different stance inside a high- heeled and a low-heeled shoe, and also functions differently inside the shoe. When walking barefoot, the heel of the foot is lifted about two inches with each step, with the ball of the foot working as a fulcrum for the step-off. The amount of heel rise is proportional to the length of the step. Therefore, the longer the stride, the higher the heel rise. In a shoe with a two-inch heel, there is no rise in the heel, because the shoe is already ac- counting for that rise. The higher the heel, the shorter the stride Figure 5: Key areas to check the fit of footwear. www.podiatrym.com OCTOBER 2007 • PODIATRY MANAGEMENT 171 Footwear...

Continuingused against the foot to check where Medical Education the ball flex line occurs. If the ball joint position is too far forward the toes will be crowded in the toe box. If it is too far back the result is abnormal tread wear marks and excessive creasing of the vamp. These measurements can be taken Figure 6: An example of ‘stock’ footwear. Figure 7: An example of custom-made footwear. using a Brannock measuring device (for more informa- • Patterns and vamps—Pat- practitioner would be fitting a tion www.brannock.com) which terns have a tremendous influ- shoe that is required to accom- provides the practitioner with ence on shoe fit. This applies es- modate a large hallux valgus more information than the tradi- pecially to the ease of getting joint a six-tie eyelet would be a tional size stick. the shoe onto the foot and better choice as the throat entry keeping it on securely. There are would be larger, enabling easier • Length—ball joint to toe long and short vamp lasts and entry and better adjustment of length—Check the length of all generally the rounder the toe the top line around the foot the toes and don’t assume that the more likely the vamp will be (Figure 5). the first toe is the longest. Gen- shorter; the more tapered the erally 1 cm. space at the end of toe the longer the vamp. Vamp Footwear Options the toes is considered sufficient. length is determined by the There are now many manu- Also remember toe width and facturers of retail footwear that is forefoot shape in relation to the both appropriate for the foot style of shoe. health of our patients and is af- fordable. Many foot problems • Ball width—This is the Some footwear benefit from a change in foot- width of the sole (ball tread) and wear style or to a style with dif- insole as well as the upper. The can be modified ferent features. Some footwear shoe has to adapt to three differ- with rocker soles, can be modified with rocker ent widths at the ball—with the soles, which are helpful in reduc- foot at rest, weight bearing and which are helpful ing forefoot pressures in the dia- under thermal conditions, i.e, betic foot and pain and pressure swelling. Experience and judg- in reducing in the rheumatoid foot. ment informs the practitioner forefoot pressures If patients have major foot which width will best suit all problems or deformity then spe- these conditions. Subjective feed- in the diabetic cialized therapeutic footwear can back from the patient will also be provided. Pedorthists and or- aid decisions. foot and pain and thotists are the professionals who pressure in the have generally assessed and pro- • Throat—This is the entry vided this therapeutic footwear point into the vamp or forepart rheumatoid foot. but increasingly podiatrists are area. There must be sufficient working alongside their pedorth- room when the shoe is fastened ic colleagues or taking on some onto the foot to allow for the of the pedorthists’ role, particu- waist and instep to move during larly in the provision of stock weight-bearing (a finger width at shoe’s design (especially in the footwear. Team working in this the back indicates sufficient room retail industry) and correct style area has demonstrated improved for this). A strong secure fastening is crucial for forefoot comfort clinical outcomes and patient to hold the rearfoot against the and fit. An example of a long satisfaction compared with work- heel of the shoe prevents forward and short pattern would be a ing in isolation.16 slide. The facings (spacing) (where six-eyelet tie and a three-eyelet It is important that podia- the eyelets are) should be usually tie style, each made on the same trists create good working rela- 10-12 mm. apart. If they are over- last. The difference in the pat- tionships with their pedorthic lapping, the volume of the shoe is terns will affect the way the colleagues in the assessment of too much, and if they are wider foot extends into the shoe and patients, shared information and apart than 12 mm., the shoe is too will also affect the instep free- in the provision of the special- small (Figure 5). dom. So, for example, where the Continued on page 173

172 PODIATRY MANAGEMENT • OCTOBER 2007 www.podiatrym.com MedicalContinuing Education Footwear... achieve optimum fit but to the depth unless it is patient the objective is to achieve demonstrated by the prac- ized footwear. comfort and/or style. titioner. Stock footwear is therapeutic It is difficult for practitioners to Because of the differences footwear that is available in a vari- recommend styles, as there are con- in the lasts used for different ety of styles and fittings, for exam- stant changes in fashion. It is better footwear and even differences in ple, extra deep, and/or extra wide to recommend certain aspects of international sizing, there is lack (Figure 6). Cus- footwear that are of standardization. This makes it tom-made foot- important fea- difficult for patients themselves wear (Figure 7) is Footwear can be tures with regard to be able to identify footwear an option when to fit (Table 3— that is suitable for their foot there is major de- perceived by Footwear Suitabil- health and their needs in respect formity such as ity Scale). These to footwear usage. To address this Charcot or ad- individuals in a features may vary problem a Footwear Suitability vanced rheuma- variety of ways and slightly according Scale was developed17 specifically toid arthritis de- to the specific for patients with diabetes. This formity (Figure this depends on foot problems. has proven to be a useful tool in 8), if there is a For example, a practice in non-diabetic patients huge difference what the shoes are patient with an and as an educational tool in en- in symmetry, required to offer. equinus foot suring that practitioners are able fixed equinus of problem may to identify, rationalize and ex- more than 20 benefit from plain the importance of each part mm., or if the wearing a sturdy of the shoe when providing ad- foot dimensions are outside the but higher heel than those recom- vice for the patient (Table 3— measurements for stock footwear. mended with Footwear Suit- forefoot pain and ability Scale). Footwear Advice deformity. It is impor- Footwear can be perceived by It is important tant for the prac- individuals in a variety of ways Footwear for the practitioner titioner to know and this depends on what the Suitability the retail trends, shoes are required to offer. Foot- Assessment to know the and sources of wear can provide a specific func- Tools footwear that are tion (e.g., toe protection in safety Footwear as- retail trends, suitable. Having shoes) but in many people it is in- sessment prac- and sources of leaflets on differ- extricably linked to body image. tices tend to be ent footwear In this respect fashion trends can subjective and footwear that are manufacturers dictate the style and type of foot- tend to focus on may be useful in wear worn by individuals. The the style of the suitable. educating and achievement of a good clinical footwear rather informing pa- outcome for the patient relies on than the suitabil- tients about the managing expectations and prac- ity of the footwear for the individ- sources of good footwear. How- titioners must recognize that pa- ual patient and their presenting ever, the most important factor in tients may have aims different foot problems. Non-specialist getting patients to change their from their own. For example, the footwear assessment relies on footwear ‘behavior’ is for the clinician’s aim might be to length and sometimes width and Continued on page 174 heel-to-ball measurement, but generally ignores the depth. Pa- tients can generally understand what is meant by width, but may not understand the concept of

Figure 8: Rheumatoid arthritis foot de- Figure 9: Diabetic neuropathic foot with formity requiring custom footwear. amputation of the fourth toe. Figure 10: Lack of symmetry. www.podiatrym.com OCTOBER 2007 • PODIATRY MANAGEMENT 173 Footwear... tients. Diabetes Res Clin Practice. Mar; 14 Vernon, D.W and McCourt, F.J., (1996) 31 (1-3); 109-14. Forensic Podiatry—a review and defini- Continuingpractitioner to understand 4 Uccioli L, Aldeghi A, Faglia E et al. tion, (1999) British Journal of Podiatry, that it may take some time. It Manufactured shoes in the prevention May. Medical Education is known that knowledge doesn’t of diabetic foot ulcers. Diabetes Care 15 Vernon W, Parry A and Potter necessarily influence behavior. (1995) 18:1376-8. M. A theory of shoe wear pattern in- 5 Having the knowledge may be the Chantelau E, fluence incorporat- Kushner T, Spraul ing a new start of a process for patients to M. How effective is paradigm for the think about change, make the cushioned therapeu- podiatric medical change, and then maintain the tic footwear in pro- Footwear profession. (2004) change.18,19 tecting diabetic Journal of the In situations where clients’ feet? A clinical assessment American Podiatric shoes contribute to subjective study. Diab Med should be part of Medical Associa- symptoms, but there is no appar- (1990) 7: 355-359. tion. 94;3:261-268. ent conscious acceptance of this, 6 Chalmers AC, every visit to the 16 Williams A then the practitioner may have Busby C, Goyert J, and Meacher K to accept that this is the patients’ Porter B, Schulzer podiatrist. Shoes in the cup- M. Metatarsalgia board—the fate of personal decision. Under these and Rheumatoid prescribed foot- circumstances negotiated care or arthritis—a ran- wear. (2001) Pros- compromise is required. domised, single thetics and Or- blind, sequential trial comparing 2 thotics International 25:53-9. Conclusion types of foot orthoses and supportive 17 Nancarrow SA Footwear suit- Footwear plays a vital role in shoes. The Journal of Rheumatology ability scale:a measure of shoe fit for the management of foot prob- (2000) 27: 7 1643-1647. people with diabetes 1999 AJPM 33;2. lems. Providing patients with the 7 Shrader J.A. (1999). Nonsurgical 18 Prochaska, J. and C. Di- correct advice or referral for spe- Management of the Foot and Ankle Af- Clemente (1984). The transtheoretical cialized footwear can impact on fected by Rheumatoid Arthritis. Journal approach: Crossing traditional bound- of Orthopaedic and Sports Physical aries of therapy. Homewood, Ill., Dow the success of other clinical inter- Therapy 29 (12): 703-717. Jones-Irwin. ventions. Footwear assessment 8 Grifka, J K. Shoes and Insoles for 19 Prochaska, J. O. and C. C. Di- should be part of every visit to Patients With Rheumatoid Foot Disease. Clemente (1982). Transtheoretical the podiatrist. Podiatrists need to Clinical Orthopaedics & Related Re- therapy: Toward a more integrative develop skills in ascertaining the search. The Rheumatoid Foot. (1997) model of change. Psychotherapy: The- patient’s problems in relation to 340: 18-25. ory, Research and Practice 19(3): 276- footwear, the 9 Koepsell TD, 288. patient’s poten- Wolf ME, Buchner tial for change DM, KuKull WA, La Additional Reading and the solutions Croix AZ Tencer AF 1) McPoil TG. (1988). Footwear. Providing patients et al Footwear style to their footwear Physical Therapy; 68(12): 1857-1865. and risk of falls in problems. ■ with the correct 2) Janisse DJ. (1992). The art and older adults Journal science of fitting shoes. Foot & Ankle; advice or referral of the American 13(5): 257-62. Editor’s Note: Geriatrics Society 3) Rossi WA, Tennant R. Profes- We wish to ac- for specialized (2004) 52 (9): 1495- sional Shoe Fitting: Chapter 8, pp.90- knowledge Robert 501. 105. Schwartz of Enes- footwear can 10 Sherrington C 4) Merriman LM, Tollafield, DR. low—The Foot impact on the success and Menz HB An Assessment of the Lower Limb: Chap- Comfort Center of evaluation of foot- ter 10, pp.227-47. The D3D Ortho- New York for his of other clinical wear worn at the peadic and Functional shoes are avail- time of fall related assistance in edit- able exclusively from RSscan Lab Ltd, hip fracture 2003 ing this CME. interventions. Violet Hill Road, Stowmarket, Suffolk Age and Aging; 32: IP14 1NN Tel: 01449 612739, Fax: 310-314. 01449 770025, Email: info@rsscan. 11 References Disabled Liv- co.uk, www.rsscan.co.uk 1 Baker N, and ing Foundation. Leatherdale B. An audit of prescription Foot wear—a Quality Issue. Provision of prescribed Footwear within the National footwear. The Diabetic Foot 2002; 100- Anita Williams is 4. Health Service. 1991. 12 Lecturer Direc- 2 Striesow F Special manufactured Bowker P, Rocca E, Arnell P, and Powell E. A study of the organisation of torate of Podiatry shoes for the prevention of recurrent ul- at the University cers in the diabetic foot. Med Klini. orthotic services in England and Wales. 1992. Report to the Department of of Salford, and a (1998). Dec 93; 12, 695-700. member of the 3 Health, UK. Donaghue VM, Sarnow MR, Centre for Reha- 13 Williams A. E and Nester C.J Pa- Giunne JM, Chrzan JS, Habershaw GM bilitation and and Veves A Longitudinal inshoe foot tient perceptions of prescribed stock footwear design. (2006) Prosthetics and Human Perfor- pressure relief achieved by specially de- mance Research. signed footwear in high risk diabetic pa- Orthotics International (in print).

174 PODIATRY MANAGEMENT • OCTOBER 2007 www.podiatrym.com MedicalContinuing Education EXAMINATION

See answer sheet on page 177.

1) Evidence supports the use of 6) Excessively oblique crease 10) What is the main reason for appropriate footwear in patients marks in the upper indicates assessing a patient’s footwear? with rheumatoid arthritis, with A) absent propulsion such as A) Footwear influences foot the benefits being in a short stride and/or flat- health. A) reduction in pain, and in- footed gait. B) Patients expect it. creased mobility. B) tailor’s bunion. C) Patients have to change B) reduced need for pain-re- C) cheap shoes. footwear styles lieving medication. D) failure of first metatarso- D) You need to make sure C) prevention of deformity. phalangeal joint dorsi- the shoes are a good value. D) increased health status flexion. scores. 11) What is the most important 7) When measuring the foot, if fitting point? 2) The upper of a shoe is com- the ball joint position is too far A) width, prised of two parts called forward the toes will B) heel-to-ball and ball-to- A) the insole and linings. A) cause abnormal tread toe B) the vamp and quarters. wear marks and excessive C) depth C) the topline and toe box. creasing of the vamp. D) heel fit D) the shank and counter. B) not reach the end of the shoe. 12) The normal shoe wear pat- 3) The structure which supports C) be crowded in the toe tern on the heel is the waist of the shoe is called box. A) central A) the toe box. D) be comfortable. B) medial B) the vamp. C) right across from medial C) the heel counter. 8) For a good fit, the facings of to lateral D) the shank. a shoe should D) slightly lateral A) allow for tightening. 4) The purpose of a ‘toe spring’ B) overlap. 13) What happens to forefoot is to C) meet. pressures with an increase A) prevent catching of the D) have a large gap. in heel height when stand- front of the shoe on the walking? ing surface. 9) It is difficult for practitioners A) Nothing B) relieve pressure on the to give advice on footwear B) It decreases toes. styles because of changes in C) It Increases C) prevent the toe box from fashion. It is better, therefore, D) It fluctuates collapsing. to D) improve the fit of the A) not bother. 14) What happens if the heel- shoe. B) recommend certain as- to-ball joint measurement is pects of footwear which long? 5) Excessive heel wear on the have important features with A) The foot will not flex. inner border indicates regards to fit. B) The foot flexes in front of A) a rigid everted rearfoot. C) wait for the patient to the flex line of the shoe. B) a rigid inverted rearfoot. find a proper style. C) The shank irritates the C) a flexible and pronated D) wait for fashion foot. foot. changes. D) The heel slips. D) a severe equinus deformity. Continued on page 176 www.podiatrym.com OCTOBER 2007 • PODIATRY MANAGEMENT 175 EXAMINATION PM’s Continuing (cont’d) Medical Education CPME Program 15) Excessive forefoot wear marks indicate Welcome to the innovative Continuing Education A) excessive pronation. Program brought to you by Podiatry Management B) excessive supination. Magazine. Our journal has been approved as a C) ankle equines. sponsor of Continuing Medical Education by the D) rigid toes. Council on Podiatric Medical Education.

16) It is important to have a firm heel counter Now it’s even easier and more convenient because it to enroll in PM’s CE program! A) provides support at the heel. You can now enroll at any time during the year B) makes the shoe look good. and submit eligible exams at any time during your C) stops the shoe from rubbing. enrollment period. D) stops the foot slipping forwards. PM enrollees are entitled to submit ten exams published during their consecutive, twelve–month 17) Compared to the dimensions of a foot, the enrollment period. Your enrollment period begins dimensions of a high-heeled shoe will be with the month payment is received. For example, A) Longer. if your payment is received on September 1, 2006, B) Shorter. your enrollment is valid through August 31, 2007. C) Wider. If you’re not enrolled, you may also submit any D) Deeper. exam(s) published in PM magazine within the past twelve months. CME articles and examination 18) Leather is often used for the uppers of foot- questions from past issues of Podiatry Man- wear as it is agement can be found on the Internet at A) permeable. http://www.podiatrym.com/cme. Each lesson B) non-permeable. is approved for 1.5 hours continuing education con- C) thermal. tact hours. Please read the testing, grading and pay- D) flexible. ment instructions to decide which method of partici- pation is best for you. 19) To increase the access to a shoe, the follow- Please call (631) 563-1604 if you have any ques- ing is required: tions. A personal operator will be happy to assist you. A) high quarters Each of the 10 lessons will count as 1.5 credits; B) a stiff heel counter thus a maximum of 15 CME credits may be C) a substantial toe box earned during any 12-month period. You may se- D) a low opening vamp lect any 10 in a 24-month period.

20) A well padded sole provides The Podiatry Management Magazine CME A) increased height. program is approved by the Council on Podiatric B) extra protection and comfort. Education in all states where credits in instruction- C) protection from slipping. al media are accepted. This article is approved for D) a good shape to the shoe. 1.5 Continuing Education Contact Hours (or 0.15 CEU’s) for each examination successfully completed.

Home Study CME credits now See answer sheet on page 177. accepted in Pennsylvania

176 PODIATRY MANAGEMENT www.podiatrym.com ✄ MedicalContinuing Education Enrollment/Testing Information and Answer Sheet Note: If you are mailing your answer sheet, you must complete exam during your current enrollment period. If you are not en- all info. on the front and back of this page and mail with your rolled, please send $20.00 per exam, or $139 to cover all 10 exams credit card information to: Podiatry Management, P.O. Box (thus saving $61* over the cost of 10 individual exam fees). 490, East Islip, NY 11730. Facsimile Grading To receive your CPME certificate, complete all information and TESTING, GRADING AND PAYMENT INSTRUCTIONS fax 24 hours a day to 1-631-563-1907. Your CPME certificate will (1) Each participant achieving a passing grade of 70% or be dated and mailed within 48 hours. This service is available for higher on any examination will receive an official computer form $2.50 per exam if you are currently enrolled in the annual 10-exam stating the number of CE credits earned. This form should be safe- CPME program (and this exam falls within your enrollment period), guarded and may be used as documentation of credits earned. and can be charged to your Visa, MasterCard, or American Express. (2) Participants receiving a failing grade on any exam will be If you are not enrolled in the annual 10-exam CPME pro- notified and permitted to take one re-examination at no extra cost. gram, the fee is $20 per exam. (3) All answers should be recorded on the answer form below. For each question, decide which choice is the best an- Phone-In Grading swer, and circle the letter representing your choice. You may also complete your exam by using the toll-free ser- (4) Complete all other information on the front and back of vice. Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Monday this page. through Friday. Your CPME certificate will be dated the same day (5) Choose one out of the 3 options for testgrading: mail-in, you call and mailed within 48 hours. There is a $2.50 charge for fax, or phone. To select the type of service that best suits your this service if you are currently enrolled in the annual 10-exam needs, please read the following section, “Test Grading Options”. CPME program (and this exam falls within your enrollment period), and this fee can be charged to your Visa, Mastercard, Ameri- TEST GRADING OPTIONS can Express, or Discover. If you are not currently enrolled, the fee Mail-In Grading is $20 per exam. When you call, please have ready: To receive your CME certificate, complete all information 1. Program number (Month and Year) and mail with your credit card information to: 2. The answers to the test Podiatry Management 3. Your social security number P.O. Box 490, East Islip, NY 11730 4. Credit card information There is no charge for the mail-in service if you have already In the event you require additional CPME information, enrolled in the annual exam CPME program, and we receive this please contact PMS, Inc., at 1-631-563-1604.

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Name ______Soc. Sec. #______Please Print: FIRST MI LAST Address______City______State______Zip______Charge to: _____Visa _____ MasterCard _____ American Express Card #______Exp. Date______Note: Credit card is the only method of payment. Checks are no longer accepted. Signature______Soc. Sec.#______Daytime Phone______State License(s)______Is this a new address? Yes______No______

Check one: ______I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be charged to your credit card.) ______I am not enrolled. Enclosed is my credit card information. Please charge my credit card $20.00 for each exam submitted. (plus $2.50 for each exam if submitting by fax or phone). ______I am not enrolled and I wish to enroll for 10 courses at $139.00 (thus saving me $61 over the cost of 10 individual exam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone. Over, please 177 ✄ (cont’d) www.podiatrym.com 11. A12. B A13. C B A14. D C B A15. D C B A16. D C B A17. D C B A18. D C B A19. D C B A20. D C B A D C B D C D (Williams) EXAM #8/07 1. A2. B A3. C B A4. D C B A5. D C B A6. D C B A7. D C B A8. D C B A9. D C B A D C B D C D 10. A B C D LESSON EVALUATION exam Please indicate the date you completed this ______the lesson? How much time did it take you to complete ______hours ______minutes How well did this lesson achieve its educational objectives? ______Very well ______Well all ______Somewhat ______Not at lesson? What overall grade would you assign this A B C D Degree______Additional comments and suggestions for future exams: ______Circle: Footwear Assessment and Management Assessment Footwear ENROLLMENT FORM & ANSWER SHEET & ANSWER FORM ENROLLMENT PODIATRY MANAGEMENT • OCTOBER 2007

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