Sizing Up Footwear

Here’s a comprehensive review of shoe types and proper fitting.

BY MEL CHESKIN, MBS, CPED

odiatrists know it only too ly) Paris Points based on 2/3 of a cen- largely credited with introducing a well, but patients need to timeter measurement. width fitting system based on A, B, C be informed and made to Because France was the dominant width sizing—the difference in width understand—there is no country on the mainland European being quarter-inch increments around standard sizing system for Continent in the sixteenth and seven- the girth for each increased width. Pfootwear. Attempts have been made teenth centuries, Paris Points became Length increments are 1/3 inch for in decades past to introduce some the standard shoe sizing system full sizes and 1/6 inch for half sizes. conformity into international shoe siz- throughout Europe. Today, with ing. The last failed attempt was in the China manufacturing almost 70% of Misconceptions and Suggestions 1950s at an International shoe confer- the world’s footwear, it would be The following is a list of basic siz- ence in Europe. SATRA (Shoe and Al- much easier to introduce a more stan- ing and fitting advice that is well- lied Trades Research Association) made a presentation to introduce a system named Monopoint. The idea was to replace the British, French, The American system and European sizing systems with was also largely credited with introducing a width fitting one central system. A few shoe manu- facturers tried to add it to the already system based on A, B, C width sizing. existing regiment of shoe sizing charts and comparisons, but it quickly faded into obscurity. dardized world-wide sizing system. known but often overlooked by podi- Historically, the main reason that The biggest challenge has always atrists when advising patients how to shoe sizing has not been standardized been shoe toe shapes—from oblique obtain the correct fit or best fitting has been the tradition for footwear to to pointed. shoe styles. be manufactured in many different • The shape of the shoe is deter- countries. The British system, com- American Shoe Size System mined by the last. Last shapes vary monly thought to be inspired by Ran- The first description of a shoe-siz- from square oblique to narrow point- dle Holme in the Academy of Armory ing system with proportional mea- ed. A quick look at the sole of the and Blazon in 1688, was loosely surements for lasts and shoes was in- shoe will usually indicate if the over- based on the width of a man’s hand troduced in America by Edwin B. all shape is suitable for a certain foot across the knuckles and the length of Simpson of New York in 1880. This type. barleycorn—hardly scientific. Howev- system, when finally adopted by The • The best time to fit new shoes is er, they still measure horses by ‘hand- Retail Boot and Shoe Dealer’s Nation- in the late afternoon or evening. Feet s’, don’t they? Around the same peri- al Association, not surprisingly dif- often increase in length and width od in history—the late Seventeenth fered from the British system by 1 1/2 after exercise, many hours of standing Century—European shoemakers sizes, and introduced a smaller scale or waking, and due to possible adopted a more empirical measure- for women, which was (approximate- edema. ment system using centimeters as its ly) 1 1/2 sizes smaller than American • Advise patients to fit new shoes basic sizing scale. French shoemak- men’s sizes (a size 9 men’s size is with the same or similar hose to be ers, however, refused to follow the equivalent to a woman’s size 10 worn regularly. Fitting shoes with a other European countries and created 1/2—1 1/2 to 2 sizes different). thin sock and then switching to a their own system called (appropriate- The American system was also Continued on page 110 www.podiatrym.com OCTOBER 2013 | PODIATRY MANAGEMENT | 109 FOOTWEAR SIZING UP

thick sock can cause tightness and edema. Most open comfort shoe cat- discomfort. egory models (sandals) are ad- • If an orthotic is recommended, justable and many closed shoes advise the patient to take along the have stretch panels. device for correct fitting when obtain- • It’s good to know that several ing new shoes. A corrective or accom- comfort shoe brands and one or two modative orthotic can increase fitting athletic shoe companies offer mixed the correct shoe size by at least a half mate sizing at minimal extra cost size. (e.g., a size 8 right mated with a size • Always advise the patient to 9 left). have both feet measured (preferably • The safest and easiest fitting on a Brannock device) before at- shoe models to recommend are ad- tempting to choose a shoe fitting. Feet justable sandals, and in closed are asymmetric and are commonly a shoes—running shoes or comfort half size (or more) different in mea- shoes offered in widths with firm surement. There are exceptions, but counters, and adequate toe spring and generally feet increase in size with long-laced eyestays. Velcro closure Figure 2: Measuring the foot on Brannock’s maturity, weight gain, pregnancy, and systems work well for geriatric and device foot deformities. arthritic patients. • It should be emphasized that ladies, children, athletic, and for ski brands (even in the same category) The Brannock Device boot sizing. do not necessarily fit the same. One At least the footwear industry has cannot assume that wearing, say, a adopted a standard foot measuring Modifications in Fitting Footwear Billions of pairs of shoes are sold Feet are asymmetric annually in the United States—most are not fitted by an experienced shoe and are commonly a half size (or more) different fitter. Probably most shoe purchases are self-fitted off-the-shelf or, of late, in measurement. ‘online’ by consumers. Human anatomy, although clinically stan- dardized, is certainly unique from in- size 9 in one category or brand will device which has been universally ac- dividual to individual. Given both of translate into the same size in an- cepted by most countries—The Bran- these statements, it is no surprise other category or brand. For exam- nock (Figure 1). Charles Brannock, a that much of the footwear bought ple, in athletic footwear, it is well Syracuse University student, built his today may not be a perfect fit for the known by fitters that Brooks run- first prototype of the device in 1926. wearer. Feet, due to the natural ning shoes fit small compared to The size system is linear and is 95- aging process, weight gain, and com- most other running shoe brands. In 96% accurate. Sizing is incremental mon foot deformities differ more ladies comfort footwear Aravon (the in 1/3 inch lengths and 3/16 in asymmetrically than other parts of ladies comfort brand owned by New widths. There are nine width mea- the body. Balance) models are known by ex- surements (which actually vary with Fortunately there are many and perienced shoe fitters to fit large foot length—AAA, AA, A, B, C, D, E, varied ways that shoe fitting can be and wide—more suitable for a wide EE, EEE). The preferred method of optimized. Pedorthists dedicate them- foot or a patient experiencing measuring the foot on the Brannock is selves to the study, fitting, and modi- standing—to allow for fying of footwear and foot orthotics in the foot to elongate order to give the wearer the ideal and expand with full shoe function. To fit correctly, it is re- weight-bearing. Heel ally important not only to size the to 1st ray metatarsal wearer, but to have a varied stock of head measurement is sizing on hand to enable the fitter the suggested shoe (and wearer) to judge the most suit- size (Figure 2). Heel able brand and fitting by trying on the to toe is sock length shoe. Changes can be made internal- size. The Brannock ly, externally, or a combination of device is made in sev- both. In this article, we will concen- eral different versions trate on the possible modifications for on the same metal inside shoe-fitting. Figure 1: The Brannock shoe measuring device template for men, Continued on page 112

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Too Tight pads can be used in a variety of shoe length insoles are available pre-cut in Other than replacing the original- models including laced, Velcro clo- full sizes. fitting sockliner with a thinner ver- sures, and loafers (Figure 4). sion, stretching is the only option for Heel cushions (or lifts) can be a shoe that is too tight and therefore Halter Pads or Taps are cork or added to raise the heel in the shoe uncomfortable and potentially dam- foam inserts that fill the forepart of a and add extra cushioning. Heel cush- aging to the foot. A full range of man- closed shoe, thus reducing the width ions are also helpful to lift the lateral ual expanding wooden shoe stretch- in the front part of the shoe as well as malleolus off the top line to avoid ers is used for this purpose. Shoe helping to prevent the foot from slip- rubbing. Added heel lifts can be a stretchers are sized 0, 00, 000, 0000 etc., according to size and width (Fig- ure 3). They are available for men Stretchers are most useful and women, and have pre-drilled holes for bunion and hammer toe to relieve pressure in tight-fitting shoes and for patients plugs. Another option for shoe-stretch- with bunions and hammertoes. ing is a simple machine with a screw mechanism using multiple metal foot shapes. This machine offers both ping forward. Halter pads are usually helpful relief for plantar fasciitis width and length stretching. Width placed on top of the sockliner in open pain. Inside heel lifts to correct leg- stretching is usually quite successful shoes. Taps are normally placed length discrepancy (LLD) should be and most helpful for bunions, ham- under a removable sockliner in closed restricted to no more than 1 cm in- mertoes and exostosis accommoda- shoes. side the shoe. If a larger lift is re- tion. Stretching the length of a shoe quired it should be added outside the is more difficult due to the toe shape Additional full insoles placed shoe. and the restriction of the outsole. Ex- under the manufacturer’s removable Heel Grippers are usually a last tending the toe box distally is possi- sockliner can reduce the fitting by at resort used as an insert around the in- ble but not highly recommended for least a half size. Insoles may be made side counter to stop slipping at the most types of footwear. from latex foam, cork, or felt. Full- heel. This is useful if the wearer has a An alternative stretch- particularly narrow heel. ing technique is the ‘ball If more than one of the and ring’ stretcher for spe- above accommodations is cific areas of the shoe. used, the shoe is really not a Stretchers are most useful good fit. Specific off-loading to relieve pressure in tight- inserts such as scaphoid fitting shoes and for pa- pads, metatarsal pads, tients with bunions and wedges, and carbon plates hammertoes. Using a will affect the fit slightly chemical stretching liquid and should be fitted when helps the stretching pro- new shoes are purchased. cess by loosening the fibers Other techniques such as in leather uppers. Stretch- softening irritating edges or ers also work well in mesh lining specific parts of a athletic shoes. shoe (usually sandals) with Plastazote® or Moleskin can Too Loose—Slipping Figure 3: Set of Shoe Stretchers prevent blisters and turn an There are a number of annoying pair of shoes into options and techniques that comfortable favorites. can be used by shoe fitters Slim feet are more diffi- to accommodate a loose-fit- cult to fit than wide feet. ting shoe or a shoe that slips Slim feet may be narrow in at the heel. width and or narrow in girth (around the foot). A Tongue Pads (that are few brands still make a available in several sizes) slim-fitting shoe for ladies are the most common fitting in a few models (SAS for aides to push the foot back example) that are sized as in a closed shoe, thus reduc- AAAA. Narrow = AA, (for ing heel slippage. Tongue Figure 4: Shoe Tongue Pads Continued on page 114

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ladies), B = narrow for men, medi- Footwear Categories shoe stores for the perfect fit. Most um for ladies, C fitting is very rarely There are more categories of often, this type of shoe needs to have used today. D = medium for men, footwear available on the market accommodations inserted such as wide for ladies, E and EE = wide for today than ever, and most specialized tongue pads, halter pads (or taps), men, extra wide for ladies. EEE and footwear is now accessible through and/or heel grippers to avoid slip- EEEE = extra wide. Some athletic the Internet. It is impossible for a re- page. and comfort brands offer a 6 E fit- tail store to stock multiple categories On a wide foot, an ill-fitting loafer ting. Again, there are no width stan- of shoes. Specialized stores that con- ends up being too tight and most un- dards; one brand’s 4E width fitting centrate on one major category have comfortable in the dorsal region of may be much wider than other brands’ 4E. In shoe-fitting, there is no substitute for knowing how a Men’s lace-up shoes in the dress category particular brand fits certain foot types. are the most comfortable.

Lacing Systems It is possible to adjust the width the best selection of models and sizes. the foot. In such instances, stretching of a laced shoe by varying the lacing The major footwear categories are the shoe may be the answer to relieve pattern. Different lacing patterns can Dress/Fashion, Athletic, Com- pressure on the dorsum. The above also be helpful in relieving pressure fort/Orthopedic, Work, and Casual. advice is good reason not to recom- on the dorsum of the foot. A deeper Within these general categories there mend buying shoes online—unless eyestay design into the vamp or toe may be sub-categories (e.g., within one knows the brand and specific box area allows for more adjustment athletic/sport shoes: winter sport model. Men’s lace-up shoes in the distally. Eyelet lacing may be conven- shoes and boots are a diversified sub- dress category are the most comfort- tional eyelet holes (straight line category and encompass highly spe- able. punched or reinforced), staggered cialized sports.) Below is a brief de- Ladies fashion shoes are another (various width) eyelets, or speed/D- scription and synopsis of the major story. In this category, comfort is a ring loops. categories. secondary consideration. The dangers For a narrow foot, the standard and woes of fashion shoes for ladies criss-cross lacing method is the best. Dress/Fashion Footwear have been well-documented both in Speed rings allow the lace to be tight- This is still the largest-selling cate- Podiatry Management articles over ened evenly with one pull. Use the gory within the footwear industry, the years and in podiatry clinics top-line control holes at the top of the but challenged strongly in volume across the continent. The phrase eyestay to narrow the collar and heel sales by the proliferation of athletic “form follows function” has been opening. A suggested lacing method shoes. In general, dress shoes for men completely thrown to the wind by for a wide foot is to lace the first set are quite sensibly designed with clas- ladies fashion shoe designers for cen- of eyelets across, then vertically up sical styles. Men’s dress shoes do not turies. Two quotes that best sum up the category are:—“It takes twenty years of wearing fashion shoes to ruin a woman’s feet,” and “Women are The hardest shoes not going to stop wearing high heels to fit in the men’s category are loafers (slip-ons with because they like what it does for their legs and posture—and so do no closure system.) men.” Fashion shoes cannot be avoid- ed; they must be worn sparingly, ad- mired, and tolerated. Within the each side of the eyestay past the fore- generally cause major problems for ladies fashion footwear category, it foot. Continue to cross the lacing pat- fitting or potential deformity in men’s would be almost impossible to offer tern at the top. feet. Cushioning is usually minimal, fitting and sizing advice—it is usually High and low arches can be best although this feature has been much ignored in favor of sex appeal. How- accommodated in a lace shoe as fol- improved over the past 30 years. ever, one general suggestion that lows: For a high arched foot (or The hardest shoes to fit in the makes sense is to recommend ad- prominent exostosis), extend the men’s category are loafers (slip-ons justable, open (strappy sandals) as laces vertically up the eyestay past with no closure system.) The best ad- opposed to closed shoes—the lower the arch or protruding area. For a low vice would be to recommend a brand the heel, the better. Perhaps the only arched foot, criss-cross the lace nor- that makes a range of width fittings. positive function for a woman to mally until halfway up the eyestay, A strange anomaly is that many men wear high heels is to make her appear then loop and criss-cross to the top with narrow feet seem to love loafers taller. eyelet. and spend countless hours searching Continued on page 115

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Dr. Dananberg’s Insolia system (a fit and comfort. Good examples of parabola halter inserted in the shank this specialization would be ice skates area of the shoe) helps to relieve pres- and Alpine ski boots. Helpful advice sure on the metatarsals and pha- for podiatrists is to work closely with langes. Possibly, the best advice a po- coaches or specialized fitters to avoid diatrist can offer a woman is to think potentially harmful foot conditions for of her high heels or platforms as ‘two the athlete. When treatment is re- hour shoes.’ quired for injuries or specific condi- tions that may be caused by ill-fitting Athletic/Sport Footwear footwear, it’s time for the podiatrist to Within this vast category, running examine the footwear—often the ini- shoes have become, next to flip flops, tial cause of the injury. the most popularly worn shoes in most parts of the Western World. The Comfort/Orthopedic Footwear reason is simple—they are well cush- (Option # 1) ioned, breathable, and comfortable. Most wearers of comfort footwear Running shoes, offered in width fit- have either discovered the benefits of tings, are one of the easiest shoes to this category earlier in life or have fit and accommodate many minor been advised by their podiatrist to foot deformities such as hammertoes, seek out a specialized store for choice cross-over toes, Haglund’s deformity, and fitting, where age dictates or foot and various exostoses. Correctly-fitted discomfort is evident. Comfort running shoes also accommodate footwear basically falls into two sub most orthotics well. groups—open shoes (sandals) and Walking shoes have many of the extra-depth, closed shoes with a clo- same comfort and fit characteristics sure system. Running shoes are often as running shoes. It is safe to recom- interchanged with closed comfort

Many specialized sport shoes require expert, experienced advice on fit and comfort.

mend to patients that they walk in shoes, mostly for men in this category running shoes but not to buy walking (Figure 6). shoes for running. Aetrex offers an A comfort shoe typically is well- adjustable heel strap model with par- cushioned and has supportive tial rear entry and heel lock as an ad- anatomical features such as a medium ditional fitting option. to aggressive longitudinal arch, deep- The sport shoe category is vast seated heel cradle, metatarsal pad, and specialized. Court shoes are an- and possibly a toe crest. Closed shoes other major sub-category. Due to the designed with firm heel counters length of time players wear court often have high toe boxes and lace or shoes, a tight-fitting court shoe Velcro® closures. Velcro is particularly should be avoided. Players need plen- helpful for arthritic patients having ty of toe room for stopping and later- trouble tying laces. Many closed al/medial movements on the court. shoes in this category are designed Certain sports, such as soccer, require with stretchable panels or straps (Fig- shoes to be fitted snuggly; the best ure 7). Comfort footwear is typically suggestion is to recommend that com- offered in width fittings in both closed petition shoes be worn minimally— and open shoes. only for competition. More comfort- Women’s comfort footwear is able training shoes are a better choice more popular in open toe sandal for practice sessions. models than in closed shoes. Open Many specialized sport shoes re- shoes are easier to fit as many come quire expert, experienced advice on Continued on page 116 www.podiatrym.com OCTOBER 2013 | PODIATRY MANAGEMENT | 115 FOOTWEAR SIZING UP

with adjustable Velcro or buckle closure ommend with confidence. For fitting a systems, and may even come in widths. shoe with an AFO or to accommodate a Unless the foot condition is severe such bulky ankle brace, the full stretch or as in PTTD or with Charcot foot, most extra-depth shoe is the best choice. other deformities, such as hallux valgus, Many extra-depth shoes contain one or hammertoes and bunions can be man- two extra insock spacers that offer addi- aged conservatively in a comfort sandal. tional room inside the shoe when Cosmetically, comfort sandals are ac- they’re removed (Figure 5). ceptable to most women; however, Medicare Diabetic shoes are closed closed shoes in this category are not comfort shoes (or athletic models) fitted readily accepted by women unless ne- Figure 5: Pedors Stretch extra-depth shoe with medical foam moldable inserts in a cessity (such as a family function) dic- closed shoe, designed with an ad- tates forcing a woman to choose between comfort and ac- justable closure system. They must be offered in a mini- ceptable appearance. The quest continues within this seg- mum of three width fittings. Diabetic footwear, to be ment of the footwear industry to meet the challenge of of- Medicare -compliant, should be fitted by a podiatrist, pe- fering more comfortable closed-fashion ‘looks’ that meet the critical eye of the older fashionista.

Orthopedic/Custom Footwear (Option # 2) Post-operative boots and shoes For more severe foot deformities and abnormalities, are made in a variety of hard when a comfort shoe is not suitable, the next option to keep a patient ambulatory is a full stretch or extra-depth and soft styles suitable for protection, readymade shoe. Several companies offer models that will comfortably accommodate an AFO or gauntlet brace. P.W. off-loading, wound care, Minor, Drew, and Pedors are all companies you can rec- and night splints.

dorthist or orthotist. Diabetic shoes should be fitted gener- ously for protection and to allow for edema, a common symptom among diabetics.

Custom-Made Shoes (Option #3) These shoes are for the most severe or difficult fittings and often the last resort for a patient to remain ambulatory is a custom-made boot or shoe. There are still many companies (such as Jerry Miller and Tru Mold) and pedor- thists that will cus- tom-make a boot or shoe from a full sock casting. This may include fillers for amputees and special modifica- Figure 6: A typical closed ladies comfort shoe tions outside the shoe such as rocker soles, flanges, and reinforced shanks and counters.

Post-Op Shoes Post-operative boots and shoes are made in a vari- ety of hard and soft styles suitable Figure 7: Stretch Mary-Jane Upper from Propet. Continued on page 117

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for protection, off-loading, wound performance categories, there are sev- are made with a toe thong, or as a care, and night splints. They are easily eral specialized sub-groups of work wrap-around slide. Either as sandals or fitted and sized as youth, ladies small, boots, such as worn by loggers (caulk- flip-flops, the thong between the hallux medium, large, extra large and men’s ing), linemen, and firefighters. Mili- and second ray is helpful for patients small, medium, large and extra large. tary and police, service industries with bunions and hallux valgus. The All are made with adjustable hook and such as catering, may also require slide wraps around (preferably with loop closure systems and firm soles. A specialized footwear for non-slip, or adjustable Velcro™ straps) and works variety of rocker soles are also avail- able. The shoe or boot must be sized long enough to protect the toes. All are Diabetics should made on wide lasts to allow for ban- dage and splint adjustment. always protect their feet indoors by wearing

Work Shoes and Boots some form of slipper. This practical category is sized as comfort footwear with plenty of room in the shoe or boot for orthotics or oil and grease resistance. If extra thick better for a wide foot. Slippers may be swelling. Work boots are often worn or double socks are worn, this may re- offered as slides, mules, or closed up- for long periods during the day in var- quire the fitter to increase the shoe or pers and are usually made with soft ious climatic and work conditions. boot size to assure a comfortable fit. linings or uppers and non-slip soles. Hard, high toe boxes are available for Fitting is not usually an issue with this protection, and non-slip lug, grease-re- Casuals and Indoor Footwear type of footwear, as long as the wearer sistant soles are common. Width fit- Clogs, mules, slippers, and the does not choose a slip-on shoe that is tings and quality materials are impor- ever-popular flip-flops fall into this too large. The risk of tripping is a sig- tant in this category. As in the other catch-all general category. Flip-flops Continued on page 118

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nificant enough danger to justify trying facturer or through a listed supplier. terest in specific sports activities have the slippers on in a store rather than Dance and ballet shoes are a good ex- the expertise to advise athletes and buying them online. Better quality ca- ample of footwear specialization. Win- patients as to the best footwear for sual slip-ons and slippers are offered in ter sports, particularly downhill ski performance and avoidance of injury. full sizes and may offer adequate toe boots, are another huge footwear cate- To understand and have the specific spring. Beware of brands that size by S, M, L, and XL if the patient has an unstable gait or uses a walker. Some patients prefer a more stable, hard slip- The experience and knowledge required per or mule, such as the Merrell clog to correctly fit footwear of all types, for all ages, for indoor wear. Diabetics should al- ways protect their feet indoors by under all ambulatory conditions and biomechanical wearing some form of slipper. requirements, should not be overlooked. Specialty Shoes Specialty Footwear is a unique re- source for people who require a high gory requiring specialized expertise in shoe-fitting knowledge in every level of expertise to achieve comfort, shoe-fitting. Each area of expertise is footwear category would require a optimal performance, and maintain peculiar to a certain category of lifetime of study. The late William foot health. Most types of specialty footwear. A separate article could be Rossi, DPM elected not to maintain a footwear are not sold in retail written for each specific segment:— podiatric practice; instead, he used his footwear or athletic shoe stores. track and field, Alpine ski boots, cy- knowledge of the foot and podiatry in Thanks to the Internet, almost any cling shoes, dancing shoes, logging order to understand the interaction be- type of specialty shoe made can be boots, the military, etc. Some podia- tween the foot and foot coverings. bought either directly from the manu- trists and pedorthists with special in- Summary No one would propose that shoe- fitting is a science, or even requires a medical degree. However, the experi- ence and knowledge required to cor- rectly fit footwear of all types, for all ages, under all ambulatory conditions and biomechanical requirements, should not be overlooked. Podiatrists see the results of poorly- or self-fitted footwear every day. For more in-depth fitting advice on specific footwear cat- egories, refer to experienced personnel in medical footwear stores. Many ex- pert shoe-fitters are pedorthists who fit and work with shoes on a daily basis. In performance footwear, seek the knowledge of coaches and trainers who work with athletes in their specif- ic sports. PM

Former UK Olympic athlete Mel Cheskin, MBS.,C.Ped. currently writes for Current Pe- dorthics, World Footwear and World Sports Activewear mag- azines and is author of “The Complete Hand- book of Athletic Footwear.” In his career as a designer, execu- tive, and consultant, Mel has worked for Nike (Cole Haan), Adidas, Puma, Bata, and Brooks shoe companies and Spenco Medical Corp.

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