Things we look for/consider when fitting shoes:

Toe Box

Heel Cup (Heel Counter)

Counter

Vamp

Upper

Cuff or Topline

Throat

Upper

Laces

Insole

Midsole

Outsole

Heel shape

Heel height

Overall Shoe height

Flexibility

Last

Materials

Workmanship/Quality Control

Foot movement

Transference of weight

Restrictions caused by the foot

Restrictions caused by the shoe

Bunions

Hammer toes

I have been wanting to write this article for a few years now.  I see the effects that shoes have on patients feet nearly every day…and many of them are not good.  I hope to shed some light on the reasons why shoes can impair our normal foot motion and the ways to prevent or correct them.

I’m going to start with the assumptions, since every hypothesis has them.  Historically, our feet evolved without modern shoes.  That means that bare feet, tree bark, large leaves, woven grass or animal hide protection (moccasins) were where we began.  The evidence of the use of footwear dates to 40,000 years ago.  Anthropological evidence from skeletons indicates that the thickness of the bones of the smaller toes began to decrease in thickness around that time. (Trinkaus, E.; Shang, H. (July 2008). "Anatomical Evidence for the Antiquity of Human Footwear: Tianyuan and Sunghir". Journal of Archaeological Science. 35 (7): 1928–1933. doi:10.1016/j.jas.2007.12.002. Retrieved July 23, 2012.)  This is believed to be a result of some form of protection being worn on the feet.  The natural fibers that were used in early shoes degrade quickly and that is the likely reason more shoes have not been found.  Still, grass sandals were discovered that were nearly 10,000 years old in a cave in Oregon (Connolly, Tom. "The World's Oldest Shoes". University of Oregon. Retrieved July 22, 2012.).  The oldest leather shoes, which more resemble a sewn-up bag that covered the foot, are nearly 5,000 years old (Ravilious, Kate (June 9, 2010). "World's Oldest Leather Shoe Found—Stunningly Preserved". National Geographic. Retrieved July 22, 2012.).  These archaeological findings suggest that we have been wearing shoes as a species for many years now.  We did not start significantly altering the design of those early shoes by adding heels until the Baroque period.  Much has changed since that time, and not all of it is for the better.  This is what this paper will be addressing.

Building on the first hypothesis, that we evolved without shoes, I would like to discuss natural vs. normal gait.  Natural gait is what we have developed over millennia.  It occurs without the use of shoes to alter the movement pattens of the feet. Any shoe that interacts with the feet without altering their movement can be considered to give, or not impede, “natural” gait.  The term “normal” gait is a misnomer.  It is a created word to describe what shoes do to the feet.  Let me reiterate…the pyramids were built, the Roman empire rose and fell, Alexander the Great lived and died…and all of these things and many more happened without the use of heels, orthotics, or running shoes that we have today and believe are integral to a good shoe.

The second hypothesis is that the foot is a self-supporting structure when it works correctly.  This is based on the work of John Martin Hiss, MD, DO.  Dr. Hiss ran the worlds largest foot and ankle clinic in Los Angeles, California and wrote three books on the foot.  Hiss suggested that when the foot and its bones, ligaments and muscles work correctly, that it did not need anything else to assist it in working correctly.  I have seen this in my practice, but also realize that it is a hotly contested topic.  Many “professionals” (which today can include Facebook experts) feel that the foot needs some kind of support to function normally.  When my patients ask me about the need for orthotics, I ask them “when you walked into the office, did you see specific places marked on the ground with preprinted places for your feet with your name on them?” Of course the answer is “no”.  My follow up is “that means that (insert your name for the power larger than ourselves here) doesn’t mind where you step, because if he/she did, there would have been marked places…  It’s one way to explain that the human foot was designed to adapt to its surroundings.

The third hypothesis is that many, if not most, shoes negatively influence the foot and its movement patterns in some way.  The alteration in motion that the shoes cause is then the culprit of pain and perhaps long term changes in the structure of the foot.  It is this area that this article will address in detail.

I often tell my patients that their shoes were like designed in Europe or New York by someone who wants them to look good, then built on a machine in China and put on your feet by someone who has no real idea how shoes are supposed to fit in the country you live in.  I then add that your shoes are designed for fashion and not function.  We all own a pair of feet.  We know what feels good to them and what does not.  If we don’t follow what feels good, or can’t discern what is supposed to be right, then we fall prey to what someone else advertises as the cure to our problem.

To move forward with how shoes fit, we need to first understand how they move.  This requires some knowledge of anatomy.  The foot has 26 bones, 33 joints (20 of which actively articulate), 144 ligaments and 20 muscles, some of which span the ankle joint with their tendons.  The take home message from this is that the foot is designed to MOVE, and thus, anything that hinders the normal motion is not part of a “natural” item of footwear.

Many things can hinder foot motion.  These include congenital foot defects, trauma (such as fractures), infections, an additive combination of small injuries, and things such as ankle sprains, or retained primitive reflexes among others.  Unfortunately, there are few healthcare professions that look at the foot mechanically anymore.  In my recent interactions with podiatrists, whose name means “foot healer," I was shocked to learn that it is incredibly rare for them to do any manipulation - at all.  Even then it is the older podiatrists that do it.  It is not taught in the podiatry schools today.  The MD’s are not taught manipulation in medical school.  That leaves the few DO’s who practice manipulation and DC’s and PT’s who learn how to treat the foot to do any actual correction of the mechanical issues.  What most healthcare professionals will do is prescribe orthotics, exercises, and surgery.  If that treatment does not work, most are told that they will have to live with the injury or pain.  Very few are looking for the actual cause of the pain and mechanical issues in the first place.  That means you will likely only get a bandaid for your problem rather than a cure.

It certainly does not work that way in my practice.  Not only did I learn from one of Hiss’ students how to do what he did, but I have taken it much further.  Rue Tikker, DPM was the practitioner who took the reins from Dr. Hiss.  Rue went on to have an illustrious career, treating over 300,000 pairs of feet in his 50 plus years of practice before he retired.  Rue is both my friend and mentor.  He has done his best to impart Dr. Hiss’ wisdom to me and entrusted me to spread it to the next generation.  But getting the foot mechanically working correctly is just the beginning.  If we have other issues that effect the way our foot moves, these can have an impact on footwear as well.  

When we are developing and growing in our first few years of life we have movement patterns that occur in all of us (or are supposed to).  These patterns of movement are called reflexes and the foot has five reflex patterns.  The stepping reflex occurs early and causes us to walk with our toes down and heels up.  This is how our first steps are meant to occur.  We also have a heel reflex which is nearly the opposite to the stepping reflex.  Here we walk with our heels down and toes up.  There is also a reflex called the Babinski reflex (not to be confused with the Babinski sign) which causes us to walk on the outer edges of our feet.  The crossed extensor reflex will cause us to lift the opposite leg when weight is applied to the first one.  The plantar grasp reflex gives up toes that are reflexively tight in a “down toward the ground” pattern and they resist moving up toward the head. I have found numerous adult patients with all five reflexes present and it is common to find at least one present in every person I check.  The effects how your feet move and how shoes fit for certain.  I have developed a method of rapidly removing these reflexes and restoring a more natural motion.  This is part of our evaluation for getting the correct footwear for you.

When it comes to shoes, understanding that the cobblers who, 150 years ago, would have custom build your shoes, are out of financial reach for most of us is vital.  That means that we are limited to what we can buy off the shelf…and there are many pitfalls with this method of purchasing shoes.  The first is quality control between pairs.  I always made the assumption that if I bought two pairs of identical shoes from the same store on the same day that I could not tell them apart when I got home.  I was mistaken…big time.  It was like comparing apples and oranges.  The box was labelled the same, but the shoes were not the same at all.  Thus, if you find a good pair, make sure to check that the next pair is the same when trying to match them.

When fitting shoes, we start with where the toe box ends in relation to your toes.  That is fairly standard.  We also look for toe box width and shape and make sure that your feet match the shoes we select.  Then we look to see if the heel cup hugs your heel while still allowing free movement.  To some extend this is adjustable with how you lace the shoe, but anything too big or too restrictive needs a different shoe or size.  The foot bed and how it interacts with your foot will determine if you are in a neutral posture, or walking with toes down to heels down.  It will also move your foot into pronation or supination.  We select the foot bed that keeps you in neutral.  Finally, the way the uppers fit your feet is vitally important.  Too tight and the shoes hurt. Too loose and the foot slips in the shoe and you are predisposed to injury.  Shoes lacing patterns can help here too.  We are searching for the perfect fit.

Over the years I have met patients at running stores, shoe stores, helped them search online and worked with many pairs of shoes in the office.  Every shoe has a range that it can adapt to your body.  We are looking for the range from the shoes that is very close to what your body needs to move normally.  When we find the right shoe and fit, your body no longer fights your footwear…and your optimal potential came be expressed.

Once we go through this process, you will have a shoe that fits your foot and will enhance performance while reducing injury…because the shoe does not hinder the foot’s natural motion.  Not many places (whether running stores, specialty shoe shops, podiatrists, or medical offices) can offer such a service.  We look forward to helping you select the right pair of shoes for you.