Chapter 4

Footwear
by G.K. ROSE, o, FRCS

While the earliest records of the human race, both pictorial and written, represented man as shod it
must be remembered that a very large proportion of the world's population at this time goes
barefooted over rough terrain without, apparently, grave disadvantages. The specialised tissues, both
skin and subcutaneous, of the sole of the foot readily undergo hypertrophic changes to provide the
necessary toughness and insensitivity to allow walking in these circumstances.
It is important to recognise that not every thickening of the skin as seen on the normally shod
foot is the cause of problems and requires to be removed but can be a useful adaptive protective
change to pressure resulting in. a satisfactory function. The wearing of foot coveting almost from the
beginning served many functions, ranging from protection against mechanical and thermal traumata
through to decorative and social purposes, such as indicating status (in Egypt Princes had always to
appear unshod in the presence of the Pharaoh), or so limiting walking capacity to indicate that the
owners were so rich as to have no need to indulge in this vulgar practice. Elevating the heel occurred
in thelSth century and shoe heels have varied in height and style since. Sometimes heel elevation was
combined with a raise of the sole (the patten) (Fig. 4/1) to elevate the foot above the contamination of
the street; but often it was confined to the heel to make the.wearer look taller and to give a stiffer,
more uptight, posture.
Only fairly recently were left and tight boots made, and an even more recent change has been the
considerable decline in the use of firm boots which provide protection for the ankle. It is not always
realised that the subtalar joint is level with the upper border of a man's shoe (see Fig. 4/5) and this
therefore exerts no control over this joint nor the ankle directly. Partly because of this, tilting
alterations to the outside of the shoe will often have little effect on the foot itself.
Fig. 4/1 (a) Mediaeval patten often put over other footwear. (b) Modern metal patten used now almost
exclusively to lengthen the good leg when the other is treated for Perthes' disease with an elongated
patten-ended caliper

Another development which has occurred in recent years has been the introduction of man-made
materials and consequently a revolution in manufacturing processes. The basic requirement still
remains: a last. This is a wooden or plastic positive which dictates the exact shape, size and fit of the
shoes built upon them. Emphatically it has to be understood that a last is not a cast. It might be
thought that if a careful weight-bearing plaster cast was made of the foot and a shoe then constructed
upon this that it must be a perfect comfortable fit, but this is far from the case as the following
allowances have to be made:
1. Alteration of foot shape in walking- the normal rise and fall of the
arches combined with supination and pronation which occurs with
every step.
2. That the shoe itself varies in shape during walking. This is particularly so in the area of the
creases over the base of the toes.
3. That 'suspension' must be provided. This term is used by prosthetists to indicate the measures
taken to prevent an artificial leg falling off during the swing phase. In the shoe this requires a
narrowing of the back to grasp the heel area, and some form of hold over the forefoot without
leforming the foot. This also reduces the tendency of the foot during stance to push forward
initially and then backwards and so avoids blistering.
4. That allowance has to be made for growth in children.
5. The manufacturer endeavours to provide shoes which will be a safe, acceptable, non-deforming
fit for as wide a range of people as is possible of each size, making allowance for the variations
which occur in length and width.
82 vooxwv-
Last making is, therefore, both a science and an art, but no-one has yet produced that
much sought design of the fashion world in which the inside is larger than the outside!
On the last, the orthodox method is to stretch leathers of varying characteristics to
produce the upper with some stiffening in e toe and in the heel to prevent it being trodden
down, combined with an appropriate lining. The parts of the upper are stitched together and
this is then stitched to the sole which is stiffened with a metal or wooden strip running from
the area where the heel is added forward to the tread.
In the modem mass-produced shoe, while some stitching may be usl in the uppers
(although even here with synthetic materials an appearance of stitching may be moulded on)
the heel and sole components are either cemented to the upper, or are moulded directly in
iosition bonding with the upper during this process. From the point of view of shoe
alterations the important difference is that whereas previously it was possible to take the
shoe partly to pieces and insert, for example, a caliper heel socket and then reconstruct the
shte, this cannot now be done particularly as the heel may be found to be of a honeycomb
structure. It has imposed on the orthotist a need to study modem adhesive techniques and in
this case to cut off the heel and then to cement on another of solid construction.
The advent of man-made materials focussed attention on an important aspect of shoe
construction, namely the need to allow for the escape of perspiration. Investigation shows
that a leather sole allows a negligible proportion of sweat to escape through it, so that there
is, in this respect, no disadvantage in replacing leather by the longer-wearing modern
plastics. Perhaps the largest proportion of moisture is removed from the shoe by the air
sucked in and expressed around the foot during the various phases of walking. A very
moderate proportion passes through a leather upper. Importantly, however, the amount lost
by all these methods does not equal that produced, so that at the end of a day the shoe is
wetter than in the morning-and frequently this does not completely disappear by the next
morning. Ideally, therefore, no pair of shoes should be worn on successive days. The early
man-made materials were completely impervious to water, but later developments have
improved this situation although they do not equal leather. Particularly impervious are those
shoes with a high shine which is produced by coating them-wh a secondary plastic layer.
Similarly, these materials may provide good thermal insulation and heat discomfort is a
common complaint of patients with rheumatoid arthritis who are provided with moulded
plastic shoes, although many tolerate this because of other advantages. Another
 FOOTWEAR 83
factor with these materials is that the creases produced inside the shoe can be sharper and harder than
those of leather and this can cause problems.
In considering shoe modifications in the medical field these can be classified as regards their
function as follows: 1. Intrinsic: designed to cause some change in posture and/or mechanical
stresses within the foot.
2. Extrinsic: designed to cause optimum distribution of mechanical stresses on the outer surfaces of
the foot. These can be sub-divided into (a) encaseraent, in general the area of the upper and (b)
inevitable, those under the sole of the foot which cannot be avoided in the act of walking. These
can be further sub-divided into (i) pressure stress and (ii) shear stress.

Intrinsic

Two very different situations occur here:

(A) The mobile postural deformity, e.g. the hypermobile pronated (flat) foot.
(B) Deformity rigid in one or more planes, e.g. in inversion the spasmodic valgus, o in several planes
the rheumatoid pronated foot.
The important difference is the degree of interface pressure between the foot and the orthosis
used. In (A), once the unstable foot (see Fig. 7/19, p. 135) is placed in the stable position which will
occur when the orthosis is put on, the body-weight passes through the bony architecture of the foot
when the force applied by the orthosis is very slight (see Chapter 7). In (B) the situation is very
different and there may be a substantial force at the interface either due to muscle spasm resisting
correction or to the fact, as in the rheumatoid foot, that a large proportion of body-weight is applied
here. The best that can be done in such circumstances is to diminish the pressure by increasing, as far
as possible, the area of application remembering that pressure equals force/area. To some extent the
patient may diminish the problem by walking slowly as this diminishes the vertical load deriving from
body-weight. In cases of muscle spasm, either discomfort or the corrective effect of the orthosis will
sometimes increase the spasm and the hindfoot can then be forced out of the shoe.
It can be seen that it is important in these circumstances to ask oneself whether the device is
corrective or supportive; if it is corrective, what is the degree of resistance to correction and what
force will then have to be applied. If it is supportive, how badly is the foot deformed and, therefore,
what support will be required, but in
84 FOOTWEAR
both circumstances to estimate whether the interface pressure can be tolerated by the
patient.

Extrinsic
Encasement has already been dealt with in considering the relationship between a cast of
the foot and a last.
In pressure stress the load is optimally distributed over the largest area and in this
respect it can be seen that the broad print of a 'flat foot' is much less likely to cause trouble
than the relatively small area of a cavus foot (Fig. 4/2). Where, in the sole of any foot, there
is a very

I NORMAl- 2 BROAD

Fig. 4/2
3 HIGH ARCHED

Variations in area of force

application with different foot
types

local prominence, as will occur with a clawed toe where the tightening of the plantar fascia
forces the corresponding metatarsal head through the sole tissue, it is customary to try and
diminish the pressure from this area by the use of an insole on which is mounted a leather-
covered foam metatarsal dome or bar of varying softness (Fig. 4/3). This should only be
used where the pressure is relatively minor, or as a temporary measure in more severe cases,
for as time goes on the pressure of the dome itself, particularly if very firm, will cause
atrophy of the tissues on which it presses with a consequent hollow which will
accommodate the dome; the relief is lost and an even more difficult situation than the
original arises. The highly specialised fibrofatty tissues in the sole of the foot are a valuable
component of gait and should be preserved with respect. For a localised single area of
pressure, surgery is a preferable option. Where considerable and permanent loss of this
tissue has occurred a modern thermoplastic closed-cell foam such as Plastazote which can
be heated and then stood upon to produce a perfect replica of the underside of the foot can
be
 FOOTWEAR 851 the best solution. It
must have beneath it a second undeformed layer of the same material, for the deformation of the first
layer will have flattened the foam cells at the point of maximum pressure, and in severe cases this will
'bottom out'.

- - dome
conversion to a 3/4 insole
Fig. 4/3 Leather-covered sorbo metatarsal dome on a full insole. For comfort the corrective placing of
the dome is important and, as it is usually too far forward, trimming of the back as shown on the
dotted line is a useful final adjustment. As pressure in the metatarsal area is often accompanied by
some clawing of the toes a full insole can press these against the toe cap and produce discomfort.
Either a three-quarter insole should be ordered or the full insole cut as indicated. In all cases of
modification the resultant insole needs then to be anchored by a single tack through the heel area

Excellent as this procedure is, in the most difficult cases such as the neuropathic ulcers of spina
bifida or leprosy, they will not heal unless shear is also removed, and to do this it is necessary to
provide a substitute for the subcutaneous tissue to allow the foot to roll forward. This is done by the
provision of an absolutely rigid rocker sole. Unfortunately the commonly provided metatarsal bar is
quite useless for this function as it is necessary that the contour should be as shown in.Figure 4/4.

Fig. 4/4

The mandatory sole contour to avoid both pressure and shear stress under the fore-foot. The sole must
be absolutely rigid
86 FOOTWEAR
Heel and sole height

The heel height is something on which advice is often sought from the physiotherapist. Research has
shown that in a nylon stocking with a heel height of two and a quarter inches or less, the friction
between the shoe and the covered foot prevents this slipping forward and causing toe problems.
Raising both the sole and heel, as in recent shoe design, increases the length of the moment arm from
the outer edge of the heel to the subtalar joint axis and facilitates inversion injuries of the ankle joint
both ligamentous and bony (Fig. 4/5). Conversely the wider the heel the safer it is from this point of
view and patients who have had such injuries, liable as they are to recurrent inversion strain, can be
greatly helped by the provision of heels which are 'floated out'. Figure 4/6 shows three types of these
which are progressively more efficient; (C) is particularly useful on the inner side in the treatment of
pronated feet. Furthermore it has to be remembered that if a support is provided within a shoe this
cannot function unless it is itself supported (Fig. 4/7).

l/ ",,' ,,' '//

"' "' ' 'i' ( " - :,,
II ,,, / \\ , , '" '

t -j,,,, :.. ,, . ;..;,,

,. .'/," :,. ,;

Fig. 4/5 Antero-posterior radiographs ofe ae (a) bareft, d (b) a sh; noN psmre in complete nes d
supinated t te umble sifin in broken nes. The instab oNy sghfly increases e bft sifin owing to the
utward rle of the cNce-enct culfin. I a sh the movement of e Ne in space is grfly incrd as is c moment
about the fulc F. These raographs were ten in a m's sh d with we consideble crease in heel height the
adver forces cr prorfionatcly. (Diagrafic reprenmfion)
 FOOTWEAR

Fig. 4/6 Various types of 'floated out' heel

87

i MENISCUS

Fig. 4H Any support applied to the foot must itself be adequately supported as in A. In B the heel
meniscus is ineffective because the bxly-weight will simply enforce rotation about the narrow heel

It is a common experience that patients with a short leg who are provided with a raised boot to
compensate for this, will soon abandon it if the raise is substantial (one or more inches). Small raises
are produced by appropriate additions to the sole and the heel up to three quarters of an inch. Above
this it is usual to insert a layer beneath the upper, running from the front to the back of the boot.
Sometimes this is given up because of the weight which can be now overcome by the use of
appropriate plastics; often it is given up because the shoe is thereby rendered rigid without an
adequate compensatory curvature of the sole contour which should be tapered from just behind the
metatarsal heads of the toe (called confusingly in the footwear trade, toe spring) and this enables the
normal'toe rocker' (see Fig. 2/13c, p 53) to be used.
Sg FOOTVEAR

For the patient with rheumatoid arthritis modern plastics enable shoes to be made from a plaster cast which
can accommodate quite considerable deformities. Inherent disadvantages of this have been • ndicated and it is now
becoming the practice to provide shoes of this construction made from standard lasts. Increased depth is
usually .provided to accommodate insoles. At the same time particular attention is paid to the fastening which
should be of a simple type, commonly using 'touch and close' material (Velcro).