Review
Footwear and orthopaedics

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Abstract

Footwear is the oldest known fashion accessory in use. Footwear is often implicated in orthopaedic problems affecting lower limbs and back. Hence footwear modifications have a major role in management of these pathologies as well. This review explores footwear and its role in causation and management of orthopaedic problems. Based on our observations we recommend that children with flexible flatfeet should be encouraged to walk barefoot to help in developing their arches. Women with risk factors for secondary arthritis of knee or back pain may be advised to avoid heels. Commercial shoes which decrease hind foot loading may be used in symptomatic management of hindfoot and mid foot problems. Similarly shoes which decrease forefoot loading may be useful in managing forefoot pathology. Flip-flops should be avoided by diabetics as they do not protect from injuries.

Section snippets

The evolution of footwear

Footwear was in use by at least the middle Upper Palaeolithic era (the Stone Age as it is more commonly called) in parts of Europe, based on archaeological evidence [1]. This has been suggested following comparative biomechanical analysis of the proximal phalanges in feet of western Eurasian Middle Upper Palaeolithic humans and those of variably shod recent humans. Spanish cave drawings from 15,000 years ago show humans with animal skins or furs wrapped around their feet. The oldest footwear

Types of feet

There are broadly three types of feet. The Egyptian type (the commonest) has a great toe longer than second, the Greek type has a second toe longer than the first and the Square type has great and second toes of same length. Egyptian feet have been incriminated in hallux valgus [4], hallux rigidus [5] and ingrowing toe nails [6]. Greek type feet (also known as Morton's type [7]) may be associated with higher risk of metatarsalgia, hammer-toes and Morton's neuroma (Fig. 1).

The effect of footwear on gait

Dusing and Thorpe [8] found in their study of 438 children that the mature gait pattern is well established in most children by the age of 7 years (although may be delayed up to 13). The medial arch also appears by the same age. Lythgo et al. [9] found that children and young adults walking with footwear had increased gait speed, step length, stride length and support base but reduced foot progression angle and cadence compared to those walking barefoot. Their short steps allow the feet to land

The effect of footwear on feet

Shoes have been implicated as a causal factor in a great many foot pathologies. In a survey of 1846 skeletally mature people, Sachithanandam and Joseph found that the prevalence of flatfeet was higher in those who started wearing shoes before the age of six [12]. Similarly, Rao and Joseph showed a prevalence of flatfoot of 8.6% in shod versus 2.8% in unshod children [13]. Pes planus was most common in children who wore closed-toe shoes, less common in those who wore sandals or slippers, and

Footwear and proximal joints

Walking barefoot has been shown to reduce the loading in osteoarthritic knees significantly [19]. Kerrigan et al. showed that high-heeled shoes increased loading in patello-femoral and medial compartments of the knee by as much as 23% compared to walking barefoot [20]. This increased loading was observed in both wide-heeled and narrow-heeled shoes [21]. High heels therefore may be one of the factors contributing to the higher prevalence of knee osteoarthritis in women. Improper shoe use has

Footwear and injuries

Heelies (shoes with a wheel embedded into the heel) have become very popular with children and have been shown to cause increased incidence of injuries [27], [28]. These injuries may be avoided by the use of protective gear, as advised by the manufacturers.

Shoe wear has been shown to predispose to lateral ligament injuries of the ankle by inhibition of the normal proprioceptive feedback mechanisms [29]. Shoes also limit the adaptive pronation during foot-strike in running and leave the foot

Heel modifications

The heel can be elevated by an insert or by external shoe modifications. External raises have the advantage of not raising the heel out of the counter, and therefore allow better grasp of the heel. Lateral heel wedging (posting) has been shown to decrease pressure under the third, fourth and fifth metatarsals and medial heel wedges correspondingly decrease pressure under the first and second metatarsals [32]. Shoe modifications have also been shown to be a simple, inexpensive and effective tool

Commercial footwear for orthopaedic problems

The observation that barefoot walking is more biomechanically efficient than shod walking has prompted manufacturers to design footwear, which mimics barefoot walking itself. The most popular commercial shoes in the market claim to create an ‘unstable’ gait [40]. Stable and unstable gaits have never previously been defined in the literature, but we hypothesise that the three rockers of natural gait are ‘unstable’, compared to the ‘stable’ gait with a rigid soled shoe and no rockers.

MBT® shoes

MBT (Masai Barefoot Technology)® shoes are currently one of the most popular in the market. The manufacturers claim that these shoes work on the principle of ‘natural instability’. MBT's patented sole construction, the soft Masai sensor, is claimed to simulate walking and standing on uneven ground. This reportedly stimulates the body to activate its natural balance mechanisms, thus strengthening the supporting, shock absorbing muscle groups in the body from the legs to the back. The

Earth® shoes

The defining feature of earth footwear is the so-called ‘Negative Heel Technology’ – an inclined sole that positions the toes 3.7° higher than the heels. This slight angle shifts weight subtly back over the heels, and is claimed to help strengthen muscles whilst also burning calories. All earth footwear also has reinforced support through the arch, which claims to maximize the effectiveness of the heel design in promoting a natural walking motion. Additionally, all earth shoes contain a

Flip-flops

Flip-flops also are claimed to simulate barefoot walking and increase calf, leg and gluteal muscle activity. Manufacturers of the popular model Fitflop claim them to be flip-flops with a built-in-gym. The different flip-flops available on the market have been reviewed by American Podiatric Medical Association (APMA), which recommends only a few. According to APMA, the lack of support in a flip-flop can leave the wearer susceptible to sprained ankles and ligament injuries, and the limited

APOS shoes

The APOS system was developed by APOS Medical and Sports Technologies Ltd., Israel and marketed in the UK in association with BUPA. The benefit supposedly comes from the design of the sole, which eliminates flat surface walking by using hemispherical, individually calibrated bio-mechanical units at the hindfoot and forefoot on the plantar surface. These units can be moved medially, laterally, forward, and backward, and may be individually adjusted in order to balance loads. In a double blind

Conclusions

Based on our observations we feel that young children with flatfeet should be encouraged to walk barefoot to strengthen intrinsic muscles and develop arches instead of using arch support insoles. Currently there is not enough evidence to support either of these. There is scope for prospective studies comparing barefoot walking and use of insoles for flexible flatfeet in children.

The commercial orthopaedic footwear market appears to be flooded with shoes, but most of these do not have enough

Conflict of interest

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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