Designing suitable shoes to prevent foot frostbite through optimization of the geometric dimensions of the shoe and sock model

To prevent frostbite in cold environments, proper dimensions and materials for different parts of shoes along with the optimal design of shoe geometry were investigated. Furthermore, the optimal geometry of shoes was computed using an optimization algorithm to provide maximum thermal protection for the foot while having the lowest weight. The results showed that the length of the shoe sole and the thickness of the sock are the most effective parameters in foot protection against frostbite. Using thicker socks, which only increased the weight by roughly 11%, enhanced the minimum foot temperature by more than 2.3 times. HIGHLIGHTSOptimal design of shoe geometry is used to prevent frostbite in cold environments.A model of a biothermal nonlinear model is developed for the barefoot.Length of the shoe sole and the thickness of the sock are the most effective parameters in protecting the foot against frostbite.For the selected weather conditions, the toes are most likely to have frostbite.The best shoe for the selected weather conditions is the shoe that has the highest amount of thermal insulation in the toe area.

An exploration of footwear preferences, attitudes and beliefs in people with knee osteoarthritis: A qualitative study

BACKGROUND

Although footwear can improve pain and function in individuals with knee osteoarthritis (OA), perspectives about footwear in this population have not been explored.

OBJECTIVES

This qualitative study explored preferences, attitudes and beliefs about footwear in adults with knee OA.

METHODS

Twenty individuals with a clinical diagnosis of knee OA (aged 45-79 years, 65% women) participated in semi-structured interviews about factors which influence footwear selection, the effect of footwear on knee symptoms, and footwear modifications. Data were analysed thematically.

RESULTS

Four themes, with sub-themes, were identified: i) there are specific footwear characteristics people look for, with comfort as their top priority; ii) shoe appearance is important; iii) footwear can aggravate or ease symptoms; and iv) people with knee OA find footwear in a variety of ways. Participants related built-in arch support, a cushioned insole and low/no heel, without addition of foot orthoses, to comfort, and were willing to pay more for comfort and quality. Appearance was also a consideration, and participants indicated they would tolerate short periods of symptom aggravation for aesthetic shoes. Participants felt that footwear choice affected their knee symptoms and risk of slipping/twisting. Participants reported that their footwear choices were determined through trial-and-error, and sometimes on advice from health professionals or shoe store salespersons.

CONCLUSIONS

There are specific footwear features important to individuals with knee OA. Knowledge of these features can be used by health professionals to inform footwear discussions with knee OA patients and serve as considerations when developing footwear targeted for this population.

Flat flexible school shoes for adolescents with patellofemoral pain: a randomised, assessor-blinded, parallel-group feasibility trial

Objectives

To determine the feasibility of conducting a large-scale randomised controlled trial on the efficacy of flat, flexible school footwear versus traditional school footwear in adolescents (aged 12-18 years) with patellofemoral pain (PFP).

Methods

Adolescents with PFP were recruited for this study. Participants were randomised to wear either a (1) flat, flexible school shoe or (2) a traditional school shoe. Participants wore the shoes as per school requirements for 12 weeks. Feasibility was assessed by (1) adherence to allocated shoe wear of ≥75% of total weekly school shoe wear time (recorded through weekly log sheets), (2) a recruitment rate of one participant per fortnight and (3) a dropout rate of ≤ 20%. Descriptive statistics were used for feasibility outcomes.

Results

24 adolescents (15 men, 9 women, mean (SD) age 14.3 (1.7) years) participated in this study. Two participants (8%) were lost to follow-up. The recruitment rate was 1.7 participants per fortnight. 11 of 12 participants (91%) in the flat flexible shoe group and 9 of 10 participants (90%) in the traditional shoe group met the minimum adherence for shoe wear. Mean weekly shoe wear was 20 (7.6) and 21 (4.5) hours per week in the flat, flexible, and traditional shoe groups, respectively.

Conclusion

Our results indicate that progression to a full-scale randomised controlled trial is feasible based on the current protocol. A full-scale randomised controlled trial powered to detect estimates of treatment efficacy using flat, flexible school shoes versus traditional school shoes is warranted and will guide evidence-based management of adolescent PFP.

The use of preferred footwear versus barefoot conditions in gait analysis: A methodological investigation

Laboratory-based gait analyses traditionally analyze baseline characteristics in individuals while they are barefoot. However, there is limited evidence on whether individuals' preferred walking shoes alter lower extremity kinematics during over-ground walking. We present novel evidence regarding the effects of shoes on lower extremity kinematics in healthy, young adults. Fifteen volunteers participated in this study which obtained lower extremity kinematic data on two over-ground walking conditions (barefoot and preferred shoes). Gait velocity, stance width, and stride length, along with sagittal plane hip, knee, and ankle angular positions were computed; hip, knee, and ankle positions were normalized to 100% of the stride. Dependent t-tests were used to compare baseline and shoe conditions for gait velocity and stance width; a two-way analysis of variance was used for stride length. A point-by-point Model Statistic analysis was used to identify significant differences in angular joint positions between conditions. Our results indicate that shoes affected the ankle angular joint position for more than half of the gait cycle, and affected the knee angular joint position, but only for approximately 20% of the cycle. The hip was unaffected by shoes. Gait velocity and stance width were statistically significant, with gait velocity being greater for shoes, and stance width being greater while barefoot. Stride length was not statistically significant between conditions. These outcomes suggest that researchers should use caution if they are considering a barefoot condition as a 'baseline' for healthy, young adults, as there are marked changes in the ankle, and in traditional gait metrics.

[The influence of footwear on the human gait]

The development of individual gait and running patterns is influenced by internal (anatomical, anthropometric) and external (activity-related, environmental) factors. The predominantly used rearfoot running style is mainly attributed to the use of cushioned shoes, although from an anthropological perspective running barefoot, and thus running forefoot, is considered to be more natural. Numerous studies have shown a long-term influence of habitual footwear use on foot morphology, running biomechanics and basic motor skills. It has further been shown that an acute change in footwear, e.g. by running barefoot, immediately changes kinematics and vertical load parameters. However, to date, there is no strong evidence for an influence of habitual footwear use or footstrike patterns on the prevalence of injuries or physical complaints.

Australian secondary school principals', parents', and students' attitudes to prescribed school footwear guidelines

BACKGROUND

Adolescents are often required to wear footwear that adheres to uniform guidelines at secondary school. There is a paucity of literature on factors influencing school footwear choice and what drives the development of school footwear guidelines. The aims of this study were to describe (i) current school footwear guidelines in secondary schools across Australia, (ii) factors that influence footwear choice in secondary school students and their parents, and (iii) principals, parents, and students' beliefs on factors which contribute to school footwear guidelines.

METHODS

An online survey was distributed to principals, secondary school students (aged 14-19 years) and their parents across Australia. The survey included questions on current school footwear guidelines, factors influencing footwear choice (for students and parents), participants beliefs on the effect footwear has on musculoskeletal health, current and previous lower limb pain, and beliefs on factors that contribute to school footwear guidelines. Parent and student responses to factors that influence their footwear choice were compared using proportional odds logistic regression. Students and parents' responses to factors influencing footwear guidelines were compared to principal responses using proportional odds logistic regression. Significance was set at an alpha of < 0.05.

RESULTS

Eighty principals, 153 parents and 120 secondary school students responded to the survey. 96% (77/80) of principals reported that their schools have set guidelines for school footwear. 88% of principals considered comfort to be important when developing school footwear guidelines. Proportional odds logistics regression showed that parents and students were 3.4 and 4.9 times more likely, respectively, than principals to rate comfort as being important when schools develop footwear guidelines. More than 40% of students reported experiencing musculoskeletal pain, and 70% of these students reported the pain to be exacerbated when in their school shoes. Less than a third of participants considered healthcare recommendations important to the development of footwear guidelines.

CONCLUSIONS

Nearly all principals that participated in this survey had set guidelines for school footwear. There is a discord between parents, students, and principals on the importance that factors such as comfort, play in the development of school footwear guidelines.

Shoes for self-managing chronic hip Pain: the SCHIPP randomized clinical trial protocol

BACKGROUND

Chronic hip pain is common and disabling and is largely due to osteoarthritis (OA). Self-management is recommended by international OA clinical guidelines yet there are few effective treatment options. Footwear has been suggested as a self-management approach, given that foot motion influences hip forces. Currently, guidelines advocate 'stable supportive' shoes for people with OA, however this is based solely on expert opinion given no research has investigated whether these shoes are effective at reducing symptoms in people with OA-related chronic hip pain. Therefore, this randomized controlled trial (RCT) aims to determine if stable supportive footwear reduces hip pain during walking compared to flat flexible footwear in people with chronic hip pain consistent with OA.

METHODS

This trial is a 6-month, participant- and assessor-blinded, pragmatic, comparative effectiveness, superiority RCT conducted in Melbourne, Australia. We are recruiting 120 participants aged over 45 years with chronic hip pain consistent with OA from the community. Following baseline assessment, participants are randomized to receive either i) stable supportive shoes or ii) flat flexible shoes. Participants are permitted to choose two different pairs of shoes in their allocated group from a range of options that match prespecified shoe classification criteria. They are advised to wear either pair of study shoes daily for a minimum of 6 hours each day for 6 months. The primary outcome is the 6-month change in average hip pain on walking in the last week. Secondary outcomes include changes in other measures of hip pain, symptoms, function in daily living and sports and recreation, hip-related quality of life, pain at other sites, adverse events, and physical activity. Other measures include co-intervention use, adherence, shoe comfort, descriptive characteristics, footwear characteristics, and objective foot measures.

DISCUSSION

This RCT will determine whether stable supportive shoes reduce hip pain during walking more than flat flexible shoes in people with chronic hip pain. Outcomes will help to inform footwear recommendations in international clinical guidelines for OA-related chronic hip pain, which to date have been based solely on expert opinion because of an absence of RCTs.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry reference: ACTRN12621001532897.

Repeatability and reliability of the footwear assessment tool in Spanish patients: A transcultural adaptation

BACKGROUND

The footwear assessment tool was designed to advise an appropriate footwear for each situation and patient. Footwear alterations structures can influence in musculoskeletal disorders, developing foot ulcers, increase the peak plantar pressure, bacterial growth, low back pain.

METHODS

To validate the study 101 subjects were recruited. The study was tested by two expert podiatrists using the tool for the assessment of footwear characteristics that is composed by five domains, fit, general features, general structure, motion control properties and cushioning system. Each domain analyzes different shoe items.

RESULTS

An excellent agreement between the test-retest. A suitable Cronbach's α was suggested for the five domains of fit (α = 0.952), general features (α = 0.953), general structure (α = 0.947), motion control properties (α = 0.951), and cushioning system (α = 0.951). Test-retest reliability was excellent for all domains. There were no significant differences between any domain (p > 0.05). There was only statistically significant difference in the item forefoot height (p = 0.011). For all the domains items there were no statistically significant difference (p > 0.05).

CONCLUSIONS

The tool for the assessment European footwear is a suitable repeatability and reliability footwear tool that can be used in Spanish language subjects.

Balance effects of tactile stimulation at the foot

Balance relies on several types of sensory information, including somatosensory senses such as touch and position sense (proprioception). As these senses decline in older adults, there is a question of whether shoes limit somatosensory feedback from the floor. Textured insoles are designed to stimulate the soles of the feet to enhance tactile feedback. Textured insoles have shown balance benefits in some populations, but it is unclear if such tactile stimulation improves a person's balance even in cushioned athletic shoes, which dampen proprioceptive signals. Here we ask whether tactile vs. proprioceptive cues contribute differently to balance control in the healthy somatosensory system. We assessed balance in 20 healthy young adults under four footwear conditions: cushioned shoes with regular insoles, cushioned shoes with textured insoles, barefoot, and minimalist shoes. Each condition was evaluated using the Y-Balance Test (YBT) and the Balance Error Scoring System (BESS), validated tests of dynamic and static balance, respectively. YBT is a dynamic reaching test performed on one leg. The BESS includes various stance conditions with eyes closed. The results showed that footwear influenced dynamic balance only, with textured insoles leading to significantly better performance than barefoot and minimalist shoes did in the YBT. These results suggest that at least for dynamic balance, balance benefits of tactile stimulation from the textured insoles offset any dampening of proprioception caused by the athletic shoes' cushioning. Future research on how these conditions compare in older adults may lead to improved footwear recommendations to reduce fall risk and injuries for that population.

Experiences of using a digital tool, the D-foot, in the screening of risk factors for diabetic foot ulcers

BACKGROUND

Individuals living with diabetes run an increased risk of developing diabetic foot ulcers (DFUs), leading to high costs to society and reduced quality of life for the individual. Regular screening is important to avoid complications.

AIM

To evaluate patients' and clinicians' experiences of using a digital tool, the D-Foot, in the screening of risk factors for developing DFUs. The secondary aims were to investigate whether patients had had their feet examined by a nurse or doctor during the past year, had been referred to podiatry and whether patients had received information about self-care.

METHODS

A prospective study was carried out, comprising 90 patients with diabetes visiting a Department of Prosthetics and Orthotics (DPO). Two Certified Prosthetists and Orthotists (CPOs) were included, and they assessed foot status and the risk of developing DFUs with the D-Foot software, prior to prescribing footwear. The quality of services at the DPO was assessed by the patients using the Orthotics and Prosthetics Users' Survey (OPUS). The CPOs answered the System Usability Scale (SUS) before and after the study to assess the usability of the D-Foot.

RESULTS

No patient had risk grade 1. One (1%) patient had risk grade 2, 78 (87%) patients had risk grade 3 and 11 (12%) patients had risk grade 4. Patients reported high levels of satisfaction on eight of ten OPUS items and the two items with lower scores were not related to the use of the D-Foot. The two CPOs reported levels above the mean regarding usability both before (77.5 and 90) and after (70 and 97.5) using the D-Foot.

CONCLUSIONS

Patients expressed a high level of satisfaction with the services when their feet were examined with the D-Foot prior to the provision of footwear. The CPOs found that the D-Foot system was usable. Several comments were made by patients and CPOs and will support the future development and testing of the D-Foot. There is a need to increase referrals for preventive podiatry and improve information on self-care for patients at risk of DFUs.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04054804.

Orthotic approach to prevention and management of diabetic foot: A narrative review

Diabetic foot is a common complication affecting more than one-fifth of patients with diabetes. If not treated in time, it may lead to diabetic foot ulcers or Charcot arthropathy. For the management of diabetic foot, shoe modifications and orthoses can be used to reduce pressure on the affected foot or provide the foot with increased stability. In addition, the shoe modifications and orthotic devices can relieve patient discomfort during walking. Appropriate shoe modifications include changing the insole material, modifying the heel height, adding a steel shank or rocker sole, and using in-depth shoes. Alternatively, a walking brace or ankle-foot orthosis can be used to reduce the pressure on the affected foot. The purpose of this narrative review was to provide a reference guide to support clinicians in prescribing shoe modifications and foot orthoses to treat diabetic foot ulcers and Charcot arthropathy.

Parents, health professionals and footwear stakeholders' beliefs on the importance of different features of young children's footwear: a qualitative study

Background

A small but building pool of evidence of the impact of footwear on children’s function means understanding the different beliefs of stakeholders about footwear key features and flexibility is critical for translation into recommendations and to support parents and caregivers in purchasing footwear for their children. Therefore, this research aimed to describe how different stakeholders (health professionals, parents, and footwear industry representatives) described the importance of flexibility and other footwear features for young children.

Methods

This qualitative study was nested within an international modified Delphi online survey. Participants responded to open-ended questions about footwear component flexibility and asked if and why flexibility in these areas were important. Participants also described any other important footwear features. Inductive thematic analysis was used to generate themes.

Results

There were 121 responses from three stakeholder groups including health professionals (n = 90), parents of young children (n = 26) and footwear industry representatives (n = 5). Overarching themes described by participants included developmental impacts of footwear, therapeutic impact and how footwear may play a role in function.

Conclusion

There were key differences in how stakeholders viewed footwear and any perceived benefits of footwear components, much of which was not backed with empirical evidence. It was also identified that health professionals are using footwear within treatment recommendations. This work highlights the importance of understanding circumstances in which footwear may have a therapeutic impact or be the first line of treatment for children with complex foot needs. This is the first step in developing contemporary footwear recommendations for parents and caregivers.

Hallux anatomy: much ado about shoes-an attempt to prove that constrictive V-shaped toe-box shoes deform the hallux

PURPOSE

A question still remains as to whether constrictive toe-box shoes (TBS) cause disability only due to pain on pressure points or if they can cause permanent changes in the hallux anatomy. The aim of this study is to compare the hallux morphology in 3 groups classified according to their use of constrictive or open TBS.

METHODS

424 patients were classified into 3 groups: group A used open TBS daily; group B used constrictive TBS daily; group C used both open and constrictive TBS. Hallux's angles, presence of exostoses and shape of the distal phalanx (DP) were analyzed on dorsoplantar weight-bearing radiographs and compared amongst groups.

RESULTS

The intermetatarsal (IMA), metatarsophalangeal (MTPA), DASA, PASA, interphalangeal (IPA), obliquity (AP1), asymmetry (AP2) and joint deviation (JDA) angles for group A were 10°, 8°, 5°, 4°, 9°, 3°, 5°, 3°; for group B were 9°, 19°, 5°, 6°, 12°, 2°, 8°, 2°; and for group C were 10°, 10°, 4°, 4°, 12°, 3°, 8°, 1°. Only the differences in the MTPA, IPA and AP2 were statistically significant (p < 0.05). The prevalence of exostoses on the tibial side of the DP was 22, 36, and 29% in groups A, B and C, respectively (p < 0.05). We found similar distributions of the different DP shapes in the three groups.

CONCLUSIONS

Our results suggest that the use of constrictive TBS, even if used only occasionally, could change hallux anatomy from a young age increasing MTPA, IPA and AP2. Moreover, we have found that DP exostoses are present as a "normal variation" in patients who wear an open TBS, but their prevalence is higher in those wearing constrictive toe-box shoes. This could be due to a reactive bone formation secondary to the friction caused by the inner border of the shoe.

LEVEL OF CLINICAL EVIDENCE

3.

Change of In-Shoe Plantar Pressure According to Types of Shoes (Flat Shoes, Running Shoes, and High Heels)

Background

The type of footwear is one of several factors that affect foot pressure. Despite its usefulness in identifying pathology and preventing and treating foot-related diseases, the type of shoes has been investigated and compared in only a few studies. This study aimed to investigate differences in plantar pressure, induced by flat, running, and high-heeled shoes in healthy, young women.

Methods

A total of 27 healthy women (27 feet) with a mean age of 21.5 ± 2.03 years were included in this study. Based on demographic data, radiologic measurements, clinical scores, temporal gait parameters, and kinematic parameters of gait, we confirmed the participants had normal feet. Then, pedobarographic data were measured by dividing each foot into seven regions to compare the three types of shoes. Peak plantar pressure and pressure-time integral were calculated using the Pedar-X system. The one-way analysis of variance and the Kruskal-Wallis test with Mann Whitney U-test were used for statistical analyses.

Results

Regarding the 7 regions of the foot, flat shoes resulted in a significantly higher pressure than running shoes in the hallux and lesser toes and the highest pressure in the metatarsal head (MTH) 3-5 and the hindfoot. In contrast, in the MTH 1 and MTH 2 regions, the high-heeled shoes had the highest measured pressure, followed by the flat shoes. Lastly, there was no high pressure in running shoes in any region except for the midfoot compared to the other shoes.

Conclusions

It can be inferred from our findings that flat and high-heeled shoes can generate a considerable burden on specific parts of the foot, which will aid in choosing appropriate shoes. Also, wearing running shoes places less burden on the overall foot.

Evaluation and optimisation of a footwear assessment tool for use within a clinical environment

Footwear has been documented as a significant factor in the aetiology of foot pain in the general population. Assessing footwear in a clinical setting continues to be practitioner specific and there is limited guidance to direct advice. Health professionals must have access to clinically appropriate and reliable footwear assessment tools to educate patients on healthier footwear choices. The primary aim of this study was to critique what elements should be in a footwear assessment tool with a secondary aim of testing the agreed tool for validity.

A combined Nominal Group Technique and then a Delphi technique from purposively sampled experts of foot health professions were employed to critique elements of footwear assessment. The agreed tool was then tested by practising podiatrists on 5 different shoes to assess the validity and reliability of the measures.

Twelve test evaluation criteria were identified receiving significant ratings to form the final footwear assessment tool consisting of five footwear themes. Application of the tool in a clinical setting validated the themes of footwear characteristics, footwear structure, motion control and wear patterns. However, the assessment of footwear fit was not reliable.

The footwear tool was refined based on the collective consensus achieved from the rounds creating a more clinically appropriate tool. The validity of this tool was assessed as high in some of the themes but for those that were lower, a training need was identified.

Footwear comfort: a systematic search and narrative synthesis of the literature

OBJECTIVE

To provide a narrative synthesis of the research literature pertaining to footwear comfort, including definitions, measurement scales, footwear design features, and physiological and psychological factors.

METHODS

A systematic search was conducted which yielded 101 manuscripts. The most relevant manuscripts were selected based on the predetermined subheadings of the review (definitions, measurement scales, footwear design features, and physiological and psychological factors). A narrative synthesis of the findings of the included studies was undertaken.

RESULTS

The available evidence is highly fragmented and incorporates a wide range of study designs, participants, and assessment approaches, making it challenging to draw strong conclusions or implications for clinical practice. However, it can be broadly concluded that (i) simple visual analog scales may provide a reliable overall assessment of comfort, (ii) well-fitted, lightweight shoes with soft midsoles and curved rocker-soles are generally perceived to be most comfortable, and (iii) the influence of sole flexibility, shoe microclimate and insoles is less clear and likely to be more specific to the population, setting and task being performed.

CONCLUSION

Footwear comfort is a complex and multifaceted concept that is influenced not only by structural and functional aspects of shoe design, but also task requirements and anatomical and physiological differences between individuals. Further research is required to delineate the contribution of specific shoe features more clearly, and to better understand the interaction between footwear features and individual physiological attributes.

Persistence of blood (DNA/RNA) on shoe soles under varying casework related conditions

Blunt force traumas by footwear can result in severe and even fatal head and upper body injuries. Oftentimes, footwear impressions are only partially available and evidential value is limited. DNA evidence on shoe soles could provide crucial evidence helping to solve crimes by linking target DNA to the activity of interest. Little is known about the persistence and detectability of biological material post such offenses and the interplay of factors affecting the analytical success. In this study, we assessed the persistence of blood on shoe soles under varying parameters such as blood location, different sneakers, weather condition, gait, amount of blood, underground and step count. We applied an optimized DNA/RNA workflow adapted to micro-traces without constraints for the primary DNA pipeline. There is a high probability to link donor DNA to the shoe sole for up to 300-400 steps, regardless of the underground, blood location, and amount of blood. Depending on the sole material and the degree of abrasion of the sole, a longer blood persistence can be observed. Considering blood, 98.2% of the initial DNA amount (1 μl initial blood volume) was lost after 100 steps walked on sole areas that are in constant contact with the ground. Proportion of foreign DNA was marginal (avg. 4.4 alleles), minimizing the probability of unintentional DNA transfer in this context. RNA typing showed high specificity but lower sensitivity than presumptive tests used for body fluid identification (BFI). Luminol is essential for targeted sampling on shoe soles, as latent blood traces (>100-200 steps) provided sufficient biological material for DNA/RNA typing. The generated data help to address the activity of interest and evaluate probabilities about prevalence of target DNA important for casework implications and assessments on activity level.

A comparison of young children's spatiotemporal gait measures in three common types of footwear with different sole hardness

BACKGROUND

It is unknown what the impact of sole hardness is on young children's gait. Yet, this feature is commonly marketed as having differing benefits for young children's walking and development.

RESEARCH QUESTION

What are the differences in spatiotemporal measures of gait during walking and running in three common types of young children's footwear with a soft sole, compared to a hard sole?

METHODS

The study used a quasi-experimental design, with the condition order randomised using a Latin square sequence. Forty-seven children were recruited (aged 2-4 years). Participants walked or ran the length of a GAITRite mat in a randomized order in a soft (Shore 48-53) or hard soled (Shore 60-65) sneaker, boot and sandal condition. Linear regression analyses were used to investigate the difference between footwear for the different gait parameters including velocity, cadence, step time, swing percentage, stance percentage, double support time and the toe in/out angle.

RESULTS

Children walked with a shorter stride length in the hard-soled sandals compared to the soft- soled sandals (p < 0.05). There were no other differences in spatiotemporal variables in the soft versus hard soled sandals during walking or running (p > 0.05). There were no differences in any spatiotemporal gait variables during walking or running in soft versus hard- soled runners and no differences in walking or running in soft versus hard-soled boots (p > 0.05).

SIGNIFICANCE

There were few differences in spatiotemporal parameters between soft and hard-soled footwear in both walking and running in three different types of footwear. This may be a positive finding for footwear designers and manufacturers, as a harder sole appeared to have limited impact on spatiotemporal gait parameters.

Children's school footwear: The impact of fit on foot function, comfort and jump performance in children aged 8 to 12 years

BACKGROUND

There is a common perception that poorly fitting footwear will negatively impact a child's foot, however, there is limited evidence to support this.

AIM

To determine the effect of shoe size on foot motion, perceived footwear comfort and fit during walking, maximal vertical jump height and maximal standing broad jump distance in children aged 8-12 years.

METHODS

Fourteen participants completed 3D walking gait analysis and jumping tasks in three different sizes of school shoes (one size bigger, fitted for size, one size smaller). In-shoe motion of the hindfoot, midfoot and 1st metatarsophalangeal joint (1st MTPJ) were calculated using a multi-segment kinematic foot model. Physical performance measures were calculated via maximal vertical jump and maximal standing broad jump. Perceived footwear comfort and fit (heel, toes and overall) was assessed using a 100 mm visual analog scale (VAS). Differences were compared between shoe sizes using repeated measures ANOVA, post-hoc tests and effect sizes (Cohen's d).

RESULTS

Compared to the fitted footwear, the smaller sizing restricted hindfoot eversion (-2.5°, p = 0.021, d = 0.82), 1st MTPJ dorsiflexion (-3.9°, p = 0.012, d = 0.54), and compared to the bigger footwear, smaller sizing restricted sagittal plane midfoot range-of-motion during walking (-2.5°, p = 0.047, d = 0.59). The fitted footwear was rated as more comfortable overall with the smaller size rated as too tight in both the heel (mean difference 11.5 mm, p = 0.042, d = 0.58) and toes (mean difference 12.1 mm, p = 0.022, d = 0.59), compared to the fitted size. Vertical and standing broad jump distance were not impacted by footwear size (p = 0.218-0.836).

SIGNIFICANCE

Footwear that is too small restricts foot motion during walking in children aged 8-12 years. Jump performance was not affected. Children were able to recognise shoes that were not correctly matched to their foot length, reinforcing that comfort is an important part of the fitting process.

Effects of a rebound shoe to reduce impact forces in jump-landing tasks

OBJECTIVES

Impact forces are risk factors for injuries during jump-landing tasks. Rebound shoes could reduce impact forces and show potential applications in training and rehabilitation programs. Here, we determine the capacity of a rebound shoe in attenuating impact forces during different motor tasks involving foot landing.

DESIGN

Crossover laboratory research design.

SETTINGS

Women not trained for jump-landing tasks performed different exercises while the vertical ground reaction force impact peak, time to peak, and asymmetries were determined. They were wearing a commercial rebound shoe and a control running shoe. Paired t-tests were used to compare the shoes and asymmetries.

PARTICIPANTS

Fifteen physically active women (average age of 23 years old, height of 1.64 m, and body mass of 63 kg).

MAIN OUTCOME MEASURES

Ground reaction forces.

RESULTS

The rebound shoe reduced the impact peak force and elicited slight asymmetries between the legs. The rebound shoe also showed a longer time to peak.

CONCLUSIONS

The rebound shoe tested reduced impact forces during jump-landing tasks, which is a potential application in training sessions and rehabilitation programs, requiring lower impact forces to the lower extremity. The effects of long-term use of these shoes still need to be investigated.

Investigating the effects of appropriate fitting footwear on functional performance level, balance and fear of falling in older adults: A comparative-observational study

The aim of the study was to assess the characteristics of footwear altogether and to compare the effect of appropriate-fitting and ill-fitting footwear on functional performance, balance, and fear of falling (FoF) in older adults. Individuals who wore appropriate-fitting (n = 61) or ill-fitting footwear (n = 92) were enrolled in the study. Footwear was evaluated using the Footwear Assessment Scale (FAS). The participants were assessed using the Berg Balance Scale (BBS) for balance, the Timed Up and Go test for functional performance and the Activities-specific Balance Confidence scale for FoF. Tests were conducted twice for each individual with or without footwear. Differences between the groups were analyzed using the MANOVA for scores of balance, performance and fear of falling and Chi-squared test for homogeneity. The Paired t-test was used to compare test scores with or without footwear. It was concluded that appropriate-fitting footwear improves balance, reduces fear of falling and may affect functional performance positively. ClinicalTrials.gov No: NCT04151654.

Toe gaps and their assessment in footwear for people with diabetes: a narrative review

BACKGROUND

Adequate footwear fit is critical in preventing diabetes-related foot ulcers. One important element is the toe gap, the difference between foot length and internal footwear length available to the foot. We summarised the literature on toe gaps in studies assessing footwear worn by people with diabetes, the methods used to measure both foot length and internal footwear length and identify ambiguities which may impact on toe gap assessment in clinical practice, and suggest pragmatic solutions.

METHODS

The Google Scholar database was searched to April 2020 for peer-reviewed studies using keywords related to incorrectly fitting or ill-fitting and diabetes, foot and ulcer which returned 979 results. Included studies within this narrative review encompassed toe gap measurement to assess footwear worn by people with diabetes.

RESULTS

A total of eight studies were included after full paper review. Toe gap ranges as used in assessments of footwear worn by people with diabetes vary, with a minimum of 1.0-1.6 cm and a maximum of 1.5-2.0 cm, as do methods of measuring internal footwear length. Only three published studies suggested possible measuring devices.

CONCLUSIONS

Toe gap ranged as used when assessing footwear fit in people with diabetes vary and a gold standard device for internal footwear length measurement has yet to emerge. International guidelines provide welcome standardisation, but further research is needed to evaluate both the effect of toe gap ranges upon pressure, plantar stress response and ulceration and available measuring devices to facilitate development of toe gap measurement protocols that may further enhance consistency in practical assessments.

The effects of shoes and insoles for low back pain: a systematic review and meta-analysis of randomized controlled trials

The aim of this review was to examine the effects of shoes and insoles on low back pain (LBP). Seven electronic databases were searched from their inception to May 2020. The methodological quality of the 14 included studies was assessed by PEDro scale. Quality of evidence was assessed using GRADE. Moderate evidence on the disability questionnaire score (SMD, 0.52; 95% CI, 0.28 to 0.77; P < 0.001) and pain score (SMD, 0.61; 95% CI, 0.36 to 0.85; P < 0.001) of the custom-made orthotics for chronic LBP compared with no orthotics/insoles intervention was found. Meta-analysis results also showed moderate evidence on the disability questionnaire score (SMD, 0.44; 95% CI, 0.05 to 0.82; P =0.03) in patients who wore unstable shoes compared with regular shoes. Pain and life quality scores showed low-quality evidence of unstable shoes for chronic LBP. Custom-made orthotics and unstable shoes can be recommended to patients as a management option of chronic LBP.

A comparison of young children's spatiotemporal measures of walking and running in three common types of footwear compared to bare feet

BACKGROUND

Clinicians and footwear manufacturers often advise young children to wear soft-soled footwear when they are first learning to walk. There is limited evidence as to why this advice is given, and if soft-soled shoes are as close to barefoot as thought.

RESEARCH QUESTION

What are the differences in spatiotemporal measures of gait during walking and running in three common types of children's footwear with a soft-soled compared to barefoot in young children?

METHODS

The study used a quasi-experimental design, with the condition order randomised using a Latin square sequence. Forty-seven children were recruited (2 - 4 years). Participants walked or ran the length of a GAITrite mat in a randomized order for barefoot and soft-soled sneaker, boot and sandal conditions. Linear regression analyses were used to investigate the main effect of each soft-soled footwear compared to bare feet in the different gait parameters.

RESULTS

For walking and running trials, cadence decreased whereas step time and stride length increased in all footwear types compared to the barefoot condition. While wearing sneakers and sandals increased the stance percentage for walking and running trials, compared to barefoot, this difference was only apparent during the running trial for the boots. Likewise, although double support time increased for both the boots and sneakers in walking and running, compared to barefoot, this difference was only observed in the sandals during walking.

SIGNIFICANCE

This research found that various types of soft-soled footwear impacted gait compared to the barefoot condition, with some differences seen between walking and running trials. These findings challenge the assumption that soft-soled footwear facilitate a similar gait to barefoot walking and running, although the clinical significance of these differences is unknown.

Predictors of adherence to wearing therapeutic footwear among people with diabetes

Aims

People at increased risk of developing diabetic foot ulcers often wear therapeutic footwear less frequently than is desirable. The aims were to identify patient groups prone to nonadherence to wearing therapeutic footwear and modifiable factors associated with adherence.

Materials and methods

A questionnaire was mailed to 1230 people with diabetes who had been fitted with therapeutic footwear. Independent variables were categorized into five domains. For each domain, variables that were associated with adherence in a univariate regression analysis were entered into a multiple regression analysis.

Results

A total of 429 (34.9%) questionnaires were analyzed. Multiple regression analyses showed significant associations (p < 0.05) between higher adherence and paid employment, current foot ulcer, previous foot ulcer, satisfaction with follow-up, self-efficacy, understanding of lost/reduced sensation as a risk factor for foot ulcerations, visible storage of therapeutic footwear at home, storage of conventional footwear out of sight, consistent choices about which footwear type to wear, and a belief that therapeutic footwear promotes ulcer healing. The five multivariate models explained 2–28% of the variance in adherence, with the strategies for footwear use domain explaining the most.

Conclusions

Patients without paid employment or without foot ulcer experience are more prone to nonadherence. To improve adherence, clinicians should advise patients to store therapeutic footwear in a visible place at home and put conventional footwear away and encourage patients’ self-efficacy and habitual use of therapeutic footwear. Future studies should investigate this topic further and explore ways to promote changes in habits. A study limitation was that all variables were self-reported.

Development and evaluation of a dual density insole for people standing for long periods of time at work

BACKGROUND

Appropriate footwear is important for those who stand for prolonged periods of time at work, enabling them to remain comfortable, healthy and safe. Preferences for different footwear cushioning or hardness are often person specific and one shoe or insole will not be the choice for all. The aim of this study was to develop a range of insole options to maintain comfort during long periods of standing at work and test insole material preferences in the workplace.

METHODS

The study consisted of two parts. Part one evaluated 9 insoles of the same geometry that varied in hardness under 2 different plantar regions (n = 34). Insole preference, plantar pressure and selected anthropometric foot measures were taken. Three insole designs based on the most preferred options were identified from this part. In part two, these three insoles were evaluated with 22 workers immediately after trying them on (1 min) and after a working day. Foot anthropometric measures and subjective questions concerning material hardness preferences and self-reported foot characteristics were used to investigate whether either had a relationship with insole preference.

RESULTS

Part one found insole preference predominantly varied according to material hardness under the medial arch rather than the heel/forefoot. Softer material under the heel and forefoot was associated with a reduction in peak pressures in these regions (p < 0.05). The most preferred insole had lower pressures under the hallux and first metatarsal phalangeal joint, and greater pressures and contact area under the medial midfoot (p < 0.05) compared to the least preferred insole. Height and foot anthropometrics were related to insole preference. In part two, under real world conditions, insole preference changed for 65% of participants between the immediate assessment (1 min) and after a whole workday, with dorsum height related to the latter (p < 0.05). Subjective questions for self-assessed arch height and footwear feel identified 66.7% of the insole preferences after 1 day at work, compared to 36% using immediate assessment of insole preference.

CONCLUSION

Preference for material hardness varies underneath the medial arch of the foot and is time dependent. Simple foot measures and questions about comfort can guide selection of preferred insoles.

Bacterial communities associated with cell phones and shoes

Background

Every human being carries with them a collection of microbes, a collection that is likely both unique to that person, but also dynamic as a result of significant flux with the surrounding environment. The interaction of the human microbiome (i.e., the microbes that are found directly in contact with a person in places such as the gut, mouth, and skin) and the microbiome of accessory objects (e.g., shoes, clothing, phones, jewelry) is of potential interest to both epidemiology and the developing field of microbial forensics. Therefore, the microbiome of personal accessories are of interest because they serve as both a microbial source and sink for an individual, they may provide information about the microbial exposure experienced by an individual, and they can be sampled non-invasively.

Findings

We report here a large-scale study of the microbiome found on cell phones and shoes. Cell phones serve as a potential source and sink for skin and oral microbiome, while shoes can act as sampling devices for microbial environmental experience. Using 16S rRNA gene sequencing, we characterized the microbiome of thousands of paired sets of cell phones and shoes from individuals at sporting events, museums, and other venues around the United States.

Conclusions

We place this data in the context of previous studies and demonstrate that the microbiome of phones and shoes are different. This difference is driven largely by the presence of “environmental” taxa (taxa from groups that tend to be found in places like soil) on shoes and human-associated taxa (taxa from groups that are abundant in the human microbiome) on phones. This large dataset also contains many novel taxa, highlighting the fact that much of microbial diversity remains uncharacterized, even on commonplace objects.

Reproducibility of foot dimensions measured from 3-dimensional foot scans in children and adolescents with Down syndrome

BACKGROUND

Children and adolescents with Down syndrome have a distinctive foot shape (such as wide and flat feet) that often leads to difficulty with footwear fitting. 3-dimensional (3D) scanning can accurately measure the foot dimensions of individuals with Down syndrome, which may assist shoe fit. However, the reproducibility of measuring foot dimensions using 3D scans in children and adolescents with Down syndrome is unknown. The aim of this study was to determine the intra- and inter-rater reproducibility of measuring foot dimensions of children and adolescents with Down syndrome using 3D scanning.

METHODS

3D foot scans of 30 participants with Down syndrome aged 5 to 17 years were obtained using the FotoScan 3D scanner. Foot dimensions assessed were foot length, ball of foot length, outside ball of foot length, diagonal foot width, horizontal foot width, heel width, ball girth, instep girth, first and fifth toe height, and instep height. Additionally, the Wesjflog Index and forefoot shape were determined. Measurements were completed by two raters independently on two separate occasions, 2 weeks apart. Intra- and inter-rater reliability were assessed using intra-class correlation coefficients (ICCs) and Gwet's AC1 statistics with 95% confidence intervals. Agreement was determined by calculating limits of agreement (LOA) and percentage agreement.

RESULTS

Eighteen participants were female and 12 were male (mean age 10.6 [3.9] years). Intra-rater reproducibility (ICCs ranged from 0.74 to 0.99, 95% LOA from - 13.7 mm to 16.3 mm) and inter-rater reproducibility (ICCs ranging from 0.73 to 0.99, 95% LOA from - 18.8 mm to 12.7 mm) was good to excellent, although some measurements (ball of foot length, outside ball of foot length, heel width and girth measurements) displayed wider LOAs indicating relatively poorer agreement. Forefoot shape displayed substantial to almost perfect reliability (Gwet's AC1 0.68 to 0.85) and percentage agreement ranged from 73 to 87%, indicating acceptable agreement.

CONCLUSIONS

The measurement of specific foot dimensions of children and adolescents with Down syndrome using 3D scans is reproducible. Findings of this study may be used to support future research measuring specific foot dimensions of children and adolescents with Down syndrome using 3D foot scans.

Effectiveness of therapeutic footwear for children: A systematic review

BACKGROUND

It is estimated that 2% of the global childhood population is living with some form of mobility impairment. Although footwear interventions are proposed to aid ambulation, there appears to be a paucity in the understanding of the effects of therapeutic footwear. This review aims to explore the effectiveness of footwear as an intervention for mobility impairment in children.

METHODS

A systematic search of MEDLINE, CINAHL, PubMed, SPORTdiscus and Scopus databases were performed. Studies which focused on children with some form of mobility impairment, age of 9 months to 18 years, therapeutic footwear that allowed walking, and outcome measures that had explored biomechanical or skeletal geometry or psychosocial aspects were included in this review. Modified Downs and Black quality assessment index of randomised and non-randomised studies were used to assess the methodologies of included papers.

RESULTS

Out of 5003 articles sourced, 13 met the inclusion criteria for this review. These were grouped into two titled "corrective and "functional" based on the types of footwear used for intervention. Studies within the corrective footwear group included participants aged 11 months to 5 years with moderate congenital talipes equino varus or mobile pes planus. While using skeletal geometry as an outcome, there was a limited fair quality (level II) evidence that corrective footwear has no significant effect on the development of pes planus but may assist in the reduction of deformity in congenital talipes equino varus. The functional footwear group included participants aged 3 to 17 years, predominantly with mobile pes planus or cerebral palsy. Based on biomechanical measures as an outcome, there was a limited fair quality (level III) evidence that functional footwear alters biomechanical parameters in mobile pes planus (spatiotemporal) and cerebral palsy (spatiotemporal, kinematic). Although psychosocial outcomes were considered within two studies, the analysis was limited.

CONCLUSION

Only a limited number of studies have explored the effects of therapeutic footwear and only in a narrow range of mobility impairments. Further high-quality research is required to improve the evidence base for the effectiveness of therapeutic footwear. This should include a wide range of mobility impairments and should focus both on physical and psychosocial outcomes.

Footwear for osteoarthritis of the lateral knee: protocol for the FOLK randomised controlled trial

BACKGROUND

Structural features of lateral tibiofemoral (TF) joint osteoarthritis (OA) occur in up to half of all people with knee OA, and co-existing lateral TF OA is associated with worse knee pain in people with mixed compartmental knee OA. Clinical guidelines for management of knee OA advocate advice about appropriate footwear, yet there is no research evaluating which types of footwear are best for managing pain associated with lateral TF OA. Biomechanical evidence suggests that "motion-control" footwear, which possess midsoles that are stiffer medially compared to laterally, may shift load away from the lateral compartment of the knee and thus may reduce knee pain associated with lateral TF OA. The primary aim of this study is to compare the effects of motion-control shoes to neutral shoes on knee pain in people with predominantly lateral TF OA.

METHODS

This will be an assessor- and participant-blinded, two-arm, comparative effectiveness randomized controlled trial (RCT) conducted in Melbourne, Australia. We will recruit a minimum of 92 people with painful lateral TF OA from the community. Participants will be randomly allocated to receive either motion-control shoes or neutral shoes and will be instructed to wear their allocated shoes for a minimum of 6 h per day for 6 months. The primary outcome is change in self-reported knee pain on walking, measured using a numerical rating scale, assessed at baseline and 6 months. Secondary outcomes include other measures of knee pain, physical function, quality of life, participant-perceived change in pain and function, and physical activity levels.

DISCUSSION

This study will compare the efficacy of motion-control shoes to neutral shoes for people with painful lateral TF OA. Findings will be the first to provide evidence of the effects of footwear on knee pain in this important subgroup of people with knee OA and allow clinicians to provide accurate advice about the most appropriate footwear for managing pain associated with lateral TF OA.

TRIAL REGISTRATION

This trial has been prospectively registered by the Australian New Zealand Clinical Trials Registry on 15/11/2018 (reference: ACTRN12618001864213).

Does the shoe really fit? Characterising ill-fitting footwear among community-dwelling older adults attending geriatric services: an observational cross-sectional study

Background

Falls in older people are common and can result in loss of confidence, fear of falling, restriction in activity and loss of independence. Causes of falls are multi-factorial. There is a paucity of research assessing the footwear characteristics among older people who are at high risk of falls, internationally and in the Irish setting. The aim of this study was to examine the proportion of older adults attending a geriatric day hospital in Ireland who were wearing incorrectly sized shoes.

Methods

A consecutive sample of 111 older adults aged 60 years and over attending a geriatric day hospital in a large Irish teaching hospital was recruited. Demographic data including age, mobility, medications, co-habitation status, footwear worn at home and falls history were recorded. Shoe size and foot length were measured in millimetres using an internal shoe gauge and SATRA shoe size stick, respectively. Participants’ self-reported shoe size was recorded. Footwear was assessed using the Footwear Assessment Form (FAF). A Timed Up and Go (TUG) score was recorded. Functional independence was assessed using the Nottingham Extended Activities of Daily Living (NEADL) Scale. The primary outcome of interest in this study was selected as having footwear within the suggested range (10 to 15 mm) on at least one foot. Participants who met this definition were compared to those with ill-fitting footwear on both feet using Chi-square tests, T-tests or Mann–Whitney U tests.

Results

The mean difference between shoe length and foot length was 18.6 mm (SD: 9.6 mm). Overall, 72% of participants were wearing footwear that did not fit correctly on both feet, 90% had shoes with smooth, partly worn or fully worn sole treading and 67% reported wearing slippers at home. Participant age, TUG score and NEADL score were not associated with ill-fitting footwear.

Conclusions

Wearing incorrectly fitting shoes and shoes with unsafe features was common among older adults attending geriatric day services in this study. A large number of participants reported wearing slippers at home.

Professional appraisal of online information about children's footwear measurement and fit: readability, usability and quality

Background

Parents increasingly use the internet to seek health information, share information and for purchasing textiles and footwear. This shift in footwear purchasing habits raises concern about how (and if) parents are getting their children's feet measured, and what support strategies are in place to support the fit of footwear. In response to this, some companies and healthcare organisations have developed resources to support home measurement of foot size, and link these measures to footwear selection, measurement and fitting. The aim of this research was to undertake an appraisal of web-based resources about measurement and fit of children's footwear, focussing specifically on readability, usability and quality.

Methods

Search terms relating to children's foot measurement were compiled and online searching was undertaken. Search results were saved and screened for relevance. Existing resources were categorised based on their source e.g. a footwear company or a health website. The 15 most commonly identified resources were reviewed by a professional panel for readability, content, usability and validity. One researcher also assessed the accessibility and reading ease of the resources.

Results

Online resources were predominantly from commercial footwear companies (54%). Health information sources from professional bodies made up 4.2% of the resources identified. The top 15 resources had appropriate reading ease scores for parents (SMOG Index 4.3-8.2). Accessibility scores (the product of the number of times it appeared in search results and its ranking in the results) were highest for commercial footwear companies. The panel scores for readability ranged from 2.7 to 9 out of 10, with a similar range for content, usability and validity.

Conclusions

Information for parents seeking to purchase footwear for their children is readily available online but this was largely dominated by commercial footwear companies. The quality and usability of this information is of a moderate standard; notable improvements could be made to the validity of the task the child is asked to undertake and the measures being taken. Improvements in these resources would improve the data input to the selection of footwear and therefore have a beneficial impact on footwear fit in children.

The impact of shoe flexibility on gait, pressure and muscle activity of young children. A systematic review

Background

There is limited evidence of shoe impact in younger children, particularly in the context of immature gait patterns. It is unclear if the impact from shoes in younger children is similar to what has been seen in older children. This systematic review aims to identify any impact of shoe features on younger children’s gait, and if there are any differences between shoe sole flexibility compared to barefoot.

Methods

Study inclusion criteria included: typically developing children aged ≤6 years; comparison of barefoot and shod conditions (walking and/or running) with shoe features or style of shoe described; sample size > 1. Novelty types of footwear were excluded, as was any mention of in shoe support or modifications. Studies were located from six databases. Study methodology was assessed using the McMasters critical review form. Sample size weighted standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated.

Results

Four studies were included. Participant age ranged from 15.2 to 78.7 months, with 262 participants across all studies. All studies had limited methodological bias based on their design type. Compared to barefoot walking, shoes increased velocity, step time and step length. Shod walking decreased cadence. Peak plantar pressure was generally lower in the stiff shoe design and there was a higher peak plantar pressure in the Ultraflex shoes. No studies were found investigating muscle activation.

Conclusions

Shoes affect younger children’s gait in spatiotemporal gait aspects, similar to those seen in older children. There is limited evidence on effects of particular shoe features such as sole hardness, on gait, and no evidence of any changes in muscle activation patterns. Further research is required to evaluate the impact of different types of shoe and shoe features in this population to provide clinical advice on the type of shoe that is appropriate in this age group.

Commitment devices in the treatment of diabetic foot ulcers

Background

Non-removable offloading devices are recommended for the treatment of uncomplicated plantar diabetic foot ulcers because adherence to using removable devices is low. However, patients may not always understand how crucial the non-removability is to ulcer healing, leaving them with the impression that it is the device per se that heals the ulcer. Thus, after ulcer healing when patients return to using removable offloading devices, typically therapeutic footwear, they often return to a low level of adherence resulting in high reulceration rates. To change this pattern of behavior based on a misconception, we need to start with how we as clinicians are conceptualizing treatment with offloading devices.

Non-removable offloading devices as commitment devices

Commitment devices are voluntary restrictions people put on their future selves to resist short-term temptations and achieve long-term goals. In this paper, it is suggested that a change from viewing non-removable offloading devices as means to force compliance, to viewing them as commitment devices could facilitate a change to a clinical thinking that emphasizes the importance of high adherence without compromising respect for patient autonomy.

Conclusion

Viewing non-removable offloading devices as commitment devices seems to be a promising approach to emphasize the importance of adherence while respecting patient autonomy. Hopefully, patients’ higher appreciation of the role of adherence can lead to higher adherence to using therapeutic footwear after healing and consequently to reduced reulceration rates.

Shoe design for older adults: Evidence from a systematic review on the elements of optimal footwear

Due to changes in foot morphology and the occurrence of foot deformities and foot pain with ageing, older people frequently wear ill-fitting shoes. This can lead to discomfort and reduced mobility. A review of the literature was performed in Medline, Scopus and Embase with three aims: (a) to evaluate the effects of shoes or shoe elements on the comfort and mobility of older adults, (b) to summarise the evidence-based elements of a safe and comfortable shoe for older adults, and (c) from that, to compile those elements into design recommendations for a safe and comfortable shoe for older adults. Safe elements of footwear include proper anatomical fit, a well-fitting toe box, limited heel height, a broad enough heel, a firm insole and midsole, an outsole with sufficient tread, bevelled heel, firm heel counter with snug fit, and an easy and effective closing mechanism. We conclude that there is a need for shoe design specifically aimed at the foot morphology and demands of older people. The shoe market should increase the availability of well-fitting shoes designed for the older foot and person.

High prevalence of Clostridium difficile in soil, mulch and lawn samples from the grounds of Western Australian hospitals

Despite being considered a major hospital-associated pathogen for many years, Clostridium difficile has been isolated increasingly from people without hospital contact. In this study, we investigated the prevalence of C. difficile in the immediate outdoor environment of several hospitals in Perth, Western Australia, to provide further insight into potential sources of community-acquired C. difficile infection. Over 6 months, a total of 159 samples consisting of soil, mulch, lawn and sand were collected from outdoor surroundings of four different old (age>50 years) and new (age<10 years) hospitals. Samples were cultured in a C. difficile selective enrichment broth. Toxin gene profiling using PCR, and PCR ribotyping, was performed on all C. difficile recovered. C. difficile was isolated from 96 of the 159 samples (60.4%). Of the 112 isolates, 33 (29.5%) were toxigenic and 49 (43.8%) were identified as novel strains. Ribotypes (RTs) 014/020 (14.3%) and 010 (13.4%) constituted the highest proportion of isolates. Interestingly, RT 017, a strain endemic to the Asia-Pacific region (but not Australia), was found in a newly laid lawn. This study adds to existing knowledge of potential sources of C. difficile in Western Australia. More research is required to determine the route of transmission of C. difficile from community sources into the hospital.

Does increased midsole bending stiffness of sport shoes redistribute lower limb joint work during running?

OBJECTIVES

To investigate if lower limb joint work is redistributed when running in a shoe with increased midsole bending stiffness compared to a control shoe.

DESIGN

Within-subject with two conditions: (1) commercially available running shoe and (2) the same shoe with carbon fibre inserts to increase midsole bending stiffness.

METHODS

Thirteen male, recreational runners ran on an instrumented treadmill at 3.5m/s in each of the two shoe conditions while motion capture and force platform data were collected. Positive and negative metatarsophalangeal (MTP), ankle, knee, and hip joint work were calculated and statistically compared between conditions.

RESULTS

Running in the stiff condition (with carbon fibre inserts) resulted in significantly more positive work and less negative work at the MTP joint, and less positive work at the knee joint.

CONCLUSIONS

Increased midsole bending stiffness resulted in a redistribution of positive lower limb joint work from the knee to the MTP joint. A larger MTP joint plantarflexor moment due to increased vGRF at the instant of peak positive power and an earlier onset of MTP joint plantarflexion velocity were identified as the reasons for lower limb joint work redistribution.

Flexion location of the first metatarsophalangeal joint and the location of forefoot bend in general purpose women's footwear

BACKGROUND

General purpose footwear could have a built-in flexion location which may not match the anatomical fulcrum location for an individual's foot. Mismatched fulcra impact on joint function, and may delay healing of an injured first metatarsophalangeal joint (first MP joint). This study compared the location of the first MP joint in an asymptomatic sample of the South African female population to the bend location set within the lasts (used by footwear manufacturers) to find whether mismatches of the flexion locations of the joint to the bending location of the footwear were likely.

METHODS

The study used a three dimensional foot measurement database of 453 female participants to find the fulcrum location of the first MP joint. The distance between the heel and the first MP joint was expressed as a percentage of the overall length of the unshod foot. Similar measures for sandals and closed shoes were derived, and all were compared to manufacturer last data.

RESULTS

The location of first MP joint ranged from 70% to 79% of total foot length, significantly different from last design specifications of 63% or 66% (p<0.0001). The range of first MP joint fulcrum locations in the same size feet occurred in a wide 24mm mediolateral band under the forefoot, termed a flexion zone.

CONCLUSIONS

The first MP joint cannot properly function as a fulcrum unless footwear has a matching flexion location. Footwear designs should incorporate a wide flexion zone located under the forefoot to permit the range of first MP joint flexion locations. Recommendations to patients are to select appropriate flexible footwear to prevent shear forces, reduce strain, prevent injury and enable range of motion function and healing of injury.

Everyday footwear: An overview of what we know and what we should know on ill-fitting footwear and associated pain and pathology

Footwear has been used to protect feet for millennia with socially exclusive population adopting stylish and fashionable shoes with expensive materials. In terms of historic timeline, only more recently footwear has been worn by all classes in the western world as an integral part of their apparel. Traditionally, footwear has been constructed from natural materials, mainly leather, but has recently benefitted from the flexibility that technology has provided with a plethora materials and new design innovations. Although it has expanded the availability for a variety of consumers, the choice and fit continue to be problematic with many individuals wearing shoes that are ill-fitting. Provision of specific footwear advice for problem feet is poorly evidenced and is heavily practitioner dependant limiting its efficacy. There is limited understanding as to the changes that can occur from regularly wearing footwear that is unsuitable in shape, style and construction which is referred to as ill-fitting. Current research on the effect that everyday footwear has on foot function and pain focuses mainly on women's shoes, particularly high heels. Defining what is a good fitting shoe, that does not damage the foot or mechanics of walking, may need to be individualised, but best fit is based on loose historical parameters rather than research evidence. The aim of this overview is to highlight aspects of current research, establishing what is known about the effect's shoes have on the feet as well as exploring the mythology around footwear fit and advice that is often historical in nature.

Forefoot disorders and conservative treatment

Forefoot disorders are often seen in clinical practice. Forefoot deformity and pain can deteriorate gait function and decrease quality of life. This review presents common forefoot disorders and conservative treatment using an insole or orthosis. Metatarsalgia is a painful foot condition affecting the metatarsal (MT) region of the foot. A MT pad, MT bar, or forefoot cushion can be used to alleviate MT pain. Hallux valgus is a deformity characterized by medial deviation of the first MT and lateral deviation of the hallux. A toe spreader, valgus splint, and bunion shield are commonly applied to patients with hallux valgus. Hallux limitus and hallux rigidus refer to painful limitations of dorsiflexion of the first metatarsophalangeal joint. A kinetic wedge foot orthosis or rocker sole can help relieve symptoms from hallux limitus or rigidus. Hammer, claw, and mallet toes are sagittal plane deformities of the lesser toes. Toe sleeve or padding can be applied over high-pressure areas in the proximal or distal interphalangeal joints or under the MT heads. An MT off-loading insole can also be used to alleviate symptoms following lesser toe deformities. Morton's neuroma is a benign neuroma of an intermetatarsal plantar nerve that leads to a painful condition affecting the MT area. The MT bar, the plantar pad, or a more cushioned insole would be useful. In addition, patients with any of the above various forefoot disorders should avoid tight-fitting or high-heeled shoes. Applying an insole or orthosis and wearing proper shoes can be beneficial for managing forefoot disorders.

Clothing and shoes of personnel as potential vectors for transfer of health care-associated pathogens to the community

In an acute care hospital, we demonstrated that the clothing and shoes that physicians and nurses wear home from health care facilities can be contaminated with health care-associated pathogens, particularly methicillin-resistant Staphylococcus aureus. These findings suggest that the clothing and shoes of personnel have the potential to serve as vectors for the transfer of health care-associated pathogens to the community.

Key concepts in children's footwear research: a scoping review focusing on therapeutic footwear

BACKGROUND

Reports suggest that children with mobility impairment represent a significant proportion of the population living with a disability. Footwear is considered to be the key extrinsic factor affecting children's gait and footwear modifications have been historically postulated to assist with locomotory difficulty. Although therapeutic footwear has been considered within the literature, there is a lack of consistency on terminology and paucity on the overall understanding. A scoping review was performed to chart the key concepts in children's footwear and to establish the range of studies that considered therapeutic footwear.

METHODS

A systematic search of MEDLINE, CINAHL, PubMed, SPORTdiscus, and Scopus electronic databases was performed using MeSH headings and free text terms in relation to children's footwear. All studies that used footwear as an intervention in children aged 9 months to 18 years with the outcome measures including design, fit, and the effects on development and health were included. Studies were charted by textual narrative synthesis into research groupings dependent on the topics discussed and the methods used in the studies.

RESULTS

The search yielded a total of 5006 articles with 287 of these articles meeting the inclusion criteria. Two overarching areas of research were identified; articles that discussed footwear design and those that discussed the effects of footwear. Eight further general groupings were charted and apportioned between the overarching areas and therapeutic footwear was charted into three subgroupings (corrective, accommodative and functional).

CONCLUSION

Children's footwear has become an increasing area of research in the past decade with a shift towards more empirical research, with most of the included articles examining biomechanical and anthropometric aspects. However, children's therapeutic footwear has not shared the same recent impetus with no focused review and limited research exploring its effects. Empirical research in this area is limited and there is ambiguity in the terminology used to describe therapeutic footwear. Based on the findings of this review the authors suggest the term children's therapeutic footwear be used as the standard definition for footwear that is designed specifically with the purpose to support or alleviate mobility impairment in childhood; with subgroupings of corrective, accommodative and functional dependent on the intended therapeutic role.

Gender differences in attitudes and attributes of people using therapeutic shoes for diabetic foot complications

Background

Therapeutic shoes can prevent diabetic foot reulcerations but their use is complicated by the fact that shoes have psychological and social meanings, which is believed to put a larger burden on women than men. The aim was to compare attitudes and attributes of women and men using therapeutic shoes for diabetic foot complications.

Methods

A questionnaire was posted to 1230 people with diabetes who had been fitted with therapeutic shoes. Women’s and men’s answers were compared using t-tests, Mann–Whitney U tests and chi-square tests with Fischer’s exact tests. P-values < 0.05 were considered statistically significant.

Results

Questionnaires from 443 (36.0%) respondents (294 men, 149 women, mean age 69.2 years) were analyzed. More men than women (p < 0.05) had paid employment (20.4% vs 9.4%), had someone who reminded them to wear their therapeutic shoes (27.6% vs 10.0%), and had a history of foot ulcers (62.9% vs 46.3%) or minor amputation (17.7% vs 6.7%). More women than men received disability pension (18.8% vs 10.2%). Women reported worse general health, lower internal locus of control regarding ulcer prevention, and more negative attitudes to the appearance and price of therapeutic shoes and how they felt about wearing them in public. Other comparisons were non-significant: other shoe attributes, education, diabetes type, current foot ulcers, major amputations, satisfaction with shoe services, understanding of neuropathy as a risk factor, locus of control regarding ulcer healing, belief in the shoes’ efficacy to prevent and heal ulcers, worries about ulcer healing and new ulcerations, self-efficacy, depression, shoe use/adherence, paying a fee for therapeutic shoes, and social support.

Conclusions

Men had worse foot complications. Women had worse general health, lower internal locus of control regarding ulcer prevention, and more negative attitudes toward therapeutic shoes. Clinicians should pay more attention to their female patients’ concerns. Future research and development should focus on improving the weight and appearance of therapeutic shoes, particularly for women. Research is also needed on how to facilitate the adaption and reevaluation process where patients change from viewing shoes purely as items of clothing to also viewing them as medical interventions.

The trouble with footwear following stroke: a qualitative study of the views and experience of people with stroke

Purpose: Foot problems and suboptimal footwear are risk factors for falls among the elderly. Footwear choice may, therefore, be important for people with balance impairment following stroke, but little is known about their experience. This study explored foot problems experienced following stroke, factors influencing footwear choices and views of footwear in use.Methods: Semi-structured interviews with 15 people with stroke, purposively sampled from respondents to a screening survey.Results: Participants typically experienced impaired mobility with balance problems and felt at risk of falling. Stroke related foot problems, including altered sensation, edema, and foot drop, predominantly on the stroke affected side, influenced footwear priorities. Footwear choices prioritized comfort, security, and convenience, sometimes in tension with concern about appearance. Challenges included choosing appropriate indoor footwear and finding shoes to accommodate their orthoses and edema. Participants highlighted perceived lack of footwear advice from health care professionals and variable experience of shoe shopping.Conclusions: Foot problems, as well as gait and balance impairment, have implications for footwear priorities following stroke, but people felt unsupported in making healthy footwear choices. Health care professionals could be trained to routinely deliver footwear assessment and advice and facilitate referrals to podiatrist, when appropriate.Implications for rehabilitationFoot problems, as well as gait and balance impairment, have implications for footwear priorities following stroke.People with stroke perceive a lack of professional advice about footwear and feel unsupported making healthy footwear choices.Health care professionals could be trained to routinely deliver an initial footwear assessment and advice as part of stroke rehabilitation.A greater transparency and knowledge of referral pathways into podiatry services for Health care professionals and patients would give access to specialist advice where appropriate.

Experience of finding footwear and factors contributing to footwear choice in people with gout: a mixed methods study using a web-based survey

Background

Gout frequently affects the foot, particularly the first metatarsophalangeal joint. People with gout commonly wear ill-fitting footwear that lacks cushioning and support, which may further contribute to foot pain and disability. Footwear with good cushioning and motion control may be an effective non-pharmacological intervention. Currently, there is limited understanding about the footwear experience in people with gout. The aim was to understand footwear characteristics, experience of finding footwear, and factors contributing to footwear choice, in people with gout.

Methods

A web-based survey of people visiting a gout education website. Participants self-reported a diagnosis of gout. The 17-item survey included questions to elicit demographic and clinical characteristics, type of footwear worn, level of difficulty finding appropriate footwear, and factors contributing to choices about footwear. A mixed quantitative and qualitative methodology was used to report survey findings.

Results

Survey respondents (n = 83) were predominately White/Caucasian (84%), male (58%), and aged between 46 and 75 years-old (73%). Thirty-nine percent were newly diagnosed (< 12 months), 43% had gout for 1–10 years, and 19% had disease over 10 years. Gout flares in the feet were reported by 77 (93%) respondents, mostly in the big toe joint (73%). Seventy-six (92%) participants completed questions about footwear. Closed-in athletic shoes (88%), sturdy walking shoes (79%), and casual closed-in slip-on shoes (63%) were most frequently worn. Orthopaedic shoes were worn least often (16%). Comfort, fit, support, and ease to put on/take off were the features most often rated as important or very important when choosing footwear. Over half the respondents (64%) reported difficulty in finding footwear. Three categories, encompassing seven subcategories, were identified from the qualitative analysis to describe experiences of footwear. Categories included difficulty finding suitable shoes; impact of shoes on activity; and preferred footwear.

Conclusions

People with gout need comfortable shoes that conform to the foot, have a wide opening, made from pliable materials with adjustable straps. The main barriers related to footwear include difficulty finding shoes that are wide enough, suitable for work and aesthetically pleasing. These findings provide clinicians with important insights into the priorities and needs of people with gout that should be considered when developing footwear interventions.

Being barefoot. Prevalence at home, in school and during sport: a cross-sectional survey of 714 New Zealand secondary school boys

Background

It may be assumed that a combination of culture, climate and economic resource are the major reasons that non-industrialised countries have a higher prevalence of barefoot activity. New Zealand is an industrialised country with comparable resources to that of many European countries; however, it seems to remain socially acceptable to carry out barefoot activities. A chance observation of students competing barefoot on a tartan track, prompted us to determine the prevalence of barefoot activity in an all-boys secondary school in Auckland New Zealand.

Method

An 11-question survey was administered at an Auckland boys secondary school, of high socioeconomic status, to determine the footwear habits of students (n = 714) during: a) daily life b) school life (c) physical education class and (d) sport. To classify students as habitually barefoot or shod, students were asked to select whether they were barefoot most of the time (2-points), half of the time (1-point) or none of the time (0-points) in three settings: around the house, during sport and during school. A score of ≥3 was required to be considered habitually barefoot. Participants were also asked to specify, when running at their most recent athletics event (100 m – 3000 m) on a track, whether they ran barefoot, in shoes, in spikes or another type of footwear. Finally, participants were asked to indicate if leg pain had interrupted running during the previous 12-months. Analysis was conducted using IBM SPSS.

Results

45% (95% CI: 41.5–49.5%) of the participants in our sample were classified as habitually barefoot. More than half of the sample reported being barefoot most of the time at home (n = 404, 56.6%) and during PE class (n = 420, 58.8%). Over 50% of the sample reported being barefoot half of the time or more during sport (n = 380, 53.2%). A smaller amount went to the supermarket (n = 140, 19.6%) or took the bus (n = 59, 8.3%) whilst barefoot around half of the time or more. The percentage of barefoot competitors declined with increasing distance: 100 m (46.5%), 200 m (41.8%), 400 m (38%), 800 m (31%), 1500 m (31%) and 3000 m (20%). The prevalence of leg pain interfering with running was 23.5%. There was no difference in the prevalence of leg pain between those classified as habitually barefoot and shod (Χ²(1, N = 603) = 0.005, p = 0.946).

Conclusion

The results of this survey demonstrate that over 50% of students at an all-boys secondary school in Auckland, of high socioeconomic status, are barefoot at home, during physical education and sport half of the time or more. These results may point towards a cultural difference between New Zealand and other modern industrialised countries.

Footwear for self-managing knee osteoarthritis symptoms: protocol for the Footstep randomised controlled trial

BACKGROUND

Knee osteoarthritis (OA) is a leading cause of musculoskeletal pain and disability globally, and abnormal knee loading is central to disease pathogenesis. Clinical guidelines recommend clinicians provide advice regarding appropriate footwear for people with knee OA, yet there is little research comparing the effects of different footwear on knee OA symptoms. Research suggests that wearing flat flexible shoes is associated with lower knee joint loads compared to stable supportive shoe styles. This two-arm pragmatic, comparative effectiveness randomised controlled trial will compare the effects of daily use of flat flexible shoes and stable supportive shoes on knee OA clinical outcomes, over 6 months.

METHODS

164 people with symptomatic medial tibiofemoral OA of moderate to severe radiographic severity (Kellgren and Lawrence Grade 3 & 4) will be recruited from the community. Following baseline assessment, participants will be randomly allocated to receive either i) flat flexible shoes or; ii) stable supportive shoes. Participants will choose two different pairs of shoes from a selection that fulfil the criteria in their allocated shoe class. Limited disclosure will blind participants to group allocation. Participants will be instructed to wear their allocated shoes daily for 6 months (minimum of 6 h/day), after which participants will be reassessed. The primary outcomes are knee pain severity on walking (measured by numerical rating scale) and self-reported physical function (measured by the Western Ontario and McMaster Universities Osteoarthritis Index), assessed at baseline and 6 months. Secondary outcomes include additional measures of knee pain, function, sport and recreation participation and quality-of-life (measured using subscales of the Knee Osteoarthritis Outcome Score), as well as pain at other sites (measured by numerical rating scale), self-reported global ratings of change in pain and physical function (measured by 7-point rating scale), and physical activity levels (measured by Physical Activity Scale for the Elderly).

DISCUSSION

This study will determine whether daily wear of flat flexible shoes improves clinical outcomes in the management of knee OA, compared to stable supportive shoes. Findings will assist clinicians in providing evidence-based advice regarding appropriate footwear for people with knee OA to self-manage symptoms.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry reference: ACTRN12617001098325 . Registered 28/07/2017.

Big issues for small feet: developmental, biomechanical and clinical narratives on children's footwear

The effects of footwear on the development of children's feet has been debated for many years and recent work from the developmental and biomechanical literature has challenged long-held views about footwear and the impact on foot development. This narrative review draws upon existing studies from developmental, biomechanical and clinical literature to explore the effects of footwear on the development of the foot. The emerging findings from this support the need for progress in [children's] footwear science and advance understanding of the interaction between the foot and shoe. Ensuring clear and credible messages inform practice requires a progressive evidence base but this remains big issue in children's footwear research.

Cost-Effectiveness of a Multifaceted Podiatry Intervention for the Prevention of Falls in Older People: The REducing Falls with Orthoses and a Multifaceted Podiatry Intervention Trial Findings

BACKGROUND

Falls are a major cause of morbidity among older people. Multifaceted interventions may be effective in preventing falls and related fractures.

OBJECTIVE

To evaluate the cost-effectiveness alongside the REducing Falls with Orthoses and a Multifaceted podiatry intervention (REFORM) trial.

METHODS

REFORM was a pragmatic multicentre cohort randomised controlled trial in England and Ireland; 1,010 participants (> 65 years) were randomised to receive either a podiatry intervention (n = 493), including foot and ankle strengthening exercises, foot orthoses, new footwear if required, and a falls prevention leaflet, or usual podiatry treatment plus a falls prevention leaflet (n = 517).

PRIMARY OUTCOME

incidence of falls per participant in the 12 months following randomisation.

SECONDARY OUTCOMES

proportion of fallers and quality of life (EQ-5D-3L) which was converted into quality-adjusted life years (QALYs) for each participant. Differences in mean costs and QALYs at 12 months were used to assess the cost-effectiveness of the intervention relative to usual care. Cost-effectiveness analyses were conducted in accordance with National Institute for Health and Clinical Excellence reference case standards, using a regression-based approach with costs expressed in GBP (2015 price). The base case analysis used an intention-to-treat approach on the imputed data set using multiple imputation.

RESULTS

There was a small, non-statistically significant reduction in the incidence rate of falls in the intervention group (adjusted incidence rate ratio 0.88, 95% CI 0.73-1.05, p = 0.16). Participants allocated to the intervention group accumulated on average marginally higher QALYs than the usual care participants (mean difference 0.0129, 95% CI -0.0050 to 0.0314). The intervention costs were on average GBP 252 more per participant compared to the usual care participants (95% CI GBP -69 to GBP 589). Incremental cost-effectiveness ratios ranged between GBP 19,494 and GBP 20,593 per QALY gained, below the conventional National Health Service cost-effectiveness thresholds of GBP 20,000 to GBP 30,000 per additional QALY. The probability that the podiatry intervention is cost-effective at a threshold of GBP 30,000 per QALY gained was 0.65. The results were robust to sensitivity analyses.

CONCLUSION

The benefits of the intervention justified the moderate cost. The intervention could be a cost-effective option for falls prevention when compared with usual care in the UK.