If the shoe fits


Understanding the difference among shoes with regards to function

Vincent Gutierrez, PT, MPT, cert. MDT


1.To briefly relate the history of the modern athletic shoe

2.To explain the differences regarding functionality among dress shoes, classic footwear, minimalist footwear and barefoot.

3.To provide general recommendations of footwear for varying populations.

  • The Shoe
  • The worlds oldest shoe is roughly 6,000 years old and was meant for foot protection. Prior to this it is theorized that all activities took place barefoot1.
  • Through the years
  • First athletic shoes
  • Keds Champions: unchanged since 19172,3
  • Modern (Classic) Shoe
  • Designed with the foot anatomy in mind (i.e. motion control)3,4,5
  • Minimalist shoes
  • In the recent years these shoes have noted increased sales and are advertised to mimic barefoot activities.
  • These shoes offer no support and increase the intrinsic/extrinsic strength of the foot musculature
  • When compared to barefoot, wearing standard walking shoes increases stride length by 6%14.
  • Heel strike is more pronounced with larger stride length and varum stresses at the knee were found (9%).
  • Impact on medial compartment OA.
  • For every 1% increase in stress, there is 6x greater risk of knee OA
  • “Flat flexible footwear are associated with significant reductions in dynamic knee loads during ambulation, compared to supportive, stable shoes with less flexible soles.”15
  • Running
  • (1980) It was advised to buy a shoe with built in support mechanisms for the arch and cushioned heel7
  • The authors make this recommendation based on the gait cycle and apply the same gait cycle to running.
  • Recent running analysis challenges this basis of running as fast walking
  • To understand this lets talk GFR
  • http://links.lww.com/CSMR/A3
  • By incorporating arch supports, there is a reduction in elastic recoil of the spring ligament and posterior tibialis, thereby reducing force output at the foot intrinsic/extrinsic3
  • Running
  • Minimalist shoes are more economical compared to classic running shoes in that the the runner utilizes less energy to run9
  • The weight of the shoe was controlled for by using ankle weights.
  • Neuropathic foot8
  • Most ulcers occur in forefoot
  • Study compares barefoot walking in patients with DM neuropathy and those without neuropathy
  • Results
  • Pt with neuropathy place more stress on the forefoot when barefoot (2x more) than controls
  • Possibly due to hammer toe formation and a lack of distribution among toes
  • Unable to feel increased stresses at the forefoot resulting in injury under met. Heads.
  • Balance
  • 100 older women (mean=82 y/a) examining usual footwear vs. barefoot on balance6
  • 68% required AD
  • 42% wore walking shoes, 17% sandals, 11% moccasin
  • Subjects with poorest balance (BBS) benefitted most from usual footwear
  • Post CVA subjects demonstrate increased gait speeds when using a classic shoe compared to barefoot or slippers11
  • Wearing dress shoes (>.5 inch heel) resulted in 15% worsening of balance testing compared to barefoot and a 12% worsening when changing from standard shoe to dress shoe. The TUG improved in standard shoes compared to barefoot12.
  • Healthy older adults demonstrate increased postural sway when wearing traditional walking shoes compared to barefoot13
  • Authors postulate due to sensory deprivation due to footwear
  • Pediatric population
  • “Influence of footwear on the prevalence of flat foot”
  • Study of 2300 children between 4 and 13 y/a
  • 1555 used footwear and 745 never wore shoes
  • 9% of shodded children presented with flat foot and only 3% of children without footwear presented with flat foot.
  • Closed toed shoes appeared to inhibit arch formation moreso than sandals/slippers.
  • The authors suggest that children should play barefoot or in sandals/slippers.
  • Recommendations
  • Running:
  • Classic Running shoes influence a RFS, which increases impact loading into the LE and runners sustain 2.5x more injuries (LBP, LE pain) when running with a RFS3,9
  • Barefoot running fosters a FFS, which strengthens the muscles of the foot3,10
  • Balance:
  • Those with poor balance are advised to wear shoes6 and avoid higher heeled shoes12
  • Healthy individuals are advised to wear minimalist shoes for static balance
  • Neuropathic foot
  • Therapeutic shoes to reduce plantar pressure at the metatarsal heads
  • Walking
  • s/p CVA should wear classic shoes for improved gait speed.
  • Healthy individuals are advised to wear minimalist/barefoot shoes to decrease risk of knee OA
  • Kids
  • barefoot or minimalist shoes
  • What’s the difference between running barefoot and running in standard/classic shoes?
  • What are two benefits and limitations of classic shoes?
  • Did this presentation add to your knowledge base and is there a change in your confidence level when recommending shoes for patients/friends?
  • References

1.Ravilious, K. National Geographic News. June 2010. Available at: http://news.nationalgeographic.com/news/2010/06/100609-worlds-oldest-leather-shoe-armenia-science/. Accessed on July 10, 2013.

2.Keds Shoes Official Site. July 2013. Available at: http://www.keds.com/store/SiteController/keds/ourstorypage. Accessed on July 10, 2013.

3.Altman AR, Davis IS. Barefoot Running: Biomechanics and Implications for Running Injuries. Curr Sports Med Reports. 2012;11(5): 244-250.

4.Griffith I. Choosing Running Shoes: The Evidence Behind the Recommendations. February 2011. Available at: http://sportspodiatryinfo.wordpress.com/2011/02/02/choosing-running-shoes-the-evidence-behind-the-recommendations/. Accessed on July 10, 2013.

5.McPoil TG. Footwear. Phys Ther. 1988;68: 1857-1865.

6.Hrogan NF, Crehan F, Bartlett E, et al. The effects of usual footwear on balance amonsgst elderly women attending a day hospital. Age and Ageing. 2009;38:62-67.

7.Heckman B. Selection of a Running Shoe: If the Shoe Fits-Run. JOSPT. 1980;2(2):65-68.

  1. Mueller MJ, Zou D, Bohnert KL, et al. Plantar Stresses on the Neuropathic Foot During Barefoot Walking. Phys Ther. 2008;88:1375-1384.
  2. Perl DP, Daoud AI, Lieberman DE. Effects of Footwear and Strike Type on Running Economy. Med Sci Sports Exer. 2012;44(7):1335-1343.
  3. Lieberman DE. What We can Learn About Running from Barefoot Running: An Evolutionary Medical Perspective. Exerc Sport Sci Rev. 2012;40(2):63-72.
  4. Ng H, McGinley JL, Jolley D, et al. Effects of footwear on gait and balance in people recovering from stroke. http://ageing.oxfordjournals.org/. Accessed on July 6, 2013.
  5. Arnadottir SA, Mercer VS. Effects of footwear on Measurements of Balance and Gait in Women Between the Ages of 65 and 93 Years. Phys Ther. 2000;80:17-27.
  6. Brenton-Rule A, Bassett S, Walsh A, Rome K. The evaluation of walking footwear on postural stability in healthy older adults: An exploratory study. Clinical Biomechanics. 2011;26:885-887.
  7. Keenan GS, Franz JR, Dicharry J, et al. Lower limb joint kinetics in walking: The role of industry recommended footwear. Gait and Posture. 2011;33:350-355.
  8. Shakoor N, Sengupta M, Foucher K, et al. The effects of Common Footwear on Joint Loading in Osteoarthritis of the knee. Arthritis Care Res. 2010;62(7):917-923.

Author: Dr. Vince Gutierrez, PT, cert. MDT

After having dedicated 8 years to growing my knowledge regarding the profession of physical therapy, it seems only fitting that I join the social media world in order to spread a little of the knowledge that I have gained over the years. This by no means is meant to act in place of a one-one medical consultation, but only to supplement your baseline knowledge in which to choose a practitioner for your problem. Having completed a Master of Physical Therapy degree, the MDT (Mechanical Diagnosis and Therapy) certification and currently finishing a post-graduate doctorate degree, I have spent the previous 12 years in some sort of post-baccalalaureate study. Hopefully the reader finds the information insightful and uses the information in order to make more informed healthcare decisions. MISSION STATEMENT: My personal mission statement is as follows: As a professional, I will provide a thorough assessment of your clinical presentation and symptoms in order to determine both the provocative and relieving positions and movements. The assessment process and ensuing treatment will be based on current and relevant evidence. Furthermore, I will educate the patients regarding their symptoms and their likelihood of improving with either skilled therapy, an independent exercise program, spontaneous recovery or if the patient should be referred to a separate specialist to possibly provide a more rapid resolution of symptoms. Respecting the patient’s limited resources is important and I will provide an accurate overview of the prognosis within 7 visits, again based on current research. My goal is to empower the patient in order to take charge of both the symptomatic resolution and return to full function with as little dependence on the therapist as possible. Personally, I strive to be an example for family and friends. My goal is to demonstrate that success is not a byproduct of situations, but a series of choices and actions. I will mentor those, in any way possible, that are having difficulty with the choices and actions for success. I will continue to honor my family’s “blue-collar” roots by working to excel at my chosen career and life situations. I choose to be a leader of example, and not words, all the while reducing negativity in my life. I began working towards the professional aspect of the mission statement while still in physical therapy school. By choosing an internship that emphasized patient care and empowering the patient, instead of the internship that was either closest to home or where I knew that I would have the easiest road to graduation, I took the first step towards learning how to utilize the evidence to teach patients how to reduce their symptoms. I continued this process by completing Mechanical Diagnosis and Therapy courses A-D and passing the credentialing exam. I will continue to pursue my clinical education through CEU’s on MDT and my goal is to obtain the status of Diplomat of MDT. Returning back to school for the t-DPT was a major decision for me, as resources (i.e. time and money) are limited. My choice was between saving money for the Dip MDT course (about 15,000 dollars) and continuing on with the Fellowship of American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) (about 5,000 dollars), as these courses are paired through the MDT curriculum or returning to school to work towards a Doctorate of Physical Therapy degree. I initially planned on saving for the Dip MDT and FAAOMPT, but life changes forced me to re-evaluate my situation. The decision then changed to return for the tDPT, as my employer paid for a portion of the DPT program. My goal for applying to and finishing the Dip MDT and FAAOMPT is 10 years. This is how long I anticipate that it will take to finish paying student loans and save for both programs, based on the current rate of payment. I don’t know if I will ever accomplish what I set forth in the mission statement, but I do know that it will be a forever struggle to maintain this standard that I set for myself.

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