Why we wear shoes
Since ancient times, people have protected their feet against the elements and rough terrain. Animal skins were used to cover the feet, lashed securely above the ankle in a crude, but effective, moccasin style. Other than for protection when walking, footwear was not used and the feet of our nomadic ancestors grew strong from coping with uneven surfaces, climbing trees, swimming in streams and scaling rock faces.
Today, footwear is as much about aesthetic appearance as basic protection (Cowell 1977, Staheli 1994). Fashion dictates the footwear people choose and it is remarkable to see the level of discomfort people will endure in order to achieve the successfully marketed ‘look’. While women are the main group to suffer as footwear fashion victims (and it can be hard to find comfortable female fashion footwear that looks good), children are not immune either. Rampant consumerism and large-scale manufacturing of footwear has seen a huge change in the supply and style of footwear in the last 50 years (ask your older patients what type and how many pairs of shoes they had as an 8-year-old and compare that with many children now). Status is another aspect of footwear selection and of course the foot fetishists are not to be overlooked (Stewart 1972).
There are many long-held opinions, e.g. that trainers/runners are not good for children’s feet, that are too general and not well founded. The selection of children’s footwear for general purpose and the fit of that shoe are probably more important than the periodic use of party shoes. It is really a matter of horses for courses.
What is known about the effects of shoes on children’s feet
Children’s footwear which incorporates arch support has been demonstrated to hasten the development of the medial foot arch if worn between ages 1 and 3 years (Gould et al 1989). The same study showed that arch development was the same by age 5 years, independent of footwear type.
Key Concepts
Key Concepts
A randomized controlled trial showed no difference in the arch profile of flexible flat foot with the use of corrective shoes or foot orthoses in children aged 1–6 years (Cohen & Cowell 1989, Wenger et al 1989).
This finding has also been supported (with less scientific rigour) by other investigators (Mereday et al 1972, Penneau et al 1982).
Large studies in India have found correlation between the use of footwear and the incidence of flat feet in children (Gould et al 1989, Rao & Joseph 1992, Sachithanandam & Joseph 1995). It is clearly a leap to assume that these results transpose across to cultures where footwear and hard surfaces now predominate.
The effects of shoes on children’s gait
The effects of putting shoes on children has been examined in different age groups and settings. An Australian study examined the effects of sneakers and Clarks first walker shoes versus bare feet on the gait of 31 children (aged 13–32 months, mean 19 months; Wilkinson 1997). The main findings were:
• Initial effects were greater for shoes than for sneakers:
– increased ankle dorsiflexion
– increased base of gait
– reduced angle of gait.
• Shoes and sneakers had different effects:
– sneakers produced ankle plantarflexion during swing phase.
• Children adapted to the effects of new footwear in less than 1 month:
– the sole of shoes became more flexible with use
– gait matured and changed aside from footwear use.
The effects of footwear on normal children in a gait laboratory found no kinetic or kinematic differences but found that wearing shoes increased stride length. As a result, it has been suggested that barefoot gait may be sufficient for most clinical studies (Oeffinger et al 1999).
A Congolese study assessed footprint data in 1851 children (aged 3–12 years). The children were from both rural and urban environments and had differing exposure to footwear, from never worn to always worn. It was concluded that footwear had very little influence on foot morphology (age and gender were the predictive factors) (Echarri & Forriol 2003, Pfeiffer et al 2006).
A recent study from Germany has looked at the effects of conventional versus more flexible shoes in the gait patterns of 8-year-old children. There were significant changes in the position and motion of the medial foot arch when conventional footwear was used. Motion was generally restricted in comparison to barefoot gait. The study concluded that more flexible footwear allowed foot motion that was more like that occurring when barefoot as opposed to when wearing more ‘supportive’ shoes (Wolf et al 2008).
Foot growth and shoe size
Key Concepts
Foot growth in children aged 1–5 years has been studied prospectively and found to correlate inversely with age, i.e. the feet of younger children grow faster than the feet of older children (Gould et al 1990).
Measuring children’s feet has long been regarded as an important practice. Ensuring that children have shoes that fit well and, by inference, will not damage the feet and yet allow for growth is particularly important. The length, width and depth of each foot needs to be assessed and then shoes selected to match these parameters and also those of style, price, preference and purpose. Shoe-fitting for children is not easy and an experienced fitter of children’s shoes is both skilled and necessarily patient. Personally, as a clinician, I have found this an invaluable liaison.
Measuring the size of the foot
As part of the undergraduate podiatry programme in Adelaide, Australia, final year students completed a shoe-fitting course courtesy of Clarks Australia (also provided by Clarks in the UK). One of the components of this course included the practical use of foot measure devices, commonly used in retail stores (Fig. 14.1).
 |
| Figure 14.1 |
The reliability of this foot size measuring technique was subsequently evaluated as a clinical research pilot study using a same subject repeated measures study design. The sample was one of convenience (n = 14), with podiatry students (n = 6, ages 20–25 years) and paediatric clinic patients (n = 8, ages 5–12 years). The examiners were two final year podiatry students and two podiatry teaching staff. All had attended the same shoe-fitting course. Results are found in Table 14.1 (Evans & Carty 2007).
| *Examiner 3 (staff) missed two subjects’ right foot length measures. | |||||
| **Examiner 3’s right foot length measures excluded. | |||||
| The examiners were two students and two clinical staff, all of whom were trained to measure foot size at the same workshop. As can be seen, the measure of length was highly reliable across all examiners, but width (girth) measures were much less reliable | |||||
| Foot size measure | Examiner 1 (student) | Examiner 2 (student) | Examiner 3 (staff) | Examiner 4 (staff) | |
|---|---|---|---|---|---|
| Intra-rater ICC (1,1) | Left right | Left right | Left right | Left right | |
| Foot length | 0.99 0.99 | 0.99 0.99 | 0.99 0.05* | 0.99 0.99 | |
| Foot width | 0.81 0.90 | 0.47 0.82 | 0.75 0.47 | 0.81 0.74 | |
| Foot length and width | 0.41 0.41 | 0.30 0.33 | 0.31 0.29∧ | 0.62 0.58 | |
| Inter-rater ICC (1,1) | |||||
| Foot length | Left = 0.99 | Right = 0.99** | |||
| Foot width | Left = 0.52 | Right = 0.61 | |||
| Foot length and width | Left = 0.42 | Right = 0.43** | |||
This pilot study indicated that all examiners were very reliable at measuring foot length. The reliability of foot width (girth) measures was less. Hence the combined foot length and width measures were also less reliable. These trends were largely consistent both within and between examiners, and regardless of professional experience. Implications include the accuracy of width versus length shoe fittings, foot growth studies, training of retail shoe-fitting staff.
In a large study of 2829 Chinese children, feet were found to grow linearly from age 3 to age 12 in girls and from age 3 to age 15 in boys. Growth was more than linear in both genders when children were aged less than 2 years and later plateaued, after linear growth cessation. Children’s feet increased in both length and width when standing, which is clearly relevant for the measuring and fitting of feet in shoes. An increase of between 2.1 and 4.4 mm was noted when the feet were weight-bearing.
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