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A Source of Multiple TroublesPerhaps the single most visible dif-

ference between the shoeless and theshod foot is the elevated heel underthe shoe. The numerous influences ofthe shoe heel on the foot and bodycolumn are not fully understood bymost medical practitioners. The practi-tioner commonly speaks of “sensible”heels. Such a heel does not exist. Anyelevated heel under a shoe automati-cally initiates an altered series of footand body biomechanics.

Standing bare-foot, the fallingline of bodyweight normallyforms a perpen-dicular, a 90-de-gree angle withthe 180-degreeangle of the foot’splantar surface.Body weight isdistributed 50-50between heel andfore-foot. (Fig. 23)

The momentany heel eleva-tion, even themost minimal, isapplied to theshoe, the normal90-degree perpen-dicular of thebody column andfalling line ofbody weight is al-

tered. The higher the heel the greaterthe body column change. The heelon a man’s shoe is about one inch inheight. On women’s shoes it variesfrom 1 to five inches—and up to sixinches in more extreme footwearstyles.

If the body column was a single,unjointed column, then even a one-inch heel under the foot could causethe rigid body column to tilt forwardor even fall. Like the Leaning Towerof Pisa, only a few inches tilt at thebottom results in a lean of severalfeet at the top. (Fig. 24)

But the body column is a series ofadaptable joints and connecting sec-tions: ankle, knee, hip, pelvis, spine,shoulders, neck and head. Unlike therigid column of Pisa, the body col-umn sections make “adjustments” tomaintain an erect stance. With eachsectional adjustment there is a shiftin the body’s center of gravity (nor-

By William A. Rossi, D.P.M.

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A continuation of the scientific review of the failings of modern shoes.

PART 2

Footwear: The PrimaryCause of Foot Disorders

P R A C T I C E P E R S P E C T I V E SP R A C T I C E P E R S P E C T I V E S

Fig. 23: Weight distribution on foot in standing, barefoot versus high heels.

Fig. 24: Left, normal body column stance barefoot; center,tilt of body column on medium heel if body was a rigid col-umn; to regain erect stance, column makes “adjustments”to create new body profile.

increased bowing of the long arch isaccompanied by a contraction orshortening of the plantar fascia as heeland ball are drawn closer together. Ifthe fascia becomes permanently short-ened, as is not uncommon among ha-bitual wearers of medium to higherheels, the fascia becomes more vulner-able to strain or tearing when lowerheels are worn, or with some traumat-ic foot action such as jogging or ag-gressive walking that results in anacute pull on the fascia. There is cer-tainly some common correlation be-tween elevated shoe heels, low tohigh, and plantar fasciitis.

It is a dogma of footwear fashionthat thin, curvy medium to higherheels are always accompanied bypointed-toe shoe styles. Higher heelsand broad or round toes are esthetical-

ly incompatible. It isonly when the higherheel is chunky or heavylooking that the roundor broad toe is accept-able. Thus the classichigh heel has a double-barreled effect, frontand rear.

However, contraryto conventional medi-cal thinking, it is not somuch the pointed-toeshoe that is mainly atfault for the toesqueeze, but the faultydesign of the last. Werepointed-toe, high-heelshoes made on betterengineered lasts, per-haps at least half of thecommon distresses of

mally about hip height). With theshift of gravity there are correspond-ing shifts in the line of falling bodyweight both in standing and walk-ing, resulting in shifts in the path ofweight distribution throughout thefoot, beginning with the rearfoot.

The muscles and ligaments asso-ciated with the body column andfoot system must also make compen-satory changes. Considering that the“simple” act of walking involves halfthe body’s 650 muscles and 208bones, the number of automatic “ad-justments” is enormous. Inevitably,a toll must be taken, most common-ly leg and back aches and, of course,foot aches.

On a medium to higher heel the

such footwear would be eliminated.While it would not transform the shoeinto a “comfort” shoe, it would beconsiderably more comfortable towear than such footwear of the past-and present.

The ligaments and muscles asso-ciated with the body column andfoot must also make compensatorychanges. Considering that the “sim-ple” act of walking involves half thebody’s muscles and bones, the num-ber and degree of adjustments areenormous. Inevitably, a toll must bepaid via a variety of related symp-toms, such as leg or back or footaches. The specifics of these involve-ments are difficult to pinpoint be-cause the overlapping effects are sonumerous and complex.

But some are traceable. For exam-ple, researchers at Harvard University,headed by physiatrist D. Casey Kerrig-an, reported in the May, 1998 issue ofLancet, on women walking barefootand again on 2-inch heels. Barefoot,they found, the weight is sharedequally by the lateral and medial sur-faces of the knee joint. But on the 2-inch heels the weight was shifted, re-sulting in a 23 percent increase ofweight borne in the center of the kneejoint. Kerrigan’s report concluded,“The resulting strain on the kneejoints, if frequent or habitual, couldwell be a contributing cause of degen-erative arthritis in the knee joints.”

On a medium to higher heel, theincreased bowing of the long arch is ac-complished in part by a contraction orshortening of the plantar fascia as footheel and ball are drawn closer together.The plantar fascia now becomes more

vulnerable tostrain and tear-ing whenlower or flatheels are worn,or with sometraumatic footaction thatcauses an acutepull on the fas-cia. There cer-tainly appearsto be some cor-relation be-tween elevatedheels and plan-tar fasciitis. If

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Fig. 25: Top, contrasting effect of elevated heel on foot,Achilles tendon and calf muscles. Tendon is shortened.Bottom, changes in leg musculature from barefoot tolow heel to high heel.

Fig. 26: Altered angles of lower leg, barefoot tohigh heel. Accommodating changes required inbody column joints to return lower leg to verti-cal position. But many women retain bent-kneestance and accompanying faults of body pos-ture and faulty weight fall on foot.

about age three or four when tots arewearing footwear with heels three-eighths to one-half inches in height.(Fig. 25) It continues and acceleratesinto the early puberty years whenreaching one inch in height (oxfords,loafers, sneakers, etc.). Few people, in-cluding medical practitioners, realizethat, relative to body height, a one-half inch heel for a tot or a one-inchheel for a nine-year-old is the equiva-lent of a two-inch heel for an adult. By

the mid or late teen yearsmost girls are into high(two inches or more)heels. By this time theshortening of the heeltendon and calf muscleshas become firmly estab-lished.

What are the futureconsequences? In thecase of women who be-come habitual wearers ofhigher heels, there usual-ly develops the classicaching of calf musclesand heel tendon syn-drome, especially whenthere are shifts to lowerheels or, for example, inan aerobics class, result-ing in stretch or stress ofthe calf muscles or thetendon.

Second, the bursa be-hind the calcaneus serves

there is a shift in body weight distribu-tion throughout the foot because of theelevated heel, it would seem to followalso that the bursa under the calcaneuswould be affected, resulting in heelsoreness or pain.

Shortened Achilles TendonAll shoe-wearing people have a

shortened Achilles tendon. It begins at

as a buffer zone between the tendonand the bone. Any change in thelength and function of the tendon re-sulting from the elevated shoe heel isgoing to affect the bursa itself.

Thirdly, the lower leg, normally ona perpendicular with the 180-degreeplane of the bare foot on the groundto form a 90-degree angle, now on ahigher heel tilts forward, reducing theleg angle to, say, 70 degrees. (Fig. 26)Some women in elevated heels learnto maintain the 90-degree angle bykeeping the knees “locked” with eachstep. But most allow the lower leg andknee to angulate. A profile view of thegait quickly reveals this. The result:body weight is no longer falling nor-mally onto the foot, but is moved for-ward onto the forefoot.

In all ground-linked sports theAchilles tendon plays a vital role, espe-cially where there are quick and vio-lent foot torsions, such as in basket-ball, football, tennis, etc. Hence ashortened heel tendon would seem tohave some influence on athletic per-formance. We tend to overlook thisbecause most athletes are shoe wearersand have the same heel tendon short-ening. But when athletic performanceis compared with shoeless athletes,then the difference in tendon lengthcan show itself dramatically.

For example, over the eight yearsl99l-1998, all the winners in the clas-sic Boston marathon were Africans.In 1998, five of the top 10 finisherswere Africans. The same pattern ap-pears in other marathons where theAfricans have participated over thepast decade. Most of these Africanrunners grew up shoeless, and manycontinue to train shoeless in their na-tive countries. All, consequently,would likely have normal, full-lengthAchilles tendons and calf muscles.This would seem to have enormousinfluence on stride and stamina in amarathon run where there are ap-proximately 44,000 Achilles tendonand calf muscle “pulls.”

The superiority of the Africanmarathoners has nothing to do withrace. African-Americans excel in theshort sprints up to 400 meters, but notone has ever won a marathon, andfew even compete in distances of onemile or more. Like all of us, African-Americans are habitual wearers ofshoes with elevated heels (along with

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Fig. 27: Concave bottom of calcaneous, with protec-tive bursa. This is normal site of heel strike, allowingfoot and weight to roll forward easily with progres-sive sequences of step.

Fig. 28: Left, normal 180-degree angle of sustentaculum tali of human foot—a vital siteof support of long arch. Right, angulated sustentaculum tali on gorilla foot. Absenceof arch prevents bipedal gait for more than a few steps. Bottom, human foot with lineof falling weight through sustentaculum tali, and through breast site of shoe heel. Continued on page 133

the crooked lasts) and hence, presumably, have the sameshortened heel tendon and calf muscles.

Heel StrikeThe term “heel strike” entered the common language

about 30 years ago with the start of the jogging/runningand physical fitness boom. It is almost always used in refer-ence to the heel strike inside the shoe, as in walking, run-ning, etc. The problem, however, is that heel strike bare-foot is usually quite different than with shoes on.

We assume that the initial strike is at the posterior-lateral edge of the heel because that is where the majortread area is. And we rarely refer to heel strike in thestanding position. But while heel strike in walking orrunning is a traumatic force, in standing there is consid-erable weight impact force on the heel. Further, wespend much more time standing than walking or run-ning. Also, in standing the pressure effect on the heel isconstant, without rest intervals between heel strikes.

The prime function of the plantar bursa under the heelis to serve as a buffer between the plantar calcanealtuberosity in the center of the calcaneas. (Fig. 27)

We assume that the path of weight movement in-side the shoe immediately after heel strike follows acommon “normal” path through the foot to steppushoff. Further, from this assumption we develop ourpremises for heel and rearfoot therapies, including thedesign and performance of orthotics.

Footwear...

Why these assumptions? Because virtually all footwearshows the majority of tread and wear at the lateral-posteri-or edge of the heel, we thereby assume that this is the nor-mal site of heel strike. That assumption deserves challenge.

On a “normal” (shoeless native) foot the initialstrike is at the posterior (neither lateral nor medial) endof the heel, moving straight forward over the tuberosityin the center of the calcaneus toward the mid-tarsaljoint, fifth ray and onto the metatarsal heads, thus cre-ating a smooth, forward rolling or rocker motion.

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Fig. 29: Usual site of arch support peak at navicular/firstcuneiform joint. But line of falling weight is at sustentacu-lum tali where shoes and orthotics provide no support.

Fig. 30: Dog, much shorter in height than a human, never-theless has 2 1/2 times greater support base for its bodyweight. Humans are much more fragilely balanced onmuch smaller base.

law; form follows function.The concave calcaneal tuberosity

serves the same purpose, allowing theheel to roll forward easily and smooth-ly on weightbearing as the weightshifts forward from heel strike. On theheel of a barefoot native the tread isover the whole plantar surface of theheel. But on the shoe-wearing foot thetread surface is concentrated almostwholly on the posterior-lateral edge ofthe heel’s toplift, with the remainderof the toplift receiving only minimalstrike and wear.

This clearly indicates that the heeltread on the natural foot differs fromthat on the shoe-wearing foot. Thequestion follows: What other changesin the whole rearfoot structure occurbecause of that altered manner of heelstrike and heel tread?

There is also the matter of heelstrike impact. Prior to the invention ofthe rubber toplift by Humphrey O’Sulli-van in 1894, shoe heel toplifts consistedalmost wholly of leather, often supple-mented with a metal clip for abrasion

resistance, Either way,the toplift was non-re-silient. The body col-umn adapted to “stepshock,” the repeatedheel strike impact some8,000 or more times aday and sending joltsup through the bodycolumn.

The high heel issimply another bodydeformation deviceused with the samemotive of sex attrac-tion and social status.Nor does the heelhave to be high. Medi-um height heels, with

Why, then, is this seemingly con-tradicted by the common heel striketread pattern at the lateral-posteriorarea of the shoe heel? Because of tworeasons; 1) the crooked or inflared lastthat alters the normal alignment ofthe foot, including the heel, and 2) theelevated shoe heel that alters the natu-ral stance of the foot heel itself insidethe shoe. Between them, not only isthe normal heel strike changed, butalso the consequent path of weightflow forward.

Again, note the tuberosity underthe center of the calcaneus. Why,along with the bursa, is it there, ex-actly in the center? For the same rea-son that every round ball—a basket-ball, for instance, when resting sta-tionary—has a small, ground-touch-ing surface from which the surround-ing portion of the ball’s surface ta-pers or contours upward. Much thesame occurs with the plantar surfaceof the calcaneus. It is the biological

slender styling, achieve the same ob-jective in modified form,

Reformers and medical practition-ers are naive in assuming that bywarning about the safety and medicalhazards of high heels, common sensewill prevail and cause women to shiftto low or “sensible” heels. Such a be-lief is delusive, and centuries of experi-ence confirm it. The aphrodisiacpower of the high heel has always hadmore power than common sense.

The Sustentaculum TaliThis small, flat shelf of bone ex-

tending from the medial-upper surfaceof the calcaneus has not been giventhe attention it deserves. It is one ofthe most important elements of thelong arch, and in enabling the foot’swhole elastic system to function effi-ciently in gait.

For example, the sustentaculumtali of the gorilla foot is angulateddownward at approximately a 45 de-gree angle, in contrast to the 180 de-gree plane on the human foot. (Fig.28)Because of this the gorilla (and otherapes) cannot maintain an erect pos-ture in walking for more than aminute or so, at which point it mustassume a quadruped gait. The gorillafoot, along with that of the chimp andorangutan, has no long arch, mainlybecause of the downslanted sustentac-ulum tali.

In fact, the 180-degree position ofour own sustentaculum tali may wellbe the single most distinguishing fea-ture of the human foot—more exclu-sive, perhaps, than the long arch,straight-ahead hallux and the ground-touching heel, all distinctively human.

Evidence of the vital arch support-ing role of the sustentaculum tali is

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Fig. 31: Left, altered angle of pelvis on high heel. Alsonote accompanying changes in body contours (but-tocks, breast).

Fig. 32: Left, base of fifth ray as an important weightbearing el-ement. Right, base of ray off ground by shoe heel, eliminatingweightbearing function. Normal weightload here now imposedon other parts of foot.

seen again in the fact that a perpendicular line of weightfalling from the body column to the foot passes exactlythrough the center of the sustentaculum tali. Any habitualor chronic shift in this line, such as caused by the elevatedshoe heel plus the crooked shoe last,would seem inevitably to have some ef-fect on the sustentaculum tali and thelong arch.

Conventional arch therapy almostalways focuses on an orthotic to “lift” or“support” the depressed or strained arch.(Fig.29) The support is mainly under thecenter of the arch curve (navicular-firstcuneiform joint). The orthotic is doingwhat deceptively appears to be the logi-cal course; following the anatomicalcontour of the arch instead of providingthe prime support where it is most need-ed—under the falling line of bodyweight through the sustentaculum tali.

What causes the tilt of the sustentaculum tali in thefirst place? As in the case of pes planus, we’re not sure; atleast there is no conclusive single cause.

So a series of rationales must be voiced. First, we can as-sume that if the sustentaculum tall is normally angled at180 degrees it will maintain its support function.

Second, if any chronic imbalances are imposed beneaththe sustentaculum tali, such as with an elevated shoe heel,then there will be a corresponding shift in the falling lineof body weight, affecting the angle of the sustentaculumtali, and with consequent effects on the rearfoot structuraland functional mechanisms.

Hence the domino sequence; tilted body column andshifting of the gravity center, resulting in a shift In thefalling line of body weight, followed by redistribution ofweight stress paths through the foot, with correspondingarch strain and rearfoot dislocations. Any combination ofvariables could become involved.

The pivotal element is the sustentaculum tali. It is sosmall and seemingly an obscure part of the foot anatomy.Yet its influence on the structural integrity of the rearfoot,as well as the midfoot and forefoot, is enormous. And inturn, it is vulnerable and influenced by the biomechanicsof the shoes beneath it.

Rearfoot Influence On GaitNatural gait is impossible when most (98 percent) of

footwear is worn. There are three main reasons for this; 1)the shoe’s elevated heel; 2) the faulty design of the last asfound in most footwear; 3) construction and design faultsfound in the shoe itself (components, materials, shoeweight, limited flexibility, etc.).

Separately or together they influence how the footfunctions inside the shoe and how the individual walks.Whereas under these conditions the foot cannot functionin a fully natural manner, the gait, so totally dependent onthe foot, also cannot be its natural self. The conditions alsowork in reverse. An alteration in natural gait changes theline of falling weight and the natural path of weight distri-bution throughout the foot.

Footwear... Let’s cite one example. Because almost all footwear hassome kind of elevated heel, the shank or midfoot section ofboth foot and shoe is lifted off the ground, denying thebase of the fifth ray its normal weight-bearing function inboth standing and walking—plus the supplementary sup-port of the cuboid. Body weight is supported almost entire-

ly by the heel and metatarsal heads, im-posing an added weightload on thesestructures. Under these conditions nei-ther the foot nor the gait can function ina fully normal manner.

If this particular shoe default of el-evated shank is combined with the in-flared or crooked last and toe spring,plus the imbalance caused by the ele-vated heel, then the rearfoot, whole-foot and gait biomechanical systemsbecome vulnerable to any of a varietyof impairments.

The erect, two-legged stride gait ofhumans is the most precarious among

all living creatures. And also the most graceful when exe-cuted in natural form. Whereas all other land creaturesstand and walk on four or more legs (if on two legs as withbirds or fowl the body is semi-horizontal, not erect), thebody weight falls within a broad base area. With humans,however, the base area is extraordinarily small relative to

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Over the eight years l99l-1998,

all the winners in theclassic Boston marathonwere Africans. In 1998,

five of the top 10finishers were Africans.

trying to balance a long broomstick onend in the same palm.

Kinesiologists regard walking asthe most complex motor function ofthe human body. Yet the foundationfor this intricately engineered bodycolumn consists of just three smallbase sites: the calcaneum, the base ofthe fifth ray, and the unit formed by

the five metatarsal heads.These are the ground-touching pillars support-ing a tall and large super-structure. For the manyelastic foot parts (musclesand tendons, ligaments,fascia) to do their workefficiently, the base sup-port pillars themselvesmust be firmly fixed intheir normal positions.Any change in the os-seous pillars is instantlyaccompanied by changesin the associated elasticparts,

Here again enter thetrouble-makers: the ele-vated shoe heel and shoeshank, crooked last, toespring, concave last bot-tom, shoe bottom filler,limited shoe and footflexibility, etc. The os-seous pillars automatical-ly are either forced out ofnormal positions, or thenormal share of weight-bearing loads are shifted.The amount and mannerof these changes dependsupon the degree of theunderlying shoe faults.

On a “medium” two-inch heel, for example,the ankle and subtalarjoints are moved out ofnormal alignment. A se-ries of compensatoryjoint “adjustments”occur throughout thebody column; knee, hip,pelvis, spine, shoulders,neck, head. The pelvis,for example, tilts from itsnormal 30-degree angleon flat heels to a 45-de-gree angle when standingor walking on a two-inchheel—and to 55 or 60 de-grees on a three-inchheel. (Fig. 31) The organs

body height and weight. A small dog,for instance, has more than double theweight-support base area beneath itsbody than does an adult human. (Fig.30) It is much like the difference ofholding a small, squat cube in thepalm of the hand as compared with

within the pelvic bowl and abdomen,would have to make correspondingadjustments in position.

The body column is a marvelouslyadapting structure in response to pos-tural changes. While the jointsthroughout the column angulate toadjust to the elevated heel, the anglesare largely concealed so that the flesh-covered column appears to be a seriesof curves—more posterior thrust of thebuttocks and more anterior thrust ofthe chest. The body movements alsochange.

Thus the irony: an essentially ab-normalized series of body angles be-come the beauty-in-motion form—asensuous, sometimes erotic dynamicwhich lures the admiring male eye.Women for centuries have been awareof this kinesic and cosmetic magic. Nowonder their long love affair with thattiny spindle of shoe heel.

Reduced Tread SurfaceThe combination of the elevated

shoe heel, elevated shoe shank at mid-foot, toe spring, and concave shoe bot-tom at the ball, together force enor-mous changes in the plantar tread sur-face, which in turn generate shifts inthe gait pattern and weight distribu-tion over rearfoot and fore-foot.

The shoe heel, even at a “low” oneinch height, lifts the shoe shank andmidfoot off the ground, eliminatingthe base of the fifth ray from its vitalweightbearing function, along withthe supplemental weightbearing func-tion of the cuboid. This normalweightbearing task must now be shift-ed elsewhere, shared by both rearfootand forefoot. (Figs. 32, 33)

The tread surface of the toplift of amen’s shoe appears to be much greaterthan on the toplift of a women’s two-inch heel (9 square inches versus lsquare inch), and as little as 1/4 squareinch on a three-inch stiletto heel. Butthose differences are very deceptive.The ACTUAL heel strike or tread areaon a men’s heel toplift is reduced toabout 1 square inch. And by the sameproportions on a women’s shoe heel.This is because the true heel tread sur-face is reduced to the lateral-rear cor-ner of the toplift. In short, what yousee isn’t what you get. No matter whatthe size of the toplift area, 70 to 80percent of it remains largely unwornbecause of faulty heel tread.

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Fig. 33: Top, weightbearing function of base of fifthray. Second, even low heel denies the ray its normalfunction. Third and fourth, same effect on flesh-cov-ered foot.

Now, compare this with a footprint of a bare foot. Thefootprint will show a full tread area—a broad heel surface,lateral border of the foot, a full metatarsal area, plus toe im-prints. The foot imprint will usually show 65 to 80 percentmore tread area than that of the shoe bottom. (Fig.34)

The questions are almost inevitable: Under theseconditions of imbalance, what hap-pens to the normal patterns of weightdistribution from rearfoot to forefoot?What tolls are taken on the wholeelastic support system of the foot?What compensations of joint abut-ments and alignments are necessary toadjust to the greatly minimized treadsurface? What happens to the patternsof heel strike and the whole dynamicsof the rearfoot? What happens to thewhole body column, already fragilelybalanced on a small base, when it islimited to an even smaller tread and support base?

A toll must inevitably be paid. Here the pathologicalconsequences become less precise because so many dif-ferent mechanical elements are involved in so many dif-ferent ways that a single point of origin is often difficultto pinpoint in a diagnosis.

Nevertheless, questions must be asked. How manyankle and knee lesions have a direct association withdrastically reduced plantar tread? How many leg, hip andback aches? And, of course, how many biomechanicaldisorders of the foot? We cannot expect some 200pounds of descending body weight to impact some 8,000times a day on a plantar tread surface little more thanthree square inches without negative consequences. Themany practitioners who place much reliance on or-thotics to resolve problems by “rebalancing” or “rehabili-tating” the foot are seeing an open door of corrective op-portunity where one often does not exist. The commonmistake here is the assumption or diagnosis that it is thefoot that is at fault, and hence the solution is to “rebal-

Footwear... ance” the foot. But far more usually it is the shoe that isat fault for any of the reasons already cited. An orthoticmay rebalance the foot, but that same rebalanced footautomatically becomes unbalanced when it is in theshoe. The orthotic is often targeting the wrong object.

The Myth of “Sensible” HeelsMedical practitioners have long advocated the wearing

of “sensible” shoes and “sensible” heels(1 inch or lower). Both are a myth. ANYshoe with an elevated heel, even a one-inch heel, automatically places the footat a functional disadvantage. The so-called sensible heel is simply less foot-negative than the higher elevations. Butin no instance is it a positive for thefoot. (Fig. 35)

The “sensible” shoe—low, broadheel, round or broad toe, oxford or tiepattern, somber styling—is in thesame genre as the sensible heel. The

common belief that it is a “proper” and foot-friendlyshoe is an illusion. Such shoes have almost all the sameinherent faults of fashion footwear: crooked lasts, con-cave bottoms, toe spring, limited tread surface, etc. Fur-ther, these shoes do not provide better fit even when fit-ted in the so-called “proper” size.

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Conventional archtherapy almost alwaysfocuses on an orthotic to “lift” or “support”

the depressed or strained arch.

Fig. 34: Normal footprint showing large tread area. Right,tread area on average shoe reduced by 60-80 percent as aresult of faulty last design, elevated shoe heel and shank,toe spring, etc.

the prescribing of orthopedic-like“sensible” shoes on two grounds; 1)they offer very little therapeutic ad-vantage over conventional footwear,and 2) most women find them asthreatening and ugly as an angry goril-la and often refuse to wear them. A pa-tient is, after all, a whole person andnot just an object from the anklesdown. Does this mean that consumersare locked in to a hopeless dilemma—the choice of foot-abusive fashionshoes or esthetically ugly footwear(sensible, orthopedic, sneakers, athlet-ic, etc.)? No. Fashion and comfortCAN sleep in the same bed—but onlyif the shoe designers and manufactur-ers learn to adopt the right design en-gineering to bring about the long-eva-sive ideal of genuine comfort withfashion. Unfortunately, podiatric med-icine has been of little or no help inachieving this. If and when it hap-

pens, it will be one of thegreat advances of the 21stcentury.

SummaryA “shoe” cannot be regard-

ed as a mere utilitarian, single-piece unit. It consists of numer-ous separate parts, each or incombination having an enor-mous influence on the foot,both anatomically and func-tionally. Hence to view thiscomplex article as a simple, an-cillary covering for the footmay well be the single mostgrave mistake of the podiatricphysician. With such a perspec-tive both the diagnostic andtherapeutic approaches to footdisorders will fall appreciablyshort of desired results. Much ismade by the podiatric physi-cian about the importance of“proper” size and fit. Yet, nei-ther podiatric medicine nor thefootwear industry itself has everestablished any fact-based stan-dards of “proper fit.” As to shoesizes, they are without stan-dards or uniformity and havebeen in a state of chaos for gen-erations, both at the manufac-turing and store levels (we arestill using shoe sizing “stan-dards” and methods formulat-ed some 625 years ago!)

A shoe, ideally, should bean anatomical and functional

Medical practitioners extol these“sensible” shoes on the premise thatthey provide more “support”. But sup-port of what? And why do the archand instep need corseting? To the con-trary, midfoot corseting denies thefoot its natural exercising function andhence would tend to weaken the tis-sues of the midfoot, By dramatic con-trast, the foot of the shoeless native,which toils for longer hours undermore conditions of duress, is totallywithout any artificial support, yet re-mains strong, healthy and largelytrouble-free.

As every podiatric practitionerknows, most women abhor the veryterm “sensible shoes”,which automati-cally translate into “orthopedic”—meaning anti-feminine, anti-esthetic.The practitioner needs to reevaluate

replica of the foot. And this can beconsidered a biomechanical law: Theless a shoe does TO a foot, the betterFOR the foot. To what degree possible,a shoe should stay out of the foot’sway. In its most elemental form a shoehas only two functions: as a non-in-trusive, protective foot covering, andas an ornamental dressing. The mo-ment a shoe assumes a therapeuticfunction for the average foot, the footis in trouble. Back to the earlier state-ment: the less a shoe does TO a foot,the more it does FOR a foot.

The modern shoe has evolved intoa complex article of engineering—though, unfortunately, much of theengineering has gone awry with manynegative consequences to the foot.Nevertheless, it is this “modern” shoethat the podiatric physician must livewith, contend with. And because it isso intimately involved with a longarray of foot disorders, it is a very seri-ous default of the professional thera-pist to give only superficial study andattention to footwear. This, unfortu-nately, has been the long history.Until the foot/shoe relationship be-comes an intrinsic part of podiatric ed-ucation and practice, podiatric medi-cine itself will remain an unfinishedprofession.

The first law of all science is objec-tivity. But in the important matter ofthe foot/shoe relationship the ap-proach has tended to be much moresubjective than objective. It has tend-ed to greatly oversimplify by assumingthat if the shoe is “sensible” in stylingand heel height, and of “proper” sizeand fit, then presto, the shoe matter isresolved.

Just as man is not an island untohimself, so the foot is not a separateand isolated object. For better orworse, it is married to the shoe. If thepartnership is to be compatible andproductive, each must hold some mea-sure of equality and respect in theirmutual interests. !

Footwear...

138 www.podiatrymgt.comPODIATRY MANAGEMENT • FEBRUARY 2001

The author , ashoe industry con-sultant, has writ-ten eight booksand over 400 arti-cles, includingextensive articleson leather andfootwear in Ency-clopaedia Brittan-ica.

Fig. 35: Top, typical “sensible” shoe and heel forwomen. Bottom, “sensible” round toe resolvesnothing. Faulty last design squeezes toes muchlike pointed-toe shoes.