Hello, this is Neil Baker,
principal podiatrist
from Ipswich Hospital,
United Kingdom.
Today, we're going to spend five or 10 minutes
looking at the basic concepts
of an ideal fitting shoe,
so we are going to examine
what makes a good shoe
and a bad shoe.
The key objectives of this slide set
are to make sure that we understand
that shoes should be fit for purpose
and that they can be both therapeutic,
i.e., to help heal and prevent ulceration
and they can be accommodative
in order to accommodate deformity.
We need to discuss what the criteria
are of a good fitting shoe.
Now, good a fitting shoe
means different things
to different people.
As a professional, a good shoe
has certain criteria for me..
For a patient,
it may be that they look nice.
We need to discuss this concept, too.
Correctly fitting shoes
are only good if they are warm,
so we have a little saying in my clinic
that we have to fit the shoe
to the head not just the foot.
We will explore that concept now.
A very eminent man, Mr. Paul Brand,
Dr. Paul brand once said that,
"The diabetic who complains
that their shoes are killing him,
he's probably right."
If a patient with neuropathy
says their shoes are hurting them,
this is a very big warning sign
and you need to be aware.
Here, you can see
some schematic diagrams
of some feet and some shoes.
On the left-hand side,
we have a shoe that appears
to be fitting the foot well.
The only problem perhaps
is that the end of the big toe
is a little too close
to the end of the shoe.
On the right,
you can see a foot with hammer toes,
a triggered first toe,
and clearly the toe
is not accommodated in the shoe.
Underneath,
you can see that
here are some considerations
for the offloading
facets of footwear,
so a shoe that is offloading
and has a rocker sole,
must have a rigid sole, for example.
It has to be the right depth and width.
The fastening must be correct,
in the right place,
and we can have different variations
on the shape, height, and width of the heel.
We also have to ask ourselves a question,
"Is a shoe better than a boot,
or a boot to better than a shoe?"
This has consequences with, for example,
if somebody's had
some lesser toe amputations
or a forefoot amputation.
Here we have a picture of a therapeutic shoe.
As you can see,
if we go along a clock face
from the right round to the left,
you can see some of the characteristics
that a really good fitting shoe should have.
As you can see,
it's not a sexy shoe,
so patients may not want to wear
this type of footwear.
As you can see,
there are three eyelets,
three holes, four laces,
this is a bare minimum to restrain
the foot from posterior-anterior shear
when the patient walks
because when a patient walks,
their foot will go forward
and the shoe will go back.
We need to be able to hold the shoe
and the foot together.
The width across the forefoot,
as you can see,
it should be wide to accommodate
the widest fitting of the forefoot.
The depth of the toe box,
so that's the dorsal section
that you can see with the little arrow
third one down,
that the toe box there has to be able
to accommodate any lesser toe deformities.
Materials for the upper of the shoe,
these may vary from leather to synthetics
but they should be a breathable material,
so a plastic shoe is not a good idea.
Obviously, we need to think about conditions
in which people work,
so if they are working in areas
where there's a lot of water,
we need to have a shoe
that has a waterproof upper.
We need to think about the height of the heel
and it's construction
with no more than 0.75 inches,
that's probably 1.50 cm.
We need to think about the heel counter.
That's the bit up the section
before it reaches the Achilles Tendon.
Right at the very end as you would see,
the top of the screen
around about eleven o'clock,
the inner lining of the shoe must be seamless.
There should be no seams
on the inside of the shoe,
so that--
looking at that, is an ideal shoe.
Would your patients wear it?
That's the question.
What are the main functions
of diabetic footwear
or correctly fitting footwear?
Clearly, any shoe
should prevent from external trauma.
It should be able to accommodate
the foot with no shoe rubs
particularly at the heel,
around the Achilles tendon,
over the bunion joints, the big toe,
or the lesser toes.
It needs to prevent from accidental damage,
so if a patient has neuropathy
and they're making a cup of tea,
dropped boiling water on their foot,
the shoe should be able to prevent
from the patient being scalded,
so we need to protect
from external accidental damage.
The shoes must also be a mechanism
for holding insoles or inserts
that can help correct deformity,
accommodate
special parts of an insole
in order to prevent ulceration
over pre ulcerated areas.
The shoe, if it's made correctly,
particularly with the heel
and sole mechanism
may be able to alter
what we call the time force interval.
That's the time in which a high pressure area
is on the ground
and bearing weights or a heavy force.
If we are thinking about the shoe correctly,
we can alter those time force,
time pressure intervals.
Hopefully,
a shoe should be able
to prevent and help
compensate for poor foot functions.
Obviously, it's got to be robust.
It's pointless having a shoe
that falls apart after five minutes.
It's got to be able to be worn
in different climatic conditions,
so a shoe in the desert will be different
to that in a paddy field.
We need to consider these things.
It's got to allow
normal everyday activity.
It's also--
and this is an important thing,
it has to be acceptable to the patient.
This is where education
is absolutely paramount.
Of course, too, it has to be affordable,
and it's got to be able to be repaired.
Ideally, it should be adaptable, too,
so if there are any alterations
that needs to be made they can be.
What are the ideal features of the shoe?
As I've said,
we need to think about the length,
the width, the depth,
the shape of the forefoot,
also, the rear foot.
What kind of fastening mechanism is there?
Whereabouts is it?
We need to think about the heel height
and the width of the heel.
The uppers,
again, we've talked about that.
The sole unit,
the lining we've talked about that
with no snitching.
Always pick up somebody's shoes
and feel inside the shoots
especially around the end of the toes.
It must be able to accommodate the foot
as we said previously.
If we look at these shoes,
this is a game called good shoe bad shoe.
What I would like you to do as an audience
is look at these men's shoes
and generally men shoes are much better
than women's shoes with regards
to accommodations in the foot.
Here, on this side,
you can see there are some very good shoes
and there is a bad shoe.
Now, if we look at the shoes, once again,
if we use a clock face,
at the top right hand corner,
we have a shoe which almost mimics the shoe
that you saw previously as an ideal shoe.
As we come down, once again,
this is a shoe that is a very good fitting shoe.
Likely to look at the front of the shoe
and ask yourself whether or not a foot
is a square or a triangle
and then try to accommodate this in that shoe.
If you look at around about seven o'clock,
eight o'clock,
you'll see a shoe which appears to be very nice,
but I've never seen somebody
who's feet turn up at the end,
so maybe that shoe's maybe not quite as good,
and the front of the shoe is very narrow.
The toe box is very, very shallow,
so the patient has to have very thin toes
in order to accommodate the shoe.
The one that the top
around about twelve o'clock
has no fastening mechanism whatsoever,
so it will slide backwards and forwards.
This will allow friction and shear forces
to the dorsum
and the plantar surface of the foot.
These shoes,
there are some good parts of these shoes,
and there's some bad parts of these shoes.
As students looking at this slide,
I'd ask you to just take on board
and think about what are the ideal things
in each of those shoes
each of those shoes
has a good part and a bad part.
Ladies shoes,
if you were to ask me which ones I like,
well, that's six o'clock,
without any doubt.
If you ask me the ones I don't like,
but are the most sensible,
that's probably five o'clock.
Which would the patient want to wear?
Well, you know and I know
which are the ones the patient
will want to wear and which are the ones
that will cause most damage to the foot.
Again, that is very clear.
The idea of this slide here is just to show you
some very different types of women's shoes.
Once again, we have to ask ourselves,
"Why do we wear the type of shoes we do?
How do we reeducate people to wear shoes
that have good features in them,
that would allow them
to protect their feet,
which is what shoes are designed to do?"
There are very few studies
on the role of footwear.
You can see here two papers
or several papers here
that show that when patients
have good fitting shoes,
the ulcer recurrence rates on these
fall right the way down,
but when patients wear their own shoes,
the reulceration rates
increases dramatically.
Once again,
I come back to that concept,
we fit the shoe to the head,
not just the foot.
We've very briefly gone over
and very quickly gone over the shoes.
To review the objectives
of this slide set again,
the shoe needs to be fit for purpose,
it can be therapeutic,
it can be accommodative.
You need to understand
what a good fitting shoe is
and how to explain that to a patient
so that they can understand
what a good shoe is.
It's absolutely useless you knowing
what a good shoe is
if the patient doesn't understand that.
Correct shoes,
once again, as we've said,
are only good if they are worn.
We have to fit the shoes
to the whole person not just the foot.
I want to thank you for listening to this.
Hopefully, you've been able
to think a little bit about shoes
and can help educate your patients
a little more effectively.
Thank you.