This study looked at the relationship between shoes purchased by a group of women receiving regular podiatry treatment and the presenting pathology, particularly whether shoes have an association with foot pathology and what choices determined the purchase decision. This group of participants, from a small locality of Cambridge UK, had independently sought podiatry treatment, as the presenting foot pain was perceived as requiring intervention.
The clinical presentations of foot pathology indicated a significantly higher incidence of HAV in the older group who were also more likely to have corns. It is known that morphological and physiological changes occur over time with bony and soft tissue changes occurring from natural ageing and prolonged mechanical strain [26]. The forefoot is reported to be wider with a greater depth in older adults and footwear that is not wide enough contributes to foot pathology [12]. However, in this study the older group had longer and narrower feet than the younger participants and did not consider having a foot measurement taken or change in footwear size when purchasing shoes. Therefore, any age-related changes that had occurred over time were not accounted for or considered by this group. This resulted in the shoe size worn to clinic being significantly narrower than the younger group with the shoe not fitting correctly to the measured size. There was no difference in width measurement from shoe or barefoot causing a tight fit of shoe. This could have led to an increase in incidence of ill-fitting footwear which is associated with the significantly higher incidence of corns formation. Further exploration of participants reasoning around these choices is warranted to investigate in greater detail the emotional behaviour associated with wearing footwear that doesn’t fit.
It is not uncommon for people to wear the wrong size of shoe; 60% of participants within both age groups from this study had a difference of more than 0.5 shoe size between right and left foot [27] with estimates of 86% wearing shoes that were narrower than their feet [20]. It is interesting to note that, in both groups, the shoes participants chose to wear to the clinic appointment were not worn for any more than 4 times a week and a variety of footwear styles were selected throughout the rest of the week. Branthwaite et al., (2012) indicated that the primary reason for footwear choice was the activity being undertaken and therefore the shoes, particularly the slip-on shoes, worn to clinic could have been selected for ease of removal in the clinic in preparation for the treatment. This is useful for clinicians completing a footwear assessment, as the results from this study suggest that footwear worn to clinic is often not the most used shoe and a thorough review of all shoes worn by an individual should be undertaken to give the most accurate and realistic advice about footwear choices. Exploring factors like footwear choice and other footwear styles worn will possibly help to reduce barriers between clinician and patient improving overall foot health and education [28].
Between the two age groups defined, there was no significant difference in the choice of footwear purchased over a 6-month period prior to data collection. However, slip on shoes were selected more frequently in the older age Group B than the younger Group A and sandals were a frequent choice for both groups but more so in the younger group. These results substantiate the findings of other research papers where the most common shoes worn by the elderly during the day were open toed shoes, slip on, sandals or slippers [24, 29]. These choices could be related to the climate and other environmental factors as the current study was conducted over the summer months and the previous referenced work was in the southern hemisphere, which may favour these types of footwear. Further work on the impact of seasonal footwear choice and foot pain will extend the understanding of the association between fit and styling of the shoes and presenting problems. This seasonal restriction needs to be considered when reviewing the results. However, slip on shoes could also be favoured by the older group over the younger participants as they are easier to put on and take off without the consideration for a fastening. Similarly, the locality of this single centre sample of participants could limit the generalisability of the observations made.
Although the heel height of a shoe is often suggested as a causative factor for HAV formation, with increases observed in forefoot plantar pressure and altered first ray function [12, 17, 30, 31], the results of the current study provide substantial evidence that age appears to be more important than previously thought in the formation of this joint deformity. However, it was not clear as to why participants with HAV chose to wear shoes that were smaller than the foot. There was a strong association between purchasing shoes and feel good factor, yet further exploration around the emotions around wearing smaller shoes was not investigated. Body image and a quest to hide deformity by choosing to wear normal fashion shoes could be responsible for this selection, as it is widely reported that orthopaedic shoes are deemed as ugly and often not worn [22].
A width difference of − 0.6 mm between the width of the foot and the shoe is significant to make a change in the comfort of the shoe. A comfortable good value shoe was considered important to make participants feel good and happy about themselves. Whilst it is commonly argued that a shoe is most comfortable when it mimics the shape of the wearers foot [32], the geometry of the forefoot which matches the shape of the toe box could be a critical factor in this opinion of comfort. However, often a shoe wide enough to fit the forefoot is not found in 66% of people [33] leading to the observed mismatch in footwear choice and foot dimension. This constraint and drawback with current footwear styling is stagnant and there is a clear need for improved understanding with possibilities for radical new last designs or innovative manufacturing of accommodative footwear uppers. With advances in technology relating to foot assessment and manufacturing techniques mass customisation of footwear is plausible. In addition, the development of 3D printing techniques makes it easy to provide patient specific footwear solution for effective clinical management. There were observed differences in the purchase decisions of these footwear between the two age groups. The younger group, when buying activity shoes, reported comfort, fit and support being the most important factors. This is similar to the previous work that suggested comfort and activity were the most significant factors that influence footwear purchases [16]. This was not observed in the older group who preferred a slip-on shoe with more fashionable factors of heel shape colour fit and comfort. This is suggestive that as women age, their body image is still of significant importance. This image is thought to play an important role in selection of fashion items regardless of age and disability [22].
To improve the level of compliance from a patient to clinical footwear advice a greater emphasis should be made on image and style of suggested footwear. Clinicians should be guided by patient’s choices and work to a realistic ideal to improve the success of footwear fit across all age groups. Individual discussions around patient choice and reasoning around footwear selection could improve understanding and influence behaviour of patients [28]. Individual education of the choices made and how that influences foot pain and pathology could improve the foot health of patients as well as influence fashion and image.
