0198-0211/92/1305-0257$03.00/0 FOOT & ANKLE Copyright © 1992 by the American Orthopaedic Foot Society, Inc.
The Art and Science of Fitting Shoes Dennis J. Janisse, C.Ped. A4Hwaukee. VVmconsin
ABSTRACT
likely, it was some type of sandal consisting of nothing more than a protective material between the foot and ground held onto the foot by means of rawhide thongs. Footwear development occurred when upper material was added around the heel and, later, to the forepart of the sandal, prOViding additional protection to the foot and, in the process, evolving into a shoe. It was not until the 14th century that uniform standards regarding the sizes of shoes were developed. Edward II decreed that three barley corns taken from the center of an ear and placed end to end would equal 1 in, and that 39 barley corns placed end to end would be equal to the largest normal foot. Since this equaled 13 in, it was designated as size 13, and other sizes were graded down, with each size differing by one barley corn or one third of an inch. Surprisingly, this system of measurement is still used today. It is also
The two primary components of achieving proper shoe fit are shoe shape and shoe size. Shoe shape refers to the shape of both the sole and the upper. Proper fit is achieved when shoe shape is matched to foot shape. Shoe size is determined by arch length rather than overall foot length. The proper shoe size is the one that accommodates the first metatarsal joint in the widest part of the shoe. A set of seven guidelines for achieving proper shoe fit is offered. Properly fitting shoes are important in avoiding foot discomfort and deformity, and are absolutely essential in patients with arthritis, diabetes, and other foot disorders.
INTRODUCTION
It is generally believed that the first type of foot covering was worn by our caveman ancestors.t" Most
Fig. 1 Both of these lasts are size 8. but would produce shoes with dramatically different shapes.
dress reprint requests to: Dennis J. Janisse, C.Ped., Pedorthic Center, Inc., 7283 W. Appleton Ave., Milwaukee. Wisconsin 53216.
Board-Certified Pedorthist, President Elect, Prescription Footwear Association (PFA), and President, PFA Research Foundation. Ad257
258
JANISSE
Foot & Ankle/Vol. 13, No. 5/June 1992
TOP LINE
OUTSOLE Fig. 3. Parts of a shoe.
Fig. 2. These size 6V2A insole patterns have a variety of shapes.
interesting to note that during King Edward's time, and up until the 18th century, shoes were symmetrically shaped and, therefore, could be worn on either foot. In fact, people were able to extend the life of their shoes by changing them from one foot to the other, much like rotating the tires on a car. SHOE SHAPE
It was quite impossible to achieve a very accurate fit when shoes were made to fit on either foot; this is because shoe shape is a key factor in shoe fit. Proper shoe fit is attained when shoe shape is matched to foot shape.t" The shape of a shoe, including the shape of both the sole and the upper, is dependent primarily upon the last, or the mold over which the shoe is made. Lasts are made in an unlimited variety of shapes and sizes, but the particular last used for a given shoe is determined solely by the rnanutacturer.F":" Figure 1 shows two size 8 lasts with dramatically different shapes. The standard last is used for most popularly priced, mass-produced shoes. It comes in limited sizes and often only in a single "medium" width. Orthopaedic
lasts, on the other hand, are made not only in a wide range of sizes and Widths, but in many shapes.' The insole patterns in Figure 2 are all a size 6V2A, but have a variety of shapes. The combination last, which is used in some massproduced shoes, is the primary orthopaedic last and has a heel that is narrower than the forefoot, providing room for the metatarsals and toes while maintaining a good heel fit. For example, a typical B width shoe made on a combination last might have a AAA heel. Additional orthopaedic last shapes include: inflare, outflare, shorttoed, and long-toed. 1 ,2,7 It is important to remember that shoe fit is affected not only by the shape of the sole, but by the shape of the upper as well. Most orthopaedic shoes are made from an in-depth type last, which results in a shoe whose upper is shaped to allow extra volume for the foot inside the shoe, and provides enough room for a generic insole or a custom insert. Specific parts of the shoe upper also affect shoe fit. Terms useful in describing the shoe upper are: (1) toe box, the part of the shoe that covers the toe area; (2) vamp, the part that covers the instep; and (3) counter, the part behind the heel. These are illustrated in Figure 3, along with other important parts of a shoe. The counter controls the heel and is important to heel fit. Many orthopaedic and in-depth last shoes have extended medial counters to help support the medial arch. A shoe that has a high toe box and a rounded toe provides the best fit by allowing the toes to fit comfortably inside the shoe. A shoe with a tapered toe box and a pointed toe applies pressure to the toes and forces them into an unnatural shape, causing calluses
FITTING SHOES
Foot & Ankie/Vol. 13, No. 5/June 1992
259
Fig. 4. A, The person in this x-ray is wearing a shoe with a tapered toe box and a pointed toe. Notice how the metatarsals and phalanges are crowded. B, Here the same person is wearing a shoe that conforms to the shape of the foot, eliminating the crowding seen in Figure 4A.
and discomfort and eventually leading to deformity. 3-5 The x-ray in Figure 4A shows the effect caused by a shoe with a tapered toe box and a pointed toe. In Figure 4B, the same foot is shown wearing a shoe of the proper shape. Little or no pressure is applied to the foot. As with the toe box, the vamp should be high enough to prevent pressure on the instep. In addition, a shoe with laces generally provides the best fit, because the laces allow adjustability and because the shoe can be fit properly without any danger of it slipping off. s Pumps and slip-ons often have virtually no vamp, so they must be fitted too snugly or they will fall off. Of the two types of throat openings, the balmoral and the blucher, it is the blucher that allows for both greater adjustability and easier entry (Fig. 5).4.6 SHOE SIZE
Once the properly shaped shoe has been found, the next step in fitting shoes is to determine the proper size. The Brannock measuring device is probably the most complete device for determining shoe size (Fig. 6). It measures overall foot length (heel to toe length), arch length (heel to arch or first metatarsal), and width. The proper shoe size is the one that accommodates
the first metatarsophalangeal joint in the widest part of the shoe; it is for this reason that shoes must be fit by arch length rather than by overall foot length. 6 The feet in Figure 7 have the same overall foot length, but require different size shoes because of the difference in arch length. ACHIEVING PROPER FIT
Determining the correct shoe shape and the right size is the primary component in achieving proper shoe fit. In addition, a properly fitting shoe should have three eights to half an inch of toe room between the end of the shoe and the longest toe, and may allow some movement of the heel in the counter since the foot will stretch during gait. 3 .6 As a summary of the information presented in this paper, the following guidelines can be established. Guidelines for Attaining Proper Shoe Fit
1. Measure both feet with an appropriate measuring device. 2. Fit shoes on both feet while weightbearing. 3. Check for the proper position of the first metatarsal joint. It should be in the widest part of the shoe.
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Foot & AnklejVol. 13, No. 5/June 1992
BLUCHER
Fig. 5 The blucher and balmoral throat openings.
BALMORAL
4. Check for the correct toe length. Allow three eights to half an inch between the end of the shoe and the longest toe. 5. The shoe must be of the proper width, allowing adequate room across the ball of the foot. 6. There should be a snug fit around the heel. 7. Proper fit over the instep is achieved by an appropriately high vamp, preferably with laces to allow adjustability. Figure 8A shows a foot that has been incorrectly fit. The toes are cramped and twisted, the longest toe is hitting the end of the shoe, and the arch of the foot does not fit into the arch of the shoe. The foot in Figure 88 is properly fit. There is ample toe room, and the foot is receiving the proper support in the arch of the shoe. A simple way to determine the fit of a patient's shoes is by performing the forefoot test. First, trace around the patient's feet while weightbearing, and then place his or her shoes on top of the tracing; this gives a graphic demonstration of properly or poorly fitting shoes.
CONCLUSION
It is my hope that this paper can provide physicians with a basic understanding of proper shoe fit, so that they will be able to effectively evaluate their patients' footwear. Properly fitting shoes are essential in avoiding foot problems, yet most people, particularly women, wear poorly fitting shoes. A study by the AOFAS Women's Footwear Comrnlttee'' of 356 women aged 20 to 60 years with no history of diabetes, rheumatoid arthritis, foot trauma, or foot surgery found that 88% wore improperly fitting shoes. As a result, 76% of the women had one or more forefoot deformities. Clearly, information concerning proper shoe fit needs to reach the consumers as well. It is also my hope that physicians will work in conjunction with a board-certified pedorthist when treating patients with arthritis, diabetes, or other foot disorders. Prescription footwear is often necessary for these patients and can be an integral part of an effective treatment program. The board-certified pedorthist can pro-
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Foot & AnklejVol. 13, No. 5/June 1992
261
Fig. 6 The Brannock measuring device. To determine overall foot length, read the number in front of the longest toe. To determine arch length, slide the arch length indicator to the first metatarsal joint, and read the number to which the indicator points. For this foot, both overall foot length and arch length are size 9.
A
Fig. 7. These feet have the same overall length, but require different size shoes because of the difference in arch length.
Fig. 8. A, This foot has been incorrectly fit. B, This foot is properly fit.
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JANISSE
vide the necessary prescription footwear and has the knowledge and expertise to ensure a proper fit.
REFERENCES 1. Edwards, C.A.: Clinical Conditions Requiring Orthopedic Footgear. Muncie, IN, Ball State University, 1985. 2. Edwards, C.A.: A Manual of Orthopedic Shoe Technology. Muncie, IN, Precision Printing, 1981. 3. Frey, C., Thompson, F., Smith, J., Sanders, M., Abda, S., and Horstmann, H.: AOFAS Women's Footwear Committee Study. Paper presented at AOFAS meeting, Anaheim, 1991.
Foot & Ankle/Vol. 13, No. 5/June 1992 4. Gould, N.: Shoes and shoe modification. In Disorders of the Foot and Ankle, Vol. III. Jahss, M.H. (ed.), Philadelphia, W.B. Saunders, 1991, pp. 2879-2910. 5. Hack, M.: Fitting Shoes. Washington, DC, American Diabetes Association, 1989. 6. Rossi, W. A., and Tennant, R.: Professional Shoe Fitting. New York, National Shoe Retailers Association, 1984. 7. Steele, R.: History of shoe making. In A Manual for Proprietors, Managers, and Assistants of Stores Dealing in Functional and Prescription Footwear. Edwards, C.A. (ed.), Muncie, IN, Ball State University, 1981, pp. 1c-76c.
The Art and Science of Fitting Shoes Dennis J. Janisse, C.Ped. A4Hwaukee. VVmconsin
ABSTRACT
likely, it was some type of sandal consisting of nothing more than a protective material between the foot and ground held onto the foot by means of rawhide thongs. Footwear development occurred when upper material was added around the heel and, later, to the forepart of the sandal, prOViding additional protection to the foot and, in the process, evolving into a shoe. It was not until the 14th century that uniform standards regarding the sizes of shoes were developed. Edward II decreed that three barley corns taken from the center of an ear and placed end to end would equal 1 in, and that 39 barley corns placed end to end would be equal to the largest normal foot. Since this equaled 13 in, it was designated as size 13, and other sizes were graded down, with each size differing by one barley corn or one third of an inch. Surprisingly, this system of measurement is still used today. It is also
The two primary components of achieving proper shoe fit are shoe shape and shoe size. Shoe shape refers to the shape of both the sole and the upper. Proper fit is achieved when shoe shape is matched to foot shape. Shoe size is determined by arch length rather than overall foot length. The proper shoe size is the one that accommodates the first metatarsal joint in the widest part of the shoe. A set of seven guidelines for achieving proper shoe fit is offered. Properly fitting shoes are important in avoiding foot discomfort and deformity, and are absolutely essential in patients with arthritis, diabetes, and other foot disorders.
INTRODUCTION
It is generally believed that the first type of foot covering was worn by our caveman ancestors.t" Most
Fig. 1 Both of these lasts are size 8. but would produce shoes with dramatically different shapes.
dress reprint requests to: Dennis J. Janisse, C.Ped., Pedorthic Center, Inc., 7283 W. Appleton Ave., Milwaukee. Wisconsin 53216.
Board-Certified Pedorthist, President Elect, Prescription Footwear Association (PFA), and President, PFA Research Foundation. Ad257
258
JANISSE
Foot & Ankle/Vol. 13, No. 5/June 1992
TOP LINE
OUTSOLE Fig. 3. Parts of a shoe.
Fig. 2. These size 6V2A insole patterns have a variety of shapes.
interesting to note that during King Edward's time, and up until the 18th century, shoes were symmetrically shaped and, therefore, could be worn on either foot. In fact, people were able to extend the life of their shoes by changing them from one foot to the other, much like rotating the tires on a car. SHOE SHAPE
It was quite impossible to achieve a very accurate fit when shoes were made to fit on either foot; this is because shoe shape is a key factor in shoe fit. Proper shoe fit is attained when shoe shape is matched to foot shape.t" The shape of a shoe, including the shape of both the sole and the upper, is dependent primarily upon the last, or the mold over which the shoe is made. Lasts are made in an unlimited variety of shapes and sizes, but the particular last used for a given shoe is determined solely by the rnanutacturer.F":" Figure 1 shows two size 8 lasts with dramatically different shapes. The standard last is used for most popularly priced, mass-produced shoes. It comes in limited sizes and often only in a single "medium" width. Orthopaedic
lasts, on the other hand, are made not only in a wide range of sizes and Widths, but in many shapes.' The insole patterns in Figure 2 are all a size 6V2A, but have a variety of shapes. The combination last, which is used in some massproduced shoes, is the primary orthopaedic last and has a heel that is narrower than the forefoot, providing room for the metatarsals and toes while maintaining a good heel fit. For example, a typical B width shoe made on a combination last might have a AAA heel. Additional orthopaedic last shapes include: inflare, outflare, shorttoed, and long-toed. 1 ,2,7 It is important to remember that shoe fit is affected not only by the shape of the sole, but by the shape of the upper as well. Most orthopaedic shoes are made from an in-depth type last, which results in a shoe whose upper is shaped to allow extra volume for the foot inside the shoe, and provides enough room for a generic insole or a custom insert. Specific parts of the shoe upper also affect shoe fit. Terms useful in describing the shoe upper are: (1) toe box, the part of the shoe that covers the toe area; (2) vamp, the part that covers the instep; and (3) counter, the part behind the heel. These are illustrated in Figure 3, along with other important parts of a shoe. The counter controls the heel and is important to heel fit. Many orthopaedic and in-depth last shoes have extended medial counters to help support the medial arch. A shoe that has a high toe box and a rounded toe provides the best fit by allowing the toes to fit comfortably inside the shoe. A shoe with a tapered toe box and a pointed toe applies pressure to the toes and forces them into an unnatural shape, causing calluses
FITTING SHOES
Foot & Ankie/Vol. 13, No. 5/June 1992
259
Fig. 4. A, The person in this x-ray is wearing a shoe with a tapered toe box and a pointed toe. Notice how the metatarsals and phalanges are crowded. B, Here the same person is wearing a shoe that conforms to the shape of the foot, eliminating the crowding seen in Figure 4A.
and discomfort and eventually leading to deformity. 3-5 The x-ray in Figure 4A shows the effect caused by a shoe with a tapered toe box and a pointed toe. In Figure 4B, the same foot is shown wearing a shoe of the proper shape. Little or no pressure is applied to the foot. As with the toe box, the vamp should be high enough to prevent pressure on the instep. In addition, a shoe with laces generally provides the best fit, because the laces allow adjustability and because the shoe can be fit properly without any danger of it slipping off. s Pumps and slip-ons often have virtually no vamp, so they must be fitted too snugly or they will fall off. Of the two types of throat openings, the balmoral and the blucher, it is the blucher that allows for both greater adjustability and easier entry (Fig. 5).4.6 SHOE SIZE
Once the properly shaped shoe has been found, the next step in fitting shoes is to determine the proper size. The Brannock measuring device is probably the most complete device for determining shoe size (Fig. 6). It measures overall foot length (heel to toe length), arch length (heel to arch or first metatarsal), and width. The proper shoe size is the one that accommodates
the first metatarsophalangeal joint in the widest part of the shoe; it is for this reason that shoes must be fit by arch length rather than by overall foot length. 6 The feet in Figure 7 have the same overall foot length, but require different size shoes because of the difference in arch length. ACHIEVING PROPER FIT
Determining the correct shoe shape and the right size is the primary component in achieving proper shoe fit. In addition, a properly fitting shoe should have three eights to half an inch of toe room between the end of the shoe and the longest toe, and may allow some movement of the heel in the counter since the foot will stretch during gait. 3 .6 As a summary of the information presented in this paper, the following guidelines can be established. Guidelines for Attaining Proper Shoe Fit
1. Measure both feet with an appropriate measuring device. 2. Fit shoes on both feet while weightbearing. 3. Check for the proper position of the first metatarsal joint. It should be in the widest part of the shoe.
260
JANISSE
Foot & AnklejVol. 13, No. 5/June 1992
BLUCHER
Fig. 5 The blucher and balmoral throat openings.
BALMORAL
4. Check for the correct toe length. Allow three eights to half an inch between the end of the shoe and the longest toe. 5. The shoe must be of the proper width, allowing adequate room across the ball of the foot. 6. There should be a snug fit around the heel. 7. Proper fit over the instep is achieved by an appropriately high vamp, preferably with laces to allow adjustability. Figure 8A shows a foot that has been incorrectly fit. The toes are cramped and twisted, the longest toe is hitting the end of the shoe, and the arch of the foot does not fit into the arch of the shoe. The foot in Figure 88 is properly fit. There is ample toe room, and the foot is receiving the proper support in the arch of the shoe. A simple way to determine the fit of a patient's shoes is by performing the forefoot test. First, trace around the patient's feet while weightbearing, and then place his or her shoes on top of the tracing; this gives a graphic demonstration of properly or poorly fitting shoes.
CONCLUSION
It is my hope that this paper can provide physicians with a basic understanding of proper shoe fit, so that they will be able to effectively evaluate their patients' footwear. Properly fitting shoes are essential in avoiding foot problems, yet most people, particularly women, wear poorly fitting shoes. A study by the AOFAS Women's Footwear Comrnlttee'' of 356 women aged 20 to 60 years with no history of diabetes, rheumatoid arthritis, foot trauma, or foot surgery found that 88% wore improperly fitting shoes. As a result, 76% of the women had one or more forefoot deformities. Clearly, information concerning proper shoe fit needs to reach the consumers as well. It is also my hope that physicians will work in conjunction with a board-certified pedorthist when treating patients with arthritis, diabetes, or other foot disorders. Prescription footwear is often necessary for these patients and can be an integral part of an effective treatment program. The board-certified pedorthist can pro-
FiniNG SHOES
Foot & AnklejVol. 13, No. 5/June 1992
261
Fig. 6 The Brannock measuring device. To determine overall foot length, read the number in front of the longest toe. To determine arch length, slide the arch length indicator to the first metatarsal joint, and read the number to which the indicator points. For this foot, both overall foot length and arch length are size 9.
A
Fig. 7. These feet have the same overall length, but require different size shoes because of the difference in arch length.
Fig. 8. A, This foot has been incorrectly fit. B, This foot is properly fit.
262
JANISSE
vide the necessary prescription footwear and has the knowledge and expertise to ensure a proper fit.
REFERENCES 1. Edwards, C.A.: Clinical Conditions Requiring Orthopedic Footgear. Muncie, IN, Ball State University, 1985. 2. Edwards, C.A.: A Manual of Orthopedic Shoe Technology. Muncie, IN, Precision Printing, 1981. 3. Frey, C., Thompson, F., Smith, J., Sanders, M., Abda, S., and Horstmann, H.: AOFAS Women's Footwear Committee Study. Paper presented at AOFAS meeting, Anaheim, 1991.
Foot & Ankle/Vol. 13, No. 5/June 1992 4. Gould, N.: Shoes and shoe modification. In Disorders of the Foot and Ankle, Vol. III. Jahss, M.H. (ed.), Philadelphia, W.B. Saunders, 1991, pp. 2879-2910. 5. Hack, M.: Fitting Shoes. Washington, DC, American Diabetes Association, 1989. 6. Rossi, W. A., and Tennant, R.: Professional Shoe Fitting. New York, National Shoe Retailers Association, 1984. 7. Steele, R.: History of shoe making. In A Manual for Proprietors, Managers, and Assistants of Stores Dealing in Functional and Prescription Footwear. Edwards, C.A. (ed.), Muncie, IN, Ball State University, 1981, pp. 1c-76c.
