The aging foot
ICAA: When it comes to fit, what are the general considerations for older adults?
PM: For footwear to support well, it must fit well. Retailers should fit shoes by slipping them on and lacing them up, instead of just finding requested sizes in the back room. Since feet come in different widths, options for extranarrow and extra-wide footwear should be available.
Problems in the forefoot become commonplace as we age, so wearing shoes that provide sufficient width and length can go a long way in reducing metatarsalgia (or forefoot pain) and preventing toenail trauma. Also, hallux valgus (bunions) are common in seniors, which makes the width and height of toe box important.
Quality control is often a problem. When buying footwear, an individual should examine each shoe carefully. A Brannock device may measure someone as one size, but that doesn’t mean it will be the right size when the person actually tries on the shoe. Sizing varies with the shoe’s country of origin. And one pair of 9B shoes can differ significantly from the next. Either the shoe fits or it doesn’t, and getting it right is paramount.
It’s often difficult to discover the differences between shoe types and separate fashion from function. Knowledgeable retail staff and direction from a physician, physiotherapist or personal trainer can help guide an individual to the right pair.
ICAA: Does this advice apply when shopping for athletic shoes?
PM: This variation in fit shows most obviously in athletic shoes, which are notorious for inconsistent sizing from model to model, and from pair to pair. But athletic shoes shine in their ability to take issue with foot mechanics. Each running shoe model is designed with a specific foot type in mind. Some models are for the very flat or otherwise excessively pronated foot, which requires maximum stability. Others are constructed for the relatively uncommon high rigid arched foot, which requires maximum cushioning and flexibility.
ICAA: What is the most common problem in foot mechanics?
PM: When reviewing the causes or predisposing factors for any number of common foot related ailments, excessive pronation is often front and center. To combat this problem, athletic shoe designers incorporate a number of footcontrol features in their shoes:
Strong plastic heel counters with additional high-density collars;
Firm Hytrel plastic inserts in the medial aspect of the shoe;
Web-like plates in the midfoot area to provide torsional rigidity; and
Wider stable base of support.
This package of features helps to set athletic shoes apart from all other footwear when it comes to managing excessive foot motion. When manufacturers incorporate all these features in one shoe, they label it a motion control shoe.
The term motion control remains the most important footwear concept to understand when recommending shoes to help alleviate any range of problems in active people. Because, as one foot specialist said, “If I could control pronation, I could control the world.”
ICAA: If excessive pronation is the most common problem, what’s the toughest problem in foot mechanics?
PM: The cavus or high rigid arched foot may be the most difficult foot to manage. This foot is so inflexible it cannot properly attenuate shock, so maximum cushioning materials prove useful, i.e. ABSORB, GEL, AIR and HYDROFLOW. As well, a shoe with increased heel height, such as a road running shoe, with a curved last and increased overall flexibility is ideal.
ICAA: What do you see as the biggest challenge in recommending footwear for older adults?
PM: Just getting the 50-plus crowd into an athletic shoe. While the comfort and support benefits of athletic shoes are obvious, the look and often non-water resistant upper act as significant hurdles for many older people. Some manufacturers try to solve the problem by marketing a walking shoe. These models often look more appealing, but they usually don’t compare to a running shoe in support, fit or cushioning.
ICAA: Where else can older adults turn for appropriate footwear?
PM: Many individuals look toorthopedic shoes for the answer. But fashion and function take a back seat here.
First, orthopedic shoes look like old people shoes—always have, but we hope always won’t. I find the design perplexing. Both older and younger adults don’t want to look like old people, so who would want to wear these shoes? Second, motion control is nonexistent in the orthopedic category, which leaves these shoes sorely lacking technically, too.
Shoemakers have yet to figure out how to incorporate motion control into a nonathletic shoe. Until they do, we will have to rely on orthopedic footwear to accommodate the significantly problematic foot and on running shoes for those who need maximum support and pronation control.
ICAA: When would you recommend orthopedic shoes?
PM: Orthopedic shoes do an admirable job for those individuals who need extra depth and seamless uppers in their footwear. Plastazote linings and deerskinor lycra uppers, combined with deep toe boxes and technical footbeds, get many people moving who would otherwise remain completely sedentary.
ICAA: Do orthopedic shoes hold any dangers for seniors?
PM: Although orthopedic shoes are accomodative, their design remains archaic. For instance, their outer soles are often slippery and relatively devoid of any tread pattern. While the smooth bottom may be good for people who shuffle when they walk and trip easily in a thick-soled shoe, they present the danger and liability of slipping in wet conditions. For an older adult, a fall may be worse than the original foot problem.
Until there is a meeting of the minds, orthopedic shoes will remain accommodative and old, rather than proactively supportive and progressive.
ICAA: How does the foot change as we grow older?
PM: The older adult foot differs from the middle-aged and adolescent foot in many way? For instance, the skin surrounding the foot thins with age. Active seniors require shoes with more padding and socks that wick moisture to cut down on blistering. Physical changes to the feet also occur.
JT: Arthritis in the great toe (hallux rigidus limitus) is common and reduces many seniors to a shuffle. A stiffer shoe sole will reduce painful dorsiflexion of the first MTP joint. The addition of a rocker bar can help many. Also, an orthotic with pronation control and extension under the first ray can often help the problem. Shoes must accommodate the orthotic with extra depth. Hammer and claw toes are likewise common, and can be accommodated with shoes with extrawidth in the toe box and soft insoles with claw bars added.
PM: Manufacturers generally design footwear to be flexible in the forefoot, so stiffness at the metatarsals is hard to find. A shoe can be made stiffer with the use of a graphite spring plate, either lodged in the midsole or placed under the insole (making it transferable from shoe to shoe). The plate takes up width when placed under the insole, so the shoe must have enough depth to accommodate the foot well.
JT: Painful metatarsalgia with a flat metatarsal arch and thinning atrophic skin can be helped with an accommodative orthotic and properly placed metatarsal pads to unload the sensitive MT heads. Likewise, hallux valgus (bunions) can be improved with an orthotic and shoe with width in the forefoot.
ICAA: What about the impact of osteoporosis?
JT: Many active aging female feet may suffer from osteoporosis. Shock absorption within the shoe and additional cushioning in the insole can prevent painful stress fractures in the calcaneus or metatarsalgia, along with 1,500mg of calcium and 400-500 IU of vitamin D in the diet.
PM: Where the need exists for maximum cushioning, mature adults can look to athletic shoes, especially road running shoes.
ICAA: What issues do you see in the active aging foot?
JT: The aging athlete’s foot loses strength and flexibility in the plantar fascia and Achilles tendon. People will discover that good shoes with additional arch support, heel control and additional heel lifts become as important as the strength and flexibility exercises outlined by their physician, physiotherapist or podiatrist.
PM: Keep in mind that most manufacturers do not put a great deal of longitudinal arch support in the shoe. Years ago, an arch cookie used to be glued into that area—it felt like a hardboiled egg, but served a supportive purpose. Today, the only way to get good support for either the long or metatarsal arches may be to replace the footbed with an off-the-shelf arch support. Some athletic shoes have a midsole buildup, called an external arch support, which is part of the motion control system.
JT: Weakness of the tibialis posterior muscle-tendon complex occurs with aging. This weakness leads to increasing pronation and medial ankle and midfoot pain. Motion control shoes, orthotics and ankle bracing can help this disabling problem.
ICAA: What special considerations exist for people with diabetes?
PM: The diabetic foot is problematic in many ways. An individual’s choice of footwear can critically influence the diabetic foot. The footwear must be smooth on the inside and can even be lined with moldable, nonabrasive materials, such as plastazote (as in the Ambulator shoes). The person’s foot must also be checked regularly, due to reduced sensitivity. Forefoot pain or metatarsalgia is common, so it’s important to limit forefoot flexibility.
TK: Persons with diabetes (PWD) may pose a difficult challenge for the shoe fitter. The single most important shoe feature for PWD is a professional fit. To achieve a professional fit, the fitter must have a basic understanding of the effect of diabetes on the feet.
There are four main risk factors for diabetes-related foot complications:
Prior history of problems;
Peripheral vascular disease (loss of circulation);
Peripheral neuropathy (loss of feeling); and
Foot deformity (hammer toes, bunions, calluses, limitation of motion, etc.).
The greater the number of risk factors, the greater the chance for problems.
An individual deemed at high risk has far more shoe gear considerations than someone without risk factors. Before fitting or recommending a shoe for someone with diabetes, the fitter would be wise to ask the individual whether he or she has loss of feeling or circulation in the feet, foot deformity or any history of diabetes-related foot troubles.
ICAA: What creates the greatest risk for foot troubles in PWD?
TK: Peripheral neuropathy, or loss of feeling. The nerves to the feet are like the sensors of a burglar alarm. If there is an intrusion, the sensors on a house alarm send a noise signal, while the sensors or nerves on a foot alarm send a pain signal. As we cannot see our feet inside our shoes, our nerves or sensors protect our feet by sending a pain alert if something rubs. The pain signals us to remove our shoes and inspect our feet.
When individuals with diabetes lose this pain alarm (peripheral neuropathy), they can incur serious damage to their feet. This damage could go undetected until a serious injury has occurred. The extent of feeling loss can be so severe that it’s not uncommon for PWD who have bad neuropathy to talk about losing their keys in their shoes and not finding them until they remove their shoes at the end of the day.
Typically, individuals with feeling loss like to buy shoes that are too small, because they can feel the shoe. When fitted properly, these people commonly complain their shoes are too big. Shoe gear for people with neuropathy or feeling loss is safety equipment for the feet, much like a helmet protects the head.
Deformity is another important consideration, especially when someone also suffers from feeling loss.
Deformed areas are prone to rubbing. For instance, a hammer toe may rub on the seam of a shoe. Extra depth shoes without seams and a soft upper is vitally important for a person with loss of feeling and deformity. Unfortunately, the shoe industry does not seem to have standards regarding depth, and what one manufacturer regards as extra depth may not be extra depth to another. High volume is a betterterm, as it cannot be misinterpreted.
Limited joint mobility is an equally important type of deformity—one that is often overlooked. For instance, a stiff great toe joint can result in increased pressure underneath the toe and/or weight transfer to the lesser metatarsal bones. In the presence of feeling loss, the increased pressure and/or weight transfer can cause sores or ulcers. To control the abnormal forces in an individual with a stiff great toe, a shoe should have a stiff sole to minimize the amount of great toe joint motion required during the propulsive phase of gait. Sometimes the shoe needs to be modified with an internal plastic plate to increase the stiffness or decrease the flex.
ICAA: What footwear would you recommend for PWD?
TK: When it comes to selecting shoes for a person with diabetes, the first and foremost consideration is a professional fit.
PM: Shoes with seamless toe boxes are generally preferred, and often supplemented by uppers made of heat moldable material or deerskin, as with orthopedic shoes. Running shoes have more seams than would be considered ideal, but the relatively stretchy mesh is often accommodative. All orthopedic shoes come in widths. It’s important that a person’s foot does not spill over the side, especially with overweight individuals.
TK: People who have diabetes and feeling loss often require cushioned protective orthotics to protect the feet. Orthotics must be factored into shoe selection and fit. Other important factors include sole width and stability.
When loss of balance accompanies feeling loss, shoes with low profile soles and a wide and stable heel can help—although sometimes heels need to be flared for further support. The actual sole is also a consideration, especially in wet climates. Many therapeutic shoes have slippery soles, which are especially risky for people with feeling and balance loss. Sole grip and width need to be checked carefully.
PM: For obvious reasons, athletic shoes offer good gripping outersoles, while orthopedic footwear are often slippery. The PW Minor shoes use a grade of urethane and an outersole design that represents a nice compromise between mobility and grip.
The choice of footwear for any active person is important. As the 50-plus population grows, so will the problems related to the foot and foot mechanics. We can only hope the selection of shoes that take issue with the specific needs of this active demographic also grows.