How Shoe Choices For Children Can Affect Foot Development

“I only buy the best shoes I can find.”

“I paid $150 for these!”

“All of the nurses and doctors wear this brand.”

“I change my shoes every three months.”

“I consulted with my local running shoe store before buying these.”

“I know I have the right shoe for my arch.”

I am sure many of you have heard these same comments and probably continually do on a daily basis. So what is the best shoe? Should this even be a question? In our society, we too often place our focus on finding a quick fix. In regards to foot injuries, that quick fix happens to be shoes. In reality, it might not actually be the solution.

Rather than beginning this discussion with what adults wear, let us take a look at what the literature advises on footwear for children. The American Academy of Pediatrics does not advise placing children into shoes until the environment necessitates it.1 When you review the pediatric orthopedic literature on shoe gear, it is also clear that children should be wearing shoes that are flexible and allow the foot to bend and move as though the child is barefoot.2-6 In his 1991 article in Pediatrics, Lynn Staheli, MD, makes the following comments.7

1. Optimum foot development occurs in the barefoot environment.
2. The primary role of shoes is to protect the foot from injury and infection.
3. Stiff and compressive footwear may cause deformity, weakness and loss of mobility.
4. The term "corrective shoes" is a misnomer.
5. Shock absorption, load distribution and elevation are valid indications for shoe modifications.
6. Base shoe selection for children on the barefoot model.
7. Physicians should avoid and discourage the commercialization and “media”-ization of footwear. Merchandising of the “corrective shoe” is harmful to the child, expensive for the family and a discredit to the medical profession.

Rao and Joseph demonstrated a higher prevalence of flat feet among children who wore shoes in comparison with those who did not.2 They found that closed toe shoes inhibited the development of the arch of the foot more than slippers or sandals. Rose advises not to address a flexible flatfoot in a child even with the use of custom orthotics, stating that treatment is not influential in the course of the flatfoot as the child ages.3

It becomes apparent even when looking at a child's foot that flatfoot deformities are more of a variant than a true pathology.

The question remains as to what truly happens to an adult’s foot if he or she continues to wear non-supportive shoes through childhood and into adolescence. Will the adult foot maintain the wider forefoot and more evenly spaced digits from childhood?

References

1. Hoekelman RA, Chianese, MJ. Presenting Signs and Symptoms. In: McInerny TK, Adam HM, Campbell DE (eds.) American Academy of Pediatrics Textbook of Pediatric Care, 5th edition, American Academy of Pediatrics, Elk Grove Village, IL, 2009, p. 1528.

2. Rao UB, Joseph B. The influence of footwear on the prevalence of flat foot. A survey of 2300 children. J Bone Joint Surg Br 1992; 74(4):525-7.

3. Rose REC. Flat feet in children: when should they be treated? Internet J Orthopedic Surg. 2007; 6(1). Available at http://www.ispub.com/journal/the-internet-journal-of-orthopedic-surgery/... . Published 2007. Accessed June 18, 2012.

4. Walther M, Herold D, Sinderhauf A, Morrison R. Children sport shoes--a systematic review of current literature. Foot Ankle Surg. 2008; 14(4):180-9.

5. Wegener C, Hunt AE, Vanwanseele B, Burns J, Smith RM. Effect of children's shoes on gait: a systematic review and meta-analysis. J Foot Ankle Res. 2011 Jan; 4:3.

6. Wolf S, Simon J, Patikas D, Schuster W, Armbrust P, Döderlein L. Foot motion in children shoes: a comparison of barefoot walking with shod walking in conventional and flexible shoes. Gait Posture. 2008; 27(1):51-9.

7. Staheli LT. Shoes for children: a review. Pediatrics. 1991; 88(2):371-5.

Editor’s note: Dr. Campitelli has disclosed that he is an unpaid Medical Advisor to Vibram USA.



Ron Raducanu, D.P.M.says: June 20, 2012 at 3:22 pm

After reading the literature you've cited, I just don't know how you can come to the conclusions that you do. A critical analysis of the literature you provide as sources for your conclusions offer little evidence to support their or your claims. They offer more suggestions and potential conclusions that, in my eyes, would not lead me to make recommendations based on what these writings say.

As to the claim about more flexible shoes being better, one of the articles suggests that these shoes flex incorrectly and distribute forces poorly. Doesn't a more flexible shoe flex more?

As to the claim that shoes in and of themselves are a causative factor in flat feet, if you look at the article carefully, it suggests that of the ones that did have flat feet, most did wear shoes, but this was a very small minority of the sample size. Most kids that wore shoes had normal feet! The correlation in that study is laughable to me. It is almost as if they were trying to make the evidence fit their needs instead of letting the evidence speak for itself. Poor examples of quality literature all the way around.

I do not recommend flexible shoes as I've seen no empiric data to suggest that they are better. My reasoning is that children (especially new walkers) require a firm base of support and since they do not have the same gait pattern as adults (very little propulsion, wide angle and base of gait), they would best be served to have straight last, more rigid shoes like skater shoes for example. There is a huge variety of shoes out there and the most important thing to keep in mind when making a purchase is their construction. THIS is where the education lies. A flexible shoe with a curved last is TERRIBLE, wouldn't you agree? There is more to a child's shoe than just one design aspect. Agree or disagree?

Reply to this comment »
Nick Campitellisays: June 23, 2012 at 11:28 pm

The idea is that our foot was designed to work barefoot.
Shoes exist only to protect the foot and allow it to function without inhibiting motion.
Rarely does a foot need corrective orthotics or shoegear, especially in children.
It's really not even debatable that pediatricians and pediatric orthopedists advise going barefoot to let the foot develop adequately and with proper muscle control.
There is no data that exists to support that a rigid shoe is better for a child because of a "firmer base of support" as it inhibits proprioception.

Thanks,
Nick

Reply to this comment »
jonisays: June 21, 2012 at 5:53 pm

Just following a tweet and landed on this thread.

I do feel that Dr. Campitelli's (unpaid) position with VFF does spoil his credibility.

While I read Dr. Raducanu's reply, his reasoning is not supported by any empiric data so I am not convinced by him that I should use rigid shoes like skater shoes, which go against my own logic.

I have not yet found a satisfactory way of dealing with the dilemma of what footwear is advisable for kids or adults. I am waiting for a new consensus of opinion to form.

Until then, if my interpretation of a video gait analysis comparing barefoot to shod movements shows one to strongly favor the other, I will advise shoe type and orthoses according to what I see.

Unfortunately, even in one individual, I can observe conflicting results. For example, improvements in knee function offset by increased midfoot collapse. Hence, I see potential harm and benefits to the individual in opposing branches of treatment and no clear indication which to favor. For this reason, I would still encourage bare/minimalist movements even in patients who do appear to need corrective treatments.

Reply to this comment »
Nick Campitellisays: June 23, 2012 at 11:36 pm

I'm sorry you feel that way about my credibility. Rather than judge, ask questions. I have been writing about this nationally now for two years and have run well over several thousand miles in minimalist shoes. I wore orthotics to run for over ten years and did nothing but injure my foot and create compensatory injuries to my legs. Proper form is incomparable to splinting or attempting to inhibit form and motion with an orthotic.

Feel free to reach out to me personally and I'll do my best to change your feelings of my credibility.

Thanks,
Nick

Reply to this comment »
Ron Raducanu, D.P.M.says: June 25, 2012 at 11:54 am

Here is the problem. You base your opinions not on what the data says but on your interpretation of it. There is equally no good data to support your claims either.

You may say I do the same thing but when challenged, you bring up new aspects to your argument. I don't remember reading anything about the proprioceptive needs of new walkers and how shoes empirically affect their feet, yet you bring it up as a reason to not recommend stiffer type shoes. What is this based on what exactly? How do you know for certain that young walkers have enough proprioceptive ability to differentiate between hard and soft shoes? Do we even know if this is a factor in their gait development? If you claim the positive, please provide the data as such.

When I recommend the stiffer soled shoes, it is because of their construction. They are stiffer so they offer more protection and also tend to have a straighter last, which doesn't canter the foot in one direction or the other. I'm also of the mind (simply by observation) that new walkers don't have the same heel to toe propulsion that adults do and that stiffer shoes mimic that better. I don't know for sure but I do know that a flexible shoe won't bend more than a stiffer shoe when the gait doesn't allow for that anyway.

If you would like some hard data, let's do it. Let's design a study in which there is a control group that walks barefoot all the time, a study group that walks in flexible shoes all the time and another that walks in stiffer shoes all the time, and follow these kids for the first 5 years of ambulation. Would you sign your kid up for that study?

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