For professional athletes and weekend warriors alike, having the right shoe and the correct fit can mean the difference between participating and sitting on the sidelines. Since most podiatrists now fit shoes in their offices, it is imperative that they develop a true expertise in this critical aspect of foot care, particularly with respect to the special needs of athletes. Providing proper shoe fit and selection for active individuals holds great potential for both injury prevention and for practice expansion. When podiatrists themselves fit patients with athletic shoes, it fills a void in areas lacking a shoe store with a large inventory and naturally offers greater profitability. Other podiatrists prefer to refer patients to athletic shoe stores. Such an approach typically offers patients a better selection and allows them to try on shoes in a relaxed, comfortable setting. Either way, the podiatrist ultimately needs to assess the functional biomechanics of the lower extremity, identifying its structural requirements and creating a plan to achieve the therapeutic objectives. Whether podiatrists elect to fit patients in the office or refer them to a store, they need to consider four simple but key considerations — size, shape, stability and style — to achieve the best clinical outcomes. When it comes to fitting shoes, choosing the right shoe size is deceptively complex. To start, manufacturers do not follow standards for length and width. Sizes vary not only between brands but also among different styles of the same brand. Sizes may even vary within a particular style if the shoe is manufactured by different factories. Despite this inconsistency, fit starts with measuring. Ideally, patients should try shoes that are made in two to four widths per half size at a store that stocks the various choices. Unfortunately, many manufacturers make shoes in only one width and most stores carry limited inventory. As a result, patients with wider feet frequently wear shoes that are too long in order to get the width they need. When the patient is standing, a properly fit shoe should have approximately a 1/2-inch to 5/8-inch space from the end of the longest toe to the end of the shoe. The correct width accommodates the foot without bulging on the lateral side and without excess material on top. Customers used to wearing shoes that fit too short often find that the right size feels too large. As long as the shoes do not slip in the heel, a bigger size is better. Why Shoe Shape Is So Important Many shoe specialists often overlook the importance of matching the shape of the shoe to the shape of the foot. While feet come in a variety of shapes, shoes are obviously mass produced with a limited number of forms called “lasts.” The lasts are designed to accommodate common foot shape characteristics. These factors include forefoot breadth, arch morphology, instep height, toe depth and heel width. Even when it is sized correctly, the wrong shoe shape still results in suboptimal fit. The following pointers on foot shapes and lasts accommodate most patients. • Most feet have a medium height arch with mild curvature in the transverse plane and a broad forefoot. Examples of lasts that best fit such feet include the “SL-1” from New Balance, the “Universal” from Brooks and the “Voyage” from Aetrex. • Part of the athletic population has feet that curve medially in the transverse plane. These lightweight shoes offer a snug, glove-like fit. An example of such a last is the “Curved” from Brooks. • Feet with low to flat arches need ample breadth in the shoe midsection. Athletes with these feet do best with shoes made on such lasts as the “Linear” from Brooks, the “SL-2” from New Balance and the “Lenex” from Aetrex. Inside Insights On Stability Athletic shoe manufacturers have seized on the concept of stability in their marketing and promise everything from limiting excessive foot motion to allowing feet to move as nature intended. Different features combine to balance cushioning and motion control, depending on the needs of an athlete’s gait. To determine a shoe’s stability, squeeze the sides of the heel counter, the rear part of the shoe. Stable shoes resist compression. Hold the shoe at the heel and at the toes, and twist. Torsionally stable shoes resist twisting whereas flexible shoes twist easily. When it comes to neutral feet, bear in mind that the foot’s longitudinal arch helps absorb impact forces in the first half of the stance phase of gait from heel strike to the middle part of midstance. Later in the stride, the arch rises, helping the foot to push off and the body to move forward with an efficient, smooth gait. When the arch lowers after heel strike and rises during the propulsive phase of gait, the athlete has a biomechanically efficient gait and the foot itself is described as “neutral.” When it comes to the walking and running of athletes with neutral feet contact on the lateral side of the heel, the foot rolls in toward the medial side and resupinates through propulsion. Old shoes generally reveal wear on the lateral side of the heel and even wear across the ball, sometimes continuing beneath the distal medial aspect. “Neutral” athletic shoes are recommended for neutral feet. These shoes should be cushioned and flexible enough to allow the foot to progress naturally through the gait cycle without unnecessary correction. Neutral shoes lack extra pronation control devices, which could injure biomechanically efficient runners but should provide adequate torsional stability. Most athletes demonstrate mild to moderate overpronation. Immediately after heel contact, the feet evert past perpendicular. This excessive motion creates strain and outweighs the shock absorption benefits of normal pronation. Athletes with low to normal arches who are mild to moderate overpronators need “stability” shoes that combine good support and midsole cushioning. Athletic shoe manufacturers incorporate many features to support the medial aspect of the heel and prevent compression beneath the plantar medial aspect, which limits rearfoot pronation. In order to save weight, manufacturers sometimes cut out the middle part of the midsole and use plastic reinforcing — also known as a “stability web”— to restore torsional stability. When There Is Severe Overpronation Some runners demonstrate severe overpronation. After the lateral heel makes initial ground contact, the foot everts excessively, diminishing the natural shock absorption benefits of pronation. To compensate, the foot and ankle strain to stabilize joint motion. Athletes with this foot type find it hard to walk and run efficiently. They often tire easily and experience such conditions as heel spurs, bunions and knee pain. Athletes with low arches who are moderate to severe overpronators need motion control shoes, which offer maximum rearfoot control and extra support on the medial side. Supportive features include aggressive stabilization and a wider base to provide support. The shoe may integrate a plastic or carbon graphite stabilization piece at the anteromedial aspect of the calcaneus. This shoe type also works well for larger athletes who need additional support and durability. What About The Impact Of Supination? In regard to supination or underpronation, athletes with rigid, normal to high arch feet with minimum pronation are generally well suited for running fast but possess limited shock absorption. Usually midfoot or forefoot strikers, these runners are more susceptible to impact injuries like shin splints, stress fractures and Achilles tendinitis. Their feet demonstrate minimum pronation and generally lack ankle joint dorsiflexion. Neutral-cushioned shoes typically work best for such feet as they feature maximum midsole cushioning and minimum medial support. Specific Shoes For Sports: What You Should Look For At one time, sneakers with canvas uppers and gum rubber soles worked well for almost any athletic activity. Now manufacturers design shoes for very specific activities and surfaces, and use a slew of high-tech components. Unfortunately, about 90 percent of the time, people do not wear shoes designed for the given activity. Therefore, foot care providers must step in and differentiate the substance of shoe style from the sizzle. Running shoes. These shoes are lightest in weight and offer maximum cushioning. They are designed for linear activity and should never be worn for court activity. Running shoes are acceptable for walking but walking shoes are never acceptable for running. Walking shoes. Similar to running shoes, athletic walking shoes often have more leather in the upper, making them more durable and slightly heavier. These shoes generally are not as boldly designed and are often more appropriate for everyday wear. Court shoes. Tennis, basketball and other court sports require quick changes in direction. Accordingly, these shoes must have superior medial and lateral forefoot support. Tennis also entails a lot of forefoot dragging so this type of court shoe often features extra thickness in the big toe area. Cross-training shoes. These versatile shoes generally come in two different versions: lighter weight models similar to running shoes and those similar to court shoes. Lightweight cross trainers are okay for running up to three miles and for use on exercise machines. For basketball, tennis and other court activities, the heavier weight cross trainer, often made from leather, is better. Hiking shoes. Hiking requires support, durability and protection from the environment. Such shoes feature thicker soles and come up higher on the foot to increase ankle support. Waterproof lining and sealed seams keep the feet dry. In Conclusion A well fitting shoe feels good. To ensure the right fit, it is best to take shoes for a test run. While patients should always anticipate a break-in period, a properly fit shoe will generally feel good right away. As mentioned above, when a person has become used to wearing shoes that are too small, the correct size usually feels excessively loose. Podiatrists need to encourage patients to try the correct fit if the shoes have no objective signs of looseness such as slipping in the heel. Soon, patients will appreciate the normal “wiggle room” of fitting shoes and the fact that their feet no longer ache at the end of the day. Dr. White is the President and founder of SafeStep. He serves as a Medical Advisor to New Balance in New York. He has specialized in proper fit of footwear for the last 15 years. Dr. White lectures in the Department of Orthopedics at the New York College of Podiatric Medicine and the Department of Applied Biomechanics at the California School of Podiatric Medicine. Dr. Caselli is a staff podiatrist at the VA Hudson Valley Health Care System in Montrose, N.Y. He is also an Adjunct Professor at the New York College of Podiatric Medicine and a Fellow of the American College of Sports Medicine.