Shoe Advice For Those That Work Long Hours On Their Feet

Many people out there have jobs that require long hours on hard floors, and their feet suffer for it.  In the next two posts, I want to discuss some tips on how shield the feet from the strain that those long hours can inflict on them, and how appropriate shoes and inserts can help make a difference.  I am splitting it up because the topic is so broad, but it is important to discuss.

The feet can withstand many hours of activity, but unfortunately we are not necessarily genetically predisposed to being able to withstand flat, hard surfaces for long hours.  In that regard, our feet need help, and that help comes in the form of shoes and sometimes inserts that go into the shoes to provide support, comfort, and foot endurance.  Shoe choices are influenced from a number of different factors, ranging from fashion to employer mandate.  People select their shoes for both personal and professional reasons, but do not always make the best choices and have to suffer the consequences.  Unfortunately, there is not one or even several specific shoes or even shoe styles that are best for the human foot.  Everyone has different structural needs that are influenced by the direct structure and shape of one’s foot, their body weight, their activity level, and the surface they walk on.  All these factors make for a very confusing picture in respect to selecting a good shoe, but there are a few ways around this. 

The first place to start is with one’s foot ‘structure’.  Foot structure simply refers to what shape of foot one has in relationship to the ground.  Some people have flat feet, some have high arches, and some are in between.  Those with very flat feet and high arches will be able to easily see what their structure is when they stand.  Those who have more subtle forms of either one of those structures may not be able to necessarily appreciate that when looking at their feet when standing, and may assume they have a ‘normal’ foot structure.  This is because many of those changes are hard to externally see, but a biomechanical exam by a podiatrist and/or an x-ray of the foot taken standing will show the true structure.  The foot’s position, incidentally, when one is seated, gives a false picture as most of the structural changes of the foot occur during standing, except for those with severe and rigidly flat feet that can be seen when seated.

Once foot structure can be determined, a few rules can be applied to shoe selection.  In general, those with flat feet need shoes that are more structurally stable.  This kind of shoe is more rigid across the bottom, and should only bend in the part of the shoe where the ball of the foot rests, not the middle of the shoe.  The shoe should also not be ‘twistable’ like a towel- it should resist attempts to twist it around.  These areas of firmness can help resist the arch collapse seen in flatter feet.  The area on the back of the heel should also be firm, and resists efforts to push it in so that it can more firmly cradle the more flexible heel area a person with a flatter foot has.  The bottom of the shoe should also be wide, hourglass shaped soles are not helpful for flat feet as the foot will spill over the narrow part of the sole.  Obviously, all these components work best in an enclosed oxford style shoe, or more ideally an athletic shoe.  Other shoe types can provide some elements of this support, including newer forms of sandals that are designed with firmer arch beds that cradle the arch better.  Shoes that are to be avoided in this category are flip flop sandals, flimsy cloth or canvas shoes, and most types of women’s  flats.  High arched feet, on the other hand, need much more cushioning, as they cannot absorb the shock generated by the ground contact when walking (something done when the foot is able to normally flatten more).  The shoe for a high arched foot needs to have a nicely cushioned sole, usually with greater thickness, to displace the shock away from the foot.  It should also be deeper to accommodate for the greater depth a high arched foot has within a shoe.  These characteristics are relatively easy to achieve in an athletic shoe, but are harder to find in a dressier style.  When selecting a dressier style of shoe for high arches, one has to more seriously consider the thickness of the sole material, as well as the softness of the material.  It should be a denser rubber or foam composite material, and should be stable as well.  People who have feet that fall in somewhere between flat and high arched should use a stable shoe similar to what one would wear if they were flat footed, as a stable shoe will provide better protection against foot fatigue over the course of a long day standing on hard surfaces.

The next thing to consider when trying to keep one’s feet comfortable all day is the need for inserts into the shoes.  Shoes alone can make a big difference in general foot comfort, but rarely do they actually contact the foot to the same degree that an insert in the shoe will.  Selecting an insert is a relatively simple process.  People with very flat feet generally need a rigid custom made orthotic to stabilize the arch and keep the foot from fatiguing after standing all day.  People with more moderate flat feet can benefit from either a custom orthotic or a semi-rigid over-the-counter insert like Footsteps or Powerstep Pro.  Those with high arches benefit from either a well padded custom orthotic or a well padded over-the-counter insert, of which there are multiple brands.  Those who have foot structures in between can benefit from over-the-counter inserts in general.  I do recommend that my patients avoid hard plastic inserts from retail insert stores, as these hard inserts are not made specifically for a single foot like hard custom orthotics.  Because of this, they may eventually irritate the foot more than they help as the ridges of the arch will not match the foot shape exactly.  Given the excessively high price one usually pays for the inserts in these stores, a custom orthotic can be manufactured, often for the same or less.  I also recommend that thin inserts like flat gel or foam inserts not be used for support or shock absorption, as they easily compress down to nothing when stepped on, and essentially are only a replacement for the sock liner padding that already comes in the shoe.

One other factor that needs to be considered is one’s bodyweight.  For many, this is a sensitive topic, but it does have a factor in general foot comfort by the end of the day.  Obviously, people who are of normal weight or mildly overweight do not need to consider their weight in selecting shoes.  Those who are very overweight or obese do have to consider their weight.  In cases of very heavy bodyweight, regardless of the foot structure, the shoes that one chooses needs to be very stable, with strong rigid material in the sole to help resist the pressure on the foot from the bodyweight.  Inserts in the shoes that provide additional rigid support are also very helpful in stabilizing the feet and improving comfort throughout the day.

I will continue this discussion next post, where I will discuss what role activity level and walking surfaces actually have on the feet and the life of the shoe, and whether some foot discomfort needs additional treatment beyond simply good shoes and inserts.

Flat Feet Explained Final Part: Surgical Treatment

This week, I will conclude my discussion on the treatment of flat fee by discussing surgical correction.  Surgery is usually reserved for people who have failed orthotic therapy, or those who have rigidly flat feet that generally will not benefit from orthotic inserts.  Each surgeon has their own criteria regarding how early they consider surgically correcting flat feet.  Some surgeons wait until all other options are exhausted, and others consider surgery much sooner in the treatment process.

Surgery must correct all components of a deformity that can be quite complex.  There are three different lines of motion that are involved in the flat foot deformity.  Each individual case has a different arrangement, where some feet are more deformed in one or two lines of motion compared with others.  The abnormal motions that dominate the deformity are the ones the surgeon needs to concentrate on, as this will affect their choice of surgical procedure.  Different surgical procedures have been developed to deal with the many nuances of the flat foot deformity.  A typical flat foot reconstructive surgery involves several different individual procedures to correct each component of the deformity.  The flat foot deformity can involve a shifting of the foot outward, a bending of the foot upward, and/or a rolling of the foot inward toward the big toe side.  By addressing the components that dominate the deformity, a surgeon can effectively reconstruct the foot to obtain better foot structure.  These procedures involve various combinations of bone cuts and soft tissue procedures that rotate, flex downward, or lengthen the foot.  More flexible deformities can tolerate the use of a blocking cone-like implant that keeps the foot from flattening, especially in younger patients.  Given the nature of the bone cuts, the foot and leg is usually immobilized during the recovery period, which can take two to three months before regular shoes can be worn.  Patients with the implant recover much faster.

Many people who have flat foot reconstructive surgery do quite well.  Such surgery does carry with it potential complications, including over or under correction, non-fusing bones, infection, and scar tissue formation.  Depending on general health, some people may not be good candidates for what amounts to be a mildly extensive foot procedure.  Proper following of all postoperative instructions is very important, as that alone can sometimes be the difference between a successful surgical outcome and a poor result.  These procedures are generally performed in an outpatient, same-day setting.

As you can see, the flat foot deformity is a very complicated condition that requires very careful consideration of all it’s components for treatment to be successful.  While most people do well in orthotics, surgery is needed in more advanced cases.

Flat Feet Explained: Part 2 Non-Surgical Treatment

This week, I am continuing my discussion on the treatment of flat feet in teens and adults. We are now ready to discuss treatment options. In basic terms, there are two options for treatment, as there are two basic types of flat feet.  The options are supportive shoes and prescription orthotics inserts, and surgical reconstruction.  The two basic types of flat feet are flexible and rigid.  Flexible flat feet (which are most common), can be pushed and held out of a flat position.  Rigid flat feet are stuck in that position, due primarily to inflexibility of a deformity that is mostly bone in nature.  Today I will discuss shoes and inserts, which are primarily helpful for most cases of flexible flat feet (but not rigid flat feet).

Over the last fifty to sixty years, our understanding of how the foot functions mechanically has grown significantly.  The mechanics of the foot are complex, and not easily measurable by direct means given the complexity with which the various joints work together to push us forward.  Our current understanding of this function is advanced, but not perfect.  Regardless, the development of the field of foot biomechanics has led to the development of the prescription functional orthotic, a device that has made it possible for countless people to enjoy their lives foot pain-free, or at least with considerably less pain.  This device is not the same as over-the-counter arch supports found in stores and TV commercials nationwide, and it is not the same as pricy off-the-shelf plastic inserts masquerading as ‘orthotics’ in numerous national retail chains.  A prescription functional orthotic is a medical device that is made of a plaster mold or 3D laser scan of the foot.  This mold or scan is created while the foot is being stabilized in a mechanically neutral position, otherwise known as the subtalar joint neutral position.  In this position, the foot is neither in a flat orientation, nor a high arch orientation.  It is roughly a position that research has determined should be the model resting position of the foot, when the foot has stopped rotating inward or outward during the walking cycle.  Many different factors contribute to getting the foot in this position, as the foot has numerous ways of compensating for any variation in structure between one part of the foot and another.  A true functional orthotic takes into account these variations, and subtle ways of angling or shaping the insert arise in the prescription process that make the resulting orthotics function even better.  Because these inserts are constructed based on the specific foot mold or scan, and slightly altered based on a complete biomechanical exam of the foot and lower leg, they will actually correct abnormal foot structure in a predictable way.  Over-the-counter inserts simply shove wads of padding or plastic into the arch blindly and hope it will be close enough to give proper support to the foot.  These kinds of inserts are usually comfortable, and do provide more arch support that a shoe alone can give.  However, they do not provide the exact level of foot structure control that a condition like flat feet often requires. Only prescription orthotics can fill this role completely.

The use of prescription orthotics allows for stabilization of the flexible flat foot when worn from shoe to shoe.  This device reduces much of the strain the bottom of a flat foot endures with standing and walking, and it can indirectly slow down the progression of flat feet related deformities, like bunions and hammertoes, by correcting the underlying cause.  The proper choice of shoe also contributes greatly to this treatment.  In general, people with flexible flat feet need a shoe constructed with that foot structure in mind.  A better choice of shoe is one that is only flexible at the ball (front) of the foot, and not in the middle of the foot. It should have a stiff sole, a stiff area that cradles the heel, and should be wide enough that the sides are not tight against the foot when it widens out as it flattens.  Most importantly, it should fit the orthotic and be comfortable to wear after many hours of activity.

For the vast majority of people with flat feet, a prescription orthotic and supportive shoe will be sufficient treatment, much like eyeglasses or contacts are sufficient for those with vision impairment. However, those that have rigidly flattened feet are not generally helped by orthotics, as the foot must be flexible for the orthotic to change foot structure.  There are also times with flexible flat feet in which orthotics do not provide enough support to control pain symptoms.  In these cases, the physical structure of the foot needs to be permanently changed to relieve pain and improve foot function.  Next post, we will discuss surgery to treat flat feet, and some of the advantages and pitfalls of that approach.

Flat Feet Explained: Part One

Over the next couple of weeks I would like to discuss the nature of painful flat feet in the older child/teen and adult, and share some of my thoughts on treatment of this foot deformity.  Since this is a fairly involved topic, splitting the discussion up will help keep the post from getting too ‘wordy‘.

To start with, I would like to explain why we use the word ‘deformity’ to describe flat feet.  Flat feet are simply a normal anatomic variation of the human foot, as much as ‘normal’ or ‘high’ arches are.  It is likely mostly genetic, and passed to our children.  This variation is quite common, but does pose a unique challenge to modern humans, who tend to wear shoes most of their lives to protect the foot skin from the dangers of civilized living.  In populations where shoes are not worn, the foot’s muscle and support system is usually able to adapt to this flat structure from an early age.  By wearing shoes, we take away some of this adaptation.  However, the danger to the foot by walking barefoot in public or on concrete, gravel, and other hard surfaces far outweighs the lack of structural adaptation, and the notion that one should walk barefoot to keep this ‘natural’ process active is potentially harmful.  Unfortunately, because of the infrastructure we have paved our ground with for thousands of years, we are far better off in shoes.  However, those of us with flat feet must now deal with the issues that come with an unadjusted foot structure.  Even though flat feet are not a deformity in the same vein as an extra toe or clubfoot, we still refer to it as a deformity because in essence it functions as a foot deformity by being the source of numerous foot problems over time.

The foot problems that develop due to flat feet are generally due to instability that is present in the foot when it is allowed to over flatten.  This instability will gradually cause numerous other actual foot deformities by forcing the foot’s muscle and support system to change the way it anatomically is supposed to function.  The change in the way certain muscles and tendons pull on the foot, and the change in how ligaments and joints are positioned, will often lead to foot deformities like bunions and hammertoes.  These deformities in and of themselves can become painful over time in certain people.  However, of more importance to this discussion is the role flat feet play in causing tissue injury, which leads to chronic pain.  When flat feet are subjected to lengthy or strenuous activity, the overly flexible nature of this foot type can allow other parts of the foot to become overly stretched and strained.  This includes the plantar fascia, a thick cord on the bottom of the foot that is the source of the common heel pain when it is injured, as well as a large tendon under the inner side of the ankle called the posterior tibial tendon.  When this tendon is injured and not treated properly, it can lead to a debilitating degenerative process that can actually allow the foot to flatten further.  Other injuries directly related to flat feet include nerve inflammation in between the long bones of the foot known as a neuronal, as well as various arthritic conditions.

Since we now understand how and why feet are flat in some people, as well as what problems they can cause, we should move on to what is typically done to treat this condition so that it does not lead to pain and suffering.  This can be done by modifying the foot structure externally (better shoes and orthotics inserts), or by physically changing the internal structure of the foot (reconstructive surgery).  On the next couple of posts, I will discuss the reasoning behind each approach, and what I feel is the appropriate situation for either external or surgical treatment.

Foot Swelling and Warmth In Kids: Finishing With Part 4

Finishing the discussion from the last several posts, I would like to discuss one more condition in children that can cause swelling and warmth in the foot.

This final group of conditions is not necessarily unique to children, but many of the individual conditions in this group appear during childhood as opposed to adulthood.

While one never wants to discuss children and cancer in the same breath, the fact of the matter is that cancer can occur in kids.  These cancers can also occur in the lower leg and foot.  Fortunately, the incidence of pediatric cancers is extremely low, and they are rather rare.  Additionally, their appearance in the feet and ankles is rare, as many appear in the thigh and elsewhere.  However, this always needs to be a consideration when looking at warmth and swelling the foot and ankle.

There are multiple forms of malignant cancer that can afflict tissues in the foot, as well as multiple forms of benign cancer.  The more common of these uncommon diseases include malignant cancer of or in bone (osteosarcoma, Ewing’s sarcoma), and of muscle (rhabdomyosarcoma).  Benign tumors in this list include masses in bone (osteochondroma, enchondroma, bone cysts),  and in fibrous tissue, fat tissue, and blood vessels.

The more serious bone cancers tend to be seen in teenagers, while benign masses tend to be seen in younger children.  The symptoms often include pain, local warmth in the skin, and sometimes swelling or the appearance of a lump over the tumor site.  Diagnosis begins with a simple exam and x-rays, and further testing is performed if a tumor is suspected.  Malignant tumors can threaten the leg, and can potentially spread to other organs, including the lungs, leading to death.  Early treatment is vital to saving the affected leg and the child’s life.  Benign tumors usually cause little in the way of real problems, but may be painful depending on their size and location and sometimes they have to be removed.

While tumors in kid’s feet are uncommon, and malignant cancer is rare, these horrible diseases still need to be considered a possibility during any evaluation of warmth and swelling in kid’s feet and ankles (and lower leg), as should all of the other conditions mentioned in the last several posts.  For these reasons, swelling and warmth should never be assumed to be a part of the process of growing, and parents of children with new warmth and swelling in their feet/ankles should take their child to see a foot specialist for an evaluation.

Foot Swelling and Warmth In Kids: Part 3

Continuing the discussion from the last couple posts, I would like to discuss more conditions unique to children that can cause swelling and warmth in the foot.

Injuries such as sprains and strains are just as common in active kids as they are in adults, and generally kids can injure the same parts of the foot as adults.  These include the Achilles tendon, the outside of the ankle, joints in the ball of the foot, as well as tendons on either side of the foot.  The same healing reaction occurs in kids during these injuries as does occur in adults.  This includes warmth, swelling, bruising, and sometimes redness.

Fractures can also occur in kids, just as in adults, and can include all of the above symptoms as well as significant pain, an inability to bear weight, and sometimes excessive motion of part of the foot due to the unstable nature of a broken bone or bones,

What is more unique to children is the potential presence of a growth plate fracture.  Children’s bones are still growing, and most bones have a section of the bone that is composed of a line of cartilage that is slowly churning out bone tissue to essentially enlarge and elongate the growing bone.  These growth plates are located on one end or another of the bone (never in the middle), and are somewhat fragile.  When enough force or stress is applied to the bone during an injury, a fracture can occur.  The fracture can disrupt the growth plate and travel through the bone on either side of the growth plate.  Sometimes, the bone does not actually fracture, but the growth plate gets crushed nonetheless, resulting in damage.

Growth plate injuries are more serious than standard fractures because the damage can result in a partial or total disruption of the bone growth process.  This can lead to partial, but deformed bone growth, or no growth at all.  If the child is young enough, the deformity from the resulting abnormally short bone later in adolescence can be significant depending on which bone was injured.  Therefore, potential fractures in children should be more carefully assessed, as growth plate fractures need closer attention and proper treatment to maintain the health of the bone and ensure they heal properly.

I will finish this discussion next week on one final serious group of conditions that can cause swelling and warmth in the child’s foot.

Foot Swelling and Warmth in Kids: Part 2

Continuing on from my last post, I would like to discuss another serious condition that can cause swelling and warmth in a child’s foot.

There are a group of diseases in the body in which the immune system, the body’s defense force, is involved in the destruction of normal tissue.  Called autoimmune diseases, the main mechanism in these conditions is the active damage of normal body tissue by an immune system run amuck.  Joint tissue can be affected by some of these conditions, and a common disease that is a part of this group of illnesses is called rheumatoid arthritis.  When this condition is seen in children, it is called juvenile rheumatoid arthritis (JRA).

JRA can start as young as 6 months of age, and usually begins before the age of 16.  It can involve many joints in the body, a smaller group of joints, or only a few.  The initial symptoms can include a swollen joint, a new rash, a spiking fever, or simply limping.  As the condition evolves, the joints may become red, warm, swollen, stiff, and the child may begin to limp or refuse to participate in activities.  More wide-spread cases can result in the child looking sick and pale, with high fevers and a rash that comes and goes with the fever.  Eye problems can also develop, that may or may not have symptoms.

The diagnosis of JRA can be made through multiple means, including blood tests, organ swelling, x-rays, and joint fluid analysis.

In the foot, rheumatoid arthritis of any variety can result in devastating deformity and joint destruction over time.  If the immune reaction against joint tissue is not controlled, eventually the joints can become worn and deformed.  There can be a slower rate of growth, and a child in chronic pain from this condition can have poor activity desire and poor school performance.

There are medicines that treat JRA just like the treatment of adult rheumatoid arthritis.  These vary per symptom severity, and many milder cases of JRA actually can go into remission for many years without any  chronic joint changes.

If your child develops joint pain and swelling, especially if a fever and/or rash is present and several joints are inflamed, it is important to have them evaluated for potential causes, which may include juvenile rheumatoid arthritis.

Foot Swelling and Warmth In Kids: Part One

Despite common thought, kids do get their fair share of foot pain and foot injuries.  Most of the time, these conditions are relatively minor issues, but still do require medical attention as foot pain is never normal at any age group.  However, there are a few situations in which urgent attention is required as the condition could be potentially very serious.  This is the case when a child’s foot is swollen, warm, and possibly red.

The causes of foot swelling and warmth, essentially the hallmarks of inflammation, are many.  It is a natural response by the body to start the healing process when the body has been injured.  However, there are times in which swelling and warmth is not directly related to a specific injury, and develops due to more serious disease in the body.

The first of these diseases will be discussed today.

While uncommon, children are at risk for developing a specific type of bone infection.  Called hematogenous osteomyelitis, this infection is somewhat unique to children.  Bones in adults can become infected by bacteria directly exposed to bone through a skin wound or abscess next to or probing to a deep bone.  Kids do not necessarily require this direct exposure, and can develop bone infection from bacteria present elsewhere in the body.  These can include respiratory infections, infected insect or animal bites, infected boils, cuts, scrapes, and abrasions, puncture wounds, or other trauma.  The bacteria then enters the blood stream, and travels to a remote bone, where it infects a specific part of the bone due to the richness of circulation in the growing bone.  About half the kids that develop bone infection are pre-school aged, and many are male (possibly due to more risk-taking in males which may lead to injury).  The large long bones of the thigh and upper arm are most commonly infected, but the smaller bones of the foot can also be infected as well.

The symptoms of this condition include pain, swelling, skin warmth, fever, and an inability to bear weight on the involved leg or foot, as well as joint stiffness and pain if the nearby joint tissue becomes inflamed.  The most common bacteria causing this infection include staph aureus and strep species, although with puncture wounds pseudomonas is present and in kids with Sickle cell anemia, salmonella is common.  Diagnosis of this conditions is somewhat trickier than in adults, and multiple types of images, including x-ray, bone scan, and MRI may be needed to make an accurate diagnosis, as well as bone and joint fluid cultures and blood work.

Treatment typically involves 4-8 weeks of antibiotics, either strong oral medications or intravenous medications.

The main problem with this condition lies in the fact that a delayed diagnosis can lead to significant bone disease in a child, and can lead to permanent deformity or joint disease as the infection destroys healthy bone tissue.  A prompt diagnosis is key to a faster recovery and better long term outcome.

I will continue this discussion next week and discuss yet another serious condition that can cause swelling and warmth in the child’s foot.

New Article on Foot and Ankle Football Injuries Is Here

As football season is upon us, I have added a new page to my site detailing common foot and ankle injuries found in football.  For those of you who have children playing this season, or those of you young enough to play yourself, this guide may be helpful in guiding you to proper treatment should a foot or ankle injury occur on the field.  Check it out at:

Check Out My Article On Foot Injuries In Youth Baseball!

As the summer baseball madness is upon us, many of you have kids playing in either recreational or travel leagues.  Foot and ankle injuries are not uncommon in this sport, and require expert care to get the young athletes back into the season.  This article discusses some to the more common foot and ankle injuries baseball players of all levels experience.  Great information on injuries involving the Great American Pastime.  Follow the link below to check it out:

Common Foot and Ankle Injuries Found In Baseball