Recommending Athletic Footwear For Runners

What is a good running shoe? How often are you asked this question? It seems that whenever a stranger learns that you are a podiatric physician, the first question he or she asks is about a shoe. Rather than asking how we can prevent foot amputations in patients with diabetes, the average American is more interested in what shoe a podiatrist is recommending.
Yet when it comes to footwear recommendations, most podiatric physicians have very little objective information on which to base their opinions. Having 25 years of clinical experience in podiatric sports medicine practice, I would like to offer some guidelines for making shoe recommendations to the running athlete.
Before looking at the foot type (the obvious primary criteria for recommending a specific shoe), look at the patient. Body mass will supercede any foot type classification in terms of footwear requirements for exercise.A 200-pound individual will require an extremely firm, stable shoe whether he or she has a stable foot or not. A 110-pound female elite runner may not require motion control features in a shoe even if she is a “pronator.”
The training regimen of the patient will dictate whether multiple shoes are necessary for long road runs and speed work on a track.Many people prefer running on trails or grass, which would alter the normal cushioning requirements that would be needed on asphalt.
Finally, the age, fitness and competitive level of the patient can significantly alter the shoe recommendation. An older runner who “plods” at a 12- minute per mile pace will have different requirements than a 20-year-old elite “toe runner” who blazes along at a sixminute per mile pace.

Emphasizing The Importance Of The Patient’s Injury History
Granted, there are other factors to weigh with the patient evaluation. The patient will probably have an injury history that one should consider. In general, podiatrists should correlate running injuries to impact shock or excessive motion. Unfortunately, there is no clear understanding of which injuries are primarily due to impact and which are due to excessive pronation or supination. Still, the experienced clinician has a sense of what footwear characteristics are desirable to prevent injury.
If the patient has had previous stress fractures, cushioning characteristics are preferable in shoe selection. Previous Achilles tendinopathy should dictate footwear with firm midsoles and ample heel elevation. There may be a current injury that will dictate a specific shoe requirement. Hallux rigidus will require a shoe with a stiff sole. Plantar heel pain syndrome will require a shoe with torsion stability. Patellofemoral pain syndrome is usually associated with excessive pronation although multiple other factors are also involved. Pronation control features in a running shoe include firm heel counters and medial posting of the midsole.

How To Facilitate Appropriate Shoe Fitting And Measurement Of The Foot

Every patient has unique shoe fitting requirements. Most people are aware or should be aware that both of their feet are not perfect matches. One foot is always a little bigger than the other. Always fit the shoe to the larger foot.
While it may seem intuitive, many patients need to be reminded when there is a need for wider shoe fit due to bunions or hammertoe deformities. A positive trend in athletic shoes over recent years has been the availability of various width options. While New Balance continues to be the only athletic shoe company offering a full range of widths, the option of narrow, medium and wide widths from many other manufacturers is a positive change for our patients.
Finally, the actual measurement of the foot can help one detect specific fit requirements. A Brannock device is an essential piece of equipment for the podiatric practice. While measuring feet may not seem to be part of the routine lower extremity exam, patients may interpret this service to be the most valuable part of their visit to your office. A simple assessment of heel-to-toe and heel-toball measurements, and comparing right to left feet will provide insights that patients can use for the rest of their lives to achieve a better shoe fit.
When there is a disparity in heel-totoe versus heel-to-ball length, the flex joints across the forefoot will be improperly aligned in the shoe. In a foot with long toes (short heel-to-ball length), the metatarsophalangeal joints (MPJs) of the foot will be too proximal in the shoe. Hyperextension of the toes may occur. In a foot with short toes (long heel-to-ball length), the MPJs will be distal to the flex joints of the shoe.These patients will also have reduced plantarflexion of the first ray during propulsion and the normal function of the windlass will be affected. Also bear in mind that significant fit problems will occur as the wide part of the foot will be aligned in the distal, narrower part of the toe box.
What the Brannock device does not measure are critical dimensions of heel width, instep height and girth, waist girth and forefoot girth. However, visual evaluation can detect a “high volume foot,” which has its own unique fitting requirements. Some athletic shoes are known to accommodate the high volume foot better than others. Matching the girth and volume requirements of a shoe to the patient is an art form that will fall under the responsibility of the shoe fitter. (See “What You Should Know About Specialty Running Shoe Stores” on page 50.)
One can evaluate the patient’s current shoe fit in the office quickly and easily. In most cases, patients will be wearing shoes that are too small. Show the patient the proper requirement for 1/2-inch space between the longest toe and the end of the shoe. This will often correspond to the width of the patient’s index finger. This index finger measuring stick should become the permanent future reference for shoe fit when the patient purchases athletic footwear. A helpful technique is to remove the insole of the patient’s athletic shoe and examine the toe imprint pattern. The distance from the toe prints to the end of the insole shows the true functional spacing that has occurred in the shoe during exercise.

Understanding The Impact Of Mechanical Requirements On Shoe Recommendations

This may be the most difficult part of decision making for shoe recommendation. There is much myth and misconception about how to classify foot types and match them to the right category of shoes. It is common for running magazines to make shoe recommendations based upon arch height.For high arch feet, a cushioned shoe is recommended. For low arch feet, a stability shoe or motion control shoe is recommended. For the “normal arch,” a neutral shoe is recommended. This general classification system makes sense based upon our clinical experience with cavus and pes planus foot types.
However, clinical biomechanics research has produced data that both confirm and refute these notions. Nigg, et al., found no correlation with arch height and maximal rearfoot eversion in a group of 30 runners.1 Williams, et al., found that runners with low arched feet had a greater magnitude of eversion and eversion velocity than runners with high arched feet.At the same time, researchers have noted that runners with high arched feet have greater rates of vertical loading (greater impact shock) than low arched runners.2
Recently, a study by Butler, et al., showed that cushioned trainer running shoes attenuate shock better than motion control shoes but the effects of these shoes are the same, regardless of arch height.3 The authors concluded it would be more appropriate to match footwear to the running mechanics of the patient rather than the arch height.
Accordingly, the podiatric physician, using the skill and knowledge of training in clinical biomechanics, should evaluate each patient in terms of running mechanics to determine the best shoe recommendation. The best way to do this is with a running treadmill evaluation. A less effective but useful evaluation is simply watching the patient run down the hall or sidewalk outside the office.
During 25 years of clinical practice, I have continued to be amazed by the differences in the mechanics of patients I observe walking in comparison to running. Patients with a rectus hindfoot during walking will suddenly pronate 6 to 8 degrees when they run. Another patient may walk with significant pronation but may suddenly appear to have almost normal alignment when running. A barefoot runner may appear normal and suddenly pronate severely in an over-cushioned shoe.
Watching a patient run will not only show whether the current running shoe is appropriate, it can also determine what mechanical factors have lead to the injury. Finally, this evaluation will help determine the recommendation for a new shoe and allow one to balance the cushioning versus stability requirements.

Why A Recommended Shoe List Is So Valuable

Today’s athletic shoe companies offer a dizzying array of styles of running shoes in multiple categories such as motion control, stability, cushioned trainers and racing flats. It is almost impossible to stay abreast of all the current styles and technologies. Even if you study and become current with all of these shoes, the companies constantly change styles and introduce new models.
This is why a recommended shoe list provided by a credible source can be invaluable to the podiatric physician. Running magazines such as Runners World and Running Times regularly publish shoe evaluations and rate shoes in all categories.These surveys offer updates on new models and technologies, but do not always provide a comprehensive look at the best shoes available.
The American Academy of Podiatric Sports Medicine (AAPSM) has published a recommended shoe list for many years on its Web site www.aapsm.org. This site is free and accessible to physicians and the lay public. Recently, the Shoe Recommendation Committee of the AAPSM has significantly expanded its efforts to evaluate shoes and provide credible, unbiased evaluation of all available current running shoes.
A recommended shoe list, which is updated semi-annually, should be available as a handout for patients. From this list, the podiatric physician can designate the shoe category that is most appropriate for the patient. One can designate certain models or brands as preferred for the patient, or write a specific “prescription” for a certain shoe. In most cases, it is best to specify a category rather than a certain model of shoe. The shoe list serves as a “library” of available brands and models that can serve as a reminder to the prescribing physician of currently available options.

Keys To Writing An Effective Shoe Prescription
Many running shoe companies offer preprinted prescription pads to make a shoe recommendation. Often, the names of preferred retailers will be listed on the prescription pad. In most cases, the pads have all available models listed by category but they are limited to the shoes of that brand only.
I prefer writing a shoe prescription that is broad and generic. I try to avoid listing specific models of shoes. Instead, I will simply write “stability shoe” and may add some fitting requirement such as “needs wide toe box.”The pitfall of listing a specific model of shoe is the fact that patients will limit themselves to trying on only the model you suggested even if the fit of the shoe is not correct for their foot.
This is the critical part of the running shoe recommendation. Give the patient a strong message that the fit and comfort of the shoe should be the final determinants for selection. While a doctor can recommend a specific model, he or she cannot be sure that this shoe will be the right match for the patient in terms of overall fit characteristics. This is when confidence in the shoe retailer must take over. If a recommended shoe does not fit properly, the retailer must be able to recommend another model in the same category that may fit better.
It is acceptable to recommend a specific brand or shoe company. For various reasons, we tend to place confidence in certain shoe companies based upon our past experience. We may have seen a recent trend in the past few years of a certain company offering shoes that patients were very happy wearing. Alternatively, we may be seeing trends of injuries in shoes containing a technology that is proprietary to a certain company. Patients will give valuable feedback about their experience with certain shoes in terms of fit and performance.

Educating The Patient About Purchasing Running Shoes
Although you may have confidence in the ability of the specialty running shoe store, you should give information to the patient regarding the fitting and selection of running shoes. These instructions can be preprinted in the prescription form to reinforce the importance.
Show the patient how to evaluate a shoe for key stability features. The American Academy of Podiatric Sports Medicine has established a Shoe Recommendation Committee that uses three essential criteria for evaluating stability in a running shoe: heel counter rigidity, forefoot flexion stability and torsional rigidity.
One can use the patient’s current running shoes as a demonstration for testing the stability and/or cushioning features. In many cases, one can correlate a flaw in the shoe with the current injury or condition affecting the patient. For example, plantar heel pain syndrome is commonly associated with shoes that have poor torsional rigidity. Emphasize this feature for patients with heel pain who are trying on new shoes.
Patients should wear their preferred running socks during the fitting process. Measure the foot with the running socks on. While the prevailing thought has always been that patients should purchase shoes at the end of the day or after activity, recent research at Northern Arizona University disputed the notion that feet expand in shoe size after exercise.4
If the patient has foot orthoses, he or she must take these devices to the running store for appropriate fitting. Depending on the style of the orthotic, instruct the patient to remove the existing sock liner of the running shoe to accommodate the orthosis. For foot orthoses without forefoot extensions, using a flat, padded insole under the orthotic may be recommended. Sometimes, an off the shelf running orthotic insole will be recommended with the shoe purchase.
A good running shoe store will allow the patient to run in the shoes as part of the selection process. Encourage patients to ask if they can run in the shoes before deciding on the best choice. It is helpful to place one brand on one foot and another brand on the opposite foot for an immediate comparison during running.
Direct patients to use fit and comfort as the ultimate criteria for shoe selection. Styling, colors and weight of the shoe should be secondary factors. Finally, if the store does not have the right size available, then the patient should ask the store to order the correct size or go to another store. Patients should not settle for a shoe that is just a little too big or too small simply because they need to buy shoes that day.

In Summary
Runners who present as patients to the podiatric physician almost always expect a shoe recommendation. It may be tempting for the podiatric physician to give a knee-jerk response of a favorite brand and model. On the other hand, with just a few minutes of evaluation, one can make a thoughtful decision that can dictate success or failure for the serious runner. The process described here is simple to do and will leave a lasting impression upon your patient. In the end, proper footwear is essential to the success of any treatment program implemented for the running athlete.

Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. He is a Past President of the American Academy of Podiatric Sports Medicine.

References:

References

1. Nigg BM, Cole GK, Nachbauer W. Effects of arch height of the foot on angular motion of the lower extremities in running. Journal of Biomechanics 26: 909, 1993.
2. Williams DS, McClay IS, Hamill J, Buchanan TS. Lower extremity kinematic and kinetic differences in runners with high and low arches. Journal of Applied Biomechanics 17: 153, 2001.
3. Butler RJ, Davis IS, Hamill J. Interaction of arch height and footwear on running mechanics. American Journal of Sports Medicine 34 (12): 1998-2005, 2006.
4. Chalk PJ, McPoil T, Cornwall MW.Variations in foot volume before and after exercise. Journal of the American Podiatric Medical Association 85(9): 470-472, 1995. For further reading, see “Key Insights On Recommending Running Shoes” in the October 2005 issue of Podiatry Today.