Footwear First

Posted by PPL Biomechanics on

Considering Why the Quality of the Footwear is of Equal Importance to any Prescribed Device.

Christine Kiernan, 20th February, 2024

When approaching a biomechanical assessment for new patients with a view to provision of foot orthoses, managing patient expectations should be at the forefront of any clinical plan. In my own experience, it is important to set realistic and achievable goals in forming a strong treatment alliance with your patient, particularly if provision of foot orthoses form part of that treatment. One of the phrases I commonly use before approaching foot orthoses is “footwear first” as I feel it is ineffective to provide expensive custom foot orthoses in poor, ill-fitting footwear.

Where supportive devices are required to stabilise a hypermobile or degenerative/arthritic foot, they will become far less effective in a flexible soled shoe that can be folded in half.  At times, simply changing footwear to a supportive styled lace up shoe with a stiffer sole can eliminate the need for custom devices.

Selecting the Right Footwear for each Individual Foot Type

Ensuring the footwear can accommodate an orthotic device is of paramount importance. Selecting the right footwear for each individual foot type however may be considered a challenge. This is particularly the case if there is a history of foot ulceration, significant joint subluxation or a history of complex foot surgery.

Evaluating the Impact of Poorly Fitted Footwear

Pressure lesions presenting on the fore-foot are often associated with ill-fitting footwear including reduced toe box volume and shape. It has also been suggested that continual wearing of poorly fitted footwear has been associated with joint pathologies and misalignment as well as fore-foot lesions, particularly of the medial and lateral border areas1,2,3.  This also has a significant impact on patients with decreased sensation leading to increased repetitive pressure4, and patients presenting with peripheral arterial disease. 

We know that people presenting with Rheumatoid or Psoriatic arthritis may also present with digital changes requiring a deeper toe box to accommodate any joint distortions. We also know from previous research that where ulceration has occurred in patients presenting with diabetes, that the risk for re-ulceration is 40% within in the first year after wound resolution with a further 60% risk after three years 9, 10. Even the commonly presenting hallux valgus can pose a problem when requiring additional width at the fore-foot of the shoe in an otherwise slender foot.

When selecting high street standard wide fitting footwear for hallux valgus, frequently the width is adequate at the forefoot although the rearfoot may not require the same room resulting in a “pistoning” heel. Occasionally, if there is a mild deviation of the hallux (grade 1 to 3 Manchester Scale)12 well fitted high street footwear or medical grade footwear may meet the patient’s individual requirements.

Considering the Individual Patient Needs

A review carried out by Frecklington et al.11   in 2018 found that the use of therapeutic footwear demonstrated a reduction in plantar pressure lesions, improvements in presenting pain and foot function along with walking velocity in people with Rheumatoid Arthritis, Gout and 1st MTP joint arthritis. Where therapeutic footwear can provide significant benefits for more at-risk or sensitive foot types, a comprehensive clinical evaluation must consider the individual patient needs. For example, a patient presenting with a large discrepancy in sizes between feet, along with a fixed bony equinus and a symptomatic limb length discrepancy of over 15mm, may be more suited to modular or bespoke footwear.

Convincing Patients to Transition to More Suitable Footwear

Another key consideration is the relationship the patient may have had with their previously loved elegant footwear. It’s often challenging to convince someone to move from a very narrow evening shoe to a more supportive, wider deeper option.

Thankfully, styles have vastly improved in recent years with more options in materials and styles. Consider having a candid conversation about how a certain shoe, that was perfectly acceptable some years ago, may now be a problem due to changes in the foot shape.  This may be an effective and kind approach to convince someone to transition to more suitable footwear.  Or at least to come to a compromise.

Prescribing Footwear

At PPL we pride ourselves on providing expert advice to our clients with respect to the selection of suitable footwear. Our team of technicians have amassed years of experience in prescription of footwear and are always happy to share their knowledge.  For  more information please click here


  1. Hurst B, Branthwaite H, Greenhalgh A, Chockalingam N, 2017, Medical-Grade Footwear: The impact of fit and comfort, Journal of Foot and Ankle Research, Vol. 10, No. 2
  2. Macfarlane DJ, Jeffcoate WJ, 1997, Factors contributing to the presentation of Diabetic Foot Ulcers, Diabetes Medicine, Vol. 14, No. 10 pp 867-870
  3. Kadambande S, Khurana A, Debnath U, Bansal M, Kariharan K, 2006, Comparative Anthropometric analysis of shod and unshod feet, Foot, Vol. 16. No. 14, pp 188-191
  4. McDonagh C, Nube VL, Frank G, Twigg SM, Penkala S, Holloway S, Snyder R, 2022, Does in shoe pressure analysis to assess and modify medical grade footwear improve patient adherence and understanding? A mixed methods study, Journal of Foot and Ankle Research, Vol. 15, No. 9
  5. Menz H, Auhl M. Ristevski S, Frescos N, Munteanu SE, 2015, Effectiveness of off-the-shelf extra depth footwear in reducing foot pain in older people: A randomized controlled trial, Journals of Gerontology, Vol 70, No. 4, pp 511-517
  6. Sudram ER, Sidek MY, Yew TS, 2018, Types and grades of footwear and factors associated with poor footwear choice among Diabetic Patients in USM Hospital, International Journal of Public Health and Clinical Science, Vol. 5, No. 2
  7. Resende RA, Fonseca ST, Silva PL, Pertence AE, Kirkwood RN, 2014, Forefoot midsole stiffness affects Forefoot and Rearfoot Kinematics during the stance phase of gait, Journal of the American Podiatric Medical Association, Vol. 104, No. 2, pp 183-190
  8. Zwaferink JB, Custers W, Paardekooper I, Berendsen HA, Bus SA, 2020, Optimizing footwear for the diabetic foot: Data-driven custom-made footwear concepts and their effect on pressure relief to prevent diabetic foot ulceration, PLOS One, accessed from: Optimizing footwear for the diabetic foot: Data-driven custom-made footwear concepts and their effect on pressure relief to prevent diabetic foot ulceration | PLOS ONE
  9. Armstrong DG, Boulton AJM, Bus SA, 2017, Diabetic Foot Ulcers and their recurrence, New England Journal of Medicine, Vol. 376, No. 24, pp 2367-2375
  10. Zwaferink JB, Custers W, Paardekooper I, Berendson HA, Bus SA, 2020, Optimizing footwear for the diabetic foot: Data driven custom-made footwear concepts and their effect on pressure relief to prevent diabetic foot ulceration, PLOS ONE, Vol. 15, No. 4
  11. Frecklington M, Dalbeth N, McNair P, Gow P, Williams A, Carroll M, Rome K, 2018, Footwear interventions for foot pain, function, impairment and disability for people with foot and ankle arthritis, Seminars in Arthritis and Rheumatism, Vol 47, No. 6, pp 814-824
  12. Menz HB, Munteanu SE, 2005, Radiographic Validation of the Manchester Scale for the classification of hallux valgus deformity, Rheumatology, Vol. 4, No. 8, pp 1061-1068

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