A shoe is like a crime scene; if you study it carefully, you can "detect" a lot about a patient's postural condition -- and usually discover the source of his/her musculoskeletal problems. Worn-out shoes -- or shoes that do not fit properly -- can interfere with the proper working of custom-made orthotics. "Bad" shoes can also have a negative effect on the feet, pelvis, and spine.

For example, a survey on women's shoes found that 88% of the women surveyed were wearing shoes that were smaller (avg. 1.2 cm smaller) than their feet (Frey C, Thompson F et al. "American orthopaedic foot and ankle society women's shoe survey." Foot & Ankle 1993; 14:78-81). Is it any wonder that 80% of the study participants reported "some foot pain," and that 76% were noted to have one or more forefoot deformity?

Poorly fitting, unsupportive shoes can cause serious problems. When a patient stands in his/her shoes, you should be able to palpate the large toe joint and find it positioned at the widest part of the shoe. If the joint is forward of this area, the shoe is too short (the shoe is seldom too long). When a shoe is ill-fitting, it is usually short and wide. Casual shoes are generally fitted short, to make certain that the foot is "wedged" into the shoe in such a manner as to avoid heel slippage.

It is very important that all shoes a patient wears are properly fitted and of proper construction. Shoes that are broken down, vamps pushed over (the top of the shoe pushed laterally), with uneven heel and sole wear usually tell a story that is easy to read.

Heel wear. Normal heel wear is slightly lateral of the mid-line. Heel wear should be even on both sides. If one side is worn more than another, this can indicate a weakness on that side.

Usually in my practice, I find the shoe that has the most wear is on the side of my patient's knee, hip or spinal problem. Observe the heel wear -- you will be amazed.

The counter. Place your thumb and forefinger on either side of the counter and squeeze; it should be very firm, with almost no give at all. Counters do much to stabilize the feet. When the foot pronates, the calcaneus tilts medially at the top and tends to "kick outward" at the bottom. A strong counter is needed to prevent the calcaneus from pushing over the side laterally.

Next, set the shoe on a hard, flat surface. If the shoe has a heel, you will find a space between the front of the heel and the point where the sole contacts the surface. The area between these two points is called the shank. Generally, the shank is reinforced to help prevent breakdown. Feet that are weak, have fallen arches, or are pronated require support in this area and tend to break down the shank when not properly supported. Even a steel shank does not always provide the necessary strength to prevent a breakdown. In these instances shank breakdown is readily recognized by the sole wear.

Sole wear. Turn the shoe over and examine the sole. Start at the toe and let your eyes follow the sole wear toward the heel. At the point where the sole wear "feathers out" and stops, draw a horizontal line with a pen or pencil. Repeat the same procedure with the opposite shoe. Determine which shoe demonstrates sole wear closest to the heel. If you find visualization difficult, measure with a rule.

The shoe that demonstrates the sole wear beginning closest to the heel indicates the side of greatest pronation. Further examination of the patient will reveal the patient usually has a weak psoas, weak abductors, and weak neck flexors on that side -- unless trauma is a factor. The patient may have symptoms of one or more of the following: knee pain, hip pain, lumbosacral or sacroiliac involvement, or cervical problems on that side -- again, unless trauma is a factor. If the shank is breaking down excessively, new shoes are recommended.

Proper footwear will do much to help your adjustments hold better. Restoring balance to the pedal foundation can be accomplished far more effectively if you take a few moments to instruct the patient as to the type of shoe that will be best for his or her particular condition. Generally, a good lace-type shoe with firm counter is best.

1. Make sure shoes fit properly -- ball of foot at widest point of shoe.

2. Remove any generic insoles from shoes before inserting custom-made orthotics.

3. Old, broken down shoes should be thrown away.

4. Buy shoes as you would buy fruit -- squeeze them in the heel area. You want a firm counter around the heel to help support pronated feet (supinated feet need a "squishy" or soft counter).