Shoes for Children: A Review
Lynn T. Staheli
Pediatrics 1991;88;371-375
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SPECIAL
Shoes
Lynn
ARTICLE
for Children:
A Review
MD
T. Staheli,
From the Department
of Orthopedics,
Children’s
Hospital and Medical
and Department
of Orthopaedics,
University
of Washington,
Seattle
The nature
of appropriate
footwear
for children
remains
a controversial
issue.
Some
physicians
believe that shoes are simply part of the child’s clothing, while others
believe
that shoes are important
therapeutic
tools capable
of correcting
deformity
and
preventing
This review
shoes,
the
the
significant
disability
later
in life.
focuses
on how the foot fares without
normal
effect
development
of footwear
recommendations
and
footwear
based
on
and
for
for
data
shoe
children.
rather
child’s
than
foot
were
Sim-Fook
impressions
or
The
natural
has been
examined
and
that
greater
the
wearing
though
noted
of the
foot,
ie,
the
studied
by several
investigators.
the feet of 186 natives
of the
Central
Africa
who
had
not
he found
some
variability
that all feet showed
excellent
worn
bare
foot,
Hoffman1
Philippines
shoes.
Al-
in the tribes,
he
mobility,
thick-
ening
of the plantar
skin,
and wide variability
in
the height
of the arch. He reported
that eversion
of
the foot was rare and that these people’s
feet were
pain-free.
Engle
and
Morton2
infections
footprints
found
of natives
no
static
studies
deformi-
118
shoe-
Chinese.
barefoot
fewer
of the
foot
compared
of the
and
and
subjects
showed
than
of those
that
the
deformities
consistently
They
showed
un-
shod human
foot is characterized
by: (1) excellent
mobility,
especially
of the forefoot;
(2) thickening
of the plantar
skin as great
as 1 cm, which
was
FOOT
state
to parasitic
non-shoe-wearing
feet
Seattle;
apparently
experiencing
They
found
that
major
Hodgson4
107
mobility
shoes.
These
BARE
the
He
and
and
found
are
fmdings
due
studied
Islands.
wearing
some
tradition.
THE
problems
trauma.
James3
Solomon
ties.
modification,
Our
of live coals,
whatsoever.”
foot,
modifications,
effective
normal
objective
of the
shoe
through
a bed
no discomfort
Center,
studied
the
feet
of
usually
determined
environment;
(3)
dorsum
of
midtarsal
with the
joints;
metatarsals
variability
in
static
features
in their
the plantar
and
foot due to the flexibility
of the
(4) alignment
of the phalanges
causing
the toes to spread;
(5)
arch
height;
and
(6)
an
absence
of
deformity.
NORMAL
unshod
natives
in the Belgian
Congo.
They
found
an absence of “static
foot deformities”
and noticed
that
because
of the extreme
thickening
of the plantar
skin,
the natives
“would
not
hesitate
to walk
the
by the surface
creases
on both
Arch
FOOT
DEVELOPMENT
development
mented
by
changes
footprint
foot
pattern
This
was
in
Morley.5
to
one
supported
children
was
This
study
with
advancing
showing
first
docu-
showed
that
the
age from
a flata longitudinal
in a study
by
arch.
Engel
and
Sta-
heli.6
In
Received
for publication
May 29, 1990; accepted
Sep 5, 1990.
Reprint
requests
to (L.T.S.)
Director,
Department
of Orthopedics, Children’s
Hospital
and Medical
Center,
4800 Sand Point
Way NE, Seattle, WA 98105.
PEDIATRICS
(ISSN
0031 4005).
Copyright
© 1991 by the
American
Academy
of Pediatrics.
1987,
sample
ment
was
made.
nal
that
This
arch
the
et a17 reported
with
a larger
normal
subjects).
Arch developdocumented
and standard
deviations
Staheli
size
(442
study
develops
range
demonstrated
during
of normal
the
that
first
the
longitudi-
6 to 8 years
and
is broad.
PEDIATRICS
Vol. 88 No. 2 August
Downloaded from www.pediatrics.org by Michael Martin on September 13, 2007
1 991
371
recently.
Pediatricians
Most recently,
Gould et al8 observed
125 subjects
for 4 years
during
early childhood.
Arch development proceeded
independently
of the type of foot-
the
and
wear
to a questionnaire
worn.
These
that the
during
occurs
studies
are
longitudinal
infancy
naturally
The
consistent
in
arch develops
and
and
childhood.
independently
radiographic
child’s foot
1988. They
bearing
changes
in
children.
eters
talar
age.
The
included
respondents
veyed,
44%
of 400 physicians
preferred
soft
high-topped
shoes,
the
associated
with
and talometatarsal
range
values
of normal
previously
1980,
developing
et al9 in
weightsurvey
of
param-
flatfeet,
angle
was
to 500
development
of footwear.
a cross-sectional
found
radiographic
They
commonly
inclination
with
in
sent
ered
very
considered
that
is,
change
and
broad
tennis
diagnostic
of
shoes
Staheli
Only
paedic
diatric
of
and
more
the
and
ufactured
in the
EFFECTS
OF
consid-
for
past
the
shoes,
32%
preferred
tennis
shoes.
“ortho-
pediatrician
and the pemost
opposed
to rigid
decade
changing
the shoe
attitudes
shoes
less
mn
children.
recommended
by producing
flexible
Dyment
respondents
279
24% preferred
the
were
to
question
found
that of the 269
and podiatrists
sur-
pediatricians
footwear.
During
has
responded
to
pediatricians
Griffin’7
shoes.”
Again,
orthopaedist
physicians
first
mn 1972,
to be satisfactory
and
7%
the
footwear.
75% of the
demonstrating
spontaneously
were reported
by Vanderwilde
provided
normative
data
from
radiographs
normal
This
were
value
of supportive
Bogan’#{176}found
that
that
constrictive
industry
among
are
somewhat
than
those
THE
FOOT
man-
past.
pes planus.
THE
HISTORY
OF
The
The
in
history
of footwear
was
1972.’#{176}He noted
that
dating
from about
reviewed
by
the earliest
10 000 years
wear,
Stewart
a status
rope.
Pointed
of Anjou
the
symbol
shoes
to hide
foreshoe
his
in Greece,
were
introduced
own
deformed
length
became
has
known
footago, was re-
covered
from
caves
near Fort
Rock,
Oregon.
were worn
in ancient
Egypt
and Mesopotamia.
tially
worn
to protect
the foot from
injury,
became
Rome,
Shoes
shoes
and
feet.
Eu-
heels
to
to signify
Shoes
a decree
length
grain
were
increase
high
were
often
the
social
sized
elevated
from
the
in
that
Measurements
which
were
mm.The
and
barleycorn,
is about
started
facilitated
the
one
third
at 3 inches
shoe
based
standard
and 7 inches
for adults.
Standard
based
on increments
of one twelfth
standardization
distribution.
de-
individual
century
shoe
of a
of an
inch.
for children
shoe widths
of an inch.
were
This
manufacturing
and
adult
shoe
by fashion.
design
During
past
shoe
for children
was
200 years,
by
quired
rigid
and
shoes,11’5
372
the
often
design
impression
“support.”
Many
by
corns,
Supportive
the
child’s
has
the
deterfoot
which
The
of
usually
this
CHILDREN’S
was
cover
not
imitate
have
aged
were
not
McKee,24
74% were
in
shoe
observed
child’s
foot
tential
studies
rigid
and
opinion
until
shoe.”
foot
disability
worn
children,
concept
that
that
that
shoes.
found
footwear
deformities
in the
CORRECTIVE
The
these
deformities
not
that
that
the
configuration
of
did not conform
to conventional
suggest
to produce
tic” appears
assumptions
to
had
2 to 4 years
the
lasts.
These
THE
of 4000
of
who
wearing
shoes that were 0.5 to 3.6 sizes
Furthermore,
Bleck,25
in a study of 1000
too small.
children,
normal
a study
noted
effects
by Emslie,23
toes.
who
the
who
been
The
These
in children
that
Socrates,
some
seen
shoes
noted
had
of the
but
that
ill-made
and
of footwear
of
painful,
observers.”2”922
deformity
on
taste
He noted
by
era
based
the feet with
walking
caused
of
disability
shoes
impossible.”
feet
18th
professor
depraved
and
render
effects
other
that
or the
foot
the
of
footwear
on children
were studied
noted that 80% of 281 children
was
a minority
the
harmful
many
footwear
objected
only
absolutely
on the
In
Dutch
noted
the toes
not
cases
disease
by
re-
compressive.
physicians
but
that
He
had
frequency
of fashion
“deformed
has
authors.
acclaimed
the
footwear.
“absurdities
significant
2000
years,
determined
mined
on
of
length
For the past
been
primarily
an
observed
dated to the pre-Christian
world unfortunately
did
went barefoot.
the
to ridiculous
14th
the
many
the
introduced
theorized
of the
Camper,’8
medicine,
shoes
by
to
status.
from
Edward
was based
on the
of barley,
ON
wearing
a time,
proportional
height
century
in some
the heel’s original
purpose
was to stabilize
the foot
of the mounted
warrior
in the stirrup.’#{176}Again,
the
original
functional
role of the shoe
was altered.
mn
grees
that
reported
the day”
Fulk
For
effect
been
caused
mi-
by Count
individual’s
social
status.
Heels
were
Europe
in the 16th century.
Stewart
France,
FOOTWEAR
SHOES
foot
the
poand
adult.
SHOE
shoe
design
to be based
on
that the growing
the
has
in children
can
be
could
the
molded
SHOES
Downloaded from www.pediatrics.org by Michael Martin on September 13, 2007
be “therapeuwidely
foot
needs
by
accepted
support
a “corrective
The
assumption
likely
to
traced
to Andry26
that
that
develop
minor
the
child’s
normally
in the
postural
foot
18th
century.
variations
No significant
is most
if “supported”
can
be
were
a
common
cause
of adult
disability
and taught
that
proper
posture,
therapeutic
exercises,
and supportive footwear
in the child would prevent
adult disability.
ported
A common
arch could
belief
was that
be permanently
the
child’s
flattened
difference
Bordelon41
ometatarsal
He theorized
in childhood
trast,
unsupunless
angle
children
with
The
effect
assessed
by
subjects
that
et al43 treated
even
today.235
Evidence
suggesting
are unnecessary
comes
First,
data
indicate
that stiff, supportive
shoes
primarily
from two sources.
that
barefooted
stronger
and healthier
feet
than those who wear shoes.
have shown
that
the arch
regardless
of footwear.
The idea that the child’s
subjects
with fewer deformities
Second,
several
studies
develops
in the child
foot
can
as those
associated
or improved
by the
external
modeling
forces
such
casts.
Other
examples
include
is based
on
First,
that
with clubfeet
application
of
as a series
of molded
the use of bracing
in
scoliosis and orthodontic
appliances
in dentistry.
Second,
that the application
of external
forces
can cause
deformity.
Examples
include
the severe
cavus deformity
induced
by binding
the feet of girls
in China and the “giraffe
neck” deformity
produced
by applying
rings around
the neck of growing
children
in Africa.
and
Hodgson4
Furthermore,
in
as noted
1958,
it
appears
by Sim-Fook
that
causes
of the
such deformities
correction
and
as bunions.
These
creation
of deformity
ternal
forces
basis
are
the
“corrective
shoe.”
The assumption
formity
is responsible
cations
such
and
plate,37
Mattison39
supports
keted.
the
forces
a myriad
in 1933 estimated
50
few objective
the
validity
“corrective
shoe.”
immediate
effect
Penneau
Two
of arch
et
shoes
data
of
de-
were
being
have
shoe
flatfeet.
wedges
one
on intoeing
study.
The
has
been
commonly
pre-
as
measured
by
ious
shoe
with
corrections
inserts
been
reported.
a
pes
a period
reduction
Berzins44
the UCBL
planus”
Labo-
of 2 years.
improvement
and
Mereday
“flexible
in
in
improvement
was
maintained
month
follow-up
period.
and
with
on
Biomechanics
for
experienced
configuration,
assessment
with
of California
(UCBL)
children
have
10 children
University
ratory
video
This study,
plus clinical
expeshoe wedges
are ineffective
in
problems.
studies
of children
with var-
All
gait,
arch
discomfort.
The
throughout
treated
insert
a
71 children
or Helfet
6-
for pes
heelcup38
for more than
improvement
1 year. Seventy-nine
percent
showed
by clinical
and radiographic
measure-
ments.
Bordelon45
reported
dren
for
treated
ported
a follow-up
pes
planus
improvement
in
of 6 of 50
with
the
inserts.
chil-
He
talometatarsal
re-
angles
following
customized
orthotic
use and in 5 of the 6
patients
seen at follow-up
the correction
had been
maintained.
These
three studies
were conducted
without
control
subjects
and
that
with
provement
graphic
studies
reported
by Vanderwilde
radiographic
were
of
open
normal
criteria
to
of im-
question.
subjects
et al.9 They
Radio-
were
recently
found
that
the
normal
range
included
talometatarsal
angles
of up
to 20 degrees
in this early childhood
age group. This
range was defined
as abnormal
by Bordelon.45
Furthermore,
the wide range of normal
puts into question the criteria
for improvement
of just 3 degrees
prospective
arch
the effectiveness
of shoe
the flexible
flatfoot.
mn a
mar-
3-year
compared
modifications.
only
tal-
in 50
published
modification
the
by radiographic
children
with
both
of their
hypermobile
of shoe
inserts
by Bleck
and Berzins.44
mn 1989, two controlled
modifi-
100 different
supports
applied
cause
of shoe
available
from studthe
concept
of the
studies
al4#{176}
studied
taken
planus
feet by radiographs
feet and with commonly
of the
heel,3#{176} Whitman
mn Great
Britain,
that
“doctor’s”
examples
by ex-
concept
external
for
as the
Thomas
Helfet
heelcup.38
and
There
are
ies assessing
studies.
that
for
footwear
in the
by custom-molded
mirrored
gait ramp.
rience,
suggests
that
managing
rotational
Several
longitudinal
Bleck
planus
be effectively
changed
by wearing
a “corrective”
shoe
observations
that fall into two categories:
deformities
such
can be corrected
have
mn con-
demonstrated.
improvement
scribed
wedges
were applied
to the sole of the shoes
of intoeing
children
by Knittle
and Staheli.42
None
of the wedges
improved
the intoeing
of the 10
the foot was supported.
An example
of the common
teaching
of the time was by Griffith,27
who advised
parents
that
their
“infants
should
be taught
to
creep, and early walking
discouraged.”
The desirability
of the stiff shoe for the child has
been
a classic
recommendation
of orthopaedists
persists
was
reported
pes
bare
that
study
evaluated
in correcting
of 129
children,
no difference
between
treated
a variety
with
those
with normal
flexible
studied
125 children
for
planus”
at the beginning.
were
prescribed.
gardless
controlled
of the
studies,
Wenger
children
of
Arch
footwear.
the
studies
with
were
et al46 found
flexible
“corrective
flatfeet
shoes”
and
footwear.
Gould
et a18
5 years.
All had “pes
Four types
of footwear
development
In these
application
SPECIAL
Downloaded from www.pediatrics.org by Michael Martin on September 13, 2007
occurred
two
re-
prospective
of
ARTICLE
“corrective
373
shoes”
tudinal
did not affect
the
arch of the child.
Regardless
of
the
development
of the
8. Acceptable
longi-
very
effectiveness
of
9. Reasonably
“corrective
shoes,” an important
consideration
is the reason
for attempting
correction
of the flexible
flatfoot.
Harris
and Beath,47
in the classic
Canadian
Army
foot study,
showed
that the flexible
flatfoot
in the
adult
is a benign
condition.
msraeli Army
study48
showed
Furthermore,
fewer
stress
individuals
The
with
suggests
that
child
the
low arches.
treatment
is probably
of the
both
a recent
injuries
in
available
evidence
flexible
unnecessary
flatfoot
and
in
in
ineffec-
wear
because
appearance
sensitive
about
priced.
Medically
not be expensive.
need
children
are
that.
satisfactory
foot-
“Tennis
shoes”
are commonly
recommended
for
children.
Unfortunately,
“tennis
shoes”
encompass
a large variety
of shoe types. Some are ideal, meeting the criteria
perfectly,
while
others
have stiff
soles
with
scribe
parents
occlusive
uppers.
the characteristics
rather
than simply
Physicians
should
of a good shoe
recommending
de-
to the
“tennis
shoes.”
tive.49
NONCONTROVERSIAL
CURRENT
USE
SHOE
MODIFICATIONS
IN
THE
FUTURE
Shoes
mize
Some
shoe
modifications
modifications
are not
may
be of value.
“corrective”
but
immediately
demonstrable
the short leg equalize
limb
effect:
length
gait.
older
(2) Shoe
inserts
in the
These
produce
some
(1) Shoe lifts for
and may improve
child
or adolescent
with rigid foot deformities
may redistribute
weight
bearing
more evenly
about
the sole for pain relief
or skin protection
of the insensate
foot. (3) Shockabsorbing
rubber
dromes
hood
footwear
inserts
such
and
with
cushioned
soles
or
tion
while
routine
NORMAL
synchild-
FEET
is important.5#{176} Shoes
that
are
the toes
and create
deformity.’6
length
likely
the child
to
fall.51
too
If
will become
Probably
the
best
model
for footwear
is the
unshod
state
as
shown
by the
studies
of barefoot
populations.
It
provides
a basis
for setting
the criteria
to achieve
The
1. Quadrangular,
configuration,
toes.23’24’52
most
to
with
effective
conform
abundant
to
footwear
the
should
normal
space
should
in the
shoe
FOR
comfort
an acceptable
add
to maxi-
and
protec-
appearance.
of maximum
would
CHILDREN
be designed
to provide
retaining
cushioning
comfort
and
The
fea-
reduce
the
incidence
of the overuse
syndromes
common
during
late childhood
and adolescence.
Physicians
need to
promote
the concept
that
shoes
are part
of the
child’s clothing,
and selection
should be based on
practical
rather
than
medical
considerations.
SUMMARY
1. Optimum
the shoe is of excessive
clumsy
and
is more
footwear.
and
incorporation
tures
adolescence.
SHOES
FOR INFANTS
AND CHILDREN
WITH
future
function
foot
ideal
be
of the
FOOTWEAR
foam
is helpful
in managing
overuse
as heel or shin pain during
later
Proper
fitting
short
compress
OF
foot
for
the
to allow free foot movement.’2’13
without
elevation
of the heel.’1
4. Porous.
Uppers
should
be made
of leather
or
unsealed
fabric to avoid skin maceration
or fungal infections.
5. Moderately
tractive.
Sole
friction
should
be
equivalent
to that of the bare foot. Soles that
are slippery
(leather)
or that
create
excessive
friction
(some rubber
soles) should
be avoided.’
6. Light
weight
to reduce
energy
expenditure.
7. Extended
above
the ankle
in the toddler
to prevent the shoe from slipping
off during
running.’7
foot
development
occurs
in the bare-
environment.
2. The primary
role of shoes is to protect
the foot
from injury
and infection.
3. Stiff and compressive
footwear
may cause deformity,
weakness,
and loss of mobility.
4. The term “corrective
shoes”
is a misnomer.
5. Shock
absorption,
load distribution,
and elevation
are
valid
indications
for
shoe
6. Shoe selection
for children
the barefoot
model.
7. Physicians
should
avoid
commercialization
and
modifications.
should
and
“media”-ization
be based
on
discourage
the
of footwear.
Merchandizing
of the “corrective
shoe” is harmful
to the child, expensive
for the family,
and a discredit
to the medical
profession.
2. Flexibls
3. Flat
374
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SPECIAL
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ARTICLE
375
Shoes for Children: A Review
Lynn T. Staheli
Pediatrics 1991;88;371-375
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