Foot Health: Footwear advice, adaptations and provision

Now I'm just gonna spend a few minutes just thinking a bit more about footwear. We talked about footwear earlier just considering really, the oval shape of your shoe choices. I think we just want to spend a little bit more time exploring that a bit further now. I think from the start, it's important to think about your footwear in terms of what you're gonna be doing with your feet on that particular day. So there's going to be certain types of footwear that you might use if you're indoors or you're walking on a level, but if you're going outside and you're on harder pavements, and lot of concrete floors for instance, the workplace or you're on ground that undulates, then your footwear needs are gonna be slightly different in order to protect your feet. If you have a look at the NRAS website, there's a whole section that has been put together by the team at University of Salford in Manchester. And there's particular information there about footwear, which I'd suggest you have a look at. There's also ARUK for instance, they provide a booklet on footwear. We got an example here, which you can have a look at in a moment. We've done our own version as well, so there's quite a bit of information out there. When you think about a shoe, I think the first thing to consider is its weight, because you probably find that during the day, you actually get quite tired, your legs are gonna be affected by heavy things on the end. And these are just two different sole units. We got three of them there. But if you compare the weights of those and that's just the different material choices, so sometimes people will buy very light shoes and then they will take them to be repaired, and actually the repairer will have to put on a harder composite unit and it actually really makes your footwear heavy, so that's the first thing to think about. I think the other thing to think about then is also the shape of your foot. So you want the shape of the front of your shoe or boot to really match up quite closely with the shape of the front of your foot as much as possible, and I appreciate for some people that becomes very difficult, we'll come on to that in a moment. We saw a slide early when Kim was talking about... And it showed a second toe that was actually hammered and it made the front for the foot quite deep as a result. So it's not just about thinking about width of the front, it's also thinking about the depth of the shoe box. If you've got a very broad foot and you put that into the shoe and it stretches the shoe, and we've got a slide to show you in a moment, it also makes a difference. So, yeah, I was saying that the... If you've got a foot that is very quite broad, and you put that in the shoe, and you've also got the toe that sticks up, that would draw the upper down because you're stretching the material one way, or pull it down in the other direction. So these are the things to think about. Also, where you've got stitching, those sorts of issues can make a difference. If you've got problems with the back part of your foot, so things like problems with the subtalar joint, that's our joint underneath the ankle joint or the posterior tibial tendon problems, Kim was talking about, that maybe a boot is gonna be better than a shoe because it's going to provide more stability. So those are the kind of things to consider, also fastenings, if you got difficulty with your hands or you belt it with a buckle or Velcro than laces. So it's all these variables. So that kind of brings back really to some of the stuff that's Sadie was talking about joint protection. And when is the benefits of footwear advices around providing protection to joints that are vulnerable, because you've got inflammatory arthritis, that makes the tissues a little bit more lax, which means they are more easily deformed by loads. And that's the big difference between our hands and our feet, isn't it, that actually when you look at the boney shapes and stuff, they are very similar, but we put our full bodyweight through our foot. If you've got problems with your walking or if you're in pain, you tend to be walking slower, so you're gonna actually put more load for longer period of time through a structure that's vulnerable, whereas if you can walk at the reasonable pace, then the actual load times are a lot shorter. So it makes a difference in terms of joint protection. Footwear can also help with relieving pain. So for instance, if you've got a foot square, it's very difficult to turn your foot inwards and outwards because this arthritic process has damaged that joint and that movement is painful. You might use a boot then that stabilizes that joint, stops the movement alongside. And so quite often we use maybe deeper insoles something like that, in this instance. That's kind of extremely deep, but it kind of makes the point. Just to provide that stability, that joint protection which then aids pain relief. And all that is, you know, if you take away the pain, on the whole, people tend to be more mobile. There's also the whole issue of falls prevention. And falling is something that happens in. If you look at the population of... People fall over, unfortunately. Sometimes people, we just have an accident. You know, I've fallen over, we've all fallen over. But sometimes people because of the health issues are falling over. But we do know that the foot problems will have an impact on falling and some people with particular foot problems are more likely to fall. And if you've gotten inflammatory arthritis, you may also have osteoporosis, so that makes you more vulnerable to fractures as a result of falling. So this whole joint stability, making people more comfortable, improving their mobility has an impact through falls as well. Your footwear choices are really important, in terms of preventing falling. So if you are barefoot or in slippers, it's something like, 20 fold increase in your risk of falling. So even indoors, try and wear stable footwear that is really well fastened to your foot. And again, think about, if you had sidewalk sorts of terrain, you're gonna be more active to what you're gonna be doing to try and make you more stable. And that's kind of also in the context of other walking aids, if people need them. And we've also just talked a little bit about wound and ulcer prevention and actually healing wounds and ulcers, and footwear choices, various insoles that they're very much a big part of that picture of actually getting some of this foot back to being intact and infection free. The picture on the corner there really shows the difference, and going back to this whole thing of stable footwear versus unstable footwear. That's quite an old picture, but I think it makes the point, it really does make a big difference in keeping people safe. Just to say, when you're looking at particular examples of where the foot will change shape and it's become very broad, and then, where you've also got a situation where you've actually got a very deep toe box needed because the depth of that foot, from the top of that toe to the bottom of the foot, has been exaggerate, where it's been enlarged by that deformity, then it's really important to try and accommodate everything. And as you can see on that far right picture, again, it's that little toe that's just got that tissue damage that we know underneath it 'cause of that change in color, there's something happening there. Really important to think about the toe box, the width of the toe box but also it already seems that might stop the material giving. The material is gonna give anyway. So the suede or the new buck materials will give better than having a firm leather. So one thing to do when thinking about choosing your footwear is to consider the material, so you want a softer material in the front part that's going to adapt the shape of the front of your foot, but without any particular seams over areas that are vulnerable, but you may be better with a more firmer material that makes the back section, particularly, if you're going for a boot as well. I think it's helpful to just think a little bit about provided footwear. And the reality is, for some people, their foot changes in shape to the point where it becomes very difficult to go to a commercial shoe shop and buy something, or they come to see a podiatrist like myself and we will be trying to manage that foot problem but we require to put an insole inside the shoe, so there is something like this. It has only got about 4 millimeter cushioning in the front part, but sometimes we need 5, 6, 7 millimeters, and you're not going to be able to get that into a commercial shoe and get the foot in as well. The risk is, if you do, you push it in and then you cause problems elsewhere. So then, it's those scenarios and particularly around problems with the tissue and the tissue breaking down or ulcerated that we will then get into provided footwear. And this is just another example of things we might put in the shoe, but it does need accommodating. And so that's, again, an example of when we're getting into provided footwear. Do you have somebody who will make shoes for you? Jimmy Choo probably doesn't do what we need, so do you have a factory that does them? Yeah, what will happen within the NHS is that most general hospitals will have attached an orthotic service. So an orthotic service is a service that provides things like footwears, insoles... It will do, say, collars for necks, any sort of device that needs having extend it to body to protect it, so splints, all that sort of stuff. And so that's a way of accessing that type of service. What happens here locally is that, there is an orthotic service attached to general hospital, but within the rheumatology service, we have a specialist footwear clinic, and there you have a podiatrist working with a shoe fitter, in this instance. Around the country, the models vary. Sometimes you have an orthotist working on their own. You may have a podiatrist who's been trained to provide footwear. There's lots of models, but, yes, you should be able to access some type of footwear provision within the NHS if you have a clinical need for that. So where you say, sometimes the patient will need an orthotic... It's so deep that you can't bend your foot in the shoe... Yeah. Does your contact, do they make a bigger shoe, a deeper shoe? Yes. You actually do that? It depends what you need. But, yeah, if you're providing, part of providing any sort of device like this is that you've got to get it into the shoe. And that's quite often a compromise, clinically, because we're working with footwear that somebody's happy with. And so we try and work that. So your choice of materials will depend on how much space you got to work with. So some with the lightweight, very flexible materials are relatively bulky, whereas others that come, fibers are very thin and slim line in terms of what you need in footwear. But the crux sometimes comes when you get to the ball of foot area, which is usually an area that we need to put some cushioning under. And the more cushioning you tend to get, the more comfort you get. But then that flips back to the shoe choice as well. So think about the shoe choices. If you have soft sole unit, then that will provide cushioning as well between the ground and the foot, so it's about thinking about the sole unit, not just what you're putting inside the shoe. I think those examples of sole interior, the hard, the heavy one is a hard resilient material, that won't provide any shock absorbing or shock attenuation for your foot. Whereas the other one is very light and it will really cushion your foot in relation to the ground. The downside is it will tend to break down and collapse more quickly and will need repairing more often. Here we've got some examples from our footwear clinic locally where I work with a shoe fitter. This is Aaron Tomkin and he is a shoe fitter. He comes from Clarks originally and he has worked in footwear all his working life. And he only works now with people with inflammatory arthritis. Here he is doing his measuring. You can see on the picture in the left. And these are some of the footwear that actually comes out through that clinic. And another thing, when you're providing footwear, clinically, we're trying to achieve particular things, we also trying to be sensitive to what people are happy to wear as well. I think that's a balance that we try to strive too. You can see that this sort of styles, standards available reflecting, really, people's needs and what area to manage in terms of hands and Velcro or laces and that sort of thing. Can you tell us how costly it is to have your shoes made by your department? I think when it comes to the cost of footwear provision, it varies because everybody's footwear is individual to them. And footwear on the whole is being made, espoused to that person to some level or other. So some, there is a range from shoes that you can order an extra width and extra depth, and that can become almost off the shelf from a specialist factor through to shoes that they will need to adapt and build around, adapted last in order to meet your need. In some cases, they may have to make the last. So that, those stages have different costs. Certainly, the footwear that we're providing I think is in the range of 320 up to 380, but it will vary depending on manufactures and it will vary considerably on individual's needs. And obviously, boots cost more than shoes. Thank you. Just a few more pictures of some different styles. And again, going back to what I was saying earlier about trying to have footwear that reflects what you're doing. So it might be that somebody has a pair of shoes but also has a pair of boots, which covers their activity or they have a trainer style pair of footwear and sort of functional pair of shoes as well alongside that too. It really depends on the individual needs. I put the picture in on the right and this lady kindly sent this to me just last week. And she obviously has particular difficulties with her mobility, but she also has very specific footwear needs in order to protect her feet. And she is wearing the pair that she's just received and she is dressed to match. And she is showing her previous pair as well. So she seems very happy with all that we've been able to do for her. I think just before we close, just run through some of that areas where you can get useful information. And obviously, the NRAS website and the helpline is a good place in terms of getting advice and guidance. Arthritis Research UK provide a lot of patient's information. And we've got an example here, I have a book about feet and footwear and arthritis. And you can go to that website. You can just view these or you can download them to print. There's information there about all the rheumatology conditions and also a lot of information about specific problems. I've put on there also The College of Podiatry, so that's the Society of Chiropodists and Podiatrists website. And on that website, you can actually find out information about general foot problems, not necessarily specific to rheumatoid arthritis or inflammatory arthritis but more, sort of, the general population. But there is also, if you're looking to find somebody in private practice to go and see him in terms of your feet and foot care, then they actually provide that facility through that website. We put on there also The Health and Care Professions Council, the HCPC website. And they are the body that, in effect, they regulate us, ourselves, our patient therapy, physiotherapy and the other care and social care professions. On that website, there's a facility to put in the name of the person you're seeing in terms of your foot care provision and you can just confirm that they are HCPC registered, which is quite a useful facility to have there. So just before we close, during the session, we've considered a number of issues. We've looked at the foot problems that people with inflammatory arthritis have. We've kind of given the background to foot problems that they are something that crop up in the general population as well. But if you've got inflammatory arthritis, then those problems can be more significant and maybe need managing in a slightly different way. We've talked a bit about medication and then go on to sort of think about these other things you might want to think about yourself in terms of making sure your feet stays safe, but what is appropriate for you to deal with yourself and what you need to go and get help out. We then looked at some specific problems and how they could be managed. And we've also talked a little about footwear before considering where to get help. Not just in terms of online resources but getting access to health professionals.