Written by By Paul LaFata, DPM

Originally shared in the May/June 2021 PPMA Newsletter

Helping Runners Pick the Right Shoes Can Prevent Running Injuries

We all know these patients. We see these patients often. They are the ones who need pointed in the right direction as what to look for in a proper walking/running shoe, and subsequently help to avoid the running injuries we see regularly in our practices. Noting that most runners have a good feel for their shoe-gear. It’s the new runners/weekend warriors that tend to need to be pointed in the right direction. 

Spelling out the ‘anatomy of a shoe’ may be in order, something I find has helped my patients considerably. Especially when presented with these common run-ning injuries that sometimes manifest from shoe-gear—most commonly hammertoes, advanced metatarsalgia, ingrown toenails with or without subungual contusion, or subungual contusion alone. 

One common condition is “Runners Toe,” one where patients have sought repeated treatment. This problem presents with subungual contusions, which may lead to lysis of the nail-plate separating from the nail-bed. The source of the problem with this condi-tion may result from anterior shearing in the shoe. Thus not allowing the heel counter of the shoe to control the heel. This sometimes results from the lacing pattern of the running shoe. 

Going Back to Biomechanics Lab
It is typical for runners to increase their shoe size by approximately one-half their normal size. This takes into consideration the increase in swelling, which can occur with long-distance running. It also can compen-sate for the anterior displacement forces in the shoe; but what are we doing, as podiatrists, to prevent the foot from sliding anteriorly when running?

Being familiar with the anatomy of a shoe can make a difference with our patients. This goes back to our days in biomechanics lab in podiatry school when we reviewed the components of a shoe: the last, the shank, the medial posting, the shock absorption, and heel counter. 

1. The “last” refers to the template of the shoe, or the model for which the shoe is constructed. The last could be board (firm), slip (flexible), or strobel constructed. Strobel is most commonly found in running shoes. The shape of the last can be straight, curved, or semi-curved.

• Straight-lasted shoes are typically more supportive, and a curved last is less supportive.
• Most running shoes are a combination of moderate support with some flex to them and use a semi-curved last.

2. Overall, the shoe is divided into three parts: upper, outsole, and midsole. The upper, is the outside tip of the shoe and is stitched to the sole. The outsole is the bottom rubber, while the midsole is the insert between the two. This insert built into the shoe offers stability, along with the manufacturer’s insert.

• Stock midsole cushioning is typically made of EVA or a manufacturer’s proprietary foam.
• Midsole support often has a stabilizing bar extending from the medial arch to the medial heel. Different vendors have their own names for these, but they all aid in support, and tend to be more effective in controlling pronators. Additional medial posting may be found in rearfoot-motion-controlling shoes.

3. A shoe’s heel counter is considered the back of the shoe.

4. The shank is a rigid insert typically placed on/in the bottom outsole to create rigidity to the shoe’s midsole, and places more stress distally, allowing toe flexion to occur.

Together these things contribute to the overall fit and the amount of stability a particular shoe can provide. Most of the major brands all carry variations of these components, which may cause an underlying problem if the shoe doesn’t fit properly.

Evaluating a Patient’s Shoe-Gear 
I find it remedial to discuss/evaluate shoe-gear with patients. I evaluate the last, insole, and support, showing them the components of the shoes that may correlate and/or contribute to their pathology. We discuss biomechanics in layman’s terms.

Most often I find that patients wear shoes that are too small. Yet I have patients who present with symp-toms identical to those who wear their shoes too small, but the shoe size is correct. Examples would be—a subungual contusion or proximal nail-fold paronychia with a normal appearing nail. Here is what I do for these patients—

1. I evaluate the patient’s shoes by taking out the insoles and showing them the “wear pattern” of their toes. If these shoes are the appropriate size yet the
toe-pattern force acts as though the shoe is small, it means the toe-wear pattern is pushing up to the edge of the insole. 

2. From here, if the shoe is the appropriate size, we discuss a shoe-lacing technique to prevent the foot from sliding in the shoe. This obviously isn’t for those patients who necessitate velcro closures.

3. The technique is called the “heel lock” and is very simple. It is an effective way to lock the rearfoot into the heel counter, and is as follows so you can consider passing this along to your patients:

• This lacing pattern/technique creates an extra pulley-like tension at the proximal laces.
• This prevents the heel from sliding forward in the shoe.
• It is effective in controlling the heel in a proper-fitting shoe. 

It may seem like a formidable task to take more time with patients, but it has been in offering this basic education on a shoe’s anatomy that has greatly bene-fited my patients. Remembering also that some patients will always need velcro closures!   

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PHOTOS:

Figure 1: Heel-lock lacing creates a loop by utilizing the top two holes. One of the holes is usually offset a bit posteriorly.

Figure 2: Tighten laces as this creates the heel lock and aids in preventing anterior shearing forces

Figure 3: Use the loop as a "Lacing Eyelet."