Clive,
Sorry, but I love a good challenge:
If one looks at this question from the perspective of
"Which came first, the chicken or the egg?", then the
argument collapses under its own weight. However, such
is not the case - it is quite clear that the foot came
first, then the shoe. With that clarified, then we need
to look next at the issue of shoe fit/design. (One
cannot simply implicate "fit" as a stand-alone
phenomenon - issues of design, the ability of the
fitter to properly choose the correct fit ((and
design)), and functional use of the shoes in specific
terrains/environments must also be considered).

Lets look at a fairly typical case - the "combination
foot". This is a fairly common, more often female, foot
type, where the rear foot is say, a AA width, and the
forefoot is a B or C width. Up till about ten years
ago, there were many shoe styles available in a
combination last, which would fit such a foot superbly.
That is, there would be good fit at the heel,
preventing excessive slippage of the heel as well as
forward movement of the foot on the foot bed, or insole
of the shoe into the forepart of the shoe, which can
create many fit-related problems, such as posterior
"pump-bumps", hammer toes, mallet toes, and ankle
instability (as the foot is not stabilized over the
center support of the shoe adequately), among other
problems. Unfortunately, shoe companies saw little need
to continue making combination-last shoes, just as they
have also curtailed the manufacture of multiple widths,
half sizes, and very large/very small sizes. The large
middle range seems to be all they care to cater to any
longer, so the rest must pay the price.

Now, all this is not to say that shoe fit is the
primary culprit for most foot problems, but there is a
distinct cause-and-effect relationship that must be
examined in greater detail by the profession. If the
foot is not held properly in place inside the shoe, it
moves around more in relationship to the shoe and the
outside environment. That means that it is more likely
to encounter forces that can have a destructive impact
on at minimum soft tissues, and on biomechanical
stability/functionality as well. To dismiss this as a
possibility is simply not logical.

The other issue here is style, or design. We can
readily admit that high-heeled shoes can have an impact
on both function of the foot and the over-all
biomechanics of the body. The number of cases of
acquired equinus that I have seen over the years is
evidence enough that a compensatory chain has long-term
consequences. Design issues related to fit and function
go much further than that, however.

Lets look at only one design issue, as an example. And
remember that we will not address this from the custom
design perspective, but rather from the standard,
mass-produced footwear perspective, because that is
what most people use for their footwear needs. Further,
we will look at this example by using a fairly typical
foot type as our "guinee pig". We will use a moderately
pronated foot, with a mildly broad angle of base of
gait, say 18 degrees, with a fairly moderate
ligamentous tonality. The subject will be about 38
years of age, be relatively normal weight, and average
height, say 5' 8".

Our subject wants a shoe for outdoor use, hicking, so
that we have a fairly well-made shoe, leather uppers,
with some man-made materials combined. This design, not
unlike many current athletic-style shoes, also employs
a closure system of lacing. Before we put our subject
in motion, however, lets look more closely at the
subject's feet.

We note that the subject has a rather short digital
structure, proportionate to their metatarsal length.
That is, stubby toes. Not really that uncommon, in
fact. Further, there is some evidence of FHL, B/L (so
that we don't get into my pet peeve area, LLD). So what
will happen to this foot when it begins to walk in
these particular shoes? (Anyone with a different take
on this should definitely speak up at this point).

The shoe will tend to "break" across the metatarsal
heads (dorsally) at an angle that does not directly
correspond to the natural metatarsal angle of these
particular feet. Depending in the thickness of the
upper material, the positioning of the seam where the
two different upper materials meet and that seam's
distance from the base of the eyelet lacing portion of
the upper, there will be either a very narrow and sharp
"break" crease, or a wider, more rounded crease. In
either case, the crease will begin to present pressure,
intermittent at first, and eventually fairly
continuous, against the dorsum of the foot proximal to
the toes. This will in turn cause several other issues
to arise.

One issue will be that the digits may eventually have
less room for movement within the toe box area of the
shoe. Depending on the prescence of existing hammered
or malleted toes, this may then increase pressure on
those toes. If such deformities do not already exist,
the likelihood of these occuring will increase as the
toes slowly begin using extensor substitution to aid
the forefoot in dorsiflexion during the beginning of
the swing phase (If the shoe does not "break" properly,
it functionally stiffens the shoe, causing the foot to
work harder during the initiation of the propulsive
phase).

I could go on, using this one hypothetical subject in
this one sample pair of shoes, to illustrate other
design-induced problem potentialities related to
biomechanical issues. But I will spare you that rather
boring spectacle, and leave the topic for now with just
this one thought:

	The foot came first. The shoe is an artificial
imposition on a pre-existing biological entity. If the
design and functional aspects (that includes the issue
of fit) do not conform to the foot, then the foot must,
to varying degrees, adapt to the parameters defined by
the given shoe. The foot has significant, but still
limited, adaptability. The shoe also has limited
adaptability. When these two objects impact one
another, logic makes it clear that there must be a
response of one to the other. If one of these two
objects were non-adaptible, then the other would be
forced to do all the compensating. Such is not the
case. Ergo, all else being equal, there must be
compensation within both objects. Now, it is the
professions job to demonstrate the particulars.

Notty Bumbo
clive chapman wrote:
>
> A web site offering advice on foot health care to the public responds to
> the question "What is the cause of most foot problems?" by implying that
> shoes that don't fit properly are the cause of many foot problems.
>
> Clearly, toes that rub against shoes (or is it shoes that rub against
> toes?) may be the cause of callus and corns, but is a similar scenario
> so for plantar lesions? And is it shoes that don't fit feet, or
> abnormally functioning feet that don't fit shoes?
>
> So the question really is this - does the problem lie with the shoe or
> with the foot?  I accept that a grossly ill fitting shoe will cause
> problems however well the foot functions. But frankly, who is likely to
> fit a shoe so badly on a normal foot when they buy it that it gives rise
> to significant lesions?  Please don't swamp me with real-life anecdotes,
> in 35 years practice I can probably match them - but it is a minority
> who are involved in severe foot abuse of that kind.
>
> My belief is that abnormal subtalar joint pronation - from whatever
> cause - is the origin of most foot problems. Many of us have had
> patients  we have treated for functional disorders, whom without
> changing footwear have had the incidental resolution of digital lesions.
> So is it the ill-fitting (ill-functioning) foot rather than the ill-
> fitting shoe that caused the digital lesion?
>
> What about toenail problems? Convoluted and involuted nails, onychauxis,
> onychogryphosis, onychophosis, onychocryptosis? Ill fitting shoes could
> certainly be a cause (and it is a rational paradigm). However, from the
> findings of a pilot study that I have carried out on 42 patients, I have
> found that there is a 98% association of such conditions with functional
> hallux limitus - especially in the presence of a hyperextended distal
> phalanx as a compensation (90%). I am assuming that it is this
> compensation which leads to the big toenail impinging on the inside of
> toecap of the shoe, with the subsequent microtrauma at each step. There
> is evidence in all cases of such an impingement on the inside of the
> toecap. Is this the ill-fitting foot again?
>
> (I am, by the way, arranging to carry out, within the next year, a large
> sample study of cases of an association between involuted and convoluted
> big toenails and functional hallux limitus and/or hallux limitus, with
> and without a hyperextended distal phalanx. If anyone has any experience
> of such a study or can offer any advice I would be glad to hear from
> you).
>
> So, is it the ill-fitting shoe, or is it the ill-fitting foot? Are we a
> group of professional who would be made redundant if every child learned
> how to fit themselves properly with shoes? Somehow the ill-fitting shoe
> theory seems demeaning to the profession, and does not in any way
> reflect the extent of the problem, nor the extent of our expertise in
> dealing with it.
>
> --- clive chapman
>

--
Notty Bumbo
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