1. Determine the foot type and foot function during gait

Foot type can be classified by the arch height, which will provide a starting point as to how the foot will function biomechanically during gait and to what level of pronation occurs in the foot, which may help determine which athletic footwear may be most appropriate. Historically, the “wet test” has been used as a quick and easy test for the lay athlete to determine arch type; however, this static test has not proven to be reliable or a clinically beneficial method of assessing or predicting the level of pronation. Either quantifying navicular drop or assessing the vertical forces beneath the foot during a dynamic evaluation can make a more contemporary and accurate determination of arch height and foot type.

The three basic categories of foot types are: low arch (flat foot), normal arch (neutral), and high arch (cavus foot ). In general, a low-arched foot is more flexible and will function dynamically with increased pronation. A normal-arched foot will function with an appropriate amount of pronation. A high-arched foot is more rigid foot and will function dynamically with limited pronation.

Gait evaluation is an important part of an athletic evaluation. Static examination of an athlete’s foot type is a good starting point; however, a dynamic evaluation will provide more information on how the foot functions in real time. Based on the dynamic function of the foot, a more appropriate recommendation can be made regarding the biomechanical needs of the athletic footwear and orthoses.

Clinical evaluation of the amount of pronation during gait can be subjectively assessed by visualizing the athlete walk and run (observational gait analysis); however, a more objective and accurate gait analysis can be performed using hi-tech video analysis and force-measuring platforms or in-shoe pressure-measuring technology. See Chap. 4 for more detailed information.

The amount of foot pronation noted during gait can be excessive, increased, biomechanically efficient, decreased, or absent (supinated). Examination of an excessively pronated foot during gait will demonstrate an internally rotated leg, an excessively everted calcaneus, a collapsing arch, and an excessively abducted forefoot.

It is important to observe not necessarily how much excessive pronation occurs, but when the excessive pronation occurs during the gait cycle.

A complete biomechanical examination should note any asymmetries starting with observation at the head and progressing distally to the shoulders, back, hips, knees and patella, legs, ankles, and feet. The amount of core strength and stability should also be assessed, as a weak core may predispose a lower extremity injury.

2. Consider any foot pathology and size and weight of the athlete

Common foot pathology which may affect the choice of appropriate athletic footwear and orthoses includes (but is not limited to) posterior tibial tendon dysfunction, spring ligament strain, metatarsalgia, plantar fasciosis, calcaneal apophysitis, hallux valgus, hallux limitus, sesamoiditis, stress fractures, neuromas, sinus tarsi syndrome, lateral ankle instability, peroneal tendon pathology, tarsal tunnel syndrome, and Achilles tendon pathology.

Lower extremity injury history and prior shoe experiences should be reviewed and discussed with the athlete. Review of leg, knee, hip, and back deformities should also be assessed.

Physical size of the foot and the weight of the patient must be considered when recommending athletic footwear and orthoses, as the foot size may affect proper fit of the shoe and may affect the choice of material and the size and thickness of a foot orthosis. Foot size can be categorized as being large, medium, or small and width being either wide or narrow. Shoe volume, width, and length must be adequate. Shoe and orthosis materials need to be sufficient to accommodate the athlete without breaking down prematurely.

3. Consider the athlete’s fitness level and demands from their sport

The physical demands of an elite, professional, or Olympic caliber athlete will be different from that of an occasional weekend warrior. The elite athlete’s training regimen will vary greatly compared to the training demands of a casual athlete, which needs to be part of the consideration when recommending athletic shoe gear.

Each sport has its own set of factors, which may affect the choice of appropriate athletic footwear and orthoses, including the types of movement necessary. For example, distance running requires straightforward heel-to-toe motion while tennis requires side-to-side and front-to-back movements on the ball of the feet.

A sport-specific show should be considered if more than 3 h/week are spent training in that sport. Sport surface also needs to be considered, whether it is a smooth court, a grassy field, artificial turf, or hard concrete.

Technologic changes to athletic footwear and orthoses occur rapidly; it is critical for the sports medicine specialist to understand and be aware of evolving terminologies, trends, and fads in order to educate the athlete regarding potential benefits and/or risks.

Running shoe selection during the first running boom of the 1970s was extremely limited and offered very few choices, features, or technology—as evidenced by Dr. Subotnick shown in Fig. 14.1 on the cover of The Running Foot Doctor, published in 1977—while a virtual explosion of athletic shoes, options, and technological features has occurred over the past 40 years.

There has been a shift in focus from using cushioned materials in the 1970s and 1980s, to using duel density materials and hard plastic devices to help “control motion” in the 1990s. Midsole materials are rated by durometer (hardness of material): the harder the midsole, the more supportive the shoe—this focus changed to using different durometer materials in different locations within the shoe in order to help guide the foot through gait more biomechanically efficient.

The term “motion control” is ubiquitous among athletic shoe manufacturers when referring to a shoe that is produced to limit excessive foot pronation and is thus referenced in this textbook as well; however, it may not be the most appropriate term. An athletic shoe material or technology does not actually “control” the motion of the foot, but it may have the effect to guide the foot through a more biomechanically efficient pathway.

The once-popular trend toward barefoot and minimalist footwear and “natural running” has shifted in the opposite direction on the pendulum—toward producing shoes providing increased or “maximal” cushioning, lower ramp angles, changes in stitching of the upper, and even in changes to the geometry and construction of the midsole and outsole.

The term “preferred movement pathway” as proposed by Benno M. Nigg, Dr.sc.nat. Dr.h.c., and advanced by Australian sports podiatrist Simon J. Barthold, B.Sc. Fellow, AAPSM, has been previously presented in regard to the intended function of athletic shoes (Personal communication).

Objective features should be considered in a running shoe :