Forefoot abnormalities occur predominantly in shoe-wearing societies. In the United States, it is estimated that 43 million persons yearly have foot complaints and that a third of these eventually seek medical care. The incidence of foot problems increases with increasing age. Footwear had been indirectly implicated as the cause of orthopedic forefoot problems in western societies.

Published studies regarding societies that do not wear shoes demonstrate that forefoot problems are relatively uncommon. Unshod natives from Pacific Rim countries and Africa substantiate the fact that these populations have relatively few foot problems. Also, as these populations age, there does not appear to be an increase in the incidence of forefoot problems. Heretofore, there has been a paucity of information regarding the incidence of these problems in men compared with women.

A review of the number of surgical procedures done over a 15-year period showed that 87% of the forefoot procedures were in women. There was an equal incidence in both men and women of surgical procedures such as ankle fusions and ankle fractures, problems that are obviously not related to constricting shoe wear.

In regard to specific diagnoses, women again had a much higher frequency of surgical procedures: hallux valgus procedures, 94%; hammertoe repairs, 81%; neuroma excisions, 89%; and bunionette corrections, 90%. With increasing age, the frequency of surgical correction increased as well. The fourth, fifth, and sixth decades were the most common age group for the surgical correction of these problems.

A conservative estimate for physician and hospital fees and time lost from work following forefoot surgical reconstruction is $2 to $3 billion a year. Although some of these procedures may be unavoidable, many may be prevented with the use of roomy, comfortable footwear.

The solution for many of these patients is to wear roomy shoes. Patient education is the key to success. The forefoot tends to spread with age, and patients cannot wear the same shoes that they wore when they were 20 years old. In a survey of 356 healthy women, 80% had foot pain or deformity. About 88% of those examined wore shoes that were too narrow by at least 13 mm (0.5 in). Most women’s feet are about 8.25 to 10 cm (3 1/4 to 4 in) wide, although many fashionable shoes are available only in an 8-cm (3-in) width. Shoes may be stretched to accommodate bony prominences. Purchasing shoes that have more forefoot width can substantially lessen the amount of forefoot discomfort.

Lowering the heel height can have an important effect on patient comfort as well. A 2-cm (3/4-in) heel increases forefoot plantar pressure by 22%; a 5-cm (2-in) heel increases plantar pressure by 57%, and an 8.25-cm (3/4-in) heel increases pressure by 76%. Initially this pressure may cause pain, but in time, may lead to hammertoe, neuroma, bunionette, and bunion formation. Obviously, high-fashion shoes cause increased pressure and pain in the forefoot, and with time, permanent deformities may occur. Lowering the heel height decreases not only side-to-side pressure, but also the pressure in the forefoot as the foot slides downward into the toe box.

Wearing shoes that hold the foot securely in place will help patients who have a complaint of a wide forefoot and a narrow heel. Lace-up, sling-back, or T-strap styles will help to hold the foot in place.

It is helpful to have a list of shoe stores where roomy shoes can be purchased. Questioning patients about where they have purchased a reasonably roomy shoe that is fashionable in appearance is a good way to keep a current list. Women on physicians’ office staff can also help with gathering information about shoe stores that have reasonable shoes.

Patients should be warned that a “break-in” period is not a good idea because it is a period when the forefoot is compressed and constricted within a tight toe box. A patient should refuse to buy a pair of shoes that are tight, constricting, or uncomfortable. It is important to make women aware of the damage associated with ill-fitting footwear. Increased public awareness is an important step in reducing the incidence of forefoot problems in women. The “emancipation” of women’s feet will not occur rapidly, but physicians can take an active role in counseling and educating their patients regarding the ill effects of high-fashion footwear.

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