Keeping Your Shoes On: Does the Closure Matter?
November 2017 Issue
With all the advances in shoe technology, one of the most overlooked aspects is also one of the most important—how the shoe is attached to the foot.
A good closure system can mean all the difference in keeping a corrective shoe firmly and snugly attached to the foot, and a bad one can have adverse effects such as contributing to ulcers or nullifying the positive benefits of a foot orthotic, or orthosis.
Just as every patient needs a particular orthosis, or shoe depth, or material, so too does the closure system need to vary to fit each patient's needs.
"The choice of closure depends on the condition of the patient," says Séamus Kennedy, BEng(Mech), CPed, president and owner of Hersco Ortho Labs, headquartered in Long Island City, New York. "We often deal with patients who are very compromised. They have diabetes, they have lost feeling, and may not even be able to reach down to their feet. It's important that there be a wide variety of closure options because of the patient's overall health."
With advances in new technology, there are more types of closures than ever to choose from. Even established closure systems such as laces and Velcro have undergone innovations in the ways they can be used. There are many options available, and the experts say it would serve pedorthists well to know what they are and how to choose the ones that will work best for their patients.
The Importance of a Good Closure System
Sometimes the importance of closures is overlooked because much of the focus is placed on technical options such as heel drop, depth, and material. But closures provide one of the most functional tasks for the overall performance of the shoe.
"It's just such a terribly important part of the shoe, and I think a lot of people don't pay any attention to it," says Dennis Janisse, CPed, president and CEO of National Pedorthic Services, headquartered in Brookfield, Wisconsin. "If there isn't a shoe closure there is no control whatsoever. A lot of our patients would love to have a slip-on shoe, but it just isn't appropriate when we want to use the shoe therapeutically."
Without proper closures, experts say other shoe corrections will not perform as well. Even the best orthotic in the world will not work correctly if the shoe is not properly attached to the patient's foot.
"When we're making the foot an orthosis or using different types of bracing, those devices are made to the foot and if the foot doesn't stay inside the shoe, there's no way they can function properly," Janisse says. "It's key that the foot stays in the shoe and the shoe stays in position."
A poor closure system is not just an inconvenience, it can be dangerous for some patients if their shoes do not fit properly. To control the shear force that contributes to diabetic ulcers, the shoe has to prevent the foot from sliding inside it. A closure is so important that one is required for a shoe to qualify for Medicare's Therapeutic Shoe Bill.
"Medicare insists that the shoe fits well," says Ron Bar, PhD, founder and CEO of Orthofeet, headquartered in Northvale, New Jersey. "[For people with diabetes], it's important to reduce the amount of friction and irritation on the foot. If there is too much movement and friction, you are putting patients at risk."
Even shoes that appear to be comfortable—such as clogs or mules—will not help much when it comes to holding a foot orthotic or orthosis inside.
"They don't work well in any system that doesn't have a closure," Kennedy says. "They slide around. With those shoes, there's not even a sufficient heel cup to hold the device in place."
Zippers also are not a great choice for corrective footwear, Kennedy says. The problem with zippers is that the shoe is not adjustable once the foot is zipped in. "Zippers might help your foot get into the boot, but once you zip it up, it either fits or it doesn't," he says.
That said, the experts point out that there are still many good options for patients.
Advances in New Closures
Shoelaces and Velcro continue to be the closure of choice for many pedorthists and shoe manufacturers, but as shoe technology has advanced, so too have options for closure. From cable and reel systems to shoelaces inspired by science fiction movies, there are more options than ever for patients. Newer options can offer the flexibility of laces with Velcro's ease-of-use. These systems might help patients who need a snug fit but may lack the dexterity to tighten or tie laces.
Cable and Reel
Once made for snowboard boots, the Denver-based Boa Technology closure system draws a thin steel cable through guides that can be tightened and released by turning a knob. While the system tightens, it stretches across the shoe like laces. It is easier to use for patients, keeps the steel laces tight, and is also easy to release. An additional benefit is that a clinician can establish the optimal fit for a patient, and the dial on the closure system will be able to spin but will not allow the patient to tighten the shoe beyond where the adjustment is set. This could be a benefit to patients with diabetes who tend to have less sensation in their feet and may tighten laces too much, causing skin perfusion.
Researchers at the Baylor College of Medicine are currently recruiting participants for a study to determine whether the Boa Technology used on shoes can help diabetic patients and prevent foot ulcers.
"It certainly has potential," says Kennedy. "It is simple to use and tightens nicely."
Elastic laces are also a possibility for patients who want shoelaces but may lack the dexterity to tie them tightly enough, Kennedy says. The elastic laces stretch, which allows a shoe to be slipped on like a loafer, but then they can be tightened when the laces are pulled through a lock.
"The advantages are that you can slide up the lock on the sneaker and you won't have to tie them again," Kennedy says. "It's a unique approach."
However, he warns, the system might not be good for patients with an AFO because the system does not allow the shoe to fully open.
"With the elastic system, you have to slide the foot in there and it might shift the foot orthotic out of place," he says.
New closure technology is turning to electronics to help ensure a good shoe fit. Inspired by the movie Back to the Future, Nike recently released HyperAdapt shoes that have battery-powered laces that are automatically tightened when a user puts a foot inside. The shoe can sense when the foot may need more or less pressure and adjusts accordingly, according to a press release from Nike. The $720 shoe is currently being marketed to athletes and is not yet widely available for distribution.
The Best Option for the Patient
When considering new technologies, the experts say to put the patient's needs first. Cost should also be considered, or at least discussed with the patient, before fabricating the shoe.
"If it's a cool device and something cool to talk about but it's not practical, then it's not a good idea," Janisse says. "Also, if you're going to add $20 to $30 to the shoe for a fancy closure, a lot of people don't have money for that. There's really some creative stuff out there, but I'm always cautious of what the cost will be and if people will use them."
While it's exciting to think about the future of closure systems, the experts say the past shouldn't be ignored. Tried and true shoelaces will always be a great closure option. A shoelace tied well can fit the shoe to the foot exactly as is needed, can be adjusted to work with various foot conditions, and is the most economic choice for a closure.
"I think people look down on the standard shoelaces," Janisse says. "They are still, in my mind, one of the best closures. The way to keep my foot in a shoe and control it best is to have an opening around the shoe as small as possible. To control the opening, laces are still one of the best ways to accomplish that."
For example, women's heels and men's loafers have to have a large opening for the foot to glide inside. But once the foot is in, there's nothing holding it steady in place. With other types of shoes, laces can create an opening wide enough for a foot to get inside but then also hold the shoe snugly on the foot to keep it from slipping inside the shoe. If a patient has had surgery or needs a wider-than-standard opening, a shoelace can also easily accommodate for that, Janisse says.
Laces are also flexible enough that they can be tied in different ways to account for different foot conditions.
If, for example, a patient has a bony prominence on the foot, he or she can use lacing techniques to allow more room around the prominence and still keep the rest of the shoe secure.
"If you have a painful area, you can find ways to lace around that spot and not cause pressure," Kennedy says.
For people wearing long boots, they can use two laces on a single boot to vary the tension on different parts of the foot, he says. Lacing techniques can also accommodate for narrow feet, wide feet, heel problems, swollen feet, or other foot conditions. All the techniques can be accomplished without the patient having to buy new shoes to accommodate for changing issues.
However, laces are not for everyone, the experts acknowledge.
"There are some people, who for a multitude of reasons can't bend down there," says Janisse.
In those cases, it is best to find a closure that works for them even if it is not quite as adjustable as a shoelace. "A lot of our patients can be elderly and may have arthritis," he says. "They may not have good dexterity. People with severe diabetes may have lost sensation in their hands and feet and others may have a range of motion issues. There are so many issues that come into play with getting the shoe on the foot. If you build a really great shoe and that patient can't get it on, everything you did is for naught."
Advances in Velcro
There is a reason that Velcro is the typical second choice for a shoe closure system—it is easy to use and can be adapted depending on the shoe.
"People who have limited manual dexterity or who can't put their own shoes on appreciate Velcro," Kennedy says.
However, the experts warn, all Velcro closures are not equal and orthotists and pedorthists should take care when recommending it as a closure system. The key to Velcro, the experts say, is to have as many places for adjustment as possible. This usually means as many straps—and in as many places—as possible. This does not always happen, Janisse acknowledges.
"What happens very often with Velcro is that, maybe for economic reasons, manufacturers put one or two straps over the closure," he says. Sometimes a shoe that may have been designed to have laces is modified with Velcro straps, often with poor results. "It might be the exact same shoe, but it doesn't fit well with Velcro."
While a single Velcro strap may be easiest for patients, it can be problematic for patients who shouldn't have any foot slippage in the shoe, such as those with diabetes, Kennedy says. "I'd recommend at least two straps, and three if possible," he says. "That way you can adjust and aren't just relying on one strap to keep the foot secure."
Another issue with Velcro is that pre-fabricated straps may not be long enough to hold the shoe firmly on the foot.
"With Velcro, the main issue is having a length of the strap that fits a wide range of foot sizes," Bar says. "It's always an issue. To overcome this issue, Orthofeet developed a two-way strap system, which features Velcro straps on both sides of the shoe. This allows for adjustment for snugness on the left and right side of the foot and helps patients who may have an easier time reaching one side of the foot than the other.
"Another advantage is that it enables [the practitioner] to shorten or elongate the strap depending on the patient's needs," Bar says.
"It's best to have as many straps as possible, but then you are getting into the issue of looks, as the shoe becomes more cumbersome and orthopedic," he says.
For patients who do not like the look of the Velcro strap but cannot comfortably tie their shoes, Orthofeet's Tie-Less Lace System comes on a sneaker or shoe that looks like a typical shoe and lacing system, but the laces are tightened by Velcro straps at the top that blend in with the shoe.
"We have to find ways to give patients what they functionally need, while still giving them a shoe that doesn't look cumbersome, which they feel more comfortable to wear," says Bar.
While shoe closures might not always be first on the minds of orthotists and pedorthists, they should not be ignored, the experts agree. A well-fitted shoe, held snug with the right closure, can help bring the best outcomes possible for any shoe intervention.
Maria St. Louis-Sanchez can be contacted at firstname.lastname@example.org.