Footwear Preferences and Priorities

The O&P company I worked for when I began my orthotic residency stocked only three styles of orthopedic shoes: a loafer for women and a loafer and work boot for men. I assumed that patient dissatisfaction with the shoes was related to the limited options. In subsequent jobs, I began offering patients more options by allowing them to select their preferred shoes from manufacturers’ complete catalogs. After finding that patients seemed to inevitably choose styles that were not optimal for their conditions, I created a condensed catalog comprising clinically appropriate designs and allowed the patients to choose from among those options. To my surprise, patient dissatisfaction did not decrease significantly, and much time was required during encounters to convince patients about the merits of the footwear their physicians had prescribed. It seemed obvious to me that, given the significant benefits of therapeutic footwear, their appearance should be a much lower priority for the patients. My initial naivete regarding the prioritization of aesthetic over clinical factors began to wane, and I became resigned to the reality that vanity appeared to be more important to many patients than function and wound prevention.

Many practitioners may be similarly resigned and may struggle as I did with suppressing frustration at this clinical reality. Practitioners can usually quickly determine, based on visual assessment and experience, which shoe designs and features are most appropriate for specific patients, while patients insist on those that are less appropriate. Even after comparing measurements of patients’ feet with their current footwear, a protracted discussion of the disadvantages of their preferred designs and the benefits of proper shoe sizing, depth, and width is often required. Clinicians and patients often use different criteria for determining what is appropriate and acceptable, and the resulting conflict consumes time and can reduce treatment effectiveness.

It is understandable that the practitioner’s primary focus is on the clinical benefits of therapeutic footwear. Attention to patients’ nonclinical criteria can give insight into how to most effectively address common objections and nonadherence to the treatment plan.

Nonclinical Criteria

In 2006, Williams and Nester reported on a study designed to explore the perceptions and preferences of patients in England with diabetes and rheumatoid arthritis (RA) regarding footwear and “compare footwear issues that are important to patients in these groups….”¹ Thirty-nine men and 55 women with diabetes and RA provided their perspectives on five pairs of men’s and women’s stock prescription footwear. Subjects were asked “to highlight ‘the most important things with regard to your footwear,’” rate “their opinions of nine aspects of each of the five pairs of shoes,” and “choose the best and worst pair of shoes.”¹ (Figure 1) The patients were also “asked what they liked the most about the shoe, and whether there was anything they disliked about the shoe. The same was completed for the shoe chosen as the ‘worst shoe,’ identifying what was disliked the most, and any aspects of the shoe that the patient did like.”¹ The patients were not able to wear the shoes, and they provided feedback based only on physical examination of them. The researchers were particularly “interested in what patients perceived to embody ‘comfort.’”¹

Regarding what the subjects considered most important, “there was a stark difference between patients with RA and diabetes, with ‘comfort’ a priority for patients with RA and ‘style’ a priority for patients with diabetes. Responses from patients with diabetes suggested that they do not focus in the first instance on practical issues, such as fit or comfort, which in reality relate closely to their clinical need, but are focusing on the more common and ‘lay’ issue of footwear cosmesis.”¹

Different disease processes and outcomes play a role in these findings. The researchers point out that “in diabetes normal foot structure is broadly maintained and more easily accommodated in retail footwear. Also, any failure in sensory function in the foot due to diabetes would reduce a patient’s ability to sense poorly fitted shoes, and in fact all shoes may feel relatively comfortable. This being the case, their attention would justifiably be elsewhere, namely on the style/look of the shoe.”¹ The pain experienced routinely by individuals with RA, on the other hand, likely motivates them to select designs that they believe will relieve it, a priority that is consistent with clinical goals. The subjects with RA in this study were able to rank one shoe the highest, but “were less able to distinguish between the shoes ranked second to fifth when compared to patients with diabetes.”¹ The “patients with RA prioritized ‘comfort’ as the main issue for their footwear, and this is perhaps a difficult issue for them to gauge visually and thus difficult for them to distinguish between the appearances of comfort levels of different shoes…. In contrast, the principal issue for patients with diabetes was style, and patients are likely to have a clear picture of what they expect, and therefore are more able to rank shoes at least in respect of this issue.”¹

Although practitioners are aware of many implications of sensory deficits, we may not sufficiently appreciate how it can contribute to patients’ lack of awareness of significant fit and pressure problems with their preferred footwear and contribute to a focus on nonclinical criteria for footwear selection. In addition to serving a functional purpose, shoes are a statement of self-perception and fashion. Patients, like the rest of us, make decisions about footwear based on a variety of factors, and it is understandable that aesthetics will be prioritized when they cannot feel the difference between different designs. The researchers conducting this study acknowledge that “the systematic breakdown of the shoe qualities into nine different aspects is quite foreign compared to the relatively ‘face value’ assessment of shoes undertaken by most people in a retail or typical clinical setting. This approach may in fact have been overly systematic and failed to correctly capture the ‘instinct’ that is used when choosing shoes.” For many of us, a common instinct when purchasing any clothing item is to choose one that we believe is visually pleasing. Is it possible that a chronic health condition or disability can actually increase the relative importance of aesthetics in an attempt to reduce stigma and the perception of being abnormal?

The researchers note that “there is clear evidence within the results that patients were compromising on their choice of footwear, even with those shoes chosen as the best…. If patients are having to compromise on their choice of footwear, it is possible that the compromise is too great and one outcome of this would be low levels of usage of the footwear, which is known to be a problem.”¹ The use of any assistive device involves tradeoffs. While we may consider the benefits of an intervention we provide worth any detriment, our calculations may change when faced with the same decisions as our patients.

The Impact of Disease Severity

In 2023, researchers in the Netherlands reported on a study designed to determine whether individuals with diabetes and “a history of foot ulceration may find different factors important compared with persons without ulceration or persons who have never used therapeutic footwear.”² They conducted focus groups with three different groups of eight patients (all of whom had diabetes mellitus and loss of protective sensation): Those with no experience with therapeutic footwear and no history of ulceration (noTF&noHoU), those with experience with therapeutic footwear but no history of ulceration (TF&noHoU), and those with experience with therapeutic footwear and a history of ulceration (TF&HoU). The subjects were asked to rank the influencing factors, and the results of the group rankings are shown in Figure 2.

It is interesting, given the loss of protective sensation, that “comfort and fit” was ranked as the most important factor by all three groups, and “reducing pain” was ranked in the top four by two of the groups. The researchers commented that “it could be that persons interpret comfort and fit as having a broader definition than only the fit of the TF…” and reference other studies that reported “that comfort (and fit) can be interpreted as more than one definition.”²

When considering use of therapeutic footwear in the future, the noTF&noHoU group discussed the prescription process extensively. “Subjects mentioned they want to be involved during the prescription process and that physicians and/or pedorthists should listen to their wishes and give them feedback on the existing possibilities. They wanted to be able to express their opinion on the appearance of TF and discuss the level of comfort and stability of the footwear.”² We may consider footwear decisions routine and so obvious that they do not warrant extended discussion, but for our patients they often represent an important transition in their understanding of their identity and disease.

“The factor appearance was not ranked in the top three of most important factors in all groups…. Group noTF&noHoU gave the highest ranking,” and group TF&HoU gave it the lowest, indicating that “with an increasing severity of foot problems, the factor appearance becomes less important.”² An interesting discrepancy was reported between the subject rankings and the discussions. “All subjects mentioned that effectiveness (e.g., ulcer prevention) of TF was more important than appearance of TF.

However, appearance was ranked higher than ulcer prevention in group-noTF&noHoU and group-TF&noHoU.”² The group of patients with a history of ulceration (TF&HoU) “was the only one that ranked the appearance of TF as less important than ulcer prevention.”² Despite being ranked as the fourth most important factor by the noTF&noHoU group, appearance “in contrast to some of the…higher ranked factors…was discussed extensively during the focus group discussion.”²

Caution should be exercised when making assumptions that go beyond the focus of specific research, particularly related to the internal process of subjects. However, the ranking could indicate that the subjects gave the “right” answer in that context, while a more realistic prioritization was revealed spontaneously in the group discussions. Perhaps the amount of discussion is a better indication of priorities than the official ranking, and this discrepancy may have been present for subjects in the other groups. As patients experience more negative consequences of their disease, they may formally acknowledge a change in priorities in favor of appropriate clinical solutions, while at the same time continuing to be motivated by appearance. The researchers concluded that “this study also showed that ulcer prevention did not have the highest priority in the different groups, despite the fact that the subjects were aware that this is the main reason for TF prescription.”²

Closing Thoughts

Rather than view patient perspectives as misguided, it would be more helpful to integrate their perspectives into our treatment process. According to Williams and Nester, “Footwear is intimately linked to body image and self-esteem, which themselves are linked to mood, levels of depression, well-being, and quality of life.”¹ They point out that therapeutic footwear may be appropriate clinically, but “it must also meet the nonclinical needs of patients…meeting these nonclinical needs will be critical to ensuring patients wear their footwear and subsequently in meeting their clinical needs. The evidence for high levels of noncompliance suggests that perhaps patients’ needs are not being met, otherwise they would be wearing the footwear supplied.”¹

Difficult conversations may be unavoidable when patient preferences conflict with appropriate clinical recommendations but approaching them with empathy can build trust with patients and improve adherence. “Patient involvement in the design process may well help, but better patient awareness and understanding of their foot and footwear needs would also be advantageous.”¹ Our role as clinicians extends beyond the provision of devices, and patient education regarding conditions and treatment options is an essential part of that professional responsibility. Offering “options during the consultation process and more time allocated for patient assessment and the establishment of a positive ‘therapeutic relationship’” are not burdens, but opportunities to increase the effectiveness of the care we provide.”¹

John T. Brinkmann, MA, CPO/L, FAAOP(D), is an associate professor at Northwestern University Prosthetics-Orthotics Center. He has over 30 years of experience in patient care and education.

References

1. Williams, A. E., and C. J. Nester. 2006. Patient perceptions of stock footwear design features. Prosthetics and Orthotics International30(1):61-71.
2. Malki, A., G. J. Verkerke, R. Dekker, and J. M. Hijmans. 2023. Factors influencing the use of therapeutic footwear in persons with diabetes mellitus and loss of protective sensation: A focus group study. PLoS One18(1):e0280264.