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R E V I E W Open Access
Incorrectly fitted footwear, foot pain and
foot disorders: a systematic search and
narrative review of the literature
Andrew K. Buldt
1,2*
and Hylton B. Menz
1,2
Abstract
Background: Correct footwear fitting is acknowledged as being vitally important, as incorrectly fitted footwear has
been linked to foot pathology. The aim of this narrative review was to determine the prevalence of incorrectly fitted
footwear and to examine the association between incorrectly fitted footwear, foot pain and foot disorders.
Methods: A database search of Ovid MEDLINE and CINAHL yielded 1,681 citations for title and abstract review.
Eighteen articles were included. Findings were summarised under the categories of (i) children, (ii) adults, (ii) older
people, (iii) people with diabetes and (iii) occupation- or activity-specific footwear. Differences in footwear fitting
between sexes were also explored.
Results: Between 63 and 72% of participants were wearing shoes that did not accommodate either width or length
dimensions of their feet. There was also evidence that incorrect footwear fitting was associated with foot pain and foot
disorders such as lesser toe deformity, corns and calluses. Specific participant groups, such as children with Down
syndrome and older people and people with diabetes were more likely to wear shoes that were too narrow (between
46 and 81%).
Conclusion: A large proportion of the population wear incorrectly sized footwear, which is associated with foot pain
and foot disorders. Greater emphasis should be placed on both footwear fitting education and the provision of an
appropriately large selection of shoes that can accommodate the variation in foot morphology among the population,
particularly in relation to foot width.
Background
Footwear has been used by humans for approximately
30,000 years [1]. Although originally worn as a protect-
ive covering for the foot, modern footwear is designed to
fulfil a range of purposes, the accomplishment of which
is judged by three criteria: form, function and fit [2].
Form relates to the aesthetic appeal of footwear, while
function relates to the ability of footwear to accomplish
its intended purpose, eg. to protect the feet of individ-
uals who undertake activities that may present a risk of
injury. Finally, fit pertains to how footwear can accom-
modate the morphology of the foot [3].
Footwear fitting is acknowledged as being vitally import-
ant as in most cases fit governs function [3]. This means
that footwear cannot fulfil its intended purpose if it does
not fit the foot correctly [2]. Furthermore, it has been sug-
gested that incorrectly fitted footwear is a major contribu-
tor to the development of structural foot disorders, such
as hallux valgus and lesser toe deformity [4,5], as well as
skin lesions, such as corns and calluses [6].
Correct footwear fitting is an inherently complex
undertaking for two main reasons. Firstly, the footwear
industry is currently unable to design and manufacture
footwear that can conform to the three-dimensional
morphology of all feet in the population [7,8]. This is
because foot morphology is highly variable between indi-
viduals, and there is limited variety in the shape of lasts
used to construct footwear [9–12]. Secondly, footwear
selection is not purely based on quantitative measure-
ments of footwear shape and size, but may be influenced
* Correspondence: a.buldt@latrobe.edu.au
1
La Trobe Sport and Exercise Medicine Research Centre, School of Allied
Health, La Trobe University, Bundoora, Melbourne, VIC 3086, Australia
2
Discipline of Podiatry, School of Allied Health, La Trobe University,
Melbourne, VIC 3086, Australia
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Buldt and Menz Journal of Foot and Ankle Research (2018) 11:43
https://doi.org/10.1186/s13047-018-0284-z
by qualitative factors [13,14]. It is therefore probable
that a substantial proportion of the population are wear-
ing incorrectly fitted footwear. With this in mind, the
aim of this review is to determine the prevalence of in-
correctly fitted footwear and to examine the association
between incorrectly fitted footwear, foot pain and foot
disorders.
Methods
An electronic database search was conducted in March
2018, using the online databases Ovid MEDLINE (1946-
#present) and CINAHL (1980-present). A set of search
terms were derived, and to broaden the search, some
terms were truncated with wildcard symbols. The follow-
ing keywords search terms were used: foot OR shoe* OR
footwear AND size* OR fit* OR length OR width OR
‘footwear fit*’OR ‘shoe fit*‘AND pain* OR disorder* OR
‘foot pain’. Results were limited to human studies pub-
lished in peer-reviewed journals. The electronic database
search was supplemented by cross-checking citations and
reference lists from relevant published studies.
A single reviewer (AKB) assessed all studies that were
yielded from the search by title and abstract. Studies that
fulfilled one or both of the following two criteria were
included: (i) studies reported the prevalence of partici-
pants wearing incorrectly fitted footwear, and (ii) studies
reported the association between wearing incorrectly
sized footwear and foot pain or foot disorders.
Results
Search results
The search strategy yielded 1681 citations. Following
title and abstract review, 18 articles were included and a
narrative summary of the findings is provided. A sum-
mary of all included studies including participant charac-
teristics, method of analysis and main findings are
presented in Table 1.
For all included studies, sample sizes ranged from 50
to 440 participants, with the median number of partici-
pants being 138. Mean or average age was reported in
all but one study [15]. One study recruited only children
[16] and four studies recruited only older participants
[17–20]. Three studies recruited only female participants
[21–23], while two other studies recruited predominantly
male populations, including underground coal miners [24]
and war veterans [25]. Participants with specific medical
conditions were recruited in seven studies [15,16,25–29],
including diabetes [25,28,29], diabetic peripheral neur-
opathy [15], Down’ssyndrome[16], Alzheimer’s disease
[27] and inflammatory arthritis [26]. Specific ethnic
groups were examined in three studies including partici-
pants of Japanese [21], Thai [19]orSingaporean[26]eth-
nicity. Finally, four studies recruited specific populations
[24,25,30,31], including war veterans [25], underground
coal miners [24], rock climbers [30] and three different
population groups from New York City (a foot specialist
private practice, an academic diabetic foot and ankle
clinic, and a charity centre serving homeless people) [31].
Study designs
The majority of included studies were cross-sectional in
design [16–30] and three studies were case-control in
design [15,31,32]. All except one study reported the
method for measuring the foot [32]. The dimensions of
the foot were measured during relaxed bipedal stance in
all except two studies that measured the foot while the
participant was in a seated position [18,19]. It has been
suggested that feet should be measured during standing
to account for changes in dimensions due to splaying of
the foot after the acceptance of bodyweight [33]. The
studies that measured the foot while sitting did not pro-
vide a justification for doing so.
All except three studies measured the length of the foot,
with most using a manual device, including a measurement
stick [18,25,29–31], Brannock® device [15,17,26,27]or
callipers [19,21,28]. Two other studies analysed the area of
a foot tracing [16,20], while another measured the dimen-
sions of a 3-dimensional scan taken from a foot mould [24].
Two studies only measured foot width [22,23]
while 10 studies measured foot width in addition to
foot length [16–20,24,26–29], using a variety of
manual devices such as a tape measure [19], Bran-
nock® device [17,26,27] or callipers [18,28,29].
Four studies measured foot width using measure-
ments from foot tracings [16,20,22,23] while one
analysed a 3-dimensional scan of a foot mould [24].
All except one study measured the shoes brought by
participants to the testing session. The only study that
did not measure the participants’shoes asked partici-
pants to report their usual shoe size [28]. For all studies,
footwear dimensions were measured using the same
method as the measurement of the foot. Most studies
used a manual device to measure footwear dimensions
[15,17–19,21–23,25–31]; two used measurements
from a tracing of footwear [16,20], and one study ana-
lysed a 3-dimensional mould of the internal dimensions
of the shoe [24].
There were differences in the way that foot and shoe di-
mensions were compared and footwear fitting assessed.
Several studies used a pragmatic approach guided by shoe
sizing [15,18,19,25–29,31,32]. For example, one study
considered a shoe to be incorrectly fitted if it was at least
half a British shoe size larger or smaller than the foot [31].
In contrast, other studies considered shoe fitting to be in-
correct if measurements such as overall area, length or
width differed between footwear and the foot [16,20–24,
30]. In these cases, even though footwear and the foot
may be different dimensions, footwear size may be
Buldt and Menz Journal of Foot and Ankle Research (2018) 11:43 Page 2 of 11
Table 1 Summary of included studies
Authors Participants Method of analysis Main findings
Akhtar et al.
[32]
100 participants. 50 participants
in foot pathology group, 12 men,
38 women, mean age: 49
(range 19–68) yrs. 50 participants
in control group, 19 men,
31 women, mean age: 41
(range 19–65) yrs.
Foot length and width and
footwear length and width
was measured (method not
mentioned). Incorrect sized
footwear defined as difference
greater than half a shoe size
between foot and footwear.
•In the foot pathology group, 21 (45%)
participants were wearing footwear at
least half a size too small
•7 (14%) participants were wearing footwear
half a size longer than their foot
•32 (64%) were wearing footwear narrower
than their foot, mean 6 (range 2–9 mm)
•In the control group, 7 (14%) participants were
wearing footwear at least half a size too small
•13 (26%) participants were wearing half a size
longer than their foot
•15 (30%) were wearing footwear that were
narrower than their feet, mean 4 mm
(range: 2–7 mm)
Burns et al.
[18]
65 participants, 26 men
39 women, median age: 82
(range 64–93) yrs. Participants
were consecutive admission
to hospital rehabilitation unit.
Foot length was measured with
the participant in a sitting position
using a standard ‘Clarks’measuring
stick. Foot width was measured with
calipers across the widest part of the
metatarsal heads Footwear was
measured according to shoe size and
dimensions measured with calipers.
Incorrect sized footwear defined as
difference between foot and footwear
greater than half a standard British shoe
(7 mm) for length or one size for width.
•32 (49.2%) participants wore footwear that
was too long
•3 (4.6%) were wearing footwear that
was too short
•21 (32%) were wearing footwear that
was too wide
•2 (3%) were wearing footwear that
was too narrow
•47 (72%) of participants wore footwear
that was incorrectly fitting based on either
width or length
•42 (65%) of participants wore footwear that
was too big (too long, too wide or both)
•4 (6%) or participants wore footwear that was
too small (too short, too narrow or both)
•Incorrect shoe length was significantly associated
with increased ulceration
•Foot pain was significantly associated with
incorrect footwear length
Carter et al.
[26]
101 participants, 51 men,
51 women, mean age:
52 ± 14.5 yrs. All participants
diagnosed with inflammatory
arthritis.
Fit assessed using previously published
footwear assessment tool.
Appropriateness of shoe size determined
according to length, width and depth.
•69 (68.3%) participants wore incorrectly
fitted shoes
•62 (61.3%) participants wore shoes that
were too short
•39 (38.6%) participants wore shoes that
were too narrow
•31 (30.6%) participants wore shoes that
were too shallow
Chaiwanichsiri
et al. [19]
213 participants, 108 men,
105 women, mean age:
68.7 ± 5.4 yrs. Mean BMI:
24.7 ± 3.3. All of participants
were ethnically Thai.
Foot length, width, arch length, toe
depth and heel width were measured
with the participant in a sitting position
using the Chula foot calliper. Internal
footwear dimensions were measured
using Chula shoe calliper and tape
measure. Incorrect sized footwear
defined as at least 5 mm difference
between the foot and footwear for
length, width, toe box measurements.
•50% of women and 34.3% of men were wearing
footwear that was narrower than their foot by
greater than 5 mm
•22% of participants (35.5% of women) who were
wearing footwear that were smaller than their feet
reported foot pain compared to 9.5% of
participants who were wearing appropriately sized
footwear
De Castro
et al. [28]
399 participants, 172 men,
227 women, mean age:
69.6 ± 6.8 yrs. 34 women
and 38 men reported
having diabetes.
Foot length was measured during
relaxed standing with a calliper
(distance between the most
prominent point in the calcaneal
tuberosity region and the 2nd toe).
The participant reported footwear
size. Incorrect sized footwear defined
as foot length at least 2 mm difference
between foot length and reported
footwear size dimensions.
•110 women (48.5%) and 119 men (69.2%) wore
incorrect size footwear (> 2 mm difference) based
on foot and shoe length
•29 women (12.8%) and 57 men (31.1%) were
wearing footwear at least 1 cm longer than
their feet
•1 (0.6%) man was wearing shoes shorter
than his feet
•There was a significant association between men
and wearing incorrectly sized footwear
•19 women or 55.9% of all women with diabetes
and 31 or 81.6% of all men with diabetes were
wearing incorrectly sized footwear
•Incorrectly sized footwear was associated with ankle
pain in women
Buldt and Menz Journal of Foot and Ankle Research (2018) 11:43 Page 3 of 11
Table 1 Summary of included studies (Continued)
Authors Participants Method of analysis Main findings
Dobson et al.
[24]
270 participants, all men,
mean age 38.3 ± 9.8 yrs.,
height 178.9 ± 5.7 cm,
weight 93.2 ± 12.5 kg. All
participants were
underground coal miners.
Participants who wore sizes
9, 10, 11 or 12 were selected
for analysis.
Three-dimensional foot scans during
bipedal stance of participants’feet were
taken. Dimensions of footwear worn by
participant (either lace up boots or gum
boots) were measured by scanning
footwear plaster moulds in the same
manner as participants’feet. Moulds were
created by pouring plaster of Paris into
footwear. Foot and footwear dimensions
were compared.
•There was a significant difference between
3-dimennsional foot dimensions and 3-dimensional
footwear dimensions
•Participants were wearing footwear that were
substantially longer than their feet
•Width of the forefoot and heel areas of footwear
were not wide enough for participants’feet
Frey et al. [23] 356 women, average age
42 yrs. Participants had no
history of diabetes,
rheumatoid arthritis, previous
foot trauma or surgery. Any
foot deformity was recorded.
Foot tracings were taken during relaxed
weightbearing. Foot width was defined
as the widest line perpendicular to a
longitudinal bisection of the foot. The
shoe was traced and shoe width was
defined as the widest line perpendicular
to a longitudinal bisection. Foot width
and shoe width were compared.
•88% of participants were wearing footwear that
was narrower than their foot (average 1.2 cm)
•In participants who had no foot pain, the average
foot–footwear width discrepancy was 0.56 cm
(20% of all participants)
•For participants without deformity the average foot
length–footwear width discrepancy was 0.60 cm
(23% of all participants)
•Of participants with a foot narrower than or equal to
footwear, 64% had foot pain and 57% had foot
deformity
•Of participants with foot wider than footwear,
84% had foot pain and 79% had foot deformity
Frey et al. [22] 255 women, average age
41 yrs. Participants had no
history of diabetes,
rheumatoid arthritis, previous
foot trauma or surgery.
Foot tracings were taken during relaxed
weightbearing. Foot width was defined
as the widest line perpendicular to a
longitudinal bisection of the foot. The
shoe was traced and shoe width was
defined as the widest line perpendicular
to a longitudinal bisection. Foot width
and shoe width were compared.
•86% of participants were wearing footwear that
were narrower than their feet (average 0.88 cm)
•In participants who had no foot pain the average
foot width-footwear discrepancy was 0.58 cm
•In participants without deformity, the average
forefoot width-footwear width discrepancy was
0.52 cm
Harrison et al.
[29]
100 participants, 52 men,
48 women, mean age
62.0 ± 14.9 yrs. All participant
were diagnosed with diabetes,
36% of participants were
administering insulin. The
median length of time that
participants had diabetes
was 5.0 years.
Foot length was measured during
standing with a ‘Clarks’measurement
device. Foot width was measured using
sliding calipers. Footwear length was
recorded using a measuring stick.
Footwear width was measured using
sliding calipers. Footwear length and
width was subtracted from foot length
and width. Incorrect sized footwear was
defined as greater or less than half a US
shoe size difference between footwear
and foot length or greater or less than
0.7 cm difference between footwear
and foot width.
•For the right foot, 63 (63%) of participants were
wearing incorrectly sized footwear
•23 (23%) participants were wearing footwear that
was too long
•10 (10%) participants were wearing footwear that
was too short
•43 (43%) participants were wearing footwear that
was too narrow
•1 (1%) participant was wearing footwear that was
too wide
•29 (29%) participants were wearing footwear that
was correct length but too narrow
•For the left foot, 65 (65%) of participants were
wearing incorrectly sized footwear
•24 (24%) participants were wearing footwear that
was too long
•10 (10%) participants were wearing footwear that
was too short
•46 (46%) participants were wearing footwear that
was too narrow
•1 (1%) participant was wearing footwear that was
too wide
•30 (30%) participants were wearing footwear that
was correct length but too narrow
•There was no association between incorrectly fitted
footwear and neuropathy or absent pulses
Kusumoto
et al. [21]
51 women, average age
21.3 years. All participants
were Japanese students.
Foot length was measured during
relaxed bipedal stance with spreading
callipers from the centre of the
posterior heel to end of longest toe.
Sizes of leather footwear and sneakers
were recorded. Foot length and length
corresponding to footwear size compared.
•For leather footwear, 8% (right feet) and 2%
(left feet) of participants wore same foot and
footwear length
•73% (right), 75% (left) participants wore footwear
longer than the foot (maximum 14 mm)
•20% (both left and right) wore footwear shorter
than the foot (maximum 4 mm)
•For sneakers 8% (right), 6% (left) of participants
wore same foot and shoe length
Buldt and Menz Journal of Foot and Ankle Research (2018) 11:43 Page 4 of 11
Table 1 Summary of included studies (Continued)
Authors Participants Method of analysis Main findings
•73% (right) 71% (left) of participants wore shoe
longer than the foot (maximum 14 mm)
•18% (right) and 22% (left) of participants wore
footwear shorter than the foot (maximum 6 mm)
Lim et al. [16] 50 participants, 28 men,
22 women, 10.6 ± 3.9 yrs.,
height 131.9 ± 18.6 cm,
weight 39.6 ± 18.4 kg. All
genetic variants of Down’s
syndrome was present
among participants.
Outline of each participants’foot was
traced onto a footprint mat while
standing in relaxed bipedal stance.
Maximum length and width of the
participants’foot and footwear was
documented in millimetres. The outline
of the sole of footwear was traced
onto graph paper. Percentage
difference between foot and footwear
dimensions was calculated for length
and width measurements.
•29 (58%) participants wore footwear narrower
than their feet
•5 (10%) participants wore footwear shorter
than their feet
•There was no significant association between
foot structure and footwear fit
López-López
et al. [27]
73 participants, 25 men, 48
women, 81.4 ± 6.4 yrs., height
162.9 ± 9.8 cm, weight
66.2 ± 12.2 kg. All participants
were diagnosed with
Alzheimer’s disease.
Foot length (distance between the
posterior heel and the end of the
longest toe) and width was measured
during relaxed standing with a
Brannock® device. Footwear length
and width was measured with a
Brannock® device. Definition of
incorrect sized footwear not stated.
•51 (69.9%) participants wore incorrect
sized footwear
•28 (38.3%) participants wore footwear that was
too long
•42 (57.5%) participants wore footwear that was
too narrow
•22 (30.1%) participants wore footwear that was
simultaneously too long and too narrow
•20 (27%) of participants wore footwear that was
simultaneously the correct length but too narrow
López-López
et al. [17]
62 participants, 29 men,
33 women, mean age
75.3 ± 7.9 yrs., height
164.1 ± 7.6 cm, weight
73.9 ± 11.3 kg. 31
participants in incorrectly
fitted footwear group,
41 participants in correctly
fitted footwear group.
Foot length and width, and footwear
length and width was measured with
a Brannock® device. Incorrectly fitted
footwear was defined as 1 mm
difference between length or width
of the foot and footwear. Each
participant completed FHSQ
(Spanish version).
•Participants wearing incorrectly fitted shoes
displayed lower FHSQ scores for section related to
foot health and health status in general
•Significant difference between the incorrect and
correct footwear fitting groups for the dimensions
of the FHSQ assessing pain, foot function, general
foot health and social function
McHenry et
al. [30]
56 participants, 45 men,
11 women, mean age
33.6 ± 11.7) yrs., height
174.9 ± 8.6 cm, weight
76.6 ± 12.5 kg. All
participants were rock
climbers with over 1
year of experience. Mean
age of climbing experience
10.8 ± 11.2 yrs.
Foot length in bipedal stance was
taken with ‘Ritz stick’. Climbing
footwear was measured along its
longest axis from the most posterior
point of the heel to the furthest
point anteriorly. For footwear with a
downturned forefoot, shoe were
flattened along the medial longitudinal
arch. Incorrectly fitted footwear was
defined as difference between foot
and footwear greater or less 1 UK
shoe size or equivalent.
•55 (98%) participants were wearing excessively
tight climbing footwear (based on length of foot
and shoe)
•Mean size reduction of 4 UK shoe sizes between
participants street footwear and climbing footwear.
•51 (91%) participants experienced foot pain while
climbing
•43 (76.8%) participants removed their footwear
intermittently throughout activity to relieve
discomfort
McInnes et al.
[15]
203 participants, 85
participants with diabetes,
118 control participants
without diabetes.
Both feet were measured using a
Brannock® device during relaxed
standing. Footwear dimensions were
measured using a calibrated internal
shoe size gauge. Incorrectly fitted
footwear were defined as a difference
between foot length and shoe size less
than 10 mm or greater than 15 mm.
•78 (66%) of participants were wearing footwear
that were the incorrect size
•42 (55%) of participants were wearing footwear
that were too short
•36 (47%) of participants were wearing footwear
that were too long
•In participants with diabetes, 70 people (82%)
were wearing footwear that were the incorrect size
•30 (43%) were wearing footwear that were
too short
•40 (57%) were wearing footwear that were
too long
Menz and
Morris [20]
176 participants, 56 men,
120 women, mean age:
80.1 ± 6.42 yrs. Participants
were residing in retirement
villages.
A footprint was taken relaxed
weightbearing, The maximum length
and width and area of the participant’s
foot was measured. The outline of each
shoe was traced onto graph paper, Fit
of most regularly worn footwear was
assessed. The percentage difference
•23 participants (13.7%) wore indoor footwear
shorter than their feet
•136 (81.4%) participants wore indoor footwear
narrower than their feet
•73 (43.7%) wore indoor footwear smaller than
the total area of their feet
•17 (10.2%) participants wore outdoor footwear
Buldt and Menz Journal of Foot and Ankle Research (2018) 11:43 Page 5 of 11
Table 1 Summary of included studies (Continued)
Authors Participants Method of analysis Main findings
between the foot and footwear
dimensions was calculated for length
and width measurements.
shorter than their feet.
•131 (78.4%) participants wore outdoor footwear
narrower than their feet
•79 (47.3%) participants wore outdoor footwear
smaller than the overall area of the foot
•Women displayed a greater disparity between
foot and shoe dimensions with respect to indoor
shoe length, indoor shoe width, indoor shoe area,
outdoor shoe length, outdoor shoe width and
outdoor shoe area
•The presence of corns and callus was associated
with inadequate footwear width
•Moderate to severe hallux valgus was associated
with inadequate width of indoor shoes and
inadequate width and overall area of
outdoor shoes
•Lesser toe deformity was associated with
inadequate length of both indoor and outdoor
shoes.
•Foot pain was associated with inadequate width
of indoor shoes
Nixon et al.
[25]
440 participants. 414 men,
26 women, mean age:
67.2 ± 12.5 yrs. All participants
were war veterans recruited
from veterans affairs medical
centre. 58.4% of participants
were diagnosed with diabetes
and 6.8% had active diabetic
ulceration.
Foot size was and width were
measured during standing with
using a standardised method and
the Apex 1141 ft measuring device
(Ritz stick). Incorrect sized footwear
was defined as a size that was at
least one full US shoe size too large
or too small. The foot was also
inspected for the presence of diabetic
foot ulceration and peripheral
neuropathy (protective sensation).
•25.5% of participants were wearing appropriately
sized footwear (based on length of foot and shoe)
•Participants with diabetic foot ulceration were
5.1 times more likely to be wearing incorrectly
fitted footwear than participants without a
wound
•Participants with diabetes and loss of protective
sensation were 4.8 times more likes to be
wearing incorrectly fitted footwear compared
to participants without neuropathy
Schwarzkopf
et al. [31]
235 participants. 71 participants
from a private clinic, 25 male,
46 female mean age 45.2 yrs. 40
participants from a diabetes foot
clinic, 18 male, 22 female, mean
age 55.6 yrs. 124 participants
from a charity care centre for
the homeless, 124 male,
0 female, mean age 44.2 yrs.
Two foot and ankle surgeons measured
foot length while standing using a
length-measuring device (Clarks meter),
foot length was represented as assumed
US adult shoe sizes. Size of the participant
current footwear was recorded.
Incorrectly fitted footwear was defined
as a difference of at least 0.5 US shoe
sizes between measured foot size and
the participants assumed footwear size.
•All participants: 82 (34.9%) were wearing
incorrectly fitted footwear (based on length
of foot and shoe)
•11 (15.5%) of participants from private clinic
were wearing incorrectly fitted footwear
•17 (42.5%) of participants from diabetic foot
clinic were wearing incorrectly fitted footwear
•54 (43.5%) participants from clinic caring for
the homeless were wearing incorrectly
fitted footwear
•There were significant differences (P< 0.01)
between the number of participants wearing
incorrectly fitted footwear from the private
clinic compared to participants from both the
diabetic foot clinic and clinic for the homeless
•28 (11.9%) participants from all clinics were
wearing incorrectly fitted footwear by greater
than 1.5 sizes
•3 (4.2%) participants from private clinic were
wearing incorrectly fitted footwear by greater
than 1.5 sizes
•4 (10.0%) participants from diabetic foot clinic
were wearing incorrectly fitted footwear greater
than 1.5 sizes
•28 (16.9%) of participants from clinic for the
homeless were wearing incorrectly fitted
footwear greater than 1.5 sizes
•There were significant differences (p< 0.01)
between the number of participants wearing
incorrectly fitted footwear greater than 1.5
sizes from the private clinic compared to
participants from clinic for the homeless
•Female gender was associated with shoe
size mismatch (p= 0.02).
Buldt and Menz Journal of Foot and Ankle Research (2018) 11:43 Page 6 of 11
correct. This is particularly relevant for length, as it has
been suggested that appropriately sized footwear should
have a space of at least 10–20 mm between the end of the
foot and the shoe [33,34]. In presenting results related to
particular participant groups in this review, a distinction
will be made between studies that deemed shoes to be in-
correctly fitted based on shoe sizing, and studies that mea-
sured differences between the dimensions of the foot and
the shoe.
Prevalence of incorrectly fitted footwear
Most studies explicitly reported fitting variables such as
length or width, or commented on overall footwear fit
by reporting only one variable, usually length. However,
there were five studies that reported the number of par-
ticipants that were wearing incorrectly fitted shoes based
on more than one variable [15,18,26,27,29]. Four
studies reported that between 63 and 72% of participants
were wearing incorrectly fitted shoes based on length
and width [18,29], while one study reported that 68% of
participants wore incorrectly fitted shoes based on three
measures (length, width and depth) [26]. One study
compared total foot and shoe area to determine footwear
fit, finding that the total area of the footwear was smaller
than total area of the foot in 47% of participants [20].
Among the studies that provided specific fitting details,
the percentage of participants wearing footwear too long
for the foot ranged between 14 [32]and73%[21](median
38% [27]) and too short between 0.6 [28]and98%[30]
(median 10% [20]). In terms of width, between 30 [32]and
88% [23](median58%[27]) of participants wore footwear
that were too narrow and one study found that only 1% of
participants wore footwear that was too wide [28]. One
study examined depth, finding that 31% of participants
wore footwear that was too shallow [26].
Association between footwear fitting, foot pain and foot
disorders
The association between incorrectly fitted footwear and
foot pain or foot disorders was investigated in eight studies
[17,18,20,23,25,28,30,31], with all but one study [31]
reporting significant associations between incorrectly fitted
footwear and some form of foot pain or foot disorder.
There were five studies that reported an association
between incorrectly fitted footwear and foot pain or im-
paired quality of life [17,18,23,28,30]. These studies
reported a strong association between tight footwear
and foot pain, with between 84 [23] and 91% [30] of par-
ticipants reporting generalised foot pain while shod.
However, the characteristics of recruited participants in-
fluenced findings. For example, the study that found that
91% of participants described foot pain was conducted
on rock climbers, who wear tightly fitted footwear to op-
timise contact with the climbing wall. There was also
evidence that loose footwear was associated with foot
pain, with 64% of participants reporting generalised foot
pain while shod [23]. Regarding quality of life measures,
one study that recruited 65 older people in Spain found
those with ill-fitting shoes displayed significantly poorer
overall foot health using the Foot Health Status Ques-
tionnaire [17]. In terms of specific regions of the lower
extremity, one study reported that incorrectly fitted foot-
wear was significantly associated with the presence of
pain in the ankle in women [28].
There were three studies that investigated the associ-
ation between incorrectly fitted footwear and foot disor-
ders [18,20,25]. Among these there was evidence that
incorrectly fitted footwear was associated lesser toe de-
formity in older people [20] and the presence of corns in
older people [18]. Importantly, there was also evidence of
a strong association between current foot ulceration
and incorrectly fitted shoes in older people with dia-
betes [18,25] with participants with current foot ul-
ceration up to 5 times more likely to be wearing
incorrectly fitted shoes compared to individuals with-
out foot ulceration [25].
Footwear fitting in specific populations
Footwear in children
Children’s feet are different to adult feet, both in shape
and posture, and are constantly changing as the child
grows [35]. In addition, the morphology of children’s feet
are more malleable than adult feet [36]. Indeed, footwear
has been used to correct pathological skeletal alignment
and foot posture among children [37]. Therefore, correct
shoe fitting in children is of paramount importance.
Only one article addressed footwear fitting in children
(under 18 years old). The study focused on children with
Down’s syndrome, who are known to have flatter, shorter
feet and are more likely to have hallux valgus compared
to children without Down’s syndrome [38,39]. This
study recruited 50 children with all genetic variants of
Down’s syndrome (mean age: 10.6, SD 3.9, range 5–
18 years) and found that 58% wore footwear that was
too narrow for their feet [16]. This indicates that chil-
dren with Down’s syndrome may be unable to acquire
footwear that can accommodate the wider dimensions of
the foot associated with the condition.
Footwear in adults
Five studies investigated healthy adults [21–23,31,32],
with three recruiting young female participants [21–23].
Only one of the studies that recruited young females
assessed footwear length. This study of young Japanese
females found that in a sample of 51 students (average
age 21 years), 75% were wearing footwear that was lon-
ger than their feet [21]. However, the maximum differ-
ence was 14 mm, which falls in the range for correctly
Buldt and Menz Journal of Foot and Ankle Research (2018) 11:43 Page 7 of 11
fitted shoes based on the recommendation of 10–20 mm
clearance between the foot and the shoe [33]. In con-
trast, 22% wore footwear that was shorter than their feet,
thus indicating a potential issue with wearing footwear
of inadequate length [21].
The two other studies that recruited young females
only considered footwear width, specifically, width in the
forefoot [22,23]. The first study of 356 American
women (average age 42, range 20 to 60 years) found that
88% were wearing footwear that was narrower than their
feet, with the average discrepancy being 1.2 cm [23].
Among these women, 37% were wearing high heeled
shoes, 49% wore flats and 14% wore sneakers. This was
followed by a subsequent study by the same authors,
using the same methods, that recruited 255 American
women (average age 41, range 20–60 years) and found
86% of participants were wearing footwear that was too
narrow, with an average discrepancy of 0.88 cm [22]. No
information about shoe type was provided in this study.
Both studies also reported that those with foot deform-
ities such as hallux valgus displayed a greater discrep-
ancy between footwear and foot width, however no
information was provided as to whether this difference
was significant [22,23].
Two further studies recruited both female and male par-
ticipants using convenience sampling of individuals that
regularly attended foot and ankle clinics [31,32]. These
studies recruited participants of similar age (mean ages 44
and 49 years, respectively) and found that between 35 and
56% of individuals were wearing footwear of incorrect
length [31,32]. Only the study by Akhtar et al. [32] inves-
tigated width, and found that 64% of people were wearing
footwear that was narrower than their feet.
Footwear in older people
There is evidence to suggest that the feet of older people
are broader in the forefoot region and have a flatter medial
longitudinal arch compared young people [40,41]. Fur-
thermore, older individuals with foot pain display a greater
number of foot deformities including hallux valgus and
clawed lesser toes compared to older people without pain
[42]. These differences in foot morphology may pose a
problem for fitting, as shoes are designed to have smooth
contours, and are not designed to accommodate irregular
bony shapes associated with foot deformity [43].
Three studies assessed footwear fitting in older people,
with mean ages ranging between 69 and 80 years [18–20].
The literature indicated that footwear width was of par-
ticular concern in older people. For example, a study by
Menz et al. of 176 older people (mean age 80.1, SD: 6.4,
range 62–96 years) found that 78% wore outdoor shoes
narrower than their feet [20]. Similarly, a study by Chaiwa-
nichsiri et al. of 213 older Thai people (mean age 68.7, SD
5.4 years) found that 50% of women and 34% of men wore
shoes that were too narrow [19]. In both cases, investiga-
tors compared width measurements between the widest
region of the shoe and the forefoot. However, Chaiwanich-
siri et al. [19] used a higher threshold to define an incor-
rectly fitted shoe (at least 5 mm difference between the
foot and shoe) compared to Menz et al. who reported in-
correct fitting if any discrepancy between shoe and foot
width was recorded [20].
Burns et al. [18] provided additional context in relation
to shoe width, finding that 33% of older individuals wore
footwear that was the same width as the foot, but was
too long, while 15% of individuals wore shoes that were
simultaneously too wide and too long. This may indicate
that, in order to accommodate a wider forefoot, some
older people may be choosing shoes that are too long
for their feet [18].
The majority of studies including older people have
assessed the fit of shoes commonly worn outdoors [18–20].
However, the fitting of indoor shoes should not be over-
looked, such is the relationship between indoor shoes and
falls in older people [44]. As was the case with outdoor
shoes, indoor shoes are commonly too narrow for the foot.
This was confirmed by Menz et al., which found that
among a sample of 176 older people, 81% of participants
wore indoor footwear that was narrower than their feet
[20]. Therefore, along with outdoor footwear it is apparent
that indoor footwear is inadequately designed to accommo-
date the foot width of older people [44,45].
The literature has suggested two reasons to explain
the overall shoe fitting findings related to older people.
Firstly, older individuals may be unable to select foot-
wear to accommodate changes in foot morphology. For
example, it may be difficult to acquire footwear that can
accommodate a wider forefoot while also being appro-
priately fitted according to foot length [46]. Secondly,
older individuals may not be aware of their correct shoe
size. Indeed, a survey of 128 older people found that
26% of men and 47% of women had not had footwear
size measured over the past 5 years [47]. If this is cor-
rect, then it is vital that health professionals ensure that
all older patients are aware of their foot dimensions and
appropriate footwear size for length and width.
Footwear in people with diabetes
The association between ill-fitting shoes and the develop-
ment of foot ulceration in people with diabetes is well
documented. Prospective studies have found that either
ill-fitting footwear alone [48,49], or minor trauma caused
by footwear is the most common precipitating factor in
the development of diabetic foot ulcers [50,51].
Five studies have investigated shoe fitting among
participants diagnosed with diabetes, with all using a
similar approach to fitting analysis based on footwear
sizing [15,25,28,29,31]. For example, two studies
Buldt and Menz Journal of Foot and Ankle Research (2018) 11:43 Page 8 of 11
considered footwear fitting to be incorrect if there
was half a size difference between the foot and footwear
[29,31] while one study applied a full size benchmark
[25]. Other studies deemed footwear size inappropriate if
the difference between foot and footwear length was out-
side a range of 10–15 mm [15] or greater than 2 mm [28].
All studies recruited similar samples of individuals with dia-
betes in terms of age (mean age range 55.6 to 67.2 years)
however there was a large range of sample sizes (range 43 to
440). Among these studies, between 33 [29] and 82% [15]of
individuals with diabetes were wearing shoes of incorrect
length. Of these, between 10 [29] and 43% [15] were wearing
footwear that was too short, while between 23 [29] and 81%
(diabetic men only) [28] wore footwear that was too long.
In terms of shoe width, there was evidence among a
sample of 568 diabetic individuals with peripheral neur-
opathy that the forefoot of most individuals with dia-
betes is broader than the most common industrial shoe
width references used by shoe manufacturers [8]. This
was supported by included literature in this review. For
example, in a sample of 100 individuals (mean age 62.0
SD 14.9, range 24–89 years), 46% of individuals wore
footwear that was too narrow [29]. However, of these
participants, 67% wore the correct length footwear,
which may indicate that a large proportion of individuals
with diabetes may be selecting footwear that is correctly
fitted for length, but are not considering, or are not able
to acquire, footwear of sufficient width [29].
There was no evidence that a greater proportion of
participants with diabetes wear incorrectly fitted foot-
wear (according to length) compared to matched con-
trols without diabetes [15,25]. However, there was
evidence of an association between incorrectly fitted
shoes and the presence of diabetes-related foot lesions.
For example, among a cohort of 440 male veterans with
diabetes, those with current foot ulceration were 5 times
more likely to be wearing incorrectly fitted shoes (at
least one full shoe size difference) [25].
The overall findings suggest that, even though a similar
proportion of individuals with and without diabetes wear
incorrectly fitting footwear, the consequences of doing so
for an individual with diabetes may be greater due to the
potential development of diabetic foot ulceration.
Activity- or occupation-specific footwear
Footwear is often designed to fulfil a range of activity or
occupational requirements. For instance, shoes may
need protective or traction properties in order to allow
the individual to safely and effectively carry out a re-
quired task [52]. One such is occupation is mining,
which requires workers to stand for long periods of time
on sometimes uneven, wet or unstable surfaces [53]. It
was identified in a study of 208 mining workers that the
boots worn by miners (both lace-up boots and gum
boots) were significantly narrower than the foot but also
significantly longer than the recommended 10–20 mm
clearance [24]. These findings could indicate an attempt
by miners to select shoes of appropriate width by wear-
ing excessively long shoes. This in turn may contribute
to the high prevalence of foot pain reported in this
population [53].
The only study that investigated activity specific foot-
wear indicated that, among 56 rock climbers, all partici-
pants wore shoes that were smaller than the foot, with
the mean difference being the equivalent of four British
shoe sizes [30]. However, despite the reported pain, these
shoe-fitting habits were deemed necessary by rock
climbing participants to attain enhanced performance by
ensuring close contact between the foot and the climb-
ing surface.
Footwear fitting differences between sexes
Women are more likely to suffer foot pain compared to
men [54,55]. Furthermore, females suffer more foot
pain while wearing shoes compared to men, most likely
due to the narrower toe box of women’s shoes [56]. Of
the studies that recruited both women and men, only
one compared shoe fitting between sexes. In this study
of older individuals, percentage difference between mea-
sures of length, width and total area was compared for
both outdoor and indoor shoes [20]. In all comparisons,
women displayed significantly greater percentage differ-
ences compared to men, thus indicating that women
were wearing relatively smaller footwear.
Three studies investigated footwear fitting among men
and women, but did not carry out significance testing to
compare fitting between the two sexes [19,28,31].
These studies provide some evidence that a greater pro-
portion of women wear incorrect sized footwear com-
pared to men. For example, one study reported a greater
proportion of women wore shoes that were too narrow
(difference greater than 5 mm between foot and shoe)
compared to men (50% women, 34% men) [19]. How-
ever, there is also some evidence that a greater propor-
tion of men were wearing footwear that was too long
compared to women. This was evident in a study of
older individuals with diabetes, including 227 women
and 172 men that found a greater percentage of men
were wearing incorrectly fitted shoes (69% men, 48%
women) [28]. Of these 31% of men and 13% of women
were wearing shoes that were at least 10 mm longer
than their feet.
Conclusions
The available evidence indicates that a large proportion
of the population (between 63 and 72%) are wearing in-
appropriately sized footwear based on length and width
measurements, and that incorrect footwear fitting is
Buldt and Menz Journal of Foot and Ankle Research (2018) 11:43 Page 9 of 11
significantly associated with foot pain, poorer overall
foot health, corns and calluses in older people and foot
ulceration in older people with diabetes. However, a
limitation of the literature is that there are variations be-
tween studies in the way that footwear fitting is mea-
sured and defined. Hence, future work should adopt
standardised approaches to assessing footwear fitting.
Of particular interest among the included literature
are findings related to specific groups of participants
that are more likely to display variations in foot morph-
ology compared to the broader population. These partic-
ipants include children with Down’s syndrome, older
people, or people with diabetes. Fitting according to foot
width was a particular concern among these groups with
between 46 and 81% of participants wearing footwear
that was too narrow. In addition, there is evidence that
older people and people with diabetes may select foot-
wear of inappropriate length in order to acquire foot-
wear to accommodate forefoot width.
Overall, the high prevalence of incorrectly fitted foot-
wear suggests that greater emphasis should be placed on
footwear fitting education so people are more aware of
their foot dimensions and appropriate foot size. Further-
more, footwear manufacturers should provide an appro-
priately large selection of shoes that can accommodate
the variations in foot morphology among the population.
In particular, a greater range of widths for each length
sizing option should be made available in order to ac-
commodate feet with wider dimensions.
Funding
No funder played any role in the study design, collection, analysis or
interpretation of data, writing of the manuscript or decision to submit the
manuscript for publication.
Availability of data and materials
The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.
Authors’contributions
AKB and HBM conceived the idea of the review. AKB carried out literature
search and extracted data. AKB drafted the manuscript with input from HBM.
Authors’information
HBM is currently a National Health and Medical Research Council Senior
Research Fellow (ID: 1135995).
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
AKB is associate editor of the Journal of Foot and Ankle Research. HBM is
editor-in-chief of the Journal of Foot and Ankle Research. It is journal policy
that editors are removed from the editorial and peer review processes for
papers they have co-authored.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Received: 12 June 2018 Accepted: 12 July 2018
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