Greetings and welcome. Today I would like to introduce proper depth as an ingredient that appears in comfortably fitted footwear. Hopefully when you hear people speaking about how deep a particular pair of shoes is they will be speaking about the toe box. While your foot lacks literal linear divisions your shoe pattern will have them. Naming conventions can vary, many people use the wrong terms to refer to portions of a foot. I've heard the instep called the arch and worse, but almost everyone understands and uses the anatomical term toes correctly. By the way, learning more about the parts of shoes and feet can increase your vocabulary. Textbooks and Google are a worthwhile past time for those who would like deeper insight into the wonderfully wild and exciting world of footwear. 

Feet are three dimensional objects that take up space inside of containers. These containers may be hosiery, footwear, a walking boot, a cast, or may take another form such as plaster that was used to take an impression of your foot or feet. Another way to think about depth is to consider how much room your toes are taking up inside of your shoes. Forget about width for a moment, we want and need to know where your toes are in relation to the top of your footwear. To clarify, the top is the portion of your shoe that covers your toenails if you have them. The top is not synonomous with the end of your shoe which is a separate consideration involving footwear length. 

A function of footwear is to protect feet. Ironically it can be the structures that are designed to provide defense from dirt, sharp objects, and other hazards such as furniture legs that are contributing to foot damage. If it was up to me everyone would have their bare feet inspected annually as an ounce of prevention is purportedly worth a pound of cure. I have some certificates proclaiming that I am qualified to fit people with therapeutic footwear. There are different levels of certification, one is a multiple choice test that requires no experience, but you can print off this sheet of paper and hang the framed piece on your wall in an effort to impress people who are coming to see you about footwear.

I have a lot of problems with this certification because in my opinion it's practically meaningless. Having this certification without experience may lead people whose feet are endangered into believing that you have a skill level you may not. Medicare fraud costs everyone. It costs taxpayers who pay for investigators, it costs patients, sometimes they end up paying with their lives or health, and unfortunately a large sum of money isn't going to give anyone back a foot that had to be amputated because footwear caused some of the very problems it sought to avoid. Sadly fraud thrives because patients often lack the knowledge and education they need to make informed footwear choices.

One easy way to determine if your footwear is the correct depth is to examine your bare toes. Nails should be an appropriate length and shape. They should be firm, smooth, and demonstrate rapid capillary refill when gently depressed. Side note - always ask a patient if you can press down on a toe, this if for your protection as well as theirs, you don't want to find out that they have a healing wound you inadvertantly compromised beneath one of their toes. Diabetics may qualify for extra depth footwear, their feet can be extremely fragile, and as the disease progresses they may have something known as LOPS which is Loss of Protective Sensation. Pain isn't always a bad thing, we want your foot to hurt if there's a Lego or a toy car in your shoe.

For people with healthy nerves it may be difficult to imagine stepping on a tack or a bottle cap and walking around with that embedded in your foot. For people with LOPS or peripheral neuropathy this may be an aspect of daily life. The elderly and mentally impaired are especially vulnerable populations that may not be able to voice their concerns which is why understanding how depth plays a role in properly fitted footwear can be critical. A girlfriend of mine asked if I would work with a client of hers who was bringing in a middle aged diabetic who had some level of mental incompetence. An examination of his feet revealed the ulcers that we knew about, but when I asked about the top and tip of his second toe on his left his caretaker gave me a blank look.

The hammer toe was an obvious condition, in this case his nail was rubbing against the insole of his shoe while the knuckle was rubbing against the underside of the top of his shoe. This man's feet were severely abducted, people at the group home paid close attention to the soles of his feet, but nobody had noticed how the end of his second toe had been abraded and they hadn't paid much attention to the reddened area on his knuckle. This man had very shallow feet, but needed the extra depth provided by therapeutic shoes because of his hammered toes. He had been wearing a Velcro style of shoe since they were easier to don, but after examining them I showed his caretaker that the sloppy worn closure was allowing his entire foot to slide forward in his shoes when he was ambulatory. 

To make a long story short the caretaker, my friend, and I spent an hour with this man when the shoes I recommended arrived. We got him into better socks that provided him with extra cushioning, and managed to aggravate the ulcers on the bottoms of his feet anyways. The Goldilocks standard of just right can be elusive in footwear. Give people too much depth and their feet can slide forward and bang into the ends of their shoes. Removing depth from people who need it can produce conditions such as corns, blisters, callusing, abrasions, shredded nails, thickened nails, jagged nails, and can be a factor in complete or partial nail removal. 

I once worked with an extremely dissatisfied customer who brought back two pairs of shoes that another employee had sold him. When I talked to my associate he remembered the client well and so did I. He had refused to listen to my fellow employee and insisted that he be sold shoes in the size that he requested. His idea was to add an insert into his shoes so I did my best to accomodate him. I measured his feet and explained that a size twelve insert wasn't going to fit into his size ten shoes. This man was wearing a worn out pair of very thin dress socks. When I handed him a pair of socks to try I noticed that his right nail was black. He tried to explain that he played baseball and pitching had led to the nail discoloration. 

When I spoke with the guy who sold this man the shoes he said he had been wearing a nine and a half and he had convinced him to try the roomier size ten. This man had been wearing shoes that were two and a half sizes too small for who knows how long. When he gave me the line about pitching being the cause of his black nail on his longer foot I asked him if other pitchers on his team also had black nails. He said he wasn't sure, I didn't really say much to this guy who was monopolizing my time and had switched tactics to try and implicate the sales associate he had worked with when he had purchased the shoes he was currently wearing.

After a long conversation with my manager she agreed to swap out two lightly worn pairs of shoes for the size that he needed. He begrudgingly shook my hand after I fitted him with functional orthotic inserts. His problem was a very shallow foot that slid forward in his footwear. To compensate for this he tried wearing shorter shoes, unintentionally, to try and give his feet a more secure feeling. Previously I wrote about size as a footwear concept and using orthotics in shoes that fit before the orthotic was added. In this case we used an orthotic to eliminate extra depth he didn't need in his shoes. By anchoring his heel with an orthotic and cushioning his toes with socks and orthotics we were able to create a more customized footwear system for him. 

What I hope people take away from this is the important of understanding the root cause of a symptom and removing that if possible to eliminate or reduce it. All of this drama could have been avoided had this man started by shopping for dress shoes that were the correct shape, size, height, and depth for his foot. Even when we gave him his size there was excessive room above the tops of his feet that required a pair of thickly cushioned socks and an expensive orthotic he may not have truly needed had his footwear been the right proportion in the first place. Depth is a tricky topic because as length increases, so does depth. My daughter has a very shallow foot so shoes are always too tall for her toes.

I have the opposite problem since my feet are taller without her length. Last year my daughter and I wore the same size, but my feet need depth while hers are already showing signs of abuse from her feet continually sliding forward in her shoes. I work in footwear, but I didn't realize that this was the problem with her feet so at fourteen she is already on the path for rigid hammer toe formation. Her second toe is still somewhat flexible, I try to keep on top of her to stretch and work it, but if she doesn't believe that her toes are going to be a problem for her in the future, and she can't associate footwear fit with increased health, there's not a lot I can do for her. Once the damage is done, it is often irreversible. Surgery will cut the tendons, but it will never restore the functionality a toe had previously. 

Depth is a simple concept that can require advanced footwear knowledge. Every day I see people whose footwear is not deep enough, or too deep for them. There isn't a measurement for it and as we learned in the case of the diabetic patient, sometimes depth is only needed for one part of the foot. It's hard to say how many people are wearing shoes that are the correct depth for them. I'll go through socks quickly because my shoes tend to be shallow, my nails tip up and cut into my socks regardless of how thin they are. This is the culmination of years of footwear that was too long for my toes which are permanently turned toward the sky because my parents and I didn't know what we were doing and theoretically didn't have the money to address the issue. 

Wearing shoes that are too deep may cause a wearer to try and grip the soles with their toes. Footwear can be a hideously fascinating study when you consider cause, and effect. I hate thinking about the feet that aren't taking toe box depth into consideration. I hate writing about these topics and living with the consequences of my own footwear decisions that I didn't realize were affecting me the way that they were. I hate seeing the bony prominence on my daughter's feet and knowing that shallower shoes probably could have prevented those from developing. Sometimes I think, this is too much, I can't deal with it, nobody cares. But then I remember how many people have been grateful, I think about how much worse my feet and my daughter's could be, and despite the imperfection of everything we write, I believe it is better to have written and shared than to not have written at all. 

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