A blog by Simone Cranage

One of the most common questions we are asked as podiatrists is in relation to kids ‘footwear. “When should my child wear shoes?” and “should they be wearing a supportive shoe or a soft shoe?”

When toddlers go forward into this exciting stage of walking independently, it’s inevitable they will stumble and lose their balance. They are trying to maintain stability and avoid falling over as best they can while they have a new view of the world. What we often observe with our early walking toddlers is wide base of support. They will lift their feet higher off the ground to achieve ground clearance during the swing phase of gait. They also keep their arms high, again as a way to attempt to maintain stability with their new skill. We also notice they take shorter, faster steps and have a short swing phase. All of this helps a toddler to maintain their balance until their nervous system and postural control mechanisms continue to develop [1] [We know in a typically developing child, their visual, proprioception and vestibular systems enables them to bring their centre of gravity to a more stable position and this usually occurs by the time they are six years old [2].

As a child matures and they progress towards an adult gait pattern, their balance improves and we see their base of support narrow. Their stride length increases and they develop a reciprocal arm swing. A more mature gait pattern is said to have been achieved at the age of 3 years with the presence of a heel strike, an increase in walking velocity and step length and reduced cadence [1].

So what happens when we add shoes into the mix for our toddlers trying hard to master their new skill? Shoes are important in our society to protect our feet from injury and from the heat and the cold. We often tell parents of the importance of a child walking barefoot to optimise the foot development, but do we have evidence to back up what we are advising parents?

It is thought that being barefoot allows toddlers to increase muscle strength within their feet and provide sensory experiences for them, allowing them to feel the sensation of their skin touching the ground. As clinicians we encourage a soft soled shoe for protection, and when they have been developed a more mature gait pattern we transition children into a more supportive shoe with firmer shoe fixtures. There is little research to guide us in the optimal shoe at each stage of walking, in particular in younger children.

We do however know how shoes can impact on an older child’s gait pattern. When children wear shoes compared to walking barefoot, they will walk faster, have a longer step and stride length and also increase their stride and step time. They also have a reduced cadence with an increase in their double support time and a longer stance time while wearing shoes. So why the changes in gait while wearing shoes? Is the increase in stride length because the shoe makes our leg longer, therefore we stride out further? Or does the increased weight of the shoe create greater inertia during swing phase, therefore we stride out further. Or is it that a child wearing a shoe has more confidence to stride out further as their feet feel more protected? [3]. There has also been discussion as to why there is an increase in double support time while wearing shoes. An increase in the double support time has been proposed to be related to a reduced proprioceptive feedback while wearing a shoe. With reduced proprioception, the foot will be in contact with the ground for a longer period of time to improve stability [4].

If we delve into this further, we look not only how a shoe impact on a child’s gait, but how does the flexibility of the shoe affect this further. The most appropriate type of shoe for children beginning to walk remains controversial. Should we put them in a stiff or a flexible shoe and at what age? Staheli reported that the optimal foot development was that in barefoot conditions and selection of a child’s shoe should be based on the barefoot model. He also stated that a stiffer shoe may offer less sensory feedback to a child learning to walk, in comparison to a more flexible shoe [5] While a further study into the effect of torsional shoe flexibility on children learning to walk suggests that typically developing children can alter their gait pattern to adapt to different shoe conditions while maintaining their gait velocity and stability. Stance time was shorter in barefoot compared to all shod conditions whether they were flexible or stiff, possibly providing less proprioceptive feedback than barefoot walking [6]

References:

1. Sutherland, D., et al., The development of mature walking. 1988, London: Mac Keith Press.

2. Bundy, A.C., S.J. Lane, and E.A. Murray, Sensory integration: Theory and practice. 2002, Philadelphia: F.A Davis Company.

3. Lythgo, N., C. Wilson, and M. Galea, Basic gait and symmetry measures for primary school-aged children and young adults. II: walking at slow, free and fast speed. Gait Posture, 2011. 33(1): p. 29-35.

4. Wegener, C., et al., Effect of children's shoes on gait: a systematic review and meta-analysis. Journal of Foot and Ankle Research, 2011. 4(3): p. 1-13.

5. Staheli, L.T., Footwear for children. Instr Course Lect, 1994. 43: p. 193-7.

6. Backland, The effect of torsional shoe flexibility on gait and stability in children learning to walk, 2014, Pediatr Phys Ther. 2014 Winter;26(4):411-7