Footniche: A new paradigm for thinking about foot care

By Joseph M. Mozena

Definitions are important because words can make the difference between understanding and misunderstanding.

I prefer a simple definition of footwear: that which covers the foot. This definition does not say it is a top covering of the foot—just a covering of the foot. In the definition of something as fundamental as footwear, I believe that less is more.

I also believe all footwear has an effect on the foot, such that, when examining a patient’s footwear, a foot-care specialist might ask: Does the footwear contribute to disease, deformity, or injury—or does it alleviate problems? Footwear that is prescribed could therefore be viewed as a medical device.

Certainly, prescribed therapeutic shoes and healing shoes are medical devices. But if we say street shoes are medically indicated, do street shoes become medical devices? When sports-specific shoes are recommended for people with diabetes, should they be considered medical devices? And because people with diabetes need shoes for different occasions, do all their shoes need to be medical devices, because all their shoes must be evaluated for those at increased risk of causing ulceration? Many patients with diabetes are labeled as non-adherent when not wearing shoes at home; should we be prescribing diabetic footwear in the hospital? And are these medical devices?

As street shoes become more sophisticated (as they have), they will be prescribed more often. The days of pathology-specific shoes are upon us.

My definition of “footwear”

In defining “footwear,” I include a diabetic insert as well as padding, or even a toe ring. Something that braces the foot would also be included. To me, footwear includes hosiery: socks, tights, stockings, and their specialized forms, such as diabetic socks and compression stockings.

Does “niche” properly describe the foot–footwear relationship?

Niche | noun ‘nich also ‘nésh or ‘nish . 2b: A habitat supplying the factors necessary for the existence of an organism or species.1

Bottom line: If it covers the foot, it’s footwear.

Where would I draw the line? I’m not sure. I do know that touching the foot is not mandatory. Think of products that offload pressure, such as a pressure-relieving ankle–foot orthosis, a pressure-relieving foot orthosis, or a zero-gravity ankle–foot orthosis. A definition such as mine leaves the door wide open; any more words would just limit, not expand, understanding.

It’s important that patients and practitioners must appreciate that any covering of the foot is footwear. Imagine a pin coming out of the bottom of the foot: it might pierce a diabetic sock, a diabetic insert, and a diabetic shoe—all of which are footwear. Note, too, that the shoe by itself may have many layers. More interesting still, if we follow the pin further from the shoe, we may encounter water, ice, dirt, toys on carpeting, wood, tile, concrete, etc.

Guardians of the foot need to think expansively

Foot-care professionals must assess and understand all the ramifications of a covering of the foot. These coverings include toe rings, nail polish, and tattoos. But does it become absurd to think of these coverings as footwear? If we are uncomfortable calling all the above footwear, should we use a new word to describe all that interacts with the foot in a particular environment and affects the relationship of the human foot to the abiotic environment? (When fungal infection invades a shoe, it may not be an abiotic environment any longer, however.)

If we think of footwear as layers only, such as the imaginary pin suggests, we miss out on their interactions with each other, such as the shoe and the sock, or the shoe and the orthosis, the surface and the shoe, or even more interesting combinations, such as the orthosis and the toe ring. Combinations are not limited to duals; they can work in a system, such as a ground-reactive force, a shoe, an orthotic, and a sock working in a more or less ever-changing closed system.

We need a new word that can describe all these relationships; an important consideration is that the word be defined broadly enough to factor in the time at which the footwear is applied to the foot. I propose the concept of a footniche.

What footniche accomplishes

Although there are many definitions of “niche” (see the accompanying box), it is readily apparent that footniche is not a perfect scientific fit. Nevertheless, the word creates a picture that is fruitful to consider. Take walking, for example: The footwear is changing through the gait cycle. (Or, should we say the footniche is changing?) Think about how that word changes our thinking about what all is involved.

Footniche seeks to define the bridge between the physical sciences and the biological sciences in a way that differs from biomechanics; footniche focuses attention on the relationships of the “stuff” that surrounds the foot—a kind of ecology of the foot, but not exactly. It is the relationships of the foot to the environment that need to be understood for medical, health, and well-being purposes. For example, the at-risk foot in diabetes needs to have any influences on it understood—a daunting task. The diabetic foot and its environment need to be assessed–not only measured and analyzed as a foot, but assessed as a unit, with interventions provided as needed. For this foot, the layers of shoes, orthotics, socks, surfaces, etc., all form a kind of foot ecosystem in which the sum is greater than its parts.

The environment is dynamically interlinked, imposing on and constraining the foot. For example, imagine a black, short, narrow, high-heeled boot on concrete in the sun. Rather than take a reductionistic view of the individual layers, how do we integrate the holistic view of complex patterns of interaction into healing? It is clear that a reductionistic view of the individual layers yields a great deal of information, but complex patterns of interactions may bring additional insights.

Another example: If we squeeze a balloon at a specific point, it will bulge out in a different area; therefore, looking only at the squeezed portion does not provide an overview of the entire system. This would be comparable to performing a diabetic amputation for local results and not realizing the cardiac overload of walking with a prosthetic limb. System thinking realizes small changes at the start of a process that can have profound changes downstream. Think about laying tiles: The first tile must be placed with meticulous precision. Placing that tile correctly solves a lot of problems downstream. But where do we begin? We begin at the beginning: namely, prevention.

What I’m proposing

We should balance the logic and measurement of our left brain with the intuitive, creative, synthesizing qualities of our holistic right cerebral hemisphere. Footniche creates a holistic visual that differs from left-brain analysis. Has foot care fallen into a comfort zone of left-brain dominance simply because we are good at analysis?

Let’s use our whole brains to practice the art and science of medicine, integrating other disciplines to garner what they have to offer into a synthesis. Certainly, biomechanics brought a wealth of knowledge to the understanding of pathologies of the foot. Where else should we be looking?

Joseph M. Mozena lives outside Milwaukie, Oregon.