Good Health Starts with Good Shoes

At dawn, Edward Y. Ho of the Taiwan Footwear and Recreation Technology Research Institute (FRTRI) transports a 150-kilo computer scanner from Taichung to the First Social Welfare Foundation on Hsinyi Road in Taipei. His mission is to measure the feet of disabled people so they can have shoes made to order. This is one of the locations he visits every month during routine trips throughout Taiwan.

Liu is a four-year-old who was born with several disabilities. In addition to mental retardation and language impairment, one of her legs is 3.8 centimeters shorter than the other. She therefore used to walk on tiptoes with her shorter leg and her gait was very unbalanced. Liu's mother watched her like a hawk, afraid that she might tumble and bruise herself.

Last year, Ho custom-made a pair of shoes for little Liu. As soon as she put them on, her gait became much steadier, and today she loves walking up and down stairs holding her mother's hand. Over the past year, the soles of her shoes have suffered much wear and tear during their walks around town. Knowing that Ho is visiting Taipei today, Mrs. Liu has brought her daughter to the foundation to order a new pair of shoes.

Mrs. Liu asks Ho somewhat anxiously: "She doesn't like wearing shoes at home. What should I do about it?" Ho suggests that she order two pairs of shoes, one for indoors and one for outdoors. Alternatively, little Liu could wear normal shoes with a special insole at home. Otherwise the development of her lumbar vertebrae might be impaired due to a long-term imbalance in her body's center of gravity.

Summer weather brings out all sorts of fashionable pointed and high-heeled shoes, but fashionable young women shouldn't buy beautiful shoes unless they fit.

Custom-made shoes

In fact, it's not just people with a foot deformity or other disability who need custom-made shoes. People with foot problems due to illness or injury often cannot find suitable footwear either.

Fifty-two-year-old Mrs. Huang suffers from rheumatoid arthritis. The disease, which is caused by an immune disorder, has already affected all her joints and deformed the joints of her fingers. Her toes are so swollen that they obstruct each other's movement, making every step an ordeal. In a normal shoe store, the only shoes that fit her are big men's shoes, which aren't comfortable. Otherwise, she can only wear sandals that show her toes all year round.

Hospitals, clinics, and social welfare organizations are now referring people who have trouble walking to the FRTRI for assistance. This is making the center increasingly popular.

The FRTRI was a joint venture founded in 1991 by the Ministry of Economic Affairs' Industrial Development Bureau and the Taiwan Footwear Manufacturers' Association. Its mission is to conduct footwear research and manufacture custom-made shoes for those who need them. To meet the needs of the hundreds of thousands of people in Taiwan who are unable to buy shoes that fit them, in 2003 the FRTRI established the Foot Orthotics Resource and Promotion Center with the support of the Ministry of the Interior. The center began to visit social welfare organizations throughout Taiwan and to offer assistance to those in need.

The process of making custom-made shoes requires great attention to detail, because feet are three-dimensional and curved, and deformed feet are particularly irregular in shape. Fortunately, science and technology have come to the rescue. A computer scanner costing more than NT$8 million which was imported from Canada allows Edward Ho to scan any type of foot, take the computer file back to the FRTRI, and design a custom-made shoe. The shoes are usually made of ox leather and lined with pigskin. To ensure a perfect, comfortable fit, the shoe is tried on, and adjustments are made if necessary. On average, it takes a month to complete a shoe from the time the foot is first measured.

The arches of the foot are extremely important, because they absorb pressure and shocks from the ground. Flat feet or high-arched feet can cause an imbalance in the body's center of gravity. An insole can correct this and provide support.

Podiatric training

As an FRTRI podiatrist who provides expert advice to shoe manufacturers, Edward Ho is one of a small minority of people who specialize in podiatry in Taiwan.

In his first year of high school, Ho moved to California with his father, a businessman. After majoring in chemistry at university, he chose an unusual career path: podiatry (also called chiropody). He enrolled in the California College of Podiatric Medicine, and graduated four years later as a qualified podiatrist.

Ho recalls with a smile: "In those days I was mad about tennis, and would hit the courts whenever I had the time. I would go through a pair of tennis shoes every three weeks." It was his desire to find out how he actually wore out his shoes that made him study podiatry.

Although Ho was licensed to practice medicine in the US and was a resident physician in California, he knew he didn't want to be a doctor. He recalls: "Being on call at any hour, having to treat patients in the middle of the night, the huge pressure, and having no time to myself were not for me."

In 1999, Ho went back to Taiwan to visit relatives and came across a newspaper job ad placed by the FRTRI. The required qualifications were a background in podiatry, anatomy, and biomechanics. After 18 years in the United States, Ho decided to return to his native Taiwan, equipped with his American expertise in podiatry.

Michelangelo once observed that the human foot is a masterpiece of art and engineering. No other animal has feet structured like those of human beings. What makes human feet unique are heels that come into contact with the ground, toes that point forward, and the arches of the foot.

The human foot contains 26 bones, 33 joints, 19 muscles, and 107 tendons. Together, the two feet have 52 bones, which is a quarter of the 206 bones in the human body. What's more, even the tiniest feet are extremely hard-working anatomic structures, second only to the heart. Feet must bear the weight of the entire body as well as pressure and shocks from the ground; they also have to adjust to all sorts of terrain, and enable people to walk and run.

American medical science began to study the human foot after World War II, when a great many American soldiers who had suffered foot injuries required special medical treatment. The manufacture of orthopedic footwear and auxiliary equipment proved to be particularly troublesome for conventional medicine. The new discipline of podiatry was developed in the 1970s after American physicians began to call for its creation. In the past 30 years, podiatry has gone from treating light foot pain to being a professional branch of medicine that diagnoses, treats, and operates on diseases of the lower limbs.

In the United States, there already exist medical schools specializing in training podiatrists, where podiatrists can practice surgery below (but not including) the knee joint and help children with foot abnormalities by carrying out nonsurgical corrective exercises for conditions such as flat feet (pes valgus), toeing-in, and toeing-out. Podiatry has had a late start in Taiwan, but quite a few hospitals and clinics now have physicians specializing in foot and ankle surgery.

Summer weather brings out all sorts of fashionable pointed and high-heeled shoes, but fashionable young women shouldn't buy beautiful shoes unless they fit.

Don't cut your toes to fit the shoe

Four years ago, the FRTRI made approximately 70 pairs of shoes a year. Demand has grown every year since then, and during the first half of this year alone, the center has had standing orders for more than 300 pairs of shoes. Ho estimates that in the past four years he has produced more than 1000 custom-made shoes for people with flat feet, leg-length discrepancy, and various foot deformities.

The most famous person Edward Ho has made shoes for is Dr. Hsu Cho-Yun of the Academia Sinica. As a result of a congenital deformity, Dr. Hsu's hands and feet are curled inward. Although before going to America to pursue his studies, he already wore shoes that were made to order, they had to have very thick cotton padding to be comfortable, because his instep was contracted downward. In the US, Dr. Hsu underwent five corrective operations to push the soles of his feet downward. The hospital also designed custom-made shoes that fit his feet.

On returning to Taiwan, Dr. Hsu took his US-made shoes to the Ministry of the Interior's Disabled Veterans Footwear Center and asked them to make the same type of shoes for him. After the center was incorporated into Taipei Veterans General Hospital, Dr. Hsu continued to have his shoes made to order by three generations of master shoemakers working for the hospital. When the shoemakers retired, the hospital referred Dr. Hsu to the FRTRI.

Edward Ho made a special shoe last for Dr. Hsu and had him try out three specially designed insoles-one flat, one arched, and one without an arch. Because they were very comfortable and durable, Dr. Hsu ordered three pairs.

"The biggest challenge when making shoes to order is not technology, but overcoming psychological obstacles," says Ho bluntly. Many disabled people want their shoes to conceal their foot deformity. Custom-made shoes can be very comfortable, but it is very difficult to meet customers' expectations that they also look good. In the case of clubfoot or equinus foot, little can be done to make a shoe look attractive. When people with such deformities see first stages of the shoe-making process, they often complain that their shoe looks like a big landing boat. Ho has to patiently explain what is and what isn't possible. Always aiming to make comfortable shoes, he also has to make as many adjustments as necessary to make the customer happy. On one occasion, he had to change the shoe design a dozen times.

Ho says that as soon as people with a foot disability try on their custom-made shoes, they can feel the difference. A man with one leg 12 centimeters shorter than the other had to wear a shoe with a built-up sole that weighed 1.5 kilos. The FRTRI used foam materials that reduced the weight of the shoe by half. The satisfied and grateful customer was delighted at how light and comfortable his new shoes were.

A nine-year-old mentally retarded boy made Ho even happier. Previously the boy had been wheelchair-bound and had to be pushed to school by his parents. But after a few months of practice with his custom-made shoes, he can now walk about freely in the classroom. Ho says that for the disabled and the elderly, auxiliary footwear is not only supposed to make day-to-day tasks less tiresome, but also gives them more independence, improves their quality of life, and eases the burden on their caregivers.

The process of making custom-made shoes is complex. On average, it takes a month to complete a shoe from the time the foot is first measured.

Preventing successive defeats

Now that the concept of custom-made shoes has begun to take root in Taiwan, how big will the custom-made shoe market be in the future?

According to statistics compiled by the Ministry of the Interior, there are 840,000 people with physical or mental disabilities in Taiwan. Forty-two percent have physical disabilities, and an estimated 350,000 have trouble walking.

Wang Tso-liang, a rehabilitation specialist at the Taipei Spine Clinic, says that people who need custom-made shoes fall into three main groups: The first group are people who have a biomechanical imbalance due to foot disease or injury, such as a high-arched feet or flat feet. The second group are people with impaired foot function due to a deformity caused by conditions such as diabetes, leprosy, or rheumatoid arthritis. The third group are children with a foot abnormality. Because children are still growing, their needs require special consideration and planning.

Regarding the first group, Wang says that those with flat feet can consider themselves fortunate. These days all hospital rehabilitation centers can have a foot orthosis made to order. The technology to make such orthoses is not terribly sophisticated. Molds can be designed by computer or made from plaster casts. Biomechanical imbalances can be corrected and a comfortable gait achieved by inserting an arch or spacer in the shoe.

The second group have lost the feeling in their feet due to nerve damage, so that they may be injured without realizing it if they bump into things, making them very prone to infection. This group has grown substantially in recent years. Diabetics are particularly difficult to deal with, because their wounds are slow to heal.

Wang points out that diabetes is the fifth-largest cause of death in Taiwan. It is estimated that in the population above 40, some 6% are diabetics, of whom 15% have a foot pathology. In recent years, the average age of diabetics has fallen. Diabetic foot pathologies, which are now more common than car-accident injuries, have become the leading cause of amputation of the lower limbs in Taiwan.

Ho also stresses the even more worrisome fact that diabetics suffer "successive defeats" because they often ignore foot ulcers, which can spread from the toes, soles of the feet, and calves, making amputation unavoidable. Amputation is not only an expensive medical intervention, but it also takes a heavy toll on patients and their caregivers.

Children with flat feet, toeing-out and toeing-in can be helped early on with corrective exercises. If parents notice that their child stumbles easily or that one shoulder is higher than the other, they should promptly take them to a hospital for a check-up.

Children's footcare must start early

After training in the surgical and rehabilitation departments of Kaohsiung Medical College, Dr. Wang went north to start his own practice. A few years ago, Wang saw many diabetic patients with foot ulcers in hospital wards. They were forced to cover their feet with plastic bags and endure pus-oozing sores. Seeing these patients shambling along hospital corridors kindled Wang's interest in podiatry.

Wang began to collect and read articles on podiatry. With the support of the FRTRI, he has surveyed the feet of more than 5000 Taiwanese. He concludes that Taiwanese people's feet tend to be "short, fat, and small." Shoes made with Western lasts sometimes don't fit Taiwanese people at all.

Wang has put a lot of thought and effort into producing custom-made shoes for children. Based on ergonomic principles, he designs shoes that can correct flat feet as well as corrective shoes that prevent feet deformities in children. Working together with the Industrial Technology Research Institute, he has already put the first nanotechnology corrective shoe on the market. Combined with a nanotech photocatalyst and nanotech far-infrared technology, these custom-made shoes have antiseptic and deodorizing properties, and stay dry and comfortable.

Wang believes that custom-made children's shoes have great market potential. Flat feet, high-arched feet, toeing-in, toeing-out, bow legs, knock-knees and other deformities of the lower limbs are very difficult to detect before age three and only become obvious during adolescence. But parents should keep a close eye on their children. If they stumble easily, if one shoulder is higher than the other, or if a shoe is worn out on one side more than the other, they should promptly take them to a hospital for a check-up comprising a biomechanical evaluation, an X-ray, measurement of both legs, and a thorough review of the family medical history. If corrective measures, including the wearing of corrective shoes, are taken early on, the prognosis is usually good.

When this girl, who has one leg shorter than the other, started wearing her custom-made shoes, her gait became much steadier.

Shoes to walk the journey of life

"If the spine is a multistory building, the feet are its foundation," says Wang Tso-liang. The importance of the feet is apparent when one considers that a foot deformity can create a pelvic imbalance, which in turn can upset the curvature of the spine. "Medical footwear" therefore deserves to become popular even among people who don't fall into one of the three categories described above.

Nurses are very health conscious and were consequently the first group of professionals to wear shoes especially designed for their needs. Other groups of people who spend long hours on their feet (which can cause varicose veins), such as teachers, hairdressers, salespeople, and weightlifters, also need specially designed shoes.

FRTRI director Liu Pao-pao, who has designed rock-climbing shoes and medical footwear for the elderly, says, "If we had presented medical footwear for specific professions or elderly people to the public ten years ago, we would not have been able to sell them. But Taiwan has entered the modern age. These days, people are much more health conscious and are willing to spend money to take care of themselves. Penny-pinching is really not worth it when it comes to one's health." In the future the FRTRI will design special shoes for the military and the police. Military footwear needs to let the feet breathe, be waterproof, and guard against athlete's foot. Once the right materials are developed, the technology can be passed on to manufacturers.

As humble as they may seem, shoes should not be looked down upon. A good pair of shoes can save your feet and support your health and wellbeing. To walk the long journey of life you need a good pair of shoes.

Diabetes is one of the ten leading causes of death in Taiwan. Many diabetics have lost the feeling in their feet due to nerve damage, and may be injured without realizing it. In serious cases, amputation is sometimes the only option. Diabetics should check their feet every day and take good care of them.

Regardless of the shape of the foot, the FRTRI can make a shoe that will fit.

Summer weather brings out all sorts of fashionable pointed and high-heeled shoes, but fashionable young women shouldn't buy beautiful shoes unless they fit.

The arches of the foot are extremely important, because they absorb pressure and shocks from the ground. Flat feet or high-arched feet can cause an imbalance in the body's center of gravity. An insole can correct this and provide support.

The arches of the foot are extremely important, because they absorb pressure and shocks from the ground. Flat feet or high-arched feet can cause an imbalance in the body's center of gravity. An insole can correct this and provide support.

A good pair of shoes can help you walk the journey of life in comfort and good health.

Regardless of the shape of the foot, the FRTRI can make a shoe that will fit.

Edward Y. Ho of the Taiwan Footwear and Recreation Technology Research Institute, who studied podiatry in the USA, scans feet of various shapes and sizes and enters the data into a computer.