Correctional health: Foot problems in prisons


Correctional health staff get inundated on a daily basis on foot wear issues. The only way to approach it, is to let the frustration not overwhelm you and to approach the challenge the scientific route.

Remember, you have not fully examined the foot in a foot complaint, if you have not examined the leg in toto… and just as important, examined the shoe. A shoe should be inspected visually, palpated on the inside, bent and twisted in all diameters.

Checklist in a shoe investigation

  • What is the shoe size and what is the inmate’s foot size?
  • Does the inmate have an unnaturally broad foot?
  • What is the foot diagnosis? (see the differential diagnosis list below)
  • How old is the shoe?
  • What jobs does the inmate perform?
  • When did the shoe problem start?
  • Does the shoe have a proper height bridge?
  • Are the left and right feet symmetrical?
  • Look at the sole if the shoe: Is it worn? How does it walk off?
  • Look for the presence of a heel, the integrity of the sole. Shoes in prison don’t have shoe laces, but they have Velcro. The reason for this is the that shoe laces get used in prison for alternative reasons such as to commit suicide or homicide, and the risk of using it in the construction of contraband
  • Palpate the inside of the shoe with your gloved hand. You may be surprised at what irregularities you may feel. You can sometimes feel where the second metatarsal distal head indentates the shoe’s inner sole; exactly at the spot where the inmate is complaining of metatarsalgia. You may also feel ridges where shoes have been stitched leading to callus formation. There may be tears leading to decreased integrity of support of the shoes. You may feel the grid of the rubbersole of the shoe etching its’ way through the inner sole of the sole and imprinting its’ template on the inmate’s foot sole; which due to repetitive exposure leads to severe foot pain. You may even find a foreign object such an old nail embedded in the shoe’s sole leading to foot pain.
  • Squeeze the lateral sides of the broadest part of the shoe. This maneuver can give you a lot of information on the ability of the rubber sole of the shoe to support the foot. As the sole of the shoe thins, it can give way and start buckling on lateral pressure. The buckling indicates that the rubber sole has become too thin and the risk of metatarsalgia will increase as well as the risk that a nail or foreign object will be able to pierce the rubber sole straight into the foot
  • Squeezing the shoe from front to back can also give an indication of the rubber sole’s integrity. It should be able to bend about 35 degrees; dependent of the shoe’s primary function, that being a daily living shoe, a sport shoe or a security or workman’s steel-tipped shoe. If the shoe can double up from front to back at about 180 °, it is clear that such a rubber sole is not supporting the foot’s natural arch. Such a soft sole may lead to foot and ankle fatigue with repetitive exercise exposure. Bending a shoe double from front to back quickly indicates where side stitching has come loose
  • The shoe should be twisted along its’ longitudinal axis. This also indicates the integrity level of the rubber sole and its’ ability to support the foot sole. Excessive twisting will lead to foot fatigue, depending on the frequency and activity level of the wearer
  • The back of the shoe should be pressed down to determine its’ rigidity. A rigid back will support the ankle. A soft back will not give the same amount of support. If you examine the heels of patients you wil find that the heels of the patients frequently have irregular surfaces due to bony exostoses, deformities or hypertrophied scar tissue due to chronic Achilles tendinitis. Previous accidents can make the heel surfaces very irregular. Examining the shoe back-to-heel fit, one can diagnose problems where the back is chaffing the wearer’s heel or Achilles tendon leading to chronic ulcers or painful callus formation. Palpation of the shoe’s heel will highlight any suturing errors of the back of the shoe, chaffing the patient. Note whether any parts of the back of the shoe is excessively shiny due to wearer’s foot pressure
  • Measure the height of shoe with your fingers inside the dome to get an indication on the space needed for wearers with high foot bridges. Examine the wearer for signs of chronic foot pressure effects such as deformity, venous and skin changes or callus formation


  • If the inmate suffers from episodic foot swelling as in chronic hypertension, kidney failure, heart failure to mention but a few, he may need to wear a size or two larger to accomodate such swelling. Conditions such as cellulitis may only be temporary. Inmates may not be housed in the housing units without shoes. If they are unable to wear shoes due to medical conditions they must be admitted into the prison hospital for treatment of their leg or foot condition. Remember the acronymn RICE (Rest, ice, compression and elevation).
  • Always examine the foot properly. Check Achilles tendon reflexes for hypothyroism. This is the easiest if the inmate sits on the bed on his knees with his ankles dangling off the examination couch in the upward position.
  • Check arterial sufficiency by examining the presence of a. dorsalis pedis and a. tibialis anterior. Capillary filling of the toes must be tested. Seek trophic changes of the skin. Neurological testing must be done
  • Palpation by placing thumb pressure over metatarsal heads, plantar fascia, bony protrusions, and ligaments can supply a lot of clinical information
  • Examine the toe nails and interdigit webspaces for pathology
  • Inmates need training on foot hygiene. Most have never been taught how to care for their feet. The dictum applies “No happy feet = no happy camper”



Painful thickened areas of skin caused by friction of a shoe against the skin. Caused by ill-fitting shoes. Frequently found when inmates make their own shoes in their shoe-making workshops. The inmates always come to the clinic requesting the quick loan of a scalpel blade to slice them thinner


This is an alternative name for calluses


This is a dermatophyte infection of the soles of feet and interdigital spaces. Tinea pedis is frequently caused by Trichophyton rubrum. The inmates must be taught to keep the interdigital spaces clean and dry. Placing their shoes in the midday sun to dry out can also assist in reducing the spore load that accumulates in the shoes, exacerbating the condition


Onychomycosis also known as tinea unguium is a fungal infection of the nail. The bail thickens, becomes skew, splits and discolours


Pes planus (Flatfoot) is a condition that runs in families in which the longitudinal arch in the foot, has not developed correctly and has flattened out


There are many different foot forms which are different due to genetic variation. The forefoot can be inverted or everted. Standard-sized shoes can give these inmates severe foot pain


This is a disorder where the foot bridge arches very high. It can lead to callus formation on the bridge of the foot and foot pain

PES CAVUS is a generic variation where the side of the foot is distinctly hollow when bearing weight


This is a heel pain and pain in the bottom of foot. It is caused by standing for long periods, exercise and obesity


This is tendinitis of the Achilles tendon, generally caused by overuse of the affected limb. Look closely and you may frequently find that the upper brim of the back of the shoes is damaging the tendon, leading to an inflammatory response in the Achilles tendon sheath


It is usually located in the first metatarsal head on the foot ball behind the big toe. It is also known as stone bruise. The second most common place of occurence is under the second distal metatarsal head


A hammer toe is the deformity of the proximal interpharyngeal joint of the second, third or fourth toe causing it to be permanently bent, resembling a hammer


Is caused by dorsiflexion of the proximal phalanx on the lesser metatarsophalangeal joint, combined with fkexion of both the proximal and distal interphalangeal joints. Claw toes affect the second, third, fourth and fifth toes


This is a wart that occurs on the sole or toes of foot. They are caused by Human Papilloma Virus (HPV)


One will be surprised to see how common stress fractures of the tibia and foot bones in the prison environment can be. There are a few prisoners that use their breaks for exercising. This exercising is frequently near-maximum capacity for 15 minutes or more, involving short distance sprinting and jumping. Stress fractures of the feet are quite possible