Keys To Selecting Footwear For Patients With Diabetes

For patients with diabetes, proper footwear is a critical part of the equation for preventing or reducing the risk of lower extremity complications. Accordingly, this author offers pertinent pointers and key nuances in ensuring the proper fit of therapeutic shoes.

   The number of people diagnosed with diabetes has doubled since 1996, according to the Centers for Disease Control and Prevention (CDC).1 In 2009, approximately 4 million people with diabetes mellitus will develop a foot ulcer.1 The ramifications of this fact are enormous and the effects are far reaching just within the podiatric profession alone.

   Foot ulcers will require a myriad of treatment options from conservative care to surgical intervention. Regardless of whatever training and expertise the treating physician has, the common goal is a healed wound. An even more difficult goal to attain, but one we all strive for, is wound prevention.

   That is where shoes enter into the discussion as an integral part of the treatment plan. For many individuals, shoes are just a necessary covering for the feet. For others, shoes can simply be a fashion statement. Once an individual develops a foot problem, the shoe takes on a whole new meaning. In these situations, the shoe becomes a medical device. Fortunately, the awareness of the therapeutic impact of shoes is growing within our profession. This is critical in helping all of our podiatric patients, but especially those with diabetes.

   In 1993, the Therapeutic Shoe Bill took effect. Since then, the awareness of this bill has grown among treating physicians as well as the Medicare beneficiary population. The underlying concept behind this legislation was and remains prevention. There are few services in medicine today that are focused solely on prevention. In fact, most of medicine seems to be geared toward disease management instead. The fact that we have this resource available to help our patients is one that we should promote every day in every podiatric practice.

   A study published in Diabetes Care looked at the total cost of providing therapeutic shoes to Medicare beneficiaries. The authors of the study concluded that providing this benefit would not increase the cost of this Medicare sponsored program.2

   Furthermore, several studies have shown repeatedly that therapeutic footwear reduces the rates of ulceration and re-ulceration.3,4Patients with peripheral neuropathy, peripheral vascular disease and various types of structural deformities, in the presence of diabetes mellitus, are at high risk for complications. Getting these patients into appropriate footwear as soon as possible is imperative.

   In addition, educating these patients with diabetes on the importance of footwear and how it can help them is critical in facilitating their adherence with the overall treatment plan. Sometimes just a pair of shoes can prevent ulceration, infection and even amputation.

Understanding The Dynamics Of Proper Shoe Fit

   Shoe fitting is an art. It is not entirely objective and this makes it challenging. Adding to the challenge is that everyone has an opinion on shoes. There will likely be different opinions on fit and effectiveness, not to mention the added complications of style and color.

   Whether it is the patient’s preconceived ideas regarding footwear or the person fitting the shoes, there has to be an understanding by both parties and a willingness and trust by the patient to be led into the right shoe.

   When it comes to therapeutic shoes, several characteristics directly relate to how well the shoe will fit the foot. To start with, look at the sizing of the shoe. These shoes need to be available in half sizes. While whole sizes allow for smaller inventory, they do not guarantee a good fit.

   In addition to lengths, shoes need to offer a variety of widths. Having at least three widths will offer some assurance that fitting will be possible. As far as widths are concerned, there are simple widths that some shoe companies will offer and there are true widths. In the former case, the outersole and midsole remain the same, and only the upper changes in width. This is not ideal.

   Picture a very wide foot fitting into a shoe with the same width sole as a narrower foot. The result will be a foot hanging over the sole on both sides. This will negatively impact the function as well as the support that the shoe will offer, and can decrease the time it takes for the shoe to wear out.

   True widths are just that. When the width increases, the entire width of the shoe does too. This includes the upper and the sole. From the perspective of the shoe manufacturer, this is more expensive. More lasts need to be fabricated from which to make the shoes but a true width is the option that will allow for better fit for wider feet.

   Another factor that affects fit is the depth that the shoe offers. Years ago, it was not always possible to find shoes that had removable insoles. This made our job of dispensing orthotic devices a lot more challenging. Fortunately, that has changed for the better over the years. The more room inside the shoe, the more adjustability there is in getting the foot to fit. This added depth is also helpful in accommodating certain deformities such as hammertoes.

   Some shoes will have a 1/8-inch insole that is removable and others will have up to a 1/4-inch insole. If one looks at how a foot fits inside a shoe, there are the obvious length and width considerations but one should consider volume as well. Feet of similar length and width measurements can take up different amounts of volume inside of the shoe. Additional insoles allow for compensation in fitting those feet of low or high volume.

   Having adequate depth inside shoes makes the job of fitting easier. It also allows us to accommodate areas of pressure on the plantar aspect of the foot and/or makes it easier to improve function with orthotic devices.

Why Lacing Is A Key Consideration

   The lacing system is another factor to assess. There are two different lacing styles that are used in fabricating footwear. There are the balmoral and the blucher styles of shoes.

   The balmoral is a front-laced shoe in which the quarters meet and the vamp is stitched at the front of the throat. The lace opening meets in a “V” shape at the bottom of the laces. One often sees balmoral shoes with men’s dress style shoes.

   When it comes to the blucher style of shoe, the laces are tied to two pieces of leather that are independently attached to the vamp. This is more of an open lacing system. The blucher type allows for more adjustability as far as fit is concerned. The lace portion of the shoe will open wider, which is necessary for patients with edema.

   The blucher style is also easier to work with when trying to customize shoe fit. For instance, in a situation in which there is a nonoperable hammertoe, a lace to toe opening is a very nice shoe modification to perform. This will allow more depth in the front portion of the shoe. This added room will prevent irritation of the toe or even ulceration.

   It is a lot easier to operate on a shoe than it is to operate on the foot. The results are sometimes better, too.

Other Pertinent Factors In Ensuring Good Fit With Therapeutic Footwear

   Other areas to look at include the heel counter, the overall construction of the shoe, and even the padding around the heel and collar of the shoe. The heel counter is often made of a thin plastic or a thicker leather is reinforced in this region.

   In some feet, this is an important factor to assess. If there is a tendency for the foot to overpronate or even excessively supinate, the heel counter may offer some resistance and additional support. Simply squeezing the shoe in this area will indicate whether it is soft or firm. Knowing your patient will tell you whether this is an important feature of the shoe.

   Sometimes more important than the heel counter is the way in which the shoe is put together. One method of construction has the upper portion of the shoe sitting on top of the sole.

   Another approach is having the unit sole attached to the upper. This type of construction difference is important in regard to how the shoe will function for the patient.

   In a foot that either pronates or supinates excessively, the more shoe that is under the foot, the better. In the case of a shoe in which the upper sits on top of the sole, the overpronated or supinated foot will force breakdown of the shoe very rapidly, rendering the shoe useless in very short order.

   Padding around the collar of the shoe and the height of the padding are also important factors to consider. This means looking at where the shoe will potentially rub against the foot, whether on the medial, lateral side or even posteriorly in the region of the Achilles tendon.

   Looking at the amount of padding is helpful but you really need to see how this padding fits up against the foot. One would think that more padding is good but this is not always the case. In the feet of people who have had diabetes for many years, there is often atrophy of the intrinsic musculature. This contributes to bony prominences plantarly as well as all over the entire foot.

   This lack of padding in the foot can be a problem, especially if the shoe has too much padding. Areas of pressure can cause rubbing, blisters and even ulcers.

   Atrophied feet often take up less volume too. This places the foot lower inside of a depth shoe. If the foot sits lower, then the collar of the shoe may actually rub near either malleolus.

   The margin of error for many of these feet is very small. A poorly fit shoe can lead to devastating consequences, even if the patient wears it for just a short period of time.

Case Study: When Poor Shoe Fit Leads To Complications

   A 62-year-old male patient presents for diabetic foot care. He has some biomechanical complaints as well. The patient underwent hip replacement surgery a few years previously. He had subsequently developed back pain and was having difficulty walking for a long duration because of the pain.

   The patient had diabetes for over 30 years. However, he underwent a pancreas and kidney transplant. This procedure ended his diabetes and eliminated his need for medication to control his blood sugar.

   The physical examination revealed diminished pulses, consistent with peripheral arterial disease (PAD), in both feet as well as complete profound peripheral neuropathy in both lower extremities. Despite technically not having diabetes mellitus any longer, the patient had the feet of someone with diabetes. The patient also had a significant leg length discrepancy. His right side was 3/8 inches shorter than his left side.

   Along with receiving regular foot care, the patient was also fitted for shoes. His doctor then modified the shoes with a midsole lift in order to address his leg length discrepancy. The outcome was excellent. The patient was not only happy with how the shoes felt but noted that his back pain was better, and he was functioning more comfortably.

   Due to this success, the patient wanted a pair of dress shoes. Typically, dress shoes fit differently than depth shoes. For a shoe to look nicer, it often has a narrower toe box. The shoe he was fitted for still qualified as a depth shoe but it had a slightly narrower last. He put on the lift and left the office.

   Disaster struck within only two hours. In between the time he put the shoes on and when he got home, an irritation occurred on his fifth toe. The toe blistered and then ulcerated.

   Due to the patient’s comorbidities, the toe did not heal and he ended up undergoing an amputation of the fourth and fifth digits. This was a very unfortunate episode that resulted from a simple pair of shoes.

   When it comes to dispensing footwear, we need to understand that the stakes are often very high in the population of people with diabetes. Shoes may seem like a simple add-on modality to help us earn a few extra dollars but we should take it seriously so as not to do any harm.

Final Words

   Who should be dispensing therapeutic footwear? Anyone who treats the foot and has an interest in dealing with therapeutic footwear. However, there is more to dispensing footwear than handing out shoes. One needs to oversee the entire process in a professional manner. There needs to be adequate space for people to move around as well as an area dedicated to inventory.

   It is very difficult to fit shoes properly out of a catalogue only. The only way to know how well a shoe fits is to put it on the foot. Often, the patient needs to try on a few pairs of shoes to make sure he or she has the best fit possible. You do not want to just give the patient what you have. Complications will occur, returns will happen and dissatisfied patients will limit your effectiveness in the long run.

   In addition, there are situations when therapeutic shoes just will not fit. In these cases, you need to see the shoe on the foot in order to determine if the shoe can be customized or whether the patient will need custom molded shoes. Customized shoes are an excellent option. This can mean any number of modifications from lace to toe openings, external lateral or medial counters, rocker soles, or even a simple stretch in a specific location.

   The best way to learn about all that is available regarding footwear is through pedorthic training. One can accomplish this by using a certified pedorthist in one’s area for referral. This can potentially set up an excellent referral pattern for your practice. Another option is to get pedorthic training yourself and for your staff. Although this may be a large time commitment, it is worthwhile for your practice and even more so for your patients.

   Whichever route you choose, you can no longer ignore shoes. They have become an integral part of practicing podiatric medicine today.

   With footwear choices growing and styles constantly changing, it takes a true commitment to do shoes right. You not only have to understand the anatomy and function of the shoe and foot, you also have to understand the business of footwear and inventory management, not to mention all of the government regulations concerning billing and documentation of dealing with footwear.

   When it is done properly and you are committed to it, it can be an extremely gratifying way to enhance the practice of podiatry and provide a service your patients will appreciate.

Dr. Levine is in private practice and is also the director and owner of Physician’s Footwear, an accredited pedorthic facility, in Frederick, Md.

For further reading, see “Understanding The Diabetic Therapeutic Shoe Program” in the October 2005 issue, “How To Establish And Maintain A Diabetic Shoe Program” in the October 2003 issue, “A Guide To Offloading The Diabetic Foot” in the September 2005 issue or “Study Questions The Necessity Of Diabetic Footwear” in the August 2002 issue of Podiatry Today.

Visit www.podiatrytoday.com to check out the archives or get information on reprints.

References:

1. Centers for Disease Control and Prevention: National Diabetes Surveillance System. Available online at: https://www.cdc.gov/diabetes/statistics/index.htm. Retrieved 2/9/2009. 2. Viswanathan V, Madhavan S, Gnanasundaram S, Gopalakrishna G, Das BN, Rajasekar S, Ramachandran A. Effectiveness of different types of footwear insoles for the diabetic neuropathic foot: a follow-up study. Diabetes Care. 2004 Feb;27(2):474-7. 3. Uccioli L, Faglia E, Monticone G, Favales F, Durola L, Aldeghi A, Quarantiello A, Calia P, Menzinger G. Manufactured shoes in the prevention of diabetic foot ulcers. Diabetes Care 18: 1376-1378, 1995. 4. Maciejewski ML, Reiber GE, Smith DG, Wallace C, Hayes S, Boyko EJ. Effectiveness of diabetic therapeutic footwear in preventing reulceration. Diabetes Care 27: 1774-1782, 2004.