Proper footwear is an important part of an overall treatment program for people with diabetes, even for those in the earliest stages of the disease. If there is any evidence of neuropathy, or lack of sensation, wearing the right footwear is crucial. By working with their physician and a footwear professional, such as a certified pedorthist, many patients can prevent serious diabetic foot complications.
Objectives
Footwear for people with diabetes should achieve the following objectives:
1. Relieve areas of excessive pressure. Any area where there is excessive pressure on the foot can lead to skin breakdown or ulcers. Footwear should help to relieve these high pressure areas, and therefore reduce the occurrence of related problems.
2. Reduce shock and shear. A reduction in the overall amount of vertical pressure, or shock, on the bottom of the foot is desirable, as well as a reduction of horizontal movement of the foot within the shoe, or shear.
3. Accommodate, stabilize and support deformities. Deformities resulting from conditions such as Charcot involvement, loss of fatty tissue, hammer toes and amputations must be accommodated. Many deformities need to be stabilized to relieve pain and avoid further destruction. In addition, some deformities may need to be controlled or supported to decrease progression of the deformity.
4. Limit motion of joints. Limiting the motion of certain joints in the foot can often decrease inflammation, relieve pain, and result in a more stable and functional foot.
Shoes
If you are in the early stages of diabetes, and have no history of foot problems or any loss of sensation, a properly fitting shoe made of soft materials with a shock absorbing sole may be all that you need. It is also important for patients to learn how to select the right type of shoe in the right size, so that future problems can be prevented. The excessive pressure and friction from the wrong kind of shoes or from poorly fitting shoes can lead to blisters, calluses and ulcers, not only in the insensitive foot, but also in feet with no evidence of neuropathy. It is highly recommended that shoe fitting for patients with any loss of sensation be done by a professionally trained shoe fitter or Board Certified Pedorthist. People with insensitive feet tend to purchase a shoe that is too tight; the size that "feels" right is often too small.
In achieving proper shoe fit, both the shape and size of the shoe must be considered. You should try to match the shape of the shoe to the shape of your foot. This means that you should be sure your shoes have adequate room in the toe area, over the instep, and across the ball of the foot, and there should be a snug fit around the heel. When considering your correct shoe size, remember that the width is just as important as the length. The proper shoe size is the one where the widest part of the foot, which lies across the foot at the base of the toes, is in the widest part of the shoe. There should also be 3/8 to 1/2-inch between the end of the shoe and the longest toe. In addition, a shoe with laces is recommended to provide the adjustability needed for any swelling or other deformities and to allow the shoe to be fit properly without any danger of slipping off.
Prescription footwear
Many patients with diabetes need special footwear prescribed by a physician. Prescription footwear for patients with diabetes includes:
1. Healing shoes. Immediately following surgery or ulcer treatment, some type of shoe may be necessary before a regular shoe can be worn. These include custom sandals (open toe), heat-moldable healing shoes (closed toe), and post-operative shoes.
2. In-depth shoes. The in-depth shoe is the basis for most footwear prescriptions. It is generally an oxford-type or athletic shoe with an additional 1/4- to 1/2-inch of depth throughout the shoe, allowing extra volume to accommodate any needed inserts or orthoses, as well as deformities commonly associated with a diabetic foot. In-depth shoes also tend to be light in weight, have shock-absorbing soles, and come in a wide range of shapes and sizes to accommodate virtually any foot.
3. External shoe modifications. This involves modifying the outside of the shoe in some way, such as modifying the shape of the sole or adding shock-absorbing or stabilizing materials.
4. Orthoses or inserts. An orthosis is a removable insole which provides pressure relief and shock absorption. Both pre-made and custom-made orthoses or inserts are commonly prescribed for patients with diabetes, including a special "total contact orthosis," which is made from a model of your foot and offers a high level of comfort and pressure relief.
5. Custom-made shoes. When extremely severe deformities are present, a custom-made shoe can be constructed from a cast or model of the patient's foot. Theses cases are rare. With extensive modifications of in-depth shoes, even the most severe deformities can usually be accommodated.
Taking good care of your feet means making sure you have the right foot wear. Whether you have been recently diagnosed or have had diabetes for many years, proper footwear can help prevent serious foot problems. Be sure to talk to your physician about the type of shoes, modifications and orthoses that are right for you.
Footwear considerations A lot of foot problems diabetics suffer are due to poor or inappropriate footwear. Here are some examples.
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Left is a picture of a typical lady's Court shoe. A plaster cast has been taken of the owner's foot. |
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In this second picture you can see that trying to place the plaster cast in the shoe is impossible. Of course, with a real foot the foot can be squashed into the shoe but it is not good for diabetics. Slip-on shoes like these are more likely to cause callous formation and press on the toe nails which may predispose towards in-growing nails. |
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A better shoe is the soft-topped lace up shoe with plenty of room in the toe-box. Lace up shoes have the advantage that they hold the foot more firmly into the heel of the shoe and do not allow the foot to slide about in the shoe the way slip-ons do. There is less likelihood of getting callous and in-growing toenails with lace up shoes. |
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It is always a good idea to get diabetics to check the inside of their shoes every day to see that there are no stones or other sharp objects inside which could injure the foot. In this example, the owner of the shoe works in a machine shop. The pieces of metal seen here are from the metal lathe that he operates in the factory. Imagine what damage they could cause to a foot lacking in sensation!
A few years ago one of our diabetics who suffers from severe neuropathy put a watch in her shoe last thing at night in order to remember to wear it the following morning. In the morning she got up, dressed and went to work wearing her trainers with the watch still in them. It was not until much later that day that she noticed that her ankle was swollen and when she removed the shoe she found the watch and a round hollow in her foot where it had been in her shoe! |
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Watch out for torn linings in shoes. They can so easily cause blisters to form. This shoe has one where the 5th toe would have been. Shoes like this should be discarded and replaced with new ones. |
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I was asked to treat an elderly patient with apparently good slippers. However.... |
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Once the slippers were removed I could see that they had no insoles whatsoever! I cannot imagine these slippers were very comfortable. Can you?
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Dr. Charles Morelli is a Board Certified Foot Surgeon and is certified by the American Board of Podiatric Surgery. This certification increases the standards and criteria a specialist must meet in order to be considered competent. Dr. Morelli has achieved the highest level of professionalism for Podiatric Board Certification. He has successfully passed the required National Board Exam and has completed a special credentialing process to validate recognition by insurance companies and hospitals. His podiatric privileges include medical and surgical foot management and the treatment of disease, deformities, and trauma. |
