Feet problems are a serious complication of diabetes. One statistic, from the book Clinical Care of the Diabetic Foot, says that 15 percent of people with diabetes develop foot ulcers, 15 percent of those with ulcers will develop osteomyelitis (an infection in the bone) and of these, another 15 percent will require an amputation. Proper foot care can prevent many ulcers from starting in the first place.
Good footwear is one of the components of good foot care. Footwear can both cause and may prevent damage to the feet. Improperly fitting shoes are the scourge of healthy feet. Too narrow or tight shoes can cause pressure on the top or soles of the foot near the metatarsals (the five bones of the mid foot), leading to blisters and ulcers. Structural deformities such as claw-toe and Charcot foot are caused by increased pressure on the soles of the feet. Statistics vary, but up to 80 percent of food ulcers may be due to poorly shod feet.
Basic foot hygiene and well-fitting shoes providing good support are all that is required for the prevention of foot ulcers in people without risk factors such as physical foot deformities, neurological or vascular problems affecting the foot.
Or to put it another way, you don’t have to give up wearing attractive shoes just because you have diabetes. Maintaining good glycemic control will lower the risk of these foot-related complications arising in the first place and allow you to keep wearing those Cole Haan’s .
Special footwear is one therapeutic option for those who are at increased risk of problems. Patients with neuropathy who have lost the ability to feel sensations in their feet are at high risk for injury. In addition, those with vascular problems leading to diminished lower leg circulation and those with foot deformities may also be good candidates for special shoes.
Therapeutic shoes help to avoid injury caused by the lining of standard shoes continually rubbing against the area of the deformity. Therapeutic shoes designed to minimize rubbing should contain a custom-molded insole and be of adequate depth to allow for a thick insole without having the top of the foot rub against the upper lining of the shoe.
The patient’s risk of ulcer formation should determine the structure of the shoes. Patients with moderate risk may need “depth shoes” which provide room for a think insole in the front area of the foot. For patients at greater risk a “rocker” outsole that prevents over extension of the toes is warranted.
Whether therapeutic shoes can help people who already have ulcers is controversial. In patients whose tactile sensations are intact, reduction in pain is the guiding light to appropriate pressure off-loading, but this isn’t feasible for patients with significant loss of feeling in the feet. There is little solid evidence to indicate that standard therapeutic shoes are able to adequately remove the pressure from sensitive areas.
Some practitioners feel that ulcers heal better with the use of a total contact cast or other non-removable device since they substantially increase pressure removal and patient compliance is better. (Many therapeutic shoes lack sex appeal, making non-adherence a rampant problem.) Total contact casts and removable walkers also have the advantage of limiting the movement in the ankle and redistributing weight from the foot to the device. This is important for ulcer healing. However, both these devices do have drawbacks and therapeutic shoes remain a staple in foot care at present.
For people with severe foot disease, Medicare Part B covers foot exams and therapeutic shoes. A physician who treats your diabetes must certify your need for the shoes and they must be prescribed by a podiatrist or other qualified doctor and provided by a podiatrist, orthotist, prosthetist or pedorthist. Medicare uses the following criteria to determine who is eligible for therapeutic shoes:
a. Previous amputation of the other foot, or part of either foot, or
b. History of previous foot ulceration of either foot, or
c. History of pre-ulcerative calluses of either foot, or
d. Peripheral neuropathy with evidence of callus formation of either foot, or
e. Foot deformity of either foot, or
f. Poor circulation in either foot