Diabetic? Protect your feet with the right footwear
Reduction of pressure, or off-loading, is an essential aspect of diabetic wound care.
Foot pressures, shock and shear can be reduced with appropriately fitted footwear, insoles and socks.
Total non-weight bearing, which allows the wound to be at rest, is the most ideal method of relieving pressures but it is hardly practical. It is therefore necessary that care must be taken in selecting the most appropriate footwear as any inappropriately applied device may cause additional problems like exacerbation of postural instability, acute infection, deep ulcers accompanied by additional contraindications.
The guidelines for selecting the appropriate off-loading devices are:
- The ability to effectively remove all pressures from the ulcer site
- Cost effectiveness
- Ease of use
- Ability to address the characteristics of the diabetic ulceration
- Ability to encourage patient adherence
Treatment and Wound Management
The primary goal in the treatment of diabetic foot ulcers is to obtain wound closure as expeditiously as possible. The resolution of foot ulcers and decreasing the rate of recurrence can lower the probability of lower extremity amputation in patients with diabetes.
Orthotics are custom made devices which serve to correct misalignments and relieve pressures in the foot. Studies have established the efficacy of footwear related pressure relieving and have concluded that in-shoe orthotics are of benefit.
Principles of Protective Footwear
Neuropathic diabetic patients with a history of foot ulceration have abnormally high pressures under the foot. These have to be reduced to prevent further risk and damage to the foot. One of the possible solutions is to use Protective or Therapeutic footwear consisting of custom designed shoes or custom made inserts. These inserts generally incorporate force redistributing features. The main characteristics of
protective footwear can be summarized as shown:
Covering To prevent injury from heat, objects, etc.
Padding To lessen the effect of musclewasting and to give a soft surface for any hard, bony projections which can be felt.
Moulding To increase the weight-bearing area and to take weight off the affected area.
Rigidity To reduce the effect of shearing stress, to stabilise the foot and correct mobile deformity.
Variety of Therapeutic Footwear vis-à-vis Risk perception thresholds
Effective footwear management and getting patients with diabetes to realize the importance of well-fitting shoe gear is a crucial component in the rehabilitation process of the diabetic patient. Ill fitting shoes stimulate lesions, often placing patients who lack foot sensation at greater risk for complications.
Research has clearly shown that podiatrists and foot-care specialists can reduce foot complications by between 45% to 75% simply by developing and implementing a comprehensive and specialized foot care regimen that employs appropriate footwear as a critical component.
While discussing footwear selection, the podiatrist or foot-care specialist should rely on the patient’s risk level to determine the allowable range of footwear.
The patient with a high risk foot (Risk Category 3), as evidenced by a prior ulcer or amputation, Peripheral Vascular Disease (PVD), insensitivity with structural deformity or Charcot foot, should be prescribed either custom-moulded or extra depth footwear
with tri-layered total contact insoles. Internal and external modifications may be added depending on biomechanics and pressure reduction needs.
Patients at moderate risk (Risk Category 2), such as those with neuropathy or PVD without significant structural deformity, have to be given a pair of properly fitting footwear with soft soles, soft uppers and appropriate insoles.
Those at low risk (Risk Category 1) without neuropathy or PVD may be prescribed a wider range of footwear which can be classified as general purpose comfort footwear but they should be re-evaluated every six months to keep track of any changes.
The variety of therapeutic footwear available can be summarized as shown:
In-Depth Shoes (Risk Category 2)
• Most common therapeutic shoe
• Made of leather or other qualified material
• Have a full length removable insole for extra room
Custom Moulded Shoes (Risk Category 3)
• Based on each person’s specific foot measurement
• Constructed from leather or other durable material
• Must be worn with removable inserts
Inserts/Metatarsal Pads/Arch Taping (Risk Category 1/2)
• Ensure comfort
• May be made to fit the individual shapes of each customer’s feet
• Removable for modification or replacement
Footwear Appropriate for Particular Risk Category
RISK CATEGORY O
|Characteristics||Type of Footwear|
|1) Intact Sensation 2) Absence of foot deformity||Often patients in this category do not need special therapeutic footwear|
|3) No history of plantar ulceration||Recommended to wear off-the-shelf General Purpose Comfort footwear|
RISK CATEGORY 1
|Characteristics||Type of Footwear|
|1) Insensate foot 2) Absence of foot deformity||Footwear fitting is critical in this category|
|3) No history of plantar ulceration||Recommended to wear pedorthic footwearwhich should provide additional depth
to accommodate a prescribed orthosis
Mechanical factors play an important role in the etiology of a majority of foot ulcers.
The stresses and strains experienced by the diabetic foot is different from that of the non-diabetic foot. This is because of the biomechanical abnormalities in the foot which is a consequence of diabetic neuropathy. The vital role of footwear has been proven beyond doubt in helping overcome the complications of the diabetic foot.
Many foot complications due to external sources are prevented only by footwear and as such, they are a pre-requisite for the diabetic foot along with other medical treatment.
However, regardless of the footwear prescribed, educating patients about proper foot gear and self-examination is paramount.