Do therapeutic shoes prevent ulcerations and amputations?

The Centers for Disease Control and Prevention estimates 50% of amputations and ulcerations could be prevented with the use of the proper shoe gear. In a study done by the CDC in 1991, 50% of plantar ulcerations reoccurred in diabetic patients who returned to their normal shoe gear after healing as compared to 20% who were fitted with the proper shoe gear.

Center for Disease Control: Lower extremity amputations among persons with diabetes mellitus, 1998, MMWR 40:737-738, 1991.

How do I properly assess a shoe?

An appropriate shoe is one that is wide enough to accommodate the widest part of the foot and extends 3/8 to _ of an inch past the longest toe. In addition, no pressure should be applied to the toes by top or the sides of the shoe. The heel height should be less than 2 inches. The upper part of the shoe should be made from a material, such as leather, that stretches and adapts, absorbs sweat, and breathes.

Jannise, DIJ Prescription insoles and footwear. From Clinics in Podiatric Medicine and Surgery. 12(1):41, 1995.

White, J. Custom shoes therapy. From Clinics in Podiatric Medicine and Surgery. 11(2):259, 1994.

What are the different types of therapeutic shoes?

1. Depth-in- lay shoes are one of the most common types of therapeutic shoes prescribed today. Patients that have neuropathy and or deformity of their toes or any other part of the foot are candidates for therapeutic shoe gear. They are oxford type shoes with a leather upper, lightweight, have shock-absorbing soles, and provide an extra 3/8 to _ inch in extra depth throughout the shoe.
2. Custom shoes, are another type of therapeutic shoe, and are indicated in patients whose foot deformity is too extensive to fit into depth-in-lay shoes and needs several modifications made to fit appropriately. Typically patients with Charcot deformity, partial foot amputations or patients with significant size differences between the two feet fit the criteria for custom molded shoes.
3. Healing Sandals are a type of temporary shoe used for patients with forefoot plantar ulcers.

Pollard, JP and LeQuesne, LP: Method of healing diabetic forefoot ulcers. Br Med J 286: 436-437.

White, J. Custom shoe therapy. From Clinics in Podiatric Medicine and Surgery. 11(2):259, 1994.

What different brands of orthopedic shoes are available?

• Royce Medical 1-800-354-1128
• Surefit 1-866-327-7797
• Benefoot 1-800-544-3668
• Darco/IPOS shoe
• Alimed 1-800-225-2610
• Apex Foot Products 1-800-526-2739
• Professional Products- Diabetic Healing Sandal 1-800-274-9005
• P.W. Minor 1-800-828-8157
• Drew 1-800-837-7463
• Sequoia 1-800-558-5806

What types of external shoe modifications exist and what are there indications?

1. A Rigid Rocker Bottom sole is a modification of the sole that prevents the forefoot from making contact with the ground during the heel off portion of the gait cycle. It can be added to the sole of the shoe or to a Total Contact Cast to decrease plantar pressures and shear forces under the netatarsalphalangeal joints and toes during ambulation. The traditional rocker bottom sole is commonly indicated for patients who have or at risk for ulcerations at the metatarsal head or who have had a previous transmetatarsal amputation. Several varieties of the traditional rigid rocker bottom sole exist, including, the more attractive or normal appearing roller sole, the double rocker sole, and the heal-to?toe rocker sole. The traditional rocker design is still considered the most effective at reducing forefoot pressures, however, some studies indicate that pressures in other regions of the foot, such as the heel, may be elevated so careful consideration should be given in the selection of appropriate footgear.
2. Metatarsal Bars are similar to rocker bottoms in that they are rigid modifications to the sole of the shoe and reduce plantar pressures underneath the metatarsal heads. However, the apex is placed further back, directly beneath the metatarsals, allowing for dorsiflexion.
3. Solid Ankle Heel Cushion (SACH) is soft material added to the heel region of the shoe to decrease pressure in the area by absorbing shock. SACH is indicated in patients with plantar heel ulcers.
4. Rigid shanks are located between the insole and the outside sole of the shoe and stretches from the heel to just proximal to the metatarsal heads. Shanks keep the shoe from bending and support the longitudinal arch of the foot. Extended steel shanks extend distal to the metatarsal heads to limit motion in the metatarsalphalangeal joints and the midfoot.

Nawoczenski, D., Burke, J., Coleman, W. Effect of rocker sole designs on plantar foot pressures. JAPMA. 78:455, 1988.

Schaff, P.S., Cavanagh, P.R. Shoes for the insensitive foot: The effect of "Rockerbottom: shoe modification on plantar pressure distribution. Foot and Ankle. 11:129, 1990.

Meuller, M. J., Strube, M. J., Allen, B. T. Therapeutic footwear can reduce the plantar pressures in patients with diabetes and transmetatarsal amputation. Diabetes Care. 20:637, 1997.

Can athletic shoes be used for accommodative purposes for people with mild deformities?

Studies have shown that athletic shoes provide enough cushioning to reduce plantar calluses by redistributing the pressures on the plantar surface of the foot. Calluses can increase plantar pressures up to 30 percent and are predisposing lesions that can lead to ulceration and infection if left untreated. Although athletic shoes are not a substitute for therapeutic shoes, they are a better alternative to regular shoes.

Soulier, S. The use of running shoes in the prevention of diabetic of plantar diabetic ulcers. Journal of the American Podiatric Medical Association. 76:395, 1986.

Young, M.J., Cavanagh, P.R., Thomas, G., Johnson, M.M., Murray H., Boulton, A., The effect of callus removal on dynamic plantar foot pressures in diabetic patients. Diabetes Medicin. 9:55, 1992.

Will Medicare pay for therapeutic shoes?

Medicare will reimburse for therapeutic shoes and other accommodative footgear if the patient meets the requirements set by the Medicare Part B Therapeutic Shoe Bill. The requirements include:

• The patient must be a diabetic seeking treatment from a qualified physician who certifies that the footgear is necessary and writes the prescription.
• The patient must have a history of ulceration, a predisposing lesion to ulceration, such as calluses, peripheral neuropathy, a foot deformity, peripheral arterial disease, or a previous amputation.

The footgear must be provided by a podiatrist or other qualified individual, such as a pedorthist, orthotist, or prosthetist.

Those patients who meet the requirements are eligible to receive one pair of therapeutic shoes and two pairs of inserts per year.

Anastasi, S.C., Footwear: Therapeutic shoe bill suffers from anonymity. Biomechanics/Diabetes. August, 1999.

Sugarman, J.R., Reiber, G. E., Baumgardner, G., Use of the therapeutic footwear benefit among diabetic Medicare beneficiaries in three states. Diabetes Care. 1998;21 (5):777-781.