The Foot Book (Continued)

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The Right Shoe: Therapeutic Shoes

Everyone should wear proper shoes, but for people with diabetes, wearing proper shoes is crucial to their health. If you have diabetes and experience particular or recurring problems with your feet, then ask a podiatrist about therapeutic shoes for diabetes. Therapeutic shoes can be considered medical devices. They are specially designed with consideration for the possible repercussions of diabetes, including poor circulation, loss of sensation, joint stiffness, excess strain on the foot, and amputation. As sensation diminishes in the feet, people with diabetes are susceptible to skin injury from repetitive pressing or rubbing of poorly fitting shoes. The goal of a therapeutic shoe is to reduce this repetitive tissue trauma to the foot. In addition to the shoe itself, therapeutic shoes come with accommodative insoles, which are described in more detail in chapter 16. The therapeutic shoe and the accommodative insole together help to reduce injury and improve function.

The US government introduced a Therapeutic Shoe Bill in the early 1990s to focus on ulcer prevention for people with diabetes. This bill stipulates that a person with diabetes can receive partial coverage of the cost of therapeutic shoes if at least one of the following situations applies: prior amputation of part of the foot, a history of developing ulcers or lesions that lead to ulcers, foot deformity, poor circulation, loss of sensation, or neuropathy. In addition to having one of these conditions, a person must be under the comprehensive care of an endocrinologist or a primary care physician. A podiatrist gives the prescription for therapeutic shoes.

There are two types of therapeutic shoe: an extra-depth shoe, which is obtained off-the-shelf according to foot size (figure 15.2), and a custom-made shoe, which is made over a mold of the person’s foot (figure 15.3). The custom-made shoe is typically reserved for people whose feet have lost all sensation and are significantly deformed. All therapeutic shoes have similar qualities. The shoe is lightweight and has good shock absorption and a last shape that is compatible with the foot type. The upper of the shoe is breathable to diminish moisture and heat and seamless to avoid rubbing or pressure on the foot. It has a padded tongue, a firm heel counter, and a rocker sole to reduce forefoot pressure. The shoe has additional depth throughout to accommodate insoles and modifications to insoles. The sole of the shoe, both the outsole and the midsole, should be the same width as the upper to avoid bulging of the upper with a wider foot. Ideally, the shoelaces or Velcro straps are attached to a piece of leather that is then stitched onto the rest of the shoe. This way, if the foot swells, the soft upper part of the shoe can expand freely without being limited by tight laces or Velcro straps.

Many podiatrists provide a service for patients to buy therapeutic shoes at their office, similar to many ophthalmologists providing eyeglass services. Alternatively, you can buy therapeutic shoes from a specialized shoe store or from a pedorthotist or prosthetist. Techniques to ensure that the shoe fits well are the same as for fitting any shoe. Regularly inspect your therapeutic shoes and insoles for signs of wear and replace them when necessary. The Therapeutic Shoe Bill allows for one new pair of shoes and three pairs of diabetic insoles per year.

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