Abstract Coles, S. (2008) Footwear and offloading for patients with diabetes.
Nursing Times; 104: 3, 40–43.
Selecting footwear that fits appropriately in order to prevent foot pathologies, such as corns and callouses, is important in the general population but even more so in people with diabetes who have associated complications of neuropathy and ischaemia (Chantelau et al, 1994). Sue Coles explains why it is necessary to adapt footwear and how this is achieved.
Author Sue Coles, D Pod M, BSc, is advanced lead podiatrist, rehabilitation and rheumatology, The Podiatry Department, Northampton
People with diabetes who have associated sensory neuropathy lose the protective sensation, which enables them to determine pain and discomfort associated with poorly fitting footwear. These people often wear shoes that are too small and it is thought that the tight fit stimulates the nerve fibres that are still functioning (Baker and Leatherdale, 1999), thus giving them the sensation that they are actually wearing a shoe. These patients may also have some foot deformity due to atrophy of the small muscles leading to clawing of the toes and a high arch profile. Deformity also alters foot function and loading (that is, how different areas of the feet bear weight). All these factors combine to increase the risk of ongoing trauma and highlight the importance of screening, supervision and education in this group (Thompson et al, 1991).
Ischaemia devitalises the skin, making it less resistant to the minor trauma of rubbing, friction, shear and pressure caused by ill-fitting footwear. More than 2% of patients with diabetes in the community develop new foot ulcers each year (Abbott and Haage, 2002).
All people with diabetes should receive advice on the type of shoe least likely to compromise their foot health. This includes best styles, general fitting tips and where these shoes can be obtained.
Footwear with extra width and depth is available and can be relatively easy to access, especially via mail order. However, if a person with diabetes purchases shoes by mail order, their fit should be assessed and checked by a registered podiatrist before the shoes are worn. Many mail-order shoes have an integral, simple, protective cushioning insole that can be removed to allow extra room for slight toe deformities or can be replaced with something more suitable by a podiatrist or orthotist.
People with an identified deformity, sensory and vascular deficits or with a history of ulceration should be referred to the multidisciplinary diabetic foot team for consideration for specialist therapeutic footwear (NICE, 2004). This team should include podiatrists and orthotists to advise on foot care and specialised footwear. The team can assess the suitability of the patient’s current footwear.
For therapeutic footwear to be effective, the patient must be involved as much as possible in the choice of colour, style and fit, as this improves concordance (Williams and Meacher, 2001).
They must understand why the footwear is required and why commercial footwear is no longer suitable. Footwear can protect the diabetic foot, but is also a risk factor for skin damage (Reiber et al, 2002). It should not be assumed that if a patient with diabetes has specialised footwear, their feet are not at risk from trauma.
Deformity can be progressive and the foot shape may change over time, making the prescribed footwear no longer suitable. In some cases the patient’s needs may change and they may require more complex provision that should be prescribed by a practitioner with advanced clinical skills. Regular inspection via a foot-protection programme and continued education is important.
Stock footwear is a step up from the commercially available footwear with extra width and depth. As the name suggests, it is ‘off the shelf’ in terms of sizes, which are standard but has greater width and depth than normal shoes. This enables the use of cushioning protective insoles without compromising the depth available at the toe, which is necessary to accommodate minor toe deformities. Stock footwear is sufficiently roomy to allow for the provision of total-contact insoles (TCIs, see Box 1) to redistribute pressure away from overloaded areas of the plantar aspect of the foot. This helps to prevent callous formation and ulcers.
Stock footwear is used as protection for feet that have previously ulcerated in normal footwear. It often incorporates special features, such as padded collars, to protect the ankles and seamless uppers. These shoes are fully enclosed to protect the foot from foreign objects.
All types of therapeutic footwear can have sole modifications, such as flared heels, to provide extra stability and support for the foot. Additions to provide rigidity, such as rocker soles, are typically used for people with neuropathic foot problems.
This is basically stock footwear but usually has one or two extra additions to accommodate deformities or fitting difficulties that cannot be overcome using stock footwear alone.
Bespoke footwear is made to measure for an individual patient. It is used when a patient has major deformities, for example Charcot arthropathy. A last is required to make this type
of footwear (a block shaped like a foot used to make and repair shoes). The depth of TCIs for this type of footwear can be factored into the initial design (Fig 3).
Footwear and offloading devices for feet not yet ready for footwear
Reducing and removing pressure from a load-bearing ulcer is key to the resolution of that ulcer. There are several methods that can be used to achieve this.
This often takes the form of a post-operative sandal or special temporary shoes designed to accommodate large dressings. These sandals are useful if a foot is recovering from surgery and can be used as a vehicle for accommodating a TCI in the later stages of wound healing. This footwear is commonly used as ‘emergency footwear’ when a wound is first discovered and it is imperative to get the ulcerated foot out of normal footwear. A temporary shoe is now available on FP10 in the community, which is suitable for some foot types. The patient should be assessed for suitability.
Scotch cast/Leicester boots
Plaster-room technicians make scotch casts that let the patient remain ambulant (Fig 4). They are lightweight, lined with soft materials and incorporate felt pads that provide a soft interface with the foot. Windows are cut in the scotch cast to correspond with the size and position of the wound and allow pressure to be deflected from the site of the ulcer.
These devices can be removed for wound care and regular wound examination. They are suitable for use in infected wounds. As with all footwear, the cast needs to be examined for wear and replaced as and when required (Knowles et al, 2002; Burden et al, 1983).
Scotch cast boots may be worn with a cast sandal or can be modified to have a more permanent sole applied to their base. A shoe raise to the opposite shoe may be required to even leg length.
Total-contact casts spread the pressure and load of weight bearing across the whole of the plantar surface of the foot and restrict ankle-joint movement. Applied by specially trained technicians, they are relatively lightweight, resemble below-knee casts and incorporate rocker soles. Total-contact casts need to be removed regularly and replaced to ensure they are not causing additional trauma to a diabetic foot that is at risk. Ideally, a member of the specialist diabetic foot team needs to be on call to enable emergency removal if required.
As these devices cannot be removed by the patient, concordance is high. However, they can reduce the patient’s quality of life. They can induce a leg-length discrepancy – the cast effectively increases leg length, which can cause hip and low back pain. Patient selection is important, as these devices will be unsuitable for those patients who are frail or unsteady.
These casts are not suitable for use with infected wounds as patients with neuropathy may not perceive the pain and discomfort associated with swelling of the limb. Additionally, they are not suitable for patients with foot ischaemia.
Despite the disadvantages of total-contact casts, evidence suggests favourable results in clinical trials (Armstrong et al, 2001; Mason et al, 1999).
Removable total-contact casts: These can be adapted from non-removable casts by bisecting the cast at the midline of the front of the leg. Velcro straps can be applied to enable a secure fit. There are many types of removeable cast available commercially, some of which have inflatable air sacs to improve fit and support (Fig 5).
Removable casts increase wound accessibility and are less likely to adversely affect the patient’s quality of life as they can be removed for sleeping and routine hygiene purposes.
Good basic footwear and foot-care advice is required for all patients with diabetes. Involvement of the specialist diabetic foot team and knowledge of local referral pathways is required for effective diabetic foot care and foot protection where a foot is deemed to be at risk.
Insoles and orthoses form an interface between the underside (plantar aspect) of the foot and the inside of the shoe.
Insoles can be made from a wide range of shock-absorbing or cushioning materials. Simple, cushioning insoles can have shaped pads designed to deflect and redistribute pressure from high-load callused or prominent joints.
Orthoses or total-contact insoles (TCIs) are usually manufactured from a plaster cast of the foot. These aim to redistribute load across the whole of the areas of the plantar surface of the foot that do and do not bear weight (Bus et al, 2004). TCIs can have additions, such as toe blocks, to fill up the toe of the shoe if the patient has had a forefoot amputation (Fig 2).
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