what-when-how
In Depth Tutorials and Information
8
of toe ulcers and a significant number of lesions elsewhere in the foot,
and
McGill et al (2005)
found that footwear trauma was the precipitating
factor in 54 per cent of ulcers in their study of 250 patients with diabetic
neuropathy. Therapeutic footwear is therefore often recommended by
clinicians in an attempt to minimize the trauma often associated with
patients' own retail footwear.
When ulceration does occur, it is necessary to offload the foot com-
pletely using total contact plaster of Paris casts or removable devices
such as the cam walker. Once the foot is ulcer free, management may
require a combination of appropriate foot orthoses and footwear.
Author
Note
Offloading one area may overload another, so care must be taken as
the shift in forces can cause ulceration elsewhere or even trigger
Charcot neuroarthropathy.
Not all patients with diabetes need therapeutic footwear, but the vast
majority will benefit from some type of insole or orthosis to improve func-
tion, redistribute foot pressures and/or provide cushioning. Extra-depth
stock therapeutic footwear may be a preferred option because it can
accommodate the foot and the chosen orthosis. This footwear is provided
in a range of sizes, fittings and combination of fittings, for example wide
and deep. The decision to opt for bespoke therapeutic footwear is taken
when the feet do not it into the range of sizes and fittings provided by
stock footwear manufacturers. An attempt at an algorithm for clinical
decision making for footwear and foot orthoses for those with diabetes
is detailed in
Table 8.1
. This has been developed from the best available
evidence and reflects what is considered to be best practice.
The effect has been studied of therapeutic footwear as a primary
intervention in the prevention of re-ulceration in those considered at high
risk of ulceration (
Cavanagh 2004
,
Busch and Chantelau 2003
). Those
patients who wore their shoes daily (regular wearers) were significantly
less likely to have re-ulceration compared with patients who wore them
infrequently. The influence of wear on the effectiveness of footwear prop-
erties has been identified, and it is recommended that patients have two
pairs at any given time. Therapeutic footwear in isolation is considered to
be less effective than when it is provided with a package of care including
foot care and foot health education (
Dargis et al 1999
,
Uccioli et al 1995
,
Edmonds et al 1986
).
There are various objectives of footwear interventions in the vulnerable
foot, and any combination of these may be indicated in any particular
patient:
