Diabetic Shoes: The People’s Choice?

Once considered an unappealing necessity, today’s diabetic footwear is stepping boldly into a new era where it enjoys growing popularity, due to easier access to fresh designs and changing public attitudes toward orthopedic-style shoes. We asked professionals in the field about characteristics of diabetic footwear, how to help patients recognize the urgent need for better foot care and footwear, and how to encourage the current trend toward finding fashion-friendly shoes they’ll be happy to wear. [caption id="attachment_242071" align="alignright" width="332"] nosorogua/stock.adobe.com[/caption] The Reasons to Wear Diabetic Footwear Are Compelling Robert Schwartz, CPed, president, CEO, Eneslow Pedorthic Enterprises, New York City, points out that his 113-year-old business is not a diabetic footwear delivery system, but an “every-foot-disorder delivery system.” “The majority of people’s problems as we get older,” he explains, “are things related to arch pain, metatarsal pain, and toe pain. They have nothing to do with diabetes—just 95 percent healthy people with painful feet. Most feet get bigger as we get older; gravity pulls us down, we shrink in height, and get bigger in the transverse plane on the flat surfaces. “The diabetic foot represents every foot disorder plus a medical condition that either exacerbates the foot disorder or, because of secondary or primary medical problems like neuropathy and lack of protective sensation, causes specialty footwear to become a greater need; because if you can’t feel that your shoes are too small, you’re going to wear shoes that are too small,” Schwartz says. From such a seemingly inconsequential oversight, minor problems like foot ulcers, calluses, and infected nails can evolve rapidly into major consequences that involve amputations. Diabetic foot ulcers are a common cause of amputation due to diabetes. Davison de Queiroz, CPed, Ocean County Foot and Ankle Surgical Associates, Ocean County, New Jersey, notes that 25 percent of his group’s business comprises amputations. “Patients want style when they’re going out in the evening. They don’t want to wear diabetic shoes. But in a shoe that is not sensible, only 15 or 20 minutes of rubbing in one spot could cause terrible consequences,” he warns. Statistics reveal that 10 to 15 percent of diabetic foot ulcers do not heal; 25 percent of those will require amputation. 1 A foot ulcer is the initial event in more than 85 percent of major amputations performed on people with diabetes. 2 An estimated 20 percent of hospital admissions in people with diabetes are due to foot ulcers. 3 But studies also show that up to 50 percent of diabetic foot ulcer cases can be prevented with appropriate education focused on teaching people with diabetes how to care for their feet. 3 Mike Lyons, DPM, Foot Health Centers, Hernando, Mississippi, considers his patients with diabetes a level above the usual, because they were previously educated about the need to see a podiatrist. “In a given year, out of thousands of visits with diabetic patients, I do zero amputations on my own patients. If they have a problem, they come in promptly to address it; whereas I may do 90 to 100 amputations in a year, just from being on call at the hospital, from people coming through the emergency room and hospital admissions—and 90 percent of those are preventable.” He also frequently performs amputations on patients who live in nursing homes. “Diabetics tend to get thick dystrophic toenails and the nurses may try to cut them, nick a patient and the wound festers until it’s noticed,” he says. “By that time, it’s too late—they end up in the hospital with an amputation. I see that every month.” Patients who have family involved in their care tend not to experience these problems, he notes. In addition to better-informed foot care, preventive protective care for the diabetic or at-risk foot is essential—and that means effective footwear, regardless of its appearance. [caption id="attachment_242072" align="alignleft" width="300"] Anastasia Horova/stock.adobe.com[/caption] Orthopedic Footwear as A Fashion Trend? Josh White, DPM, CPed, vice president, Orthofeet, Northvale, New Jersey, points out that the population of patients who are obese with prediabetes is growing. “The need for therapeutic shoe fitting is becoming more pervasive, as there is a growing population of obese, sedentary people, as well as others who are not only living longer but remaining active. More people are facing foot challenges and need pedorthic and podiatry services.” Fortunately, patients’ willingness to wear appropriate footwear is improving, thanks to the increasing variety of “condition-appropriate” shoes now available on the general market, he notes. Many of the key features of orthopedic shoes—foot-friendly shapes, depths that allow removable inserts of orthotics, Velcro closures, rocker soles, and breathable materials—are also commonly seen in shoes sought by regular retail consumers. “These features used to not be available to the mass market but are now chosen by people who don’t need orthopedic shoes, because the desire for comfort is pervasive,” he says. When orthopedic shoes were less attractive, patient compliance was a much bigger challenge, White confirms. “But we’re now in the middle of a transformation. The shoes they need are becoming the shoes they want—and that’s a good thing. Increasingly, people are buying orthopedic and semi-orthopedic shoes themselves.” Conversely, the number of therapeutic shoes reimbursed by Medicare has been going down since 2014. Under the Therapeutic Shoe Program, orthopedic shoes must meet these requirements: Be available in at least three different widths Be of sufficient depth to accommodate a removable foot bed Have a form of closure “In the 1990s when the program originated, fitters had very few shoe styles to choose from,” White says. “Now there are hundreds. Many people who qualify for and could receive shoes paid for by Medicare are unaware of their entitlement and pay for shoes out of their own pockets. Medicare reimbursements for shoes total less than $100 million per year—a small percentage of the $7 billion spent on comfort and therapeutic shoes each year. “There’s been a convergence of shoe styles that are both purchased by people for their own use and also selected by practitioners for fitting of prescribed patients. Orthopedic shoe manufacturers are focusing on aesthetics, and getting better at it: Orthofeet, for example, balances the therapeutic aspect of the footwear with design and promotion of their styles, making them appealing enough, effective enough, and cost-effective enough for the wearer or third-party payer to handle.” Dennis Janisse, CPed, president, CEO, National Pedorthic Services, West Bend, Wisconsin, recalls his start as a fitter 50 years ago. “We had unbelievable shoes that accommodated every kind of problem, but they looked very orthopedic. People were in tears because that was something they really had to wear, but they were ugly, and everybody knew they had a problem. And yet the footcare they received was so much better [than more attractive styles].” de Queiroz also recalls when the Therapeutic Shoe Bill was first approved. “The ambulator came in one style for men and women—laces or Velcro, black or brown only. Now, the variety is tremendous, with many different companies making different shoes and a lot more choices available. “But when you’re dealing with a major problem—severe bunions, hammertoes, Charcot foot, Charcot deformity—they don’t have a choice of style because we cannot deviate from the shape of the foot. Companies like Apis Footwear try to accommodate the deformity, but it still is not a pretty shoe, because the foot is not a pretty foot. And if the left foot looks different from the right, that will draw unwanted attention.” Diabetic footwear patients prefer slip-on shoes, de Queiroz points out. “They don’t like laces or Velcro because some of them are dealing with dexterity issues, or they cannot bend down to tie the laces or fasten the Velcro because of back or hip problems; but slip-ons are not approved by Medicare. And a shoe that is not secure on the foot can cause friction and lead to complications.” Janisse agrees that the shoe companies are doing a lot better job with styling, pointing to designs from Dr. Comfort, Anodyne, Orthofeet, and others, but he points out that sacrifices have been made. “Years ago, in addition to multiple sizes, we also had multiple widths and multiple lasts (the form over which the shoe is made). In those days, some of the companies had ten or 12 lasts for men and women, so along with the sizing you also matched the shape of the shoe to the shape of the foot—that’s no longer possible.” When Medicare started paying for footwear, manufacturers had to produce footwear that fell within that reimbursement allowable, he explains. “Because the manufacturers couldn’t really produce a shoe here in the United States within that price range, the corporate orthopedic shoes started to be manufactured in China, because we had to provide shoes that were competitive in the reimbursement market. “When that happened, everything changed, because we moved away from our typical selection of multiple widths—from AAA to D—and went to very basic narrow, medium, wide, and wide-wide; and few companies even offered narrows. “Shoes are looking some better, but it’s made it harder for us to do a real good job of fitting, because we don’t have widths and shapes available,” Janisse says. David Brown, CPed, Northern Orthotics & Prosthetics, Marquette, Michigan, points out that some companies do offer extra width options. “We use a wide array of brands, but our most common would be Propet, Dr. Comfort, Anodyne, Apis/Mt. Emey. We also use Orthofeet, Drew, Apex, I-Runner, and Pedors. Most of these brands can be ordered up to a men’s 14/15 XW(4E/5E). Mt. Emey has a few styles that can be ordered up to a men’s size 20 and widths up to 14E. The company we use depends on a case-by-case assessment of need and foot presentation.” [caption id="attachment_242073" align="alignright" width="300"] Studio KIVI/stock.adobe.com[/caption] “All diabetic shoes are orthopedic shoes,” he explains, “and we can sell them as such; but there’s a higher set of standards in order to be considered diabetic.” de Queiroz also cites several companies that make more attractive shoes, but he is careful which styles he guides patients to choose from their catalogs. “They have to have a high toe box, a secure wide Velcro strap or laces. The companies I use most often are Anodyne, Dr. Comfort, Apis, and Surefit.” Janisse also recommends New Balance, Brooks, and Keen shoes, as well as other popular brands that offer more sizes and widths. “Personally,” Lyons comments, “I don’t think the definition of diabetic footwear means much—I have had patients who have gotten ulcers from diabetic shoes that led to amputation, because some diabetic shoes you can get at your local pharmacy or call and they’ll just send them to you. “It’s all about visiting someone who’s skilled in it, like a pedorthist, that’s going to make sure that the shoe is fitting properly. And these are for at-risk patients—not every diabetic needs them. That’s why a good foot exam is the key. If you have good sensation, good circulation, your diabetes is under tight control, you don’t need to go to the level of having some special shoe made for yourself. “The biggest thing with footwear is just getting something that doesn’t have pressure points,” he says. “You or I may know there’s a pressure point because it’s uncomfortable, whereas a diabetic doesn’t even know there’s a pressure point. Getting fitted for a shoe—maybe not necessarily some clunky diabetic shoe—but just have your podiatrist or your family doctor check to make sure that you don’t have any area of that shoe that could possibly cause a problem.” Janisse, who does not accept Medicare, agrees, and says he would rather send his self-pay patients to shop in the real world and find a shoe they like, which he’ll try to customize to provide appropriate support and fit. “If I give them a shoe they don’t like, they’re not going to wear it; if they choose one they like, they probably will. “There are shoes out there that have nice broad toe boxes, which very few of our providers offer us in the pedorthic footwear arena. And today, sandals, dress shoes, athletic shoes, casual shoes, work boots—everything comes with a removable insole. So as long as that shoe fits appropriately, we can modify it and put orthotics in it.” Education and Awareness—the Keys to Compliance “The most common problem I have dealing with diabetic patients is lack of education: a lack of knowing what to look for, and the warning signs of what’s going wrong,” Lyons notes. “People get an ulcer in their foot, and they can’t feel it—they’re not checking their feet daily and don’t know there’s a problem until they smell something. And by the time you can smell something, it’s dangerously advanced.” Exacerbating the awareness problem is a growing shortage of certified pedorthists to educate them. With all former college pedorthic programs closed, aspiring CPed candidates face a crisis currently being addressed by Janisse and other industry leaders. Most sources also stressed establishing a trusting rapport with patients. “Even people that have a history of not being compliant will get on board when they learn that we’re providing them with a service beyond just simple shoes and insoles, with knowledge that has a profound effect on their life and their normal daily activities,” says Brown. “Keep that relationship open. I see most of my patients on a yearly basis and have done so for more than eight years.” Networking with other providers on the patient’s footcare team was often recommended. “Reach out to your referral sources,” Brown advises. “And in a lot of cases, specifically with the primary care docs and the wound care docs, to learn what they’re actually looking for. Keep the lines of communication open.” “The most necessary thing is collaboration with other specialties,” Lyons urges. “To do our best for the patients we’re all seeing, we need to talk to each other. “Pedorthists should introduce themselves to their local podiatrists, endocrinologists, neurologists, and optometrists. If a person has retinopathy (diagnosed by an optometrist), they definitely have neuropathy and they have small vessel disease, so they’re all connected. If I have a patient that’s at risk, I make sure that they have an optometrist, a neurologist, endocrinologist. “Build a relationship with podiatrists, foot and ankle surgeons, and also with diabetic educators,” Janisse suggests. “Those are the people who are often advising diabetes patients where to go for their footwear or prescriptions.” White points out that Medicare has a diabetes prevention program—which essentially pays people to learn healthy eating habits and follow CDC recommendations for moderate exercise several times a week. He suggests pedorthists and podiatrists become involved with exercise opportunities like the Walk with a Doc program and collaborate with referring doctors to encourage patients’ participation. (Author’s note: For more information, visit walkwithadoc.org.) Partnering with community diabetic educators was also suggested by several sources. “Most are registered with the American Diabetes Association,” Lyons says. “Here patients and professionals can locate their local diabetic educator and weekly informative classes. There’s a big disconnect with people actually knowing that they’re out there and that this education is paid for by Medicare.” Janisse reminds us that these caring educators work with support groups that often need speakers. “Get to know your diabetes educator—let them know how you fit diabetic shoes and what you carry, and how to protect patients with knowledge of the shapes, size, and features of the shoes many of them are buying. That sounds like you won’t get any business from that, but ultimately, you will; and if not, that’s just your public service.” For best patient compliance, apply psychology—and offer choices. White admits that the work of fitting a patient with an orthopedic shoe entails as much psychology as technical skill in the fitting. He speaks of helping patients to set their expectations—when shoes are fitted, he encourages them to “use them and wear them out.” [caption id="attachment_242074" align="alignright" width="300"] Monkey Business/stock.adobe.com[/caption] Replacement of the shoes is an annual benefit—but fewer than 50 percent of patients stick with the Medicare program to get their new shoes annually. He believes this failure is due to the fact that they did not get a proper fitting or were not adequately educated and encouraged. “Having a wide array of selections and making sure that people understand that they have a choice is essential,” Brown says “If they don’t feel comfortable with what they’re going to go home with, they may not be back.” Schwartz advocates also connecting with the Pedorthic Footcare Association (PFA)—the only organization that represents pedorthists. “That’s where pedorthic education continues to happen. By using PFA we can do appropriate marketing and PR to the medical community and awareness campaigns so people recognize pedorthists as trusted professionals who provide life-changing value that no one else is trained to offer.” Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer. References Pemayun, T. G. D., R. M. Naibaho, D. Novitasari, N. Amin, and T. T. Minuljo. 2015. Risk factors for lower extremity amputation in patients with diabetic foot ulcers: a hospital-based case–control study. Diabetic Foot & Ankle 6:10.3402/dfa.v6.29629. doi:10.3402/dfa.v6.29629. Brownrigg, J. R. W., J. Apelqvist, K. Bakker, N. C. Schaper, and R. J. Hinchliffe. 2013. Evidence-based management of PAD and the diabetic foot. European Journal of Vascular and Endovascular Surgery 45(6):673-81. Yazdanpanah, L., M. Nasiri, and S. Adarvishi. 2015. Literature review on the management of diabetic foot ulcer. World Journal of Diabetes 6(1):37-53.

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