Paul Brand, MD, is recognized as the father of diabetic foot care in the United States and taught about the basic foot care education and training necessary for patients.
“Brand said, for example, that they must change their shoes at least once every day during the day. Even if the shoe is rubbing, if you change it after lunch, any rubbing by the other shoe will probably be in another place—or at least reduced. So, you’re averting the continuous shearing and pressure that’s going on between your shoes and your feet. And your feet get bigger during the day, so the shoes you put on in the morning are fitting tighter—so there was education and training,” says Robert Schwartz, CPed, president/CEO, Eneslow Pedorthic Enterprises, New York City.
“If you put more weight on your footwear, it’s going to wear out faster, due to more pressure and more shear. Since your foot gets bigger because your body is getting bigger, swelling is going to go to your feet and ankles, and what fits you today isn’t going to fit you tomorrow. If you start at the beginning of the day with a fairly snug shoe, at the end of the day it’s going to be higher risk. So it’s all about self-management; providing guidance and direction on helping the patient—just getting handed a pair of orthopedic shoes and three insoles is not going to help them.” “Long-term benefits aren’t presented—it’s only about relieving your pain right now—today.”
Schwartz quotes a physical therapist/pedorthist at the New York University wound clinic who said, ‘It’s criminal that they’re doing bracing and surgery for people who need shoes because the reimbursement is so low that no one can afford to provide the shoes. So you have to do things that cost ten times as much.’
“In Canada or Europe,” Schwartz says, “orthopedically challenged patients go to the shoemaker and/or pedorthist first and do everything conservatively. People live in their orthopedic shoes and don’t get bunion surgery, because the shoes relieve the pain. In America they get bunion surgery, and they don’t get the orthopedic shoes. Instant gratification; higher profits.
“The original reason for creating the therapeutic shoe bill was to demonstrate that it costs no more money to provide people with a pair of shoes than what it was costing to deal with their medical problems. That was in 1990s—it started as a trial in a few different states. That model is so broken now.”
Socks Are Key
Davison de Queiroz, CPed, Ocean County Foot and Ankle Surgical Associates, New Jersey, says that it can be challenging to convince some patients of the importance of socks. “They like to wear shoes without socks and that creates a lot more problems with fungus, etc.,” he says.
“A lot of diabetic socks that I see are good above the ankle, without constricting, but they have a toe area with a thick seam. That thick seam causes problems. Dr. Comfort socks fit well above the ankle and in the foot area and the toe area, and they are created with bamboo charcoal fiber on the plantar aspect of the sock; it fits the foot better, it prevents moisture around the foot, and it doesn’t cause irritation,” de Queiroz says. “A very good sock—it’s worth paying the extra price because they’re durable. I have several pairs myself and they last a long time.
“Emphasize the fact that when one is diabetic, they have to be extremely careful and take care of their feet—not wear open shoes, not wear sandals, avoid having their toes exposed. They must wear socks. I must remind each patient how important it is to wear shoes with socks, and well-fitting socks. They cannot be too loose, too long or too short: If they’re too big they can crease and create a pressure area where the seam is too thick.”
Customizable Shoes
Dennis Janisse, CPed, president, CEO, National Pedorthic Services, offers advice about what patients should look for in a popular shoe for potential diabetic/orthopedic customization:
- Look for something with a removable insole, so if the individual needs an orthotic, there is room for it. Look for shoes that come in more than one width. Nike and Adidas have all kinds of bells and whistles, but they only come in one width. Those bells and whistles don’t mean anything if the shoe doesn’t fit.
- Avoid the minimalist mentality in the footwear industry, which offers lightweight shoes with little support, and soft, cushiony soles. The only way to make a shoe lightweight is to put air in the sole. The way they make it lighter is to blow air into it—so some of those soles are like marshmallows. If someone has a deformity, or is just a big person, that material literally will compress in one wearing. If you pronate badly or have a different deformity in your foot, that material will compress medial or laterally and take on the shape of the deformity that you have.
- The shoe must have a semi-rigid counter in the back, where support is needed.
- Look for a shoe shape that mimics the shape of the foot. Keen shoes, for example, have an oblique, square toe similar to time-honored protective shapes.
- Firm soles are essential. Shoes should bend up around the metatarsal heads, but some minimalist designs bend in the middle of the foot and offer no stability whatsoever.
Threats to Diabetic Foot Care
“There are a lot of diabetic shoes sitting in people’s closets because they essentially got something for free. They got them but aren’t necessarily encouraged to use them. There is a lot of fraud in that area,” said Mike Lyons, DPM, Foot Health Centers, Hernando, Mississippi. “In my experience the patients who do get them are like clockwork—they show up every year with their paperwork for a new pair. But the percentage of diabetics in my practice that actually have diabetic shoes is very low—maybe 15 percent. Some just don’t want them and others find that the Medicare Advantage plans will not pay for them. Anyone who switches to a Medicare Advantage plan cannot get the shoes covered by Medicare. Many patients are unaware of that,” Lyons says.
“Forty percent of people who qualify for Medicare are in a Medicare Advantage plan, which may or may not cover purchases under the Therapeutic Shoe Bill. It’s not possible to track how many of them are getting reimbursed through the Advantage plan for their shoes,” says Josh White, DPM, CPed, vice president, Orthofeet, headquartered in Northvale, New Jersey.
White notes that there are fewer clinicians fitting shoes, either because of the low reimbursement and risk of audit or the overall shortage of pedorthists. He believes the shortage is due to increasingly difficult educational requirements as well as the difficulty of getting materials and the hands-on experience to become proficient.
“More people are covered by plans that pay less, with 41 percent of Medicare patients now covered by low-reimbursement Medicare Advantage plans, so the [pedorthic] profession is less lucrative. But there is great optimism in the current transition from fee-for-service reimbursement to value-based care which rewards success.”
Janisse also reports the problems facing aspiring pedorthists, as all college or university post-graduate pedorthic education programs are closed at the time of this writing—a crisis that is being addressed by Janisse and other industry leaders.
Hopefully, with time, recognition of the value of preventive and protective care for the diabetic foot will bring us full cycle, to recover and restore the original intent of the therapeutic shoe bill—and to demonstrate that diabetic shoes are a cost-effective alternative to treating the more serious medical issues that evolve in the absence of such care.
