An estimated 15 million Americans are affected by diabetes. At least half will need foot care and would benefit from shoe modifications or orthosis. Care of the diabetic foot offers the greatest challenge and probably the most significant achievement in pedorthic care. Management of the diabetic foot is the benchmark of pedorthic footwear in comprehensive medical care.

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As members of the team providing long-term treatment to the diabetic patient, the Practitioners at Foot Support play an important role in the care of the diabetic foot. First, we provide the necessary prescription footwear, including shoes, shoe modifications, and orthoses. We also assist patients with proper shoe selection and shoe fit, and maintain the required inventory to ensure that patients receive the type of shoes prescribed.

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The second part of the Practitioners role is in patient education. Practitioners at Foot Support are a valuable resource for instructing patients in all aspects of footwear: the purpose and proper use of the prescribed footwear, criteria for good fit, and appropriate shoe materials and styles for the diabetic foot. 

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Foot Support Practitioners reinforce information other team members provide on foot inspection, hygiene procedures, and injury prevention. They also stress the need for follow-up so that the Practitioner can make necessary minor adjustments to the current footwear and determine whether changes in the prescription are needed as the patient's feet change.

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Third, Practitioners at Foot Support play an important role in monitoring progress of patients who come with a written prescription from their physician. The Practitioner serves as the link between the physician and the patient. On return visits, the Practitioner checks the performance of the prescription footwear and inspects the footwear and the patient's feet, looking for signs of excessive skin pressure, such as redness or callusing.

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The Practitioner notes the effectiveness of the prescription footwear and may recommend modifications or adjustments. Practitioners see patients as often as necessary to ensure that the prescription has been filled correctly and functions properly. Following the initial prescription, the Practitioner recommends regular check-ups.

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OBJECTIVES IN PEDORTHIC CARE OF THE DIABETIC FOOT

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*  Relieve areas of excessive plantar pressure

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*  Reduce shock

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*  Reduce shear

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*  Accommodate deformities

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*  Stabilize and support deformities

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SHOES FOR THE DIABETIC FOOT

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The condition of the patient's feet dictates shoe requirements. A properly fitting shoe may be sufficient, but if the patient requires prescription footwear, a depth shoe is usually required. In the most severe cases, a fully custom-made shoe is needed.

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Many diabetic patients, especially those with neuropathy, wear shoes that are too tight. Because of the lack of sensation, the size that feels right is often too small. Excessive pressure and friction from poorly fitting shoes can lead to blisters, calluses, and ulcers in the insensitive foot. To meet the objectives of pedorthic care of the diabetic foot, the Practitioner must begin with a properly fitting shoe.

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ORTHOSES

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A pre-made cushion insole can provide adequate shock absorption for patients in the early stages of diabetes with no evidence of neuropathy. However, patients requiring prescription footwear need the total-contact orthosis or functional foot orthosis designed specifically for their foot mechanics.

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APPLICATION TO SPECIFIC PROBLEMS

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Specific conditions for which physicians write prescriptions include ulcers, Charcot deformities, and amputations, all problems associated with the diabetic foot.

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In filling these prescriptions, Practitioners are called upon to select appropriate footwear, apply external modifications, and fabricate orthoses. Modalities are chosen on the basis of the individual foot, the problem, and the degree of deformity.

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