Diabetic Foot: Footwear helps – when it is worn

Recent studies provide scientific evidence, that the use of appropriate footwear among patients with diabetic foot problems is crucial for the prevention and healing of foot ulcers. However, footwear can only help reduce stress on tissue when it is worn. But by determining if the footwear is really worn, you probably should not rely on what the patients tell you.

Plantar ulcer recurrences are extremely frequent; they occur not long after the healing of the previous ulcer. The role of footwear in preventing re-ulcerations has been the subject of controversial discussions in recent years. From a pedorthists perspective it is therefore gratifying, that several studies confirm pedorthic practice, which has been mainly based on experience so far. Data from different studies show that well done foot beds are an effective measure for the recurrence prophylaxis of neuropathic plantar ulcers.
Arts et al. found that high risk regions of the foot in diabetic patients with neuropathy and recently healed plantar foot ulcers can be offloaded significantly with the adjustment/modification of custom-made shoes and their footbeds.
The study of Ulbrecht et al. suggests, that in the manufacture the foot shape and the plantar pressure measurement should be considered. Those would be significantly better suited for the avoidance of ulcer recurrences than the standard produced foot beds with the help of foam print and modification requests from the physicians.
The research group of Sicco Buss concludes from their data that calluses, dermatorraghia and blisters are highly significant for the prediction which patients develop a foot ulcer. A regular screening for non-ulcerative skin lesions has a high sensitivity to recognize patients with an extraordinary risk for an ulcer and to take the corresponding podiatric measures.
Also the treatment with shoes, the pressure load and first of all the wearing of effective shoes were considered. This study proves that effective shoes and the treatment of non-ulcerative skin lesions are effective measures to reduce this strong risk for our patients.
Greater adherence relates to better ulcer-related clinical outcomes. However,adherence to protective footwear seems to be poor. Ehrmann et. al found,that footwear was worn only a few hours a day and on many days not at all, when they monitored patients over several weeks. Achieving better adherence will be one of the challenges in treating patients with diabetic foot problems.
These findings are already incorporated in the updated updated Australian guideline on footwear for people with diabetes. 10 key recommendations were formulated to guide health professionals managing people with diabetes in choosing the most appropriate footwear for the person’s specific foot risk needs. The updated Australian guideline provides a comprehensive overview of all aspects concerning the footwear for people with diabetes. The fact that the guideline is based on the best available evidence might make it a model for others countries who are seeking for guidelines to improve the provision of footwear for patients with a diabetic foot syndrome.

A detailed summary of the above mentioned studies and the Australian guidelines you will find in the new issue of “foot&shoe”. Copies are available here.

References:
Arts ML, de Haart M, Waaijman R et al.: Data-driven directions for effective footwear provision for the highrisk diabetic foot. Diabet Med. 2015 Jun;32(6):790-7
Ulbrecht JS., Hurley T., Mauger DT., Cavanagh PR: Prevention of Recurrent Foot Ulcers with Plantar Pressure- Based In-Shoe Orthoses: The CareFUL Prevention Multicenter Randomized Control Trial. Diabetes Care 37,1982-1989, 2014.  
Waaijman R, de Haart M, Arts MLJ, Wever D, Verlouw AJWE, Nollet F, Bus SA: Risk Factors for Plantar Ulcer Recurrence in Neuropathic Diabetic Patients. Diabetes Care 37,1697-1705, 2014
Ehrmann Dominic, Spengler Monika, Jahn Michael, Dipl, Niebuhr Dea, Haak Thomas, Kulzer Bernhard, Hermanns Norbert: Adherence Over Time: The Course of Adherence to Customized Diabetic Insoles as Objectively Assessed by a Temperature Sensor. Journal of Diabetes Science and Technology 1–6, December 27, 2017
Jaap J. van Netten, Peter A. Lazzarini, David G. Armstrong, Sicco A. Bus, Robert Fitridge, Keith Harding, Ewan Kinnear, Matthew Malone, Hylton B. Menz, Byron M. Perrin, Klaas Postema, Jenny Prentice, Karl-Heinz Schott and Paul R. Wraight: Diabetic Foot Australia guideline on footwear for people with diabetes; Journal of Foot and Ankle Research (2018) 11:2