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Foot Care Q&A: Part 2

by Joy Pape, RN, BSN, CDE, WOCN, CFCN

Earlier in the year we brought you Part 1 of this article, in which five foot-care experts — including four podiatrists and one pedorthist — gave advice on basic foot care, dry skin, discolored toenails, athlete’s foot, hammertoes, bunions, and peripheral neuropathy.

In this installment our experts take on shoes, socks, insoles and orthotics, home remedies, and pedicures. Our five experts are the following:

• Dr. Keith A. Beauchamp, DPM, a podiatrist who has a private practice in Macon, Missouri.

• Dennis Janisse, C.Ped, a certified pedorthist who is President and CEO of National Pedorthic Services, Inc., and is a Clinical Assistant Professor in the Department of Physical Medicine and Rehabilitation at the Medical College of Wisconsin.

• Dr. Neil Scheffler, DPM, a podiatrist with a private practice in Baltimore, Maryland. He is the coauthor of 101 Foot Care Tips for People With Diabetes, second edition, published by the American Diabetes Association in 2006.

• Dr. Pedro Smukler, DPM, a podiatrist with private practices in New York City.

• Dr. Stephanie Wu, DPM, MSc, a podiatrist and Associate Dean of Research, Associate Professor of Surgery, Associate Professor of Stem Cell and Regenerative Medicine, and Director of the Center for Lower Extremity Ambulatory Research (CLEAR), at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, in Chicago.

1. What about diabetic shoes? Are they really necessary?

Many shoe retailers advertise “diabetic shoes,” but what does that term really mean? And do all people with diabetes need this type of shoe?

Dennis Janisse: Medicare has their definition, and that is what many people now refer to. Basically you need shoes that come in different lasts (or “shapes”), sizes, and widths, and someone who can properly fit them for the patient. There are four different categories (0, 1, 2, and 3) from what is called the LEAP [Lower Extremity Amputation Prevention] Program risk categories and management. People in category 0 don’t need a special shoe but do need one that is protective and fits well. I do recommend them for people in categories 1 through 3. We use some styles of New Balance, Propét, Aetrex, and p.w. minor. There are certainly other brands, so I really think you need to cherry-pick them with your foot-care expert. This is not something people should do on their own.

Dr. Beauchamp: I do not believe that everyone with diabetes needs diabetic shoes, and clearly neither does Medicare. The diabetic shoe program was designed to be implemented for those patients who clearly demonstrate need through a variety of conditions, including previous ulceration, loss of protective sensation, pre-ulcerative callus with neuropathy, and peripheral vascular compromise [reduced blood flow]. These symptoms must be clearly documented in the [patient's] chart, and a letter of certification indicating need from the family practice or primary-care physician who concurs with my findings is also necessary for Medicare approval.

A diabetic shoe offers extra depth and insoles that are formed to the diabetic patient’s foot, with particular attention to accommodate for deformities to reduce risk of ulceration and potential amputation. They are necessary for many patients in an effort to reduce amputation risk. The economic costs of amputations are astronomical in the long run, but even more important, the five-year mortality rate in the diabetic patient population that has a below-the-knee amputation is 50%. Potentially, in some instances, diabetic shoes have saved lives.

Dr. Smukler: In principle, not all people with diabetes require what is considered a diabetic shoe. All you need is a wide shoe with a high toe box that can accommodate orthotics designed to address a variety of foot problems. You need to make sure your shoe fits right and protects your feet. There are certain circumstances, such as Charcot foot [a condition in which the bones of the foot are weakened and can fracture, eventually leading to changes in the shape of the foot], that necessitate special custom-made shoes.

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