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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.

Dr. Scheffler: The shoes aren’t diabetic. People with diabetes don’t all need special shoes, although if they have one of the three problems I mentioned earlier — neuropathy, peripheral arterial disease, and deformity — or calluses, having the special shoes is helpful. Many insurance companies, as well as Medicare, will pay for shoes if the patient meets certain criteria. Sometimes just a running shoe, with cushioning and a high toe box, is adequate.

People with diabetes who actually run need a good running shoe. Go to a specialty store that sells shoes to marathon runners and has a good shoe fitter, not just a part-time salesperson. Brands of running shoes I recommend for people who don’t have [foot] problems are Brooks and Asics.

Dr. Wu: Only people with loss of protective sensation need to wear diabetic shoes. These are extra-depth shoes with a special diabetic insert in them, made with softer material than most orthotics. They help protect the area. Extra-depth shoes can also accommodate custom diabetic inserts from your foot doctor.

2. Do I need to wear diabetic socks? Are there any particular brands or types you recommend?

Dr. Smukler: These are socks that do not have a seam, and I seldom recommend them because I see such a limited benefit to the population I serve.

Dennis Janisse: It depends on many conditions that can potentially exist. For example, do you have severe swelling, loss of sensation, extreme sweating or lack of sweating, or an amputation? Yes, if you have these problems, you could benefit from proper socks, but they really have to be dispensed by someone that understands you and your problem. The broad term “diabetic socks” means nothing today.

Dr. Scheffler: I recommend socks that are not cotton, socks with products that wick perspiration away from your skin and don’t bind. Look for acrylic socks; some have copper or silver that kill bacteria and fungi. “Diabetic socks” are usually the ones without seams, so they won’t rub, and some have a wider top, which is helpful if your legs are large or swollen. Some brands I recommend are Aetrex and Dr. Comfort.

Dr. Beauchamp: Diabetic socks are usually made of materials that are not offensive to skin integrity. They can be virtually seamless in an effort to reduce friction and pressure on delicate skin areas.

Dr. Wu: Diabetic socks are for people who have lost protective sensation. They have no seam. The bottoms and toes should be white so you can see if there is any bleeding or if a foreign object is sticking to the foot or shoe.

3. What are insoles and orthotics? Do I need them?

Dr. Smukler: Orthotics are customized inserts for your shoes. Insoles are what you find in the store. Orthotics are used when you need to change the way your foot functions. Do you need them? Not if you don’t have a problem with your foot. If you have a problem with the function of your feet, then yes. Your podiatrist can recommend whether or not you need this. A lot of people want me to put orthotics in their high heels to make them work. I tell them I treat their foot problem, not their shoes’ problems. When it comes to insoles, sometimes buying a cheap cushion for your shoe is all you need.

Dr. Beauchamp: Orthotics are devices constructed from an image of an individual’s foot to correct particular mechanical deformities or biomechanical forces throughout the gait cycle of the individual as he walks. These images may be generated via computer topography of the foot or plaster or fiberglass negative casting techniques. Correction can be made to these images, thereby reducing the deforming forces that may be causing the foot pain. Insoles tend to be over-the-counter pads that add cushion or gel to the shoe. Some are even antimicrobial in nature. They do not offer corrective support but can add comfort to a pair of potentially uncomfortable shoes.

Dr. Wu: Orthotics are meant to change the way someone walks. Diabetic, or what we call accommodative, inserts help take off the pressure rather than changing the way you walk.

Insoles are a generic, broad term for diabetes inserts. When you get your inserts, you need to take out the original [insole], or you will be rubbing against the top of your shoe.

Dennis Janisse: Again, this all depends on the condition of your foot. Many people will and do benefit from the “proper” insert, premade or custom. These inserts always have to be fitted with the shoe, as well as with cushioned socks, because they could alter the shoe fit and cause worse problems. Inserts can protect, cushion, keep the feet dryer, be antifungal/antibacterial, provide support, and/or control the foot.

Dr. Scheffler: A true orthotic changes the way a foot functions. This should be a prescribed item by a podiatrist or orthopedic surgeon that is made to treat your specific problem. If you have pronation [your feet roll in when you walk] or a flat foot, they can be designed to hold your foot in the right position. They can take pressure off the bone or nerve that’s causing a callus or pain. Not everybody needs these, but if you have a problem, you do. An insole is anything that goes inside your shoe for cushioning. Sometimes your insurance will pay for it. Get only the kind your doctor advises.

4. Are there any home remedies your patients have told you about that work?

Dr. Smukler: What happens is that a patient comes in with a firm belief that a particular home remedy works. If it isn’t causing the person any harm, I’m usually all right with using it.

Dennis Janisse: A lot of people think alcohol or peroxide is a cure-all, which they are not. They can harm your feet, especially if you have a wound.

Dr. Wu: I recommend to always check the remedy out with your foot doctor, especially if there is no evidence [from research] to support it. For the most part, if it is not meant to treat a serious foot problem, and if the product is not hurting you, then I am usually OK with it.

Dr. Beauchamp: I know of a few home remedies that may be of benefit. For gout, once an acute case is under control, eating cherries or drinking some of the cherry concentrate drinks on the market can help prevent future attacks. Of course, you need to be concerned about how this affects your blood glucose levels. You can always check it to find out.

In the case of mild toenail fungus, Vicks vapor rub has worked wonderfully on about 40% of cases. My thinking is that if [a remedy] cannot cause harm and patients are asking to try it, I should let them. Sometimes we’re both pleasantly surprised, and sometimes we just move to a more aggressive or conventional therapy if it doesn’t seem to be working out. I always involve patients in the decision-making process. They seem to respect that, even if the home remedy doesn’t work out. We can always say we tried, and in these days of rising drug costs, they appreciate the effort to save them some money.

5. Should people who have diabetes get a pedicure?

Dennis Janisse: Although I don’t recommend [pedicures], I know people do get them. If they do, they should go to someone that understands diabetes, someone who has some medical training.

Dr. Smukler: This is highly dependent on who does the pedicure and on the condition of the person’s feet. Some people end up happy, and some people end up with serious problems. I recommend caution and mostly discourage my patients from having pedicures.

Dr. Wu: One should be very selective about with whom and where one gets a pedicure. Tell the person you have diabetes. I hate to say an absolute “no” [to pedicures]. But when in doubt, the pleasure is not worth the risk.

Dr. Beauchamp: Pedicures are typically given in cosmetology salons. Nail care should be performed by medical professionals. Usually there is some risk involved in [getting a pedicure] when someone has a condition such as diabetes, peripheral vascular disease, antiplatelet therapy, etc. These conditions make it necessary to seek professional treatment.

Dr. Scheffler: A person who has diabetes should think about the following before getting a pedicure:

• Serious foot and leg infections have been contracted in nail salons and spas from coast to coast. Fungi, viruses, and bacteria lurk in the soaking tubs and on the instruments of pedicurists, waiting for your unsuspecting toes.

• Toenail infections such as onychomycosis (a fungus) can be contracted at nail salons. This type of infection makes your toenails look discolored, and they may become thick, brittle, or flaky. The same fungi may also infect the skin, causing athlete’s foot. The skin may form blisters, itch, or be dry and scaly. If the infection is between the toes, the skin may be moist.

• Viruses are another possible source of infection. A common viral infection is a wart. More serious viral infections, such as hepatitis C and HIV/AIDS, can be potentially transmitted by careless pedicurists. Yes, if the skin is broken, even these deadly bloodborne pathogens can be caught during a pedicure!

• Bacterial infections from Mycobacterium fortuitum as well as the drug-resistant bacteria MRSA (methicillin-resistant Staphylococcus aureus) have been reported following pedicures. MRSA causes serious infections that can even lead to death. Some infections can start out looking like small insect bites but may enlarge into pus-filled boils, requiring strong antibiotics. These infections may leave permanent scars.

Does this mean you should never get a pedicure? That is up to you. This is a decision only you can make. I just want you to know what you might be getting yourself into. I am really not a fan of pedicures. As a foot specialist, I have seen many foot infections that were caused by pedicures. There are many people who get pedicures regularly who have not experienced problems.

If you do choose to have a pedicure, consider these tips:

• Become your own investigator. Check for licenses and recent inspection certificates. Insist on cleanliness. Are they disposing of items that cannot be sterilized, such as emery boards, nail buffers, and toe separators? Do they use sharp instruments to shave corns and calluses? In most localities, this is not allowed by law. Besides, your podiatrist should advise you about the causes of these areas of hard skin and what should be done to prevent them or treat them properly.

• What is used for bathing your feet? It should be a plain tub of water that is soaked with disinfectant for at least 15 minutes between clients. Better yet, you should purchase disposable tub liners that separate you from the tub. Also, there should be no moving water. Any tub that has jets or bubbles cannot be adequately cleaned in the time between you and the customer who was in the tub before you. Bacteria can flourish in the plumbing and filter screen.

• Do not shave your legs before your pedicure. Shaving opens hair follicles and may cause tiny nicks in your skin that are openings for bacteria to invade.

• Buy your own instruments and bring them with you. Complete kits are available, some even in attractive carrying cases, which should be yours alone. This kit, in addition to the disposable tub liner, would effectively isolate you from harmful bacteria, viruses, and fungi. Your podiatrist may have these items available for sale.

• If you discover a problem such as a change in color or thickening of a toenail, or a strange spot that wasn’t there before, call your podiatrist for an appointment. It’s much easier to treat a condition early in its course rather than later.

Editor’s note: Dr. Scheffler’s comment was adapted from his article “Pedicures — Hazardous to Your Feet?” published in inMotion (a publication of the Amputee Coalition), July/August 2008.

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