By Roy H. Lidtke, DPM, CPed
Ask 10 people what they look for in a pair of shoes, and you may well get 10 different answers. But ask 10 podiatrists what they recommend in shoes for people with diabetes, and you’ll probably get about the same answer 10 times, with “good fit” near the top of most lists.
People with diabetes are at high risk of developing both impaired circulation to the feet and nerve damage in the feet. Impaired circulation causes wounds on the feet to heal more slowly, raising their risk of becoming infected. Nerve damage can cause loss of sensation in the feet, which means a person may not feel heat, cold or pain in his feet. He may not notice that his shoes are rubbing or pinching or even that he is walking on small objects such as paperclips that have fallen into his shoes.
The combination of impaired circulation and nerve damage sets the stage for foot ulcers. When you add ill-fitting shoes to the mix, the risk of developing an ulcer goes even higher. But finding shoes that fit well is not impossible, and they don’t have to be ugly, either.
Many people with diabetes can wear off-the-shelf shoes with no modifications. However, people who have foot deformities such as bunions, hammertoes or Charcot joint (a form of joint breakdown) may need special inserts or specially made therapeutic shoes. In addition, people who have certain diabetes complications, such as a previous ulcer, and who have Medicare Part B may qualify for therapeutic shoes or inserts paid for in part by Medicare. (For more on this, click on “Medicare Therapeutic Shoe Program.”) Talk to your health-care provider about whether you need customized shoes or inserts or whether you can safely wear unmodified shoes.
Assuming you can wear off-the-shelf shoes, here are some shoe characteristics to keep in mind when shopping for and trying on shoes. (For a labeled diagram, click on “Anatomy of a Shoe.”)
Seams (where two pieces of material are stitched together) are stiffer than uncut materials and can be irritating if they rub against the feet. For this reason, people with loss of sensation in their feet or with very delicate skin may be better off choosing shoe styles with no seams in the toe box. Manufacturers commonly reinforce the toe box with plastics or fiberboard to make the area more durable. These materials can also be a source of friction, especially for people who have hammertoes or other changes in foot shape that cause the toes to rub against the top of the shoes.
To avoid purchasing a shoe with a toe box that could irritate your feet, feel inside the shoes with your hand for stiff or scratchy seams or any rigid, well-defined structure. If you can feel any of these potential irritants, put the shoe back and try another model.
The tongue should be wide enough and padded enough so that the laces don’t dig into the top of your foot. Some tongues have two slits in the middle through which you can thread the laces. Doing so helps hold the tongue in place so it does not slip to one side or the other.
The throat is the opening where your foot enters the shoe. Make sure that the rim of the throat, known as the collar, is well padded and low enough that it does not rub your anklebones.
This part of the shoe cups the heel. Because it needs to be stiff to control motion at the back of the foot, manufacturers often embed rigid materials here as well. However, there should also be adequate padding in this area to keep hard materials from rubbing against the foot.
The higher the heel counter, the more control it will provide. This is generally a good thing, as long as it does not dig into or rub against the back of the foot, anklebone or Achilles tendon (the tendon that joins the calf muscles to the heel bone). Shoes with a high heel counter usually have a notch for the Achilles tendon so this does not occur.
The foot sits directly on the sock liner which, in off-the-shelf shoes, is generally made of a single layer of foam. Buying shoes with a removable sock liner makes it possible to replace the liner with one that is custom-made to fit your foot or an off-the-shelf product that provides more cushioning or a better fit. A custom insert should have at least three layers — a soft layer of foam on top and two stiffer layers on the bottom to provide some resilience.
The midsole is the middle portion of the sole, which serves to cushion the foot. It can be difficult for the average shopper to evaluate the quality of a shoe’s midsole, but a knowledgeable shoe fitter should have information about the types of midsoles that come with various shoe styles and their relative merits.
Several years ago, a trend started where manufacturers began removing foam from the arch area of the midsole to reduce the weight and cost of the shoe. The logic was that since people don’t walk on their arches, they shouldn’t need support in this area. The problem with this thinking, however, is that the shoe becomes weaker, and therefore more flexible, when material is removed. The more flexible the center of a shoe, the more stresses it produces across the middle of the arch because the shoe bends in a place the foot does not. Manufacturers quickly became aware of this problem and began reinforcing the arch area with stiffer plastics.
To make sure that you choose a shoe with an arch that is strong enough, hold the shoe by the heel and push the toe box slightly up and toward the back of the shoe. The shoe should bend at the joint of the toes the way a foot does when pushing off. If it instead bends at the arch, don’t buy it.
This part of the shoe, usually made from carbon rubber, comes in direct contact with the ground, so it needs to be resilient and flexible.
A rocker-bottom shoe has the sole angled up from the ground at the heel and toe. This type of sole can help reduce pressure on the feet in a number of ways. It is a particularly helpful feature for people who have limited joint mobility (a condition in which the tissue around the joints becomes stiff and inflexible) because the rocker replicates the normal rolling motion of the foot, sparing the stiff joints from moving as much as they otherwise would have to. This also reduces the stress across the skin of the feet. Rocker bottoms additionally keep the feet continually moving forward, facilitating the normal heel-to-toe rolling motion and reducing the amount of time that pressure is applied to the bottom of each foot.
To check whether the shoe you have selected has a rocker bottom, place it on a flat surface and push down on the heel. If there is a rocker in the heel, it will make the toe rise off the ground. Likewise, push down on the top of the shoe in the toe area. If there is a rocker in the toe, it will make the heel rise off the ground.
The amount and angle of the rocker changes from shoe to shoe, so the best way to test the one on the shoes you are looking at is to try the pair on and walk around the store. If the rocker is in the correct place for your foot, you will feel as if the shoe is pushing you in the direction you are walking. Because of this sensation, it may take some time to get used to walking in shoes with rockers. Also, because rocker soles have less contact area with the ground than regular soles, it is important to be cautious on uneven terrain.
Although there are a wide variety of shoes that are suitable for people with diabetes, there are also a few styles that should be avoided. High-heeled shoes fall into this category. High heels put increased pressure on the ball of the foot and place the back of the foot in an unstable position. They also increase shear, or the movement of foot tissues in opposing directions. Shear is a primary cause of calluses, blisters and ulcers. A suitable heel will be less than one inch in height.
Slip-on loafers are another style that is best left in the store. Because there is very little of the shoe covering the top of the foot, these shoes provide inadequate support. They are also typically made of unpadded, rigid leather, which can be a source of friction.
Sandals that have straps between the toes are unsuitable as well, since the straps can cause irritation.
Having your feet measured each time you buy shoes is an important part of making sure the shoes you select fit your feet. Feet tend to change shape and size over time, so few people can wear the same shoes at age 50 as they did in high school. In addition, many people have one foot that’s larger than the other, so you should have both feet measured. The tool used for determining shoe size is called the Brannock Device. It measures the width, taken across the ball of the foot; the arch length, measured from the heel to the ball of the foot; and the overall length from heel to toe. To get an accurate measurement, stand naturally with your weight divided evenly between both feet. Remember that your feet tend to swell the longer you are on them, so it is a good idea to shop for shoes toward the end of the day.
Ideally, the size for the arch measurement and the size for the heel-to-toe measurement should match. If they don’t, the size is usually based on the longer of these two measurements. But these numbers don’t tell the whole story, because even shoes with the same numerical size can vary in shape, height of the toe box, and overall depth. A person with a very thick foot or with joint changes in the foot may require an “extra-depth” shoe to accommodate the bulk of the foot or special shoe inserts. An expert shoe fitter will measure the height of the foot and the circumference of the foot around the arch, and use these numbers to match the foot with the appropriate shoe.
If you have narrow feet, shoes with wide-set eyelets will allow you to pull the laces tighter, if necessary. If you have wide feet, shoes with closely set rows of eyelets may work better.
Once your feet have been measured and you have chosen a shoe style, the real test is how they feel on your feet. Make sure you are wearing the type of sock or stocking you normally wear, and don’t forget to also bring any orthotics or inserts you will be wearing in the shoe.
Put on both shoes and attach the laces, buckles or straps, then stand up. There should be some room, preferably 1/2 inch to 5/8 inch, between the tip of your longest toe and the front of the shoe. Walk around, and make sure that your arch is fully supported and that the break or bend of the shoe is located at the ball of your foot. Check how the width accommodates the ball of your foot — if the upper portion of the shoe is bulging out over the midsole, the shoe is too narrow and you should ask for a larger width. As you walk, note whether your heel moves around in the shoe. Try rising up onto your toes (holding onto something for support) and notice whether the heel slips off the back of your foot. A properly fitted shoe should slip slightly in the heel, particularly when new, but it should not move excessively or slide off the back of the foot. Make sure the sides of the shoe aren’t hitting your anklebones when you stand still or walk. Roll your feet to the insides as if you were trying to flatten your arches, then to the outsides, as if to roll over onto your ankles. The shoe should feel like it is trying to restrict these motions, but it should not feel like it is placing excessive pressure against any one spot on the foot. Walk around the store for as long as you need to make sure the shoe is comfortable and supportive. Shoes should not need to be broken in, stretched or otherwise modified. If this is suggested, do not purchase the shoes, because they are the wrong ones for your feet.
It is a good idea to look for a shoe store with certified shoe fitters or certified pedorthists on staff. (You can get a list of certified pedorthists in your area by visiting the website of The American Board for Certification in Orthotics, Prosthetics, & Pedorthics at www.abcop.org.) A knowledgeable staff person will know the subtle differences in the sizes and shapes among brands and even among models within a brand. This kind of information and the help of a professional can be especially useful if you have any loss of sensation in your feet that prevents you from being able to tell whether a shoe is rubbing. A store with certified staff on board will generally also be happy to special order shoes for you if they do not have your size.
Although shoes should fit comfortably off the shelf, with no need for breaking in, you can fine-tune the fit by adjusting or changing the laces and lacing patterns.
Generally, round laces tend to stretch more than flat laces, making them a good choice for walking shoes. As you walk, your foot changes shape. Shoes and laces with some give, or flexibility, can accommodate those changes, while rigid shoes and inflexible laces will create pressure against your skin. The amount of give in a shoe is also influenced by the type of eyelets the laces go through. As a general rule, fabric or leather loops give more than plastic or metal eyelets, and eyelets give more than punched-out holes. However, hard plastic or metal eyelets can irritate the top of the foot, so choose shoes with loops or punched-out holes whenever possible.
Lacing patterns can be altered to accommodate a variety of foot shapes. For example, there is a tendency for the front of the foot to widen as a result of neuropathy, a flattening arch, or simply increasing age. If the front of the foot is wide and the heel is narrow, or if the foot swells significantly during the day, two sets of laces can be used so the bottom tie can be loosened, allowing for more room in the front of the shoe. (For more information and diagrams, click on “Lacing Patterns.”)
A person who has a high arch or a bump on the top of his foot can skip the crisscross lacing pattern in the area near the arch or bump and instead string the laces straight up to the next eyelet. Another way to deal with a high arch is to weave the laces straight across the tongue of the shoe, rather than diagonally. If more room is needed in the toe area, try stringing one end of the lace from the bottom eyelet to the top eyelet on the opposite side, then pulling the lace to lift the front of the shoe and increase room in the toe box. If the heel of the foot is narrow or is slipping inside the shoe excessively, the laces can be looped through one another at the top before being tied.
The key to finding a comfortable, attractive shoe is to find a store with a wide selection. Stores that have footwear from around the world are a good place to start; there are many well-designed shoes from Europe and New Zealand. Take your time selecting a pair, and ask about the return policy just in case the style you select turns out not to be the right one for you. And remember this process — you will need to repeat it whenever you get a new pair of shoes, which should be every 6 to 12 months.
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