Appropriate and acceptable footwear is vital for patients with diabetes. Special footwear can be prescribed to help heal and prevent foot ulceration caused by neuropathy or neuro-ischaemia (Coleman, 1987; Uccioli et al, 1995).
Patients who have been prescribed special footwear often do not wear it (Lord and Foulston, 1989). Various reasons are given for this, including ‘the shoes are too big’, ‘too heavy’, ‘they don’t fit and are unsightly’, and ‘they are too painful’ (Ward, 1993).
Careful fitting is essential when special footwear is prescribed for patients with insensitive feet. Patients with diabetes who wear their prescribed shoes have a 25–28% recurrence rate of foot ulcers compared with 55-85% in those who wear their own shoes (Edmonds, 1987; Chanteleau and Leisch, 1994; Uccioli et al, 1995). Adequate cushioning of neuropathic feet has also been shown to reduce ulcer recurrence (Chanteleau et al, 1990). To achieve this, shoes must be large enough to accommodate padding.
It is extremely important for the wearer to be involved in the prescribing process, otherwise the prescribed shoes are less likely to be worn. The wearer must understand why special shoes are needed and have a choice of styles and colours (Uccioli et al, 1995; Herold and Palmer, 1992).
Patients with sensory neuropathy tend to wear shoes that are too small, as the tight fit stimulates the remaining functioning nerve fibres. This will cause increased pressure on the foot in the shoe and a delayed hyperaemic response (Walmsley et al, 1989); it may also cause ulceration by reducing capillary filling. In patients with neuro-ischaemia, pressures as low as 10mmHg can totally occlude capillary vessels (Carter, 1973).
Diabetic foot clinic procedure
Most of the patients who are referred to the diabetic foot clinic have foot ulcers. The major contributing causes of these lesions are neuropathy and neuro-ischaemia. The patients are treated by a multidisciplinary team which includes a podiatrist with an interest in diabetes and an experienced shoe fitter.
Patients are assessed by the podiatrist. If special footwear is indicated, they are booked in to see both the shoe fitter and the podiatrist. The shoes are provided free of charge from the following range:
- Extra-depth stock
- Adapted extra-depth stock
- Bespoke (made-to-measure) shoes
- Felt boots (Figures 1–3).
Although patients do not have to pay for the shoes, they are informed of their cost. Patients are repeatedly advised to wear the shoes whenever ambulant. They are offered a choice of styles in a wide range of colours.
Patients are usually supplied with one pair of shoes initially, and then a subsequent pair following an initial review, if the prescription is satisfactory. This process allows any problems with the shoes or insoles to be sorted out swiftly. The shoe fitter is employed by a specialist shoe manufacturer. The special insoles prescribed are made either by our in-house laboratory or by the shoe manufacturer.
Method
The data reported here were collected from a questionnaire, clinical case notes and patient examinations/interviews. A total of 79 patients were included in the study, which took place between April 1994 and March 1996.
All patients had either foot ulceration or recently healed foot ulcers (within 1–20 weeks). The study group had all been issued with their shoes and moulded insoles in the previous 6–18 months.
Ulcer status was recorded as healed or not healed at the start and upon completion of the audit. The questionnaire was completed at the time of the audit during patient interviews at the hospital foot clinic, and ulcer status was confirmed as healed or not healed.
Patients were asked how frequently they wore their shoes: never; always; indoors only; or outdoors only. At the same interview the shoes and insoles were carefully inspected by the podiatrist to see whether or not wear marks present were consistent with the answers given at the interview.
Results
A total of 79 patients were recruited to the study, and 119 pairs of shoes and insoles were supplied. The numbers of each type of shoe were as follows:
- 30 pairs of bespoke made-to-measure shoes (25.2% of the total) at an average cost of £261.64 each
- 41 pairs of extra-depth stock shoes (34.5% of the total) at an average cost of £90.23 each
- 46 pairs of adapted extra-depth stock shoes (38.6% of the total) at an average cost of £111.26 each
- 2 pairs of felt boots (1.7% of the total) at a cost of £23 each.
Examples of the shoes and insoles provided are shown in Figures 1–5.
The patients were told to wear their shoes all the time, including indoors.
- Three patients never wore their shoes (3.8% of the total). One of these patients had his remaining limb amputated as a result of ischaemia. The other two patients said the shoes were ‘too big and ugly’. One of these patients has a large Charcot joint deformity, and the other has grossly oedamatous legs and feet.
- Sixty-six patients (83.5%) wore their prescribed footwear all the time.
- Four patients (5.1%) wore their shoes indoors only, and two of these were housebound. One of these patients said that she wore the shoes all the time but the wear marks did not support this; upon confrontation she admitted to only wearing them indoors. She said that she did not want to wear laced shoes with a skirt or dress when going out and wanting to look ‘smart’.
- Six patients (7.6%) wore their shoes outdoors only. The main reason given was the belief that the shoes were prescribed for outdoor use only (Table 1).
The shortest time that shoes were worn during the study period was 6 months and the longest time was 18 months (excluding those who never wore their shoes).
Ulcer status was recorded at the time of footwear issue and again at audit. Healed ulcers were defined as ulcers that had completely re-epithelialised. At the time of issue, 49.4% of patients had open ulcers and 50.6% had healed ulcers. By the time of the audit, only 15.2% of patients had open ulcers and 86.1% of patients had healed ulcers (Table 2). There was no significant difference between the performance of different types of shoe with respect to ulcer healing.
The number of new ulcers deemed to be caused by the footwear was two (2.5% of patients). The number of recurrent ulcers at previously healed sites was 1 (1% of patients).
Discussion
Correctly fitted and appropriately worn special footwear has been shown to be clinically effective in reducing foot ulceration (Edmonds, 1987; Chanteleau and Leisch, 1994; Uccioli et al, 1995; Chanteleau et al, 1990?). Nevertheless, patient compliance and satisfaction rates for special shoes can be poor (Lord and Foulston, 1989; Herold and Palmer, 1992; Knowles and Boulton, 1996; Disabled Living Foundation, 1991; Fisher and McLellan, 1989).
It is essential that those who prescribe shoes should be adequately trained. Two letters in the British Medical Journal would suggest that this is far from the case (Rowley, 1989; Soorikumaran, 1989).
It is our opinion that a shoe fitter should be involved in diabetic foot clinics. This is because they are specifically trained to fit and supply highly specialised footwear, and may have some knowledge of pathomechanics. The podiatrist in this clinic works in tandem with the shoe fitter to explore fully all of the mechanical options available, and the patient is encouraged to contribute to the decision-making process. An informed patient who is involved in his/her own care is more likely to comply with instructions regarding the wearing of special shoes.
Regular reviews are vital so that any problems that arise may be dealt with swiftly. This limits the potential damage that can occur from poorly fitting shoes or insoles, and reinforces a caring approach to the ‘at-risk foot’ while encouraging a self-caring attitude in the patient.
Shoes or special insoles should not be prescribed without an early follow-up appointment being arranged. This is particularly true for patients with peripheral neuropathy, who may be unaware of potential problems caused by poorly fitting shoes.
Conclusion
These audit results are encouraging, although only a small number of patients were involved and the follow-up period was short. The authors attribute the good compliance rate for wearing prescribed footwear achieved in this audit to concerted effort to involve patients in the prescribing process and to regular review involving both podiatrist and shoe fitter. The audit confirms that, if special shoes and insoles are worn correctly, ulcer healing and recurrence rates are extremely good.
One of the differences between this study and other studies is the greater use of adapted stock shoes, with only 25% of the patients being prescribed bespoke shoes, etc. The cost differential between these two types of shoe is approximately £150 per pair, which suggests that the wider use of adapted stock shoes for ‘at risk’ patients is both economical and effective.
Where shoes or insoles were incorrectly fitted, ulceration followed swiftly, within 4 weeks of issue. This further highlights the importance of early review. Proper provision of special footwear to the ‘at risk’ patient should achieve a reduction in lower limb amputation rates.
Publisher’s note
Figures 1–5 are not available in the online version.
