March 2011

Footwear: Advantages of a whole-patient approach

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As important as it is to fit the foot properly within the shoe, that’s only one part of the process. Patients’ comorbidities, personality, and fashion sense all determine the extent to which a pair of footwear can maximize a diabetic patient’s outcomes and minimize complications.

By Shalmali Pal

It is a double-edged sword: The diabetes epidemic has served practitioners well when it comes to footwear and patient compliance. A decade ago, Roy Lidtke, DPM, CPed, FACFAOM, recalled having a tough time making his patients understand the natural progression of their disease from neuropathy to potential amputation.

“Patients dismissed our advice and figured out that we were only trying to scare them,” said Lidtke, associate professor of podiatric medicine and surgery at Des Moines University and director of the Center for Clinical Biomechanics at St. Luke’s Hospital in Cedar Rapids, IA. “Unfortunately, the disease is so prevalent now that most of my patients know someone who has lost a leg.”

Of course, patient compliance is hardly the end of the story when it comes to choosing a pair of diabetic shoes. Fit, quality, and comorbidities all play a part in finding the best practice for fitting diabetic footwear.

Beyond Brannock

The Brannock devices remains the foremost instrument of measurement, but do not take the device’s results as gospel, the experts advised.

“The Brannock is only going to give you the foot size, not shoe size,” said Bill Meanwell, CPED, founder, CEO, and director of the International School of Pedorthics in Broken Arrow, OK. “What we have done in the diabetic community is take the foot size and convert it to the shoe size, assuming that the shoe companies are making the shoes to follow the measuring device. The Brannock is only a starting place.”

Meanwell recommended that the optimal fit should include the foot position and the angle of the foot. Rather than placing the Brannock device straight out from the patient’s foot, Meanwell asks the patient to walk in place for a few steps.

“If (the) toes point outward when the patient walks in place, then the Brannock should be in the same relationship as the foot. So if the right toes are pointed out more than the left, then the Brannock should follow the angle of the foot,” he said.

The size difference between the foot and the shoe can be quite significant. This is actually true regardless of diabetes; Meanwell hypothesized that the majority of people wear shoes that are too small for their feet. While a non-diabetic person may get away with that for short periods, a diabetic patient—particularly one with peripheral neuropathy—cannot afford the same risk.

Meanwell used his own foot as an example: Measured straight from heel to ball, his foot clocks in at a size 10.5. But after a few steps in place with his foot stopped in its natural position, the measurement from heel to ball increases to a size 13.

“So the whole foot and arch elongates due to the foot position,” Meanwell stressed. “You need to observe the patient walking in place to establish the true foot position, measure accordingly, and bring out the sizes that you believe will fit the foot.”

Further adjustments can then be made with insoles, socks, or supports.

Patients are often in denial about their shoe size despite what the Brannock shows them, said Gary M. Rothenberg, DPM, CDE, CWS, attending podiatrist and director of residency training at the Miami VA Healthcare System. He said he often reverts to “kindergarten” tactics when illustrating changes to the feet over time.

“People think they are going to be the same shoe size for their entire lives, especially when it comes to the width of the foot,” said Rothenberg, who is also the chair of the foot care specialty practice group for the American Association of Diabetes Educators. “One of the most demonstrative things that we do is put a piece of paper down on the floor and trace the person’s (bare) foot. Then I’ll put the shoe they came in with on top of that tracing. More often than not, we demonstrate to them that they are trying to cram their foot into a narrow shoe.”

Finally, don’t be averse to a close inspection.

“I think it’s important to get down on your hands and knees and to feel around the shoe. Look at it it closely, looking for signs of tightness or too loose a fit. The finger around the throat of the shoe is always a good one,” said Lidtke, who is also an assistant professor of internal medicine, section of rheumatology at Chicago’s Rush University Medical Center. “If you can get a finger around, then the shoe is probably too loose. The heel needs to be fairly tight whereas the front of the foot needs to be fairly loose.”

The experts agreed that, upon immediate fitting, the patient will praise the shoes, but the right pair generally requires a bit more time and commitment.

“Any new pair of shoes will have to be broken in. I don’t encourage my patients to put on a new pair of shoes and walk the mall,” Rothenberg said. “I tell my patients to wear the shoes for an hour in the house, take them off, and assess their feet. Look for any changes: Signs of inflammation, infection, blisters, redness. Then the next day, wear them for two hours and do the same. It basically takes two weeks to break in a new pair of shoes. At one week, you should be wearing them for half a day and at two weeks, you should be wearing them for a full day.”

Meanwell suggested working the shoes over manually before putting them on the patient.

“Force bend the heel counter so that you take the last shape out,” he said. “Just take your fingers over the top of the heel counter and squeeze it a bit. You’ll make it a bit wider and that will reduce the slipping of the heel. Also, put a little bend in the forefoot. Again, it’ll take some of the initial slip out of the shoe.”

Fitting without feeling

The issue of fit becomes more complicated when working with diabetic patients with neuropathy. The experts agreed that it is with these patients that the footcare specialist’s knowledge becomes paramount.

For instance, shoe laces can prove to be troublesome for neuropathic patients because they invariably tie the shoe too tight. One solution to that problem is a shoe with elastic on the sides.

“When you put on the shoe, it’s almost like a slip-on shoe with Lycra in it so it won’t squeeze the foot too tightly,” said Bret M. Ribotsky, DPM, who is in private practice in Boca Raton, FL.

For Mary Elizabeth Crane, MS, DPM, FACFAS, CWS, managing partner of the Foot and Ankle Associates of North Texas in Grapevine, fitting a neuropathic patient may mean breaking one of the cardinal rules of patient-provider relationships: Don’t listen to the patient.

“Proper fit has a lot more to do with the fitter being satisfied,” Crane said. “I know that’s contrary to what we’ve been told, but if you have a patient that has lost their protective threshold, and if she feels that the shoe fits properly, it’s probably a half size too small. The shoe has to compress the foot for a patient with neuropathy to actually feel it.”

Meanwell echoed Crane’s assessment, and suggested tightening up around the collar of the eyelet rows to make the shoe feel tighter than it really is.

The idea of a dynamic fit is important for any patient, diabetic or otherwise, but it is particularly crucial in neuropathic patients who are unable to make a judgement call about how shoes feel, Meanwell added. He recommended fitting the longest toe, which may not be the hallux, on all patients.

“There needs to be at least 3/8 of an inch to 1/2 of an inch from the end of the longest toe to the end of the shoe. You want to make sure that there’s room for movement within the shoe,” he said, pointing out that as a person bends his foot to propel forward toe off, the foot moves forward in the shoe. “You need the additional space to accommodate for movement.”

As a rule of thumb, Lidtke advised going a half size larger and then relying on your footwear customization skills to make it work.

“If (the shoe is) larger, I can always fill in, but if it’s small, it’s harder to stretch. This is really where your expertise as a shoe fitter comes into play,” he said.

Material advantage

Although the technology behind synthetic materials has improved, nothing beats the real deal.

“Fine-grain natural leather is better than a man-made material because it’s more durable and more breathable,” Crane said. “Remember that Medicare only approves one pair of diabetic shoes per year. A shoe that’s not made of quality material is going to break down before a year and a lot of these patients don’t have the money to pay for another pair (out-of-pocket).”

But even the highest quality leather is rendered ornamental if the nuts and bolts of the shoe, specifically the shoe last, are subpar. A quality shoe will have midsole and outsole widths that have been been incrementally graded out, so that a size 2E shoe has a midsole and outsole sized for a 2E rather than allowing a wide foot to overhang the midsole, Meanwell said.

The patient’s concept of quality may also revolve around style. While it may seem like gender bias, experts say a demand for fashion is more common among female patients, regardless of age.

“We’ve found that, in the 65 to 75-year age range, (people) still want a good-looking shoe. I have 72-year-olds who say, ‘I don’t want to look like a little old lady,’” Crane said.

Fortunately, manufactures have stepped up to the challenge offer shoes that meet both health and style needs. But the experts agreed that health must take precedence over fashion, especially when a patient has serious foot health issues.

“For instance, women patients will want a certain style like a Mary Jane,” Lidtke said. “They really want that style of shoe, but after multiple attempts with various sizes and widths, I see that their foot is just not suited for it. At that point, I have to say, ‘It’s time to consider a different style.’”

Ritbotsky estimated that nearly half the time he spends with his diabetic patients is devoted to selecting the shoe style. Ultimately, he stresses to patients that the shoes are not designed to be pretty, they are designed to be functional.

“If we can make them less ugly, that’s fine,” he said. “And I think the companies have done a good job making the shoes less ugly.”

Ultimately, even if the shoe comes very close to style standards, a footcare specialist has to be practical about what their patients will or won’t do outside the office. Meanwell certainly knows that.

“I’m a CPed with 30-plus years in the business,” he said. “My own mother has posterior tibial tendon dysfunction and I made her a beautiful pair of custom shoes–and she only wears them to the podiatrist’s office.”

Compromising for compliance

Even if the patient is perfectly content with a stylish diabetic shoe, the reality is, they will come up with various reasons not to have to wear them. A desire to be more fashionable than functional can turn the most compliant patient into a shoe rebel.

Again, the experts stressed a strategy of compromise before resorting to scare tactics.

“The reality is, diabetic patients don’t want what you have to sell, so you can’t be a combatant,” Meanwell said.

Meanwell said he would recommend that the patient find a fashion shoe that has the right shape for the foot and fits properly. For women, he’d get them to agree to skip the stilettos. He would then emphasize that the fashion shoe should only be worn in certain social situations, for no more than an hour or two. The rest of the time, and certainly immediately before and after wearing of the fashion shoes, the patient must wear the diabetic shoes to protect the foot.

Ribotsky takes a similar, but slightly different approach, by taking the focus off the shoes. Instead, he said he finds a motivating factor in a patient’s life as a starting point for compliance.

“You have to show a patient the result they will obtain by following your advice,” he said. “I believe that compliance has a lot to do with selling the result. Patients don’t really care that the heel won’t break down with this shoe or that this sock will prevent ulceration. They care about being able to take their grandkids to Disney World; they care about staying out of a wheelchair; they care about avoiding the hospital. Those are all concerns that can affect their daily lives and you do that by selling the result.”

On the other hand, Crane said she has no problem with a little fear factor.

“Some of my patients will say that I’m very brusque, but I feel you have to be straightforward. For example, a patient comes in with multiple calluses on his feet, but you know that he has accommodating orthotics to offweight those calluses,” she said. “The first question you ask is, ‘Do you only wear your shoes when you are out of the house?’ [The patient] doesn’t realize that he is at-risk inside the house; a tile floor may be putting stress on the feet or he could step on a tack and it’s three days before he realizes it. I explain that if that happens, he’ll be back to see me and I’ll just make an appointment in the emergency room to take off half the foot. I point-blank ask them how they feel about that.”

There will always be patients that prove to be particularly challenging. But before unleashing the dire threats, Ribotsky suggested taking a step back and learning something about a difficult patient.

“Figure out who your patients are: Are they kinesthetic learners? Auditory learners? Visual learners? Make that determination and then be very confident in your delivery,” he advised. “There are always patients who won’t listen. I tell them, ‘The more complications you have, the better it is for me.’”

Comorbidities

When it comes to accommodating comorbidities, some choices are obvious: A patient with arthritis would be better off with slip-on shoes; a patient who had a stroke and has trouble controlling the left side of her body will need Velcro straps that she can pull with the right hand.

But when asked about addressing comorbidities in diabetic patients, the experts all agreed that the one they contend with most often is obesity.

When it comes to shoe fitting, there is not much that can be done about the patient’s weight problem.

“Most of the patients know that they are overweight,” Lidtke said. “You don’t really have to lecture them about losing weight. So with obese patients, it’s important to look at function. If the patient has abnormal function, the shoe is going to break down much faster. For example, an obese patient may have a lot of side-to-side movement when he walks, then you may have to modify the shoe that is designed for walking heel-to-toe. Or if the patient pronates excessively, this could cause more friction and tissue breakdown. Padding may not be the solution; you may have to create a custom orthosis to control that motion.”

Crane said that she always has her patients put their shoes on, and take them off, in front of her, several times if necessary. This is particularly important when working with an obese patient who may not understand how to navigate their physical limitations.

“You can’t assume that the patient knows how to put on a pair of shoes. You have to watch them do it. You have to make sure that this is a user friendly shoe,” she said. “I had a lady the other day and I had to teach her how to put her shoe on. She had an AFO brace and she had this custom diabetic shoe. She was having a difficult time because she was putting the brace on and then trying to put the shoe on. She was overweight and she couldn’t bend down that far. I showed her that she should put the brace in the shoe and then slide her foot into the brace and the shoe at the same time. She was genuinely surprised at much easier that was.”

Treating the whole patient

Patient support means communicating with other physicians, the experts agreed. Report to your findings to the referring physician and any other relevant physicians, either in a written document, through an electronic health records system (EHS) or a phone call.

Crane pointed out that Medicare requires that the referring physician’s notes state that a diabetic shoe is medically necessary, so the doctor relies on the footcare specialist to tell them about the patient’s foot health.

“They aren’t thinking about [feet]. They are thinking about hypertension or hemoglobin levels,” she said. “We do the Comprehensive Diabetic Foot Exam and then we send those findings to the physician, explaining why the patient needs diabetic shoes. We also provide educational materials for the other physician’s offices. It’s as constant back and forth.”

In addition, the footcare specialist needs to make it a point to know the patient’s total health history.

“I want the shoes made for the patient’s true pathology,” Ribotsky said. “You have to get the patient the right diagnosis so that you can get them what they need; so they won’t have further problems. We need to address all the pathologies that the patient has.”

Sponsored by an educational grant from Dr. Comfort

2 Responses to Footwear: Advantages of a whole-patient approach

  1. Douglas Young says:

    Hi

    I have enjoyed reading this article, its up to date information and interesting responses from other health porfessionals is refreshing. I work as an Orthotist in South Wales, UK. I have diabetic footwear clinic that I run along side the diabetic foot clinic. I have foudn recently that improving compliance can be helped by investiigating the patients activity level and daily routine. Many elderly patients spend more time indoors that out, and those with prescription footwear are not keen to wear them indoors. I always advise against a shop bought slipper for the obvious reasons. However more recently I ahve foudn specialist commercial house shoes which can accomodate orthoses and I have also been fortunate enough to use a footwear company who now make house shoes to the spec of prescription footwear, the only difference being a softer upper. The house shoe accomodates the insoles whether it be a simple flat cushioned material or a TCI, it maintains the heel stiffner and toe box feature, reverse fastening velcro or laces if required and always a solid sole unit of light weight e.g. microcellular.

    Has anyone else tried this?

  2. I agree that the whole patient approach is the way to go here. I wish all medicine would move in this general direction. Treating specific injuries leaves much to be desired, and can have negative consequences down the road. Very well done article. Enjoyed it greatly.

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