Unraveling The Controversy Over Diabetic Footwear

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By Jeff Hall, Editor-in-Chief

How helpful is therapeutic footwear for patients with diabetes? It has been one of the most hotly debated questions over the last few months, especially in the aftermath of a controversial study that was published last year in the Journal of the American Medical Association (JAMA). (See “Study Questions Necessity Of Diabetic Footwear,” News And Trends, August 2002.)
The randomized study of 400 people who had diabetes and a history of foot ulcers had three study groups. One group wore therapeutic shoes and custom inserts, another group wore therapeutic footwear and prefabricated inserts, and a remaining group wore their own shoes. Researchers found little difference in re-ulceration rates among the different groups.
Podiatrists have raised questions about the study. The study authors have maintained they did not discount the use of therapeutic shoes, but rather that their study could not prove the effectiveness of the shoes.
Anecdotally, you hear a lot of praise of therapeutic footwear in helping treat the lower-extremity problems of patients with diabetes. One podiatrist says his experience with therapeutic shoes has been “universally positive.” Another DPM says he has seen many “success stories” in which ulcers healed “because of the shoes and orthoses (patients) received.”
However, there do appear to be some obstacles when it comes to assessing the effectiveness of therapeutic shoes. Compliance is one of them. A couple of doctors have noted that when they’ve seen cases in which patients have re-ulcerated despite using therapeutic footwear, it is usually preceded by the patient wearing dress shoes or sandals to an occasion a couple of days beforehand.
Another DPM notes that compliance can be especially problematic among patients who have diabetes and neuropathy. In order to actually “feel” like they’re wearing shoes, these patients get used to wearing footwear that is much tighter than their actual size. “When you get them the right-sized shoes, they often complain that they are way too big,” notes the podiatrist.
There is also a bit of learning curve in prescribing orthopedic shoes, according to those in the know. In last month’s issue, Alexander Reyzelman, DPM, noted he has seen “many patients that have been wearing inappropriately prescribed and dispensed therapeutic shoes, which have resulted in a new ulceration.” (See “Panel Revisits Controversial Footwear Study,” News And Trends, February, 2003.) Another DPM notes there is still “no substitute for putting a shoe on a foot” and that there is “a large subjective component to it.”
It’s also clear that therapeutic footwear, in and of itself, is not a panacea. However, as one DPM/CPed points out, it can be a potential source of blame because everyone has some level of understanding of shoes.
He saw one diabetes patient who had PVD and neuropathy along with some biomechanical complaints. He gave the patient therapeutic shoes and “he was walking better than ever and doing more.” When he came back for another pair later, he got something different. A small blister occurred on his little toe. It became infected and the patient went on to have an amputation. The DPM/CPed poses the question: Was it the shoes or the long-term chronic disease?
Perhaps the JAMA study will be the impetus for future studies on the effectiveness of therapeutic shoes for patients with diabetes. However, given the potential obstacles of compliance, a learning curve and the progression of an individual’s disease, I wonder if the profession will ever know for sure beyond a case-by-case basis.

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