Reassessing The Impact Of Diabetic Footwear
Many sources in the literature describe the presence of pedal deformity and recurrent ulcerations associated with diabetes mellitus.1-4 Establishing a multidisciplinary team of physicians is essential for avoiding complications among these patients with diabetes.5,6 Unfortunately, the pedorthotist/orthotist is a frequently underutilized member of this team. Indeed, certified CPeds can make the difference between success and failure of diabetic limb salvage and ulcer prevention. Certainly, the importance and impact of diabetic footwear cannot be ignored as a key component in managing patients with diabetes. Given their knowledge of functional and accommodative devices, braces and orthoses for offloading the foot, pedorthotists/orthotists can play a valuable role in preventing reulceration after conservative cure or in providing stability and protection to a limb after extensive surgical limb salvage.7 The CPed can also assist patients who have undergone an amputation. Pedorthotists can make prosthetic devices for these patients and aid them in following through with their rehabilitation. Our pedorthotist/orthotist is able to provide in-office service for individuals who are unable to travel to and from their facility. When it comes to using proper footgear and bracing, each patient has different needs with uniquely different pathology.8,9 Some people may need custom devices due to gross deformation of the foot. Others may need special materials to cushion, prevent friction, and/or offload prominent bony areas of the foot. In order to effectively minimize or prevent injury, one must determine the presence or absence of protective levels of sensation.10 Other risk factors for ulceration in patients with diabetes include: a duration of diabetes for more than 10 years; poor blood sugar control; male gender; foot deformity; soft tissue contractures and intrinsic muscle atrophy causing increased plantar pressures; and amputation.11-13 A Guide To Risk Categories Of The Diabetic Foot For a breakdown of the risk categories of the diabetic foot, see the table “Risk Categories And Management Of Diabetic Patients With Foot Ulcers” below.14 Identifying the level of pathology is essential for determining an appropriate course of treatment. • Risk category 0 represents patients who have been diagnosed with diabetes but have intact protective sensation, no history of ulceration and no gross foot deformity. Appropriate management of this patient should include extensive patient education, proper footwear and a follow-up visit at least every 12 months. • Risk category 1 represents the patient who has a loss of protective sensation, but has no history of ulceration or gross deformities of the foot. The pedal pulses may or may not be diminished. Appropriate management of this patient should include podiatric visits every three to six months, extensive evaluation of footwear and liners, extensive patient education and observation of compliance issues such as glucose control (record keeping), weight loss and foot hygiene. One should perform a baseline non-invasive vascular exam if pedal pulses are diminished. • Risk category 2 represents those who have much more risk for potential serious problems. These patients have no protective sensation. They may or may not have a history of plantar ulceration but they do have a deformity of the foot. Deformities in this stage may include digital contractures, equinus, thinning of the plantar substance of the foot (intrinsic muscle atrophy), and cutaneous changes you would see with varying amounts of vascular depletion. Appropriate management of these patients usually requires clinic visits as often as every one to three months, custom molded liners in extra-depth shoes (or custom molded shoes in the presence of gross structural changes), extensive education and consults with appropriate specialists. • Risk category 3 represents neuropathic patients with a history of plantar ulcerations, more severe contractures and deformity, and varying levels of vascular compromise. These patients may start showing more gross deformities associated with Charcot neuroarthropathy. Management of these patients may require involvement with a vascular surgeon, followed by addressing any plantar prominences or soft tissue contractures causing ulceration.