Study Sheds New Light On Therapeutic Footwear For Patients With Diabetes

By Brian McCurdy, Associate Editor

While there has been a plethora of studies in recent years that have tackled therapeutic footwear for people with diabetes, a new study reveals a dramatically lower rate of foot ulcers among those who wear therapeutic footwear and insoles. The study, which was published recently in Diabetes Care, found that 33 percent of patients who wore their own shoes had new foot lesions while approximately four percent of those who wore therapeutic footwear and insoles experienced new ulcers. The study, which was conducted in India, tracked 241 patients with diabetes who either had previous foot ulcerations or were at risk for ulcerations. According to the study, the four study groups were divided up as follows: • group one patients who wore sandals with 10-mm insoles of microcellular rubber and an 8-mm rubber outsole; • group two patients who wore sandals with 5-mm polyurethane foam insoles, 5-mm microcellular rubber midsoles and 10-mm ethylene vinyl acetate outsoles; • group three patients who wore sandals with 6-mm polyurethane insoles, 10-mm ethylene vinyl acetate outsoles and 6-mm cork midsoles; and • group four patients who declined the prescribed sandals for economic reasons and wore their own footwear with a hard leather board insole. Using in-shoe pressure measurements, the authors found that those who wore their own shoes had an increased foot pressure (40.7 + 20.5 kPa) in contrast to the other groups whose foot pressures ranged from 6.2 to 6.9 kPa. Guy Pupp, DPM, says the study reinforces the importance of therapeutic footwear in preventing recurrent ulcers among high-risk patients with diabetes. “A diabetic patient with a history of previous ulceration or amputation is at an increased risk for further ulceration, infection and subsequent amputation,” says Dr. Pupp, Clinical Director of the Southeast Michigan Surgical Hospital Foot and Ankle Clinic in Warren, Mich. He notes these conditions may be compounded further by neuropathy and peripheral vascular disease. When patients do not wear the proper footgear, Dr. Pupp says he has seen “significant recurrence of ulcers” and has noted “catastrophic results” among patients who had previously underwent successful limb salvage surgery. David G. Armstrong, DPM, says the study by Viswanathan, et. al., is the latest to confirm the notion that good shoes “seem to work. “Prescriptive footwear, when appropriately constructed, can reduce peak plantar pressures and that reduction appears to have an effect on preventing wounds,” notes Dr. Armstrong, a member of the Board of Directors for the American Diabetes Association. Tips On Choosing Materials For Therapeutic Insoles In the study, researchers point out that materials such as polyurethane, ethyl vinyl acetate (EVA), microcellular rubber and cork are lightweight, durable, flexible and absorb shock. However, Nicholas Sol, DPM, CPed, says he has tried the aforementioned materials for patients with diabetes and rejected them in favor of using multi-laminates. He has had particular success with a tri-laminate material. He says he heats the material to 275º and molds it directly to the patient’s protected feet. After it has cooled, the material is easily trimmed and shaped to fit the shoe. With this material, the softest layer is against the foot and the hardest material is against the shoe, according to Dr. Sol, who has a private practice in Colorado Springs, Colo. “I find that this combination maintains shape and is easy to both mold and modify,” says Dr. Sol. For David Levine, DPM, CPed, the key is to use soft materials that do not bottom out and can absorb shock. While he says there are a lot of materials to choose from, he tends to use Microcell, poron, p-lite, Spenco, cloud crepe, cork and plastazote for these patients. In regard to the characteristics he looks for in insoles for diabetic footwear, Dr. Armstrong prefers a low durometer material over a progressively higher durometer material under that softer material, which he says you would ideally mold to the foot. Why Pressure Measurements Are Important Dr. Armstrong, who is an incoming Professor of Surgery, Chair of Research and Assistant Dean at the William M. School College of Podiatric Medicine at Rosalind Franklin University of Medicine, also emphasizes the importance of taking pressure measurements before and after molding to gauge the efficacy of your prescription. While doing this in a busy practice may be difficult, Dr. Armstrong says it is well worth doing. “This is rarely done but I believe we should do this so we can prove to ourselves, our patients and the people paying for these that we are accomplishing what we want to accomplish clinically,” he notes. Do Arch Supports Help Prevent Fifth Metatarsal Injuries? By Brian McCurdy, Associate Editor Basketball players may be a lay-up or pivot away from a fifth metatarsal fracture. However, researchers at Duke University say adding extra arch support to basketball shoes may help reduce the stresses that cause these injuries. The researchers recently presented their findings at the Annual Meeting of the American Academy of Orthopedic Surgery, according to an article on Using electronic pressure sensors and electromyography (EMG) sensors, researchers assessed foot muscle activity among 11 of Duke’s athletes, who performed common basketball maneuvers with regular basketball shoes and shoes with accentuated arch support. According to the study, the researchers found the additional arch support significantly reduced the forces upon the fifth metatarsal that occur during pivots and lay-ups. “It appears that supporting the arch may reduce the stresses encountered beneath the fifth metatarsal and help prevent these injuries in the future,” noted Joseph Guettler, MD, one of the study researchers, to Arch Supports Or Custom Orthoses: What Is More Effective? While Patrick DeHeer, DPM, says fifth metatarsal stress fractures are not very common, he points out that fractures to the fifth metatarsal base “are fairly common” in basketball players. Dr. DeHeer, the team podiatrist for the Indiana Pacers, says the study shows a high level of stress to that anatomical area over time “could be the underlying cause of this fracture.” He compares it to Achilles tendinitis, which eventually leads to tendon degeneration and finally rupture in athletes. Given the intensity of the sport, the size of the athletes and the type of surface that the sports is played on, basketball players are prone to overuse injuries, according to Dr. DeHeer. He says the additional arch support may have some preventive value. “I think anything that helps improve foot mechanics and still offers some form of cushioning and shock absorption is very important in preventing overuse injuries that often plague basketball players,” notes Dr. DeHeer, a Fellow of the American College of Foot and Ankle Surgeons. However, Dr. DeHeer emphasizes his belief that a well-made basketball-specific orthoses would be “far superior” than a medial arch support. Richard Braver, DPM, applauds the new research as he has treated numerous fifth metatarsal fractures in NCAA basketball players and says they “can be the physician’s arch nemesis.” However, Dr. Braver, a Fellow of the American Academy of Podiatric Sports Medicine, concurs with Dr. DeHeer, noting that custom orthotics may provide even greater benefit than arch supports in preventing these injuries. He says there are many considerations that go into ordering a custom orthotic device, whether it’s using a vertical or posted rearfoot or a varus or valgus forefoot, a first metatarsal head cutout, etc. Also, one must decide the depth of the heel cup, the flexibility of the shell, calcanealcuboid elevation, the amount of cushioning, etc. The team podiatrist for Fairleigh Dickinson and Montclair State Universities, Dr. Braver says a good biomechanical exam is key to providing effective treatment as it will allow you to detect structure and gait deviations. However, Dr. DeHeer notes that the current design of basketball shoes can thwart the impact of orthotic therapy. “The shoe companies keep making shoes more narrow and difficult to fit orthoses into, which is troubling when trying to treat a professional or high-level basketball player,” points out Dr. DeHeer. Exploring Ideas For Future Studies Dr. Braver, a Fellow of the American College of Foot and Ankle Surgeons, suggests future research should compare the effects of players who in-toe with those who out-toe. In his experience, fifth metatarsal base fractures were more common among patients who in-toed and in players with bowed legs. He suggests that comparing the high-arched and low-arched gaits would be useful in determining predisposing factors toward these fractures. “One must watch the basketball player while walking, running the court and while guarding another athlete to see if he in-toes or inverts the foot during these maneuvers,” emphasizes Dr. Braver. “The side-to-side motions and pivoting motions inherent to basketball play put the in-toer at greater risk of these fractures.” CMS Says Electronic Claims Will Be Paid Twice As Fast As Paper Claims By Brian McCurdy, Associate Editor If you are still filing paper claims for Medicare patients, expect slower reimbursement than colleagues who file electronic claims. That’s the new message being sent by the Centers for Medicare and Medicaid Services (CMS) to those who are not complying with the standards mandated by the Health Insurance Portability and Accountability Act (HIPAA) last October. Starting July 6, the CMS will not reimburse paper claims until at least 27 days after they are received, compared to two weeks for electronic claims submitted according to HIPAA standards, according to a recent article. Approximately 70 percent of the healthcare industry are adhering to the HIPAA standards, although this estimate is apparently composed of large healthcare institutions, according to the American Medical Association (AMA). American Podiatric Medical Association (APMA) President Lloyd Smith, DPM, says he believes the 70 percent compliance rate is in line with the APMA membership. He also thinks the idea of electronic claims being twice as fast as paper claims in obtaining reimbursement will provide a spark for those who remain non-compliant. “I hope most of our APMA members will become compliant so that their payments will be prompt and accurate,” says Dr. Smith. As the CMS notes, podiatrists who submit legacy claims after July 6 will get paid, but the government agency will treat the claims as if they were submitted on paper. While the compliance numbers for large institutions are relatively high, experts estimate that the HIPAA compliance rate for small practices is below 15 percent, according to the report. If you are using an outside vendor for billing and that vendor is either not HIPAA-compliant nor is attempting to get compliant, experts told that it would be wise to start searching for another billing company. NY Podiatrists Urge Legislature To Reject Medicaid Cuts By Brian McCurdy, Associate Editor Podiatrists across New York state closed their offices and podiatric students joined them in March in traveling to Albany to protest a proposed elimination of Medicaid coverage for visits to podiatry clinics. About 500 DPMs and students participated, according to Hiram Chirel, DPM, the Executive Director of the New York State Podiatric Medical Association (NYSPMA). Article VII of the state health budget, which was pending approval as this issue went to press, would eliminate Medicaid coverage for visits to Medicaid adult podiatry clinics. While the state reportedly estimates a potential savings of $600,000 in 2004 and $1.2 million in 2005, NYSPMA President Bruce Waxman, DPM, says these cuts will actually result in greater costs to the health system because those receiving Medicaid will have to go to the emergency room or undergo more expensive examinations. The cuts may also lead to more patients delaying or putting off treatment, potentially leading to unnecessary amputations among high-risk patients. The association also notes that the proposal will have a severely negative impact on the New York College of Podiatric Medicine as residents will not be able to treat patients at the Foot Clinic in Harlem, which is run by the college, or at other state clinics. Since hospitals receive funds for residents, hospitals will also suffer financially, the NYSPMA contends. The association notes the federal cost of running New York residency programs is about $15 million. “Since a college that cannot sustain its residency programs cannot attract students or continue to operate, the very existence of this institution is threatened,” the association says of the New York college. The state has 260 approved podiatric residency programs. “Whoever made that (proposed) cut never looked at all the ramifications,” says Dr. Chirel. “It’s really not a savings at all. It’s just a shifting of funds.” In Brief Merz Pharmaceuticals has announced that it is sponsoring online education courses for podiatrists through the American Podiatric Medical Association (APMA) and Podiatric Residency Education Services E-learning Network Training (PRESENT) courseware. DB Consultants, Inc. is sponsoring training seminars for users of its AS/PC® system in the Northeastern United States. Courses are available for basic-level training, power user training and an advanced workshop. The seminars will be held in Trumbull, Conn. and will run May 20, Aug. 19, Sept. 16 and Nov. 11. For more information, call DB Consultants at (610) 847-5065 or go to to download a seminar schedule.

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