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By Brian McCurdy, Senior Editor

Study: Wrong Shoe Size In Veterans Tied To Diabetic Ulcers

     Shoes that fit poorly are often named as a factor in the development of diabetic foot ulcers. A recent study in the Journal of the American Podiatric Medical Association (JAPMA) questioned whether veterans wear appropriately sized shoes and found that three-quarters of those studied did not.      Study authors evaluated the shoe sizes of 440 veterans at Southern Arizona Veterans Affairs (VA) Medical Center. Of those, 58.4 percent had diabetes and 6.8 percent had an active diabetic foot ulcer. Researchers found only 25.5 percent were wearing shoes in an appropriate size. Inappropriately sized shoes were defined as shoes that were at least one full size too small or too large, notes the study.      Those with a diabetic foot ulcer were 5.1 times more likely to have ill-fitting shoes than those without an ulcer, according to the study. To help prevent ulceration, authors advocate “meticulous” screening for discrepancies between the foot and shoe size.      Several podiatrists who have experience with treating veterans have had similar experiences with inappropriate shoe size.       “Most of my patients, veteran or non-veteran, do not wear the appropriate shoe size,” says study co-author David G. Armstrong, DPM, PhD, a Professor of Surgery, Chair of Research and Assistant Dean at the William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine in Chicago.      Dr. Armstrong adds that other studies have suggested that three-fourths of people wear inappropriately sized shoes. At Edward Hines Jr. VA Hospital, the staff estimates nearly half of its veterans wear shoes that do not fit, according to Ronald Sage, DPM, a Staff Podiatrist at the Hines VA. Mark Caselli, DPM, has encountered a “very high incidence” of veterans wearing shoes that are too small. He says this is common among vets in their 70s and 80s, with diabetes and without.

Understanding The Reasons Why People Wear Ill-Fitting Shoes

     Why do some veterans not wear proper footwear? Dr. Caselli, a staff podiatrist at the VA Hudson Valley Health Care System in Montrose, N.Y., says ill-fitting shoes may be due to the “frugal nature” of the patients, who may try to get the most out of a pair of old shoes.      Along the same lines, Dr. Sage cites economic reasons, saying many VA patients simply cannot afford properly fitted quality shoes. However, he says in the VA system, DPMs can obtain therapeutic shoes for most high risk diabetic or dysvascular patients.      Neuropathy may be another cause of ill-fitting shoes as patients may be unable to feel if their shoes are too tight, according to Dr. Caselli. In general, Dr. Caselli has found that “ … most of the diabetic ulcers on the dorsum of the foot, especially toes and the sides of the foot, were due to shoes that are too small. Ulcers on the plantar aspect of the foot are not often related to improper shoe size but tend to be due more to a lack of shock absorption.”      Dr. Caselli says another factor is that the foot becomes larger and wider as people age, and also gets bigger due to edema. He notes that patients tend to remember their shoe size, even if the foot was measured 30 years ago, and believe they should always get that same size shoe.       “People have to get out of the habit of feeling that their shoe size is like a Social Security number. Sizes can be different and can change,” notes Dr. Armstrong, a former Director of Research and Education within the Department of Surgery, Podiatry Section at the Southern Arizona Veterans Affairs Medical Center.

What Are The Best Methods For Screening Shoe Size?

     Doctors and patients should assess each the size of each shoe as a separate unit rather than relying on the size info of a specific brand, according to Dr. Armstrong. JAPMA study researchers used the Apex 1141 “Ritz stick” (Aetrex) to measure patients’ feet.      Dr. Sage feels the best screening device is a good podiatric exam. With the exam, one can identify pressure points, blisters or chronic pressure keratosis, any of which can indicate an ill-fitting shoe.      As Jeffrey Robbins, DPM, says, the most effective way of screening for shoe fit is inspecting the shoe on and off the foot for friction lesions on the foot and abnormal wear on the shoe. “Just using a measuring device alone does not cut it,” advises Dr. Robbins, the Director of Podiatry Service at the VA Central Office in Cleveland.      Dr. Caselli suggests having patients stand with their shoes on to be evaluated for shoe length, width and depth. He encourages DPMs to use a Brannock device. Dr. Caselli says it provides a good baseline for shoe size and the device educates patients, particularly when the size measured is different from the size of the patient’s shoe.

Can A Diabetic Wound Score Guide Antibiotic Therapy?

By Brian McCurdy, Senior Editor      How closely does a diabetic wound score correspond to patients’ clinical response to antibiotic treatment? One recent study formulated a diabetic wound infection score to answer the question.      The study, presented as a poster at the American Podiatric Medical Association Annual Scientific Meeting, evaluated data from the SIDESTEP study. Researchers tracked 373 patients who had taken piperacillin/tazobactam or ertapenem (Invanz, Merck). The study concluded that higher baseline diabetic wound scores were linked with lower clinical response rates.      In measuring wounds in the study, the researchers used parameters that included purulent and non-purulent drainage, erythema, induration, tenderness, pain and increased local warmth. The scoring system grouped patients in groups numbered 0 through 3 with 3 as the highest wound score.      As the authors note, developing a wound scoring system may aid in determining if a patient requires antibiotic therapy and in selecting the final antibiotic regimen.      Mark Kosinski, DPM, uses the Infectious Diseases Society of America (IDSA) Clinical Classification of Diabetic Foot Infections and notes that the system proposed in the poster “seems to be a logical outgrowth of the IDSA system.” As he says, the SIDESTEP system quantifies physical signs and symptoms according to severity and gives those signs a grade. He feels the wound score proposed in the SIDESTEP poster will be useful in determining wound infection severity and empiric antibiotic therapy as well as foreseeing treatment outcomes.       “Grading systems of this type are useful for predicting with a reasonable degree of certainty what organisms one can expect to find in a given wound and allow us to get a critical jump on treatment before culture and sensitivity results are known,” opines Dr. Kosinski, a Professor in the Department of Medicine at the New York College of Podiatric Medicine.

Does The Wagner System Promote A ‘Common Language’?

     What types of wound scoring systems are in use in different facilities? Guy Pupp, DPM, uses a modified version of the Wagner classification. “Many specialists such as vascular specialists, infectious disease specialists, endocrinologists, orthopedists and cardiologists are aware of the Wagner classification and I find it most convenient to standardize reports and have a ‘common language,’” says Dr. Pupp, the Clinical Director of the Foot and Ankle Clinic at Southeast Michigan Surgical Hospital in Warren, Mich.      In regard to the Wagner system, Dr. Pupp adds categories such as size of the lesion, vascular status, presence of cellulitis and neuropathic status. While residency programs at various institutions are aware of other classification systems such as the University of Texas score, the DEPA score and PEDIS system, Dr. Pupp says the Wagner classification is “clinically the most useful” due to its familiarity among other specialists.      The modified Wagner classification has been useful in predicting outcomes, according to Dr. Pupp. If a patient with a Wagner grade 2 wound has significant vascular disease, uncontrolled blood glucose levels and neuropathy, he or she has more risk and a poorer prognosis than a patient who has a Wagner grade 2 ulcer but has good vascular perfusion, good HA1c levels and no neuropathy.       “I feel there are other more informative wound classifications but if they are not used or understood by physicians among the ‘specialist spectrum’ who treat diabetic wounds, their clinical usefulness is questionable,” notes Dr. Pupp.

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