When it comes to diabetic wound care, footwear matters – and proper diabetic patient shoe assessment is key.
Wound clinicians know how devastating foot amputations are for diabetic patients. But what you might not know is that a whopping 50% of diabetic foot amputations are a direct result of patients wearing improper footwear. Surprised? Unfortunately, this staggering statistic is accurate. But the good news is that there’s something we can do about it. If we get diabetic patients to wear the proper shoes, we can cut diabetic foot amputations in half.
Where to start
If you want be on the diabetic wound prevention team (and we hope you do), shoe evaluation is key. Which means you must be able to properly assess fit and wear patterns. And the only way to do this is to start by first asking the patient to wear the same shoes to the appointment that he or she wears every day.
But take note: a polite request might not do the trick, as patients are commonly tempted to wear different, nicer or newer shoes that won’t get them “in trouble.” So be firm, and explain the importance of a proper footwear assessment and its role in preventing ulceration and amputation.
What to look for
Once you have your diabetic patient’s shoes in front of you, here are the qualities you will need to look for (and hopefully find):
- A closed toe that mimics the shape of the foot – a wide toe box that allows toes to move and accommodates any foot deformity. Pointed or open toes are not suitable.
- An overall firm and snug fit, but with 1cm between the longest toe and the end of the shoe (when the patient is standing). We don’t want added pressure to the tops of the toes or on the toenails.
- Heels less than 1 inch, because the taller the heel, the greater the pressure on the ball of the foot. This leads to increased callous formation and ulcerations.
- A firm heel. Hold the sides of the heel between your thumb and forefinger and push. If the heel compresses, it won’t give the patient enough support when walking.
- Shoes with laces, buckles or elastic to hold them in place. Slip-ons require that the toes curl in order to hold the shoe on, increasing the chance of callous formation or ulceration on the top of toes.
- A smooth sole without seams.
- Cushioning to absorb shock and reduce pressure on the feet.
- Material that “breathes.” Avoid plastic and vinyl, as they can encourage fungal infections.
Provide the proof
If a patient is resistant or doesn’t understand why their shoes aren’t appropriate ones, you may have to demonstrate and provide the proof. This is where the Harris mat comes into play – a device that creates an ink imprint of the patient’s foot and reveals areas of higher pressure. During your footwear evaluation, use the Harris mat, or try this related technique:
- Ask the patient to stand on a white piece of paper.
- Trace the outline of the foot with a marker.
- Then, align the patient’s shoe on top of the outline.
If the outline of the foot expands beyond the shoe, you’ve identified improper fit. You’ve also produced an excellent visual aid for your patient.
Take it and shake it
Have you ever heard of the “take it and shake it” technique? This is something your patient should get in the habit of doing before putting on their footwear.
First, they should point the toes of the shoes up toward the ceiling, and shake it. Why? Because all types of small objects end up in shoes – pebbles, Legos, paper clips – you name it. A diabetic patient with neuropathy won’t feel these objects, even after a severe wound has developed. As we discussed in the blog “Urgent! Risks and Diagnosis of Diabetic Foot Infections,” 56% of all diabetic foot ulcers become infected, and an infected foot wound precedes about two-thirds of amputations.
Further educate your patients
There are things that diabetics can do to help prevent further complications, including how they shop for shoes, and their foot care at home. Provide patients and their families instructions on how to to do both.
First, share these pointers for successful new shoe shopping:
- Patients should be re-measured each time they get new shoes.
- Shop late in the day – when feet are typically more swollen and at their largest.
- Try on both shoes and walk around in them to ensure they are comfortable.
- If the patient has serious foot problems or deformities, they should be referred for specially molded inserts and or shoes.
In addition to knowing how to purchase new shoes, diabetic patients must practice proper foot care at home. Unfortunately, sharing the following instructions will not likely make you popular, but they are crucial nevertheless:
- Their feet must be inspected (either by themselves or a caregiver) every single day, and without exception.
- If the patient cannot pick up his or her feet to inspect the bottoms, provide a mirror, or have them enlist the help of a family member.
- Diabetic patients should not ever walk barefoot, period. Even if the distance from the bed to the toilet is only six steps, the patient should always put on some type of shoes. Without shoes, the risk of injury to the bottom of his or her feet is increased exponentially.
- Finally, 82.1% of diabetics have skin with dryness (xerosis), cracks or fissures, which can lead to foot ulcers. Therefore, the skin must be kept moist. For a discussion about keeping the skin moist on diabetics, see the related post, “Dry Skin Alert: Foot Xerosis in Diabetic Patients”.
Are you on the team?
Are you ready to be a part of the diabetic wound prevention team? We hope you are excited to take an active part in helping educate your diabetic patients about proper foot care. What are the biggest challenges you face when talking to diabetic patients about footwear? Are there other techniques or ideas you’d like to share? Please tell us about your experiences, or leave related comments below.
Wound Care Education Institute® provides online and onsite courses in the fields of Skin, Wound, Diabetic and Ostomy Management. Health care professionals who meet the eligibility requirements may sit for the prestigious WCC®, DWC® and OMS national board certification examinations through the National Alliance of Wound Care and Ostomy® (NAWCO®). For more information see wcei.net.