Chapter 13

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Chapter XIII
DIABETIC FOOT AND FOOTWEAR CHOICES
 CHOOSING FOOTWEAR FOR DIFFERENT CLINICAL STATES
 FOOTWEAR SIZE AND MEASUREMENTS
 GUIDELINES FOR PROPER SHOE FIT
 INSOLES
 ROCKER SOLES
After the wound heals in a diabetic foot, it is necessary to protect the foot. This can be
best achieved by use of proper footwear. It must be remembered that the foot of a
person with diabetes is insensitive. Therefore the footwear needs to be designed to
protect as well prevent the injuries. A person with diabetes should never walk
barefoot. The footwear prescription will depend upon the stage of neuropathy,
presence of deformity/or previous operations. The diabetic foot can be at various
stages of risk of ulceration. The following clinical scenarios with the possible choices
of footwear may help a clinician to make some basic decisions on the same.
Person with diabetes with normal response to monofilament test:
This type of patient needs to be educated about protecting the feet .The footwear
should have wide toe box, adequate depth and soft insoles of material like micro
cellular rubber, plastazoat or polymer and total heel counter. The sole should be rigid
to prevent / reduce the pressure on the MTP joints
Person with diabetes with positive filament test:
This is a foot at risk. The footwear should be of wide toe box, extra depth, and
molded insole and total heel counter. The footwear should be inspected at regular
intervals to detect areas of increasing pressures. Any new areas of pressure will
require appropriate changes in the insoles.
Person with diabetes with partially healed planter ulcer:
This type of patient requires orthowedge shoes with the site of wedge depending
upon the site of the ulcer. A smaller ulcer can be managed with insole wing pad that
can relieve the pressure on the ulcer bearing area significantly
Person with diabetes with foot deformity:
This type of patient requires specially molded Total Contact Cradle Insole. This is a
composite insole made from 3-4 materials like polyethylene, plastazoat and cork
rubber. The molded insole is made from the plaster cast of the foot specially made for
this purpose. This cradle insole should be fitted in the shoes with wide toe box and
extra depth and rocker sole and complete heel counter.

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Person with diabetes with partially amputated foot:
This type of patient requires front filler of soft material in the shoes to fill for the
amputated portion, with wide toe box and extra depth.
The footwear size:
It should be judged preferably in the evening when the patients usually have
gravitational swelling. This gives correct fit of the shoes. In the Indian context closed
shoes with leather material are not socially accepted. Therefore the footwear that
should be chosen be of the sandals type and devised for the patients. These sandals
should have a good heel counter, rigid sole and well fitting straps. Every person with
diabetes should use footwear only with well fitting socks. Well fitting socks can
reduce the shear force by 30%. Taking into account the cost of the footwear,
frequency of change of footwear or its components careful planning is required
before prescribing footwear. We still do not have technologies to create and supply
appropriate footwear to all parts of the country though many efforts are on to create
the same locally. Correctly planned footwear can go a long way in preventing the
injuries in a patient of diabetes.
Objectives of diabetic footwear:
Relief of excessive plantar pressure, by orthowedge shoes (Fig. 29)
Reduction of shock
Reduction of shear
Accommodation of deformity
Stabilisation of deformity
Essentials of measuring shoe size:
Overall foot length (heel to the longest toe)
Arch length (foremost contact point from heel to 1st metatarsal)
Width
Guidelines for proper shoe fit:
Measure both feet
Fit shoes on both feet separately while weight bearing and in the evening
Check for positioning of 1st metatarsal joint
Allow ½ inch between end of longest toe & end of shoe
Look for snug fit around the heel
Check for proper width

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Types of rocker soles:
Mid rocker sole: Relieves metatarsal
pressure
Heel to toe rocker sole: It is useful in
the following abnormalities.
Fixed claw toes
Hammer toes
Calcaneal ulcers
Mid foot amputations
Severe angle rocker sole: It is useful
in following clinical situations:
Ulcer metatarsal heads
Toe only rocker sole:
Hallux rigidus
Ulcer distal part of toe
Hammer toe
Ulcer metatarsal heads
Negative heel rocker sole:
Fixed ankle
Dorsiflexion
Double rocker sole:
Charcot foot
Total contact inset (TCI)
Top layer:
Soft moldable polyurethane foam
Middle layer:
Closed cell foam
Bottom layer:
Cork / denser polyurethane foam