Part 6: Detection and Prevention of Foot Problems in Type 2 Diabetes

of the foot than men who spent 27% of their time wearing dangerous shoes. Both menand women spent nearly 30% of their time in slippers, stockings and barefoot for theirregular activities.Custom made orthopaedic footwear is expensive, costing considerably more thanmanufactured footwear. In addition, acceptance and use of custom made orthopaedicfootwear is poor. A survey of 62,170 people with diabetes who were Medicarebeneficiaries in 3 American states found low utilisation of therapeutic footwear. Ofthe 13% who fell into the “high risk” group, only 2.9% claimed for footwear and ofthe 14% with possibly increased risk, claims were made by only 0.7% (Sugarman etal, 1998). Other authors also report low levels of compliance with therapeuticfootwear, often related to the appearance of the footwear (Chantelau & Haage, 1994;McCabe et al, 1998). In contrast, specially designed, extra depth, extra width shoeswith a rocker bottom were well accepted by 24 male Veterans with 88% compliance(Reiber et al, 1997).The studies reviewed in this Section have used a variety of footwear and/or insolesand/or socks. The term “therapeutic footwear” has mostly been used in studies to referto the use of specially manufactured shoes or to the use of casts (total or half,removable or non-removable). A variety of insoles, either customised or not, andmade of a variety of materials have been studied.Evidence – Footwear to Reduce Ulceration and AmputationTherapeutic footwear reduces the risk of ulcer recurrenceMason et al (1999) performed a systematic review of diabetic foot ulcer preventionstrategies and identified only 1 randomised trial (Uccioli et al, 1995) on the effect oftherapeutic footwear. Although this study showed a beneficial effect, Mason et al(1999) recommended confirmatory studies on larger numbers of people with diabeteswith comparisons of ‘optimised’ normal shoes and special therapeutic shoes toconfirm the relative effectiveness and cost-effectiveness of wearing therapeutic shoes.The study by Uccioli et al (1995) was a multicentre, RCT which assessed therapeuticfootwear and ulcer recurrence in people with previous foot ulcers. Manufacturedtherapeutic shoes were designed according to Tovey’s guidelines as previouslydescribed. Customised insoles were also provided. Foot ulcer relapses weresignificantly lower in the group of 33 wearing therapeutic shoes compared with thecontrol group of 36 wearing their own shoes (27.7% v 58.3%, OR 0.26, CI 0.2-1.54;p=0.0009). In multiple regression analysis adjusted for severity of disease, age andsex, the use of therapeutic shoes was negatively associated with foot ulcer relapse(coefficient of variation - 0.32, CI -0.54 to -0.08; p=0.009).A cohort of 51 people with diabetes were provided with protective footwear,cushioned with insoles after healing of a neuropathic foot ulcer and followed for up to4 years (Chantelau & Haage, 1994). In those who wore the protective footwear for>60% of daytime hours, ulcer recurrence was reduced by 50% (p=0.0002) comparedwith those who wore their footwear less frequently. After 2 years, the protective effectwore off, suggesting that footwear needed adaptation and renewal within this time75