The Diabetic Foot: Proper Footwear and Care Are Crucial

Complications from diabetes can affect virtually every part of the body. The diabetic foot is of particular concern. With proper care, regular examinations, and properly fitting footwear (in conjunction with appropriate glycemic control), ~50% of amputations can be prevented.

Uncontrolled diabetes leads to foot complications through several mechanisms. Progressive neuropathy leads to a loss of sensation in the feet to the point where a patient may not feel heat, cold, friction, or sores. Patients with diabetes also experience impaired circulation to the lower extremities, which prevents wounds from healing appropriately and thereby increases the risk of infection.

Prevention of these complications starts with patient education. Pharmacists should take the opportunity to counsel all diabetic patients regarding several important points, which include the following:

1. All patients with diabetes should check both feet daily. They should look for any signs of friction spots, red areas, sores, cracked skin, swelling, or blisters. If they are unable to see the bottom of their feet, they should use a mirror.
2. The feet should be washed carefully every day in warm water and dried carefully between the toes. The water temperature should be tested on the arm to ensure that it is not too hot or too cold.
3. Proper grooming includes trimming of the toenails straight across only, not down into the side edges. The edges can be filed with an emery board if needed. Patients should use lotion on dry areas of skin if needed, being careful not to apply any between the toes.
4. Physical activity increases blood flow to the feet. Patients should be reminded to walk regularly if they are able and to do toe and ankle exercises during periods of inactivity. They also should be advised not to cross their legs so as not to impair circulation.
5. Patients with diabetes never should walk barefooted. They should wear socks as well as shoes. They always need to protect their feet from hot and cold or injury.
6. Properly fitted shoes are a must. Patients need to understand how a comfortable shoe should fit. Medicare patients should know that they may qualify for the Medicare therapeutic shoe program, and some many need help enrolling.

Poorly fitted shoes are a primary cause of foot ulcers in patients with diabetes. Some of these patients will be able to find comfortable off-the-shelf shoes. They should try, however, to find an experienced shoe fitter, and make sure that their feet are measured each time they purchase new shoes. The shoes should fit properly in both the length and the width, with adequate room for the toes. Properly fitted shoes should not require a break-in period but should feel comfortable when purchased.

Pharmacists have a unique opportunity to help Medicare patients who have a need for therapeutic shoes. Medicare's therapeutic shoe program will cover 80% of the allowable cost for 1 pair of shoes each year for those diabetic patients who qualify. Typically, a patient's secondary insurance carrier will cover the remaining 20%. Simply being diagnosed with diabetes is not enough to qualify for the program, however. A patient must be in a diabetes treatment plan and have at least 1 of the following:

• A history of foot ulceration
• A history of preulcerative callus
• Partial or complete foot amputation
• Peripheral neuropathy with evidence of callus formation
• A foot deformity
• Poor circulation

The therapeutic shoe prescription must be written by a podiatrist or a trained physician who is familiar with fitting shoes for patients with diabetes. Qualified patients are limited to the following per calendar year:

• No more than 1 pair of off-the-shelf extra-depth shoes (ie, shoes that have room to accommodate innersoles or orthotics) and 3 additional pairs of inserts selected by a podiatrist
• No more than 1 pair of custom-molded shoes and 2 additional pairs of inserts

Community pharmacists have the opportunity to speak with patients regarding healthy foot care and the importance of obtaining properly fitted shoes. If patients might qualify for the Medicare therapeutic shoe program, they should be informed about their options and helped with referrals to their appropriate health care provider. Many patients who could truly benefit from the program are unaware that it even exists.

Dr. Brian is a clinical specialist with Cornerstone Health Care, High Point, NC.