The Diabetic Foot: Proper Footwear and Care Are Crucial

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

Uncontrolled diabetes leads to foot complicationsthrough several mechanisms. Progressive neuropathy leadsto a loss of sensation in the feet to the point where a patientmay not feel heat, cold, friction, or sores. Patients with diabetesalso experience impaired circulation to the lowerextremities, which prevents wounds from healing appropriatelyand thereby increases the risk of infection.

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

• All patients with diabetes should check both feet daily.They should look for any signs of friction spots, redareas, sores, cracked skin, swelling, or blisters. If theyare unable to see the bottom of their feet, they shoulduse a mirror.
• The feet should be washed carefully every day in warmwater and dried carefully between the toes. The watertemperature should be tested on the arm to ensure thatit is not too hot or too cold.
• Proper grooming includes trimming of the toenailsstraight across only, not down into the side edges. Theedges 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.
• Physical activity increases blood flow to the feet.Patients should be reminded to walk regularly if theyare able and to do toe and ankle exercises during periodsof inactivity. They also should be advised not tocross their legs so as not to impair circulation.
• Patients with diabetes never should walk barefooted.They should wear socks as well as shoes. They alwaysneed to protect their feet from hot and cold or injury.
• Properly fitted shoes are a must. Patients need to understandhow a comfortable shoe should fit. Medicarepatients should know that they may qualify for theMedicare therapeutic shoe program, and some manyneed help enrolling.

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

Pharmacists have a unique opportunity to help Medicarepatients who have a need for therapeutic shoes. Medicare'stherapeutic shoe program will cover 80% of the allowablecost for 1 pair of shoes each year for those diabetic patientswho qualify. Typically, a patient's secondary insurance carrierwill cover the remaining 20%. Simply being diagnosedwith diabetes is not enough to qualify for the program, however.A patient must be in a diabetes treatment plan andhave 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 apodiatrist or a trained physician who is familiar with fittingshoes for patients with diabetes. Qualified patients are limitedto 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 ororthotics) and 3 additional pairs of inserts selected by apodiatrist
• No more than 1 pair of custom-molded shoes and 2additional pairs of inserts

Community pharmacists have the opportunity to speakwith patients regarding healthy foot care and the importanceof obtaining properly fitted shoes. If patients mightqualify for the Medicare therapeutic shoe program, theyshould be informed about their options and helped withreferrals to their appropriate health care provider. Manypatients who could truly benefit from the program areunaware that it even exists.

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