1. Diabetic Footwear- current practice, the bridge between art and science and
implications in clinical practice: A systematic review
Sayed Ahmed1*,2,Paul Butterworth1, John Whitting1, Susan Nancarrow1
1 School of Health & Human Sciences, Southern Cross University, Australia.
2Comfort and Fit (Asia Pacific) Pty Ltd, NSW, Australia
Background
In diabetic patients significant offloading can be achieved
at high risk foot regions by modifying custom made
footwear based on in-shoe pressure analyses. The goal of
this study was to systematically review the literature for
footwear prescription for ulcer prevention and reduction.
Methods
Seven electronic databases (Medline, Cinahl, Amed,
Proquest, Scopus, Academic Search Premier and Cochrane
databases) were searched in November 2014 and 9
articles were identified for review (Fig-4). Keywords
included: diabetic foot, footwear, orthoses, plantar
pressure (Fig-5).
Discussion & Conclusion
The goal of diabetic footwear is to redistribute and reduce
plantar pressures and avoid mechanical stress on the dorsum
of the foot. This can involve the fabrication of total contact
accommodative insoles, fully customised orthopedic footwear
incorporating arch supports, metatarsal bars and pads, rigid
forefoot rocker or rocker sole with specific pivot point location
and angle (Fig-1 & 2). Further high quality studies, including
clinical trials, should be conducted in order to inform the
clinical and scientific communities regarding the effects of
these aspects of footwear design in diabetic populations.
Fig-2: Prevalence of ulcers for each region of the diabetic foot
References
1. Arts, M. L. J., Waaijman, R., de Haart, M., Keukenkamp, R., Nollet, F., & Bus, S.
A. (2012).
2. Bus, S. A., Haspels, R., & Busch-Westbroek, T. E. (2011).
3. Rizzo, L., Tedeschi, A., Fallani, E., Coppelli, A., Vallini, V., Iacopi, E., & Piaggesi,
A. (2012).
4. Paton, J., Bruce, G., Jones, R., & Stenhouse, E. (2011).
5. Tang, U. H., Zügner, R., Lisovskaja, V., Karlsson, J., Hagberg, K., & Tranberg, R.
(2014)
6. Lo, W. T., Yick, K. L., Ng, S. P., & Yip, J. (2014)
7. Botek, G., Owings, T. M., Woerner, J., Frampton, J., & Cavanagh, P. R. (2007)
8. Mueller, M. J., Lott, D. J., Hastings, M. K., Commean, P. K., Smith, K. E., &
Pilgram, T. K. (2006).
9. Davia, M., Germani, M., Mandolini, M., Mengoni, M., Montiel, E., & Raffaeli, R.
(2011).
10. Arts, M. L. J., Haart, M., Waaijman, R., Dahmen, R., Berendsen, H., Nollet, F.,
& Bus, S. A. (2015).
11. Waaijman, R., de Haart, M., Arts, M. L., Wever, D., Verlouw, A. J., Nollet, F., &
Bus, S. A. (2014).
Take Home Messages
 Ill-fitting/inappropriate footwear has been identified as the
root cause of 21 to 76% of foot ulcers and/or amputations
in diabetic patients.
 Presence of a minor lesion is clearly the strongest
determinant of ulcer recurrence in the diabetic foot.
 Effective offloading below target pressure in footwear (In-
shoe peak pressure, <200 kPa) and high adherence (>80%)
to the prescribed footwear can protect the insensate foot
and reduce the risk of ulcer recurrence by more than 50%.
 Total-contact inserts (TCIs) and metatarsal pads (MPs)
cause substantial and additive reductions of pressures
under the metatarsal heads.
 Insole material’s mechanical, thermal and skin-insole
material’s friction properties are the ideal parameters to
justify clinical suitability for diabetic patients.
Results
This review found 6 randomized controlled trials which
examined the efficacy of footwear and innersole
interventions, with various features and specifications to
offload the diabetic foot. Factors which influenced
increased plantar pressures were footwear/insole
interventions, footwear/insole design and compliance. In –
shoe pressure analysis, used to select the target regions for
pressure optimization and to modify the footwear to
offload that region of interest (ROI), was found to be
effective in offloading the ROIs in the diabetic feet (Fig-3).
Fig-1: Materials and components design for diabetic footwear
Armstrong (1998)
Fig-3: Foot pressure analysis for optimum offloading