1363267070 13 chapter13

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Chapter 13

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1363267070 13 chapter13

  1. 1. 89 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.
  2. 2. 90 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
  3. 3. 91 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

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