Footwear

Insensitive feet must always have shoes on them and the shoes must be appropriate.

Footwear is the most important part of wound management.  To heal a wound is the easy part; to provide adequate orthotics and footwear that prevent reulceration is the real challenge.  Every patient with a loss of protective sensation (LOPS) must be fit with shoes that are adequate in terms of length, width, toe box design, upper design and material (preferably leather) , sole structure, ease of putting on or taking off and weight.  The shoe must fit the foot rather than the foot fitting the shoe.

Discussion, consideration and decisions on options for appropriate protective footwear and preparation of necessary modifications should be carried out during the wound healing phase and/or resolution of an acute Charcot fracture.  This assures that shoes will be available and finished with the necessary modification when the wound is healed and ready for progressive ambulation.   Initiation of full weight bearing ambulation is strictly prohibited until wound closure, solid healing is established and proper footwear is dispensed.  Progressive ambulation in footwear can be initiated 1-2 weeks after wound closure under the direction of the therapist.  Any use of footwear other than prescribed can be detrimental to foot health.  In the event that footwear is not ready for use when the patient is ready, he/she should continue the use of a protective device such as the splint, plastizote boot or sandal.  

The choice of footwear for patients can be referenced as follows:

Condition of foot	Well-fitting shoe	Pictured Examples
Loss of protective sensation No foot deformity	SAS diabetic shoe Tennis shoe
Loss of protective sensation Mild to moderate deformity No history of plantar ulceration xxx	Tennis shoe X-depth shoe/contour last Shoe which can accommodate an orthotic
Loss of protective sensation Moderate to severe deformity History of plantar ulceration History of Charcot fracture	X-depth shoe/contour last Superdepth/rigid sole shoe Wide shank shoe, custom shoe/boot Lower leg bracing

Footwear modifications are sometimes needed to provide the biomechanical support and subsequent protection of the insensitive foot.  Various modifications include rigid rocker sole, medial/lateral flare, cowboy heel, negative heel, stretching upper for toe deformity and/or additional space in the shoe, velcro closures and sole addition for leg length discrepancy.