“Yes,  I know I have an ulcer and high sugars contribute to slower wound healing, but I have to eat; I can’t just cut out everything. I know smoking ain’t best, but I smoking since I was 15, so you can’t expect me to stop just so! It isn’t like I would lose my foot, I don’t have to worry. I didn’t know this diabetes thing so serious.”  These are some of the comments by patients on a regular basis!

As podiatrists, the diabetic foot is critical to us. What we often encounter is that a  management/ treatment plan is discussed and agreed upon, yet the patient is non-adherent. Some common causes of non-adherence are:

1) dementia/ alzheimer’s in the elderly

2) arthritis or other physical disabilities

3) visual problems

4) financial issues, combined with rising costs of medications

5) limited family support

6) competing life issues

7) lack of discipline.

Diabetes wreaks havoc on a vast number of body systems. Unfortunately, the legs and feet act as a retaining pool for a collection of many of these problems, including neurological, vascular, and connective tissue issues. Not wearing footwear, or proper footwear are the most dangerous things an individual with diabetes can do.  With regard to their feet, it puts them at risk of developing a foot ulcer, and subsequently, amputation.

Diabetic Foot Ulcer Formation

In order to appreciate the necessity of utilising appropriate footwear, one must understand the aetiology of the neuropathic diabetic foot ulcer. The lack of physical sensation in the neuropathic foot, effectively shuts down the body’s warning system, when damage is being done to the foot. Without the capacity to feel trauma induced pain on the sole of the foot, formation of diabetic foot ulcers result, without the individual ever feeling any discomfort.

The sources of these repetitive traumas, are often the ground reaction forces associated with weight bearing. During walking, ground reaction forces push and pull the soft tissue of the foot. The stresses imparted to the feet by the ground reaction forces lead to inflammation, and eventually destroy the soft tissue beneath bony prominences of the foot.

Offloading

In the presence of sufficient vascular supply, the two primary factors for healing diabetic foot ulcers are appropriate debridement of all dead tissue, and spreading the pressure from the ulcer site. Offloading is accomplished by distributing loading forces across the sole of the foot, thereby eliminating isolated pockets of excessive stress. A number of modalities have been developed for offloading the feet, including total contact casts (TCCs).

Apart from treating the ulcers, specialised footwear is usually prescribed to prevent them.  Customised and prefabricated orthotics, as well as shoes, are routinely dispensed to high risk patients. Numerous studies have demonstrated these to be effective in offloading the foot. Additionally, some preliminary studies have shown prescriptive footwear to be helpful in preventing ulcer recurrence.

State of Compliance

Despite the necessity of offloading the foot to allow for ulcer healing, compliance with footwear is far from optimal. A survey-based study in the United States, found that only 28% of patients reported that they wore their diabetic footwear more than 80% of the day. Appearance, comfort, and weight were the most common complaints about their shoes. Another noteworthy finding, was patients who perceived their diabetic foot condition to be more severe than others with  similar foot complications, were not any more compliant with their footwear.

The neuropathic absence of pain, most likely makes it easy for patients to convince themselves, that they are not significantly injuring their feet during intermittent times of non-compliance. Lack of education also contributes to non-compliant behaviour. For example, many individuals consider calluses to be protective in nature. However, calluses on the feet actually result in increased pressure (similar to walking on any other hard object), and stress on the soft tissue below, thereby contributing to ulcer formation. Another misconception is the idea that carpeting in the home provides adequate protection to the feet. That, coupled with the idea that walking without appropriate footwear is permissible, as long as it is only a short distance, are likely reasons why compliance within the home is so poor.

Future of Compliance

Enhanced and more effective education is needed to improve off-loading compliance. Individuals with diabetic neuropathy,  need to appreciate that each step they take without their protective footwear, is hazardous. Unprotected steps may result in a new ulcer, by allowing a foreign object to pierce the skin, or by acting as the final cumulative stressor needed to form a break in the skin. For individuals with ulcers already present, a few unprotected steps can negate the day’s healing that occurred while the foot was off-loaded. Be warned…

Your feet mirror your general health . . . cherish them!