For most people, bad shoes mean heel blisters or arch pain, and they pass quickly. But for people with diabetes, poor-quality shoes can cause serious problems, such as foot ulcers, infections, and even amputations.
But these problems are not inevitable. It took Ralph Guanci some effort to learn to choose his shoes with care, and to stick with them because they are indeed a good medicine for his feet.
Guanci, 57, a Carlisle, Massachusetts, businessman, was diagnosed with type II diabetes 25 years ago. For the first 20 years after his diagnosis, his feet looked normal, so he never considered choosing a shoe type for it, saying, “I wear what I want to wear.”
But a few years ago, something went wrong with the feet: a bone bruise in the foot caused recurring blister infections on the bottom of the foot. After doctors healed Kwan’s foot with surgery and antibiotics, he began wearing only one type of comfortable shoe recommended by his podiatrist.
As Guan recalls, “There was only one time I didn’t insist on wearing these shoes, and it was something I regretted.” On a business trip, he switched out of the podiatrist-recommended shoes and put on a more upscale pair. “I wanted to dress stylishly, so I wore an expensive pair of shoes,” he says. He didn’t plan to walk too much, but after dinner his colleagues improvised a 3-kilometer walk back to the hotel.
“When I got back to my room, I had blood all over my socks and a huge blister on my foot,” Guan said. That night, he took a flight back and went straight to the podiatrist’s office. The blister on the ball of his foot forced him to go on crutches, and it took four months to heal, according to Kwan.
Diabetes can cause loss of sensation in the feet
Why are the feet of diabetics so fragile?
People with diabetes know that good blood sugar control can reduce the risk of complications, but poorly controlled diabetes can deal a double blow to the feet.
Diabetes can lead to nerve damage or neuropathy, which reduces the sensitivity of the feet to pain. The range of nerve damage in the off word is wide. After years of nameless tingling in his feet (i.e., signs of abnormal nerve function), he has lost all sensation in both feet. He said, “I once hurt my big toe, but only noticed swelling of the toe, other than that I didn’t feel anything.”
Doctors see many patients affected in this way: those who step on broken glass, knitting needles, syringes or nails never feel pain and therefore don’t expect to be injured.
They also don’t feel foreign objects in their shoes. James McGuire, M.D., a podiatrist, physical therapist, and director of the Leonard S. Abrams Center for Advanced Trauma Healing at Temple University School of Podiatric Medicine in Philadelphia, Pa. He describes a patient who was unable to perceive the presence of a star-shaped toy in his shoe and “put it on, walked up, and the toy moved with it to his foot, walked around all day, and he ended up with an infection as a result.
Diabetes can trigger poor circulation
In addition to loss of sensation, diabetes can cause poor circulation because high blood sugar can cause narrowing of blood vessels, both large and small. Wounds heal more slowly when blood flow to the foot is reduced.
Foot deformities can lead to ulcers
In addition to these two major threats, foot deformities such as bunions or mallet toes can create pressure points that can lead to ulcers, according to James.
“Any type of foot injury or injury is a major concern,” said Kenneth Snow, MD, acting chief of the Adult Diabetes Unit at the Joslin Diabetes Center, “and of course, ulcers are only one of these problems. Any type of laceration that is not taken seriously and treated can lead to serious problems, especially for at-risk patients. Foot complications can even lead to amputation.
John Giurini, MD, podiatrist and chief of podiatry at Beth Israel Deaconess Medical Center, said, “Most foot complications occur 10 to 15 years after a patient develops diabetes. But in those patients with very poor glycemic control, complications may appear much earlier.”
Select shoes carefully
“There are a lot of factors that go into shoe selection, including not only how long the patient has had diabetes, but also does the patient’s feet feel normal, and are there any abnormalities or deformities in the feet? These are all factors that must be considered when choosing a shoe type,” John said.
Experts say that people with diabetes can wear regular shoes if they have good blood sugar control and healthy feet. They are not at a higher risk of problems than the general population,” McGuire said. They can wear any shoe they wear regularly, but be conscious of getting their feet checked regularly.” Experts urge all people with diabetes to check their feet carefully every day for blisters, ulcers, cuts, redness, heat, swelling, ingrown toenails and other abnormalities, and to tell their doctors about these changes.
Heels can also be worn by women with diabetes who have healthy feet and no or only minor foot deformities. John said, “They can wear fashionable shoes for short periods of time if they don’t plan to walk too much.” He suggests that such patients can wear heels in the office and sneakers to and from work. John also added that if they need to wear high heels for speaking on stage, they should wear comfortable shoes before and after this time.
But female patients at high risk for foot problems should stay away from high heels. “People with diabetes who have more significant sensory loss, poor circulation or problems like mallet toe and bunions have to be more careful,” John said.
McGuire recommends that patients with sensory impairment stay away from high heels and narrower fashion shoes because they can’t feel the pain and pressure these shoes put on the forefoot and toes.
What kind of shoes are bad for people with diabetes? “It’s flip-flops,” John said. “These shoes expose the toes (and are prone to injury), have poor support, and the straps between the toes can cause blisters or inflammation.”
“I don’t like rigid leather shoes,” he continued, “These shoes can’t bend, so when you get a blister or inflammation, these shoes can’t get bigger.”
John also wears protective water shoes when he swims to further protect his feet. Walking around barefooted hurts his feet, so wearing flip-flops at home is also a good way to go.
Diabetic foot protection shoes
John says that if a person with diabetes has minor foot deformities or impaired sensation and circulation, it’s wise to switch from regular footwear to comfort shoes or diabetic foot care shoes.
“Diabetic-specific shoes feature a deeper and rounder, wider toe made of soft leather for foot abnormalities like mallet toe and bunions,” John said.
Experts also mentioned jogging shoes and walking shoes as better alternatives.
Patients complained to McGuire that diabetes forced them to wear shoes that weren’t fashionable. “They have to change what they wear and how they dress,” he said, “and some of them simply refuse, stay normal, don’t admit to having diabetes or don’t admit that they have to change their lifestyle, and those are just the most basic desires. But the damage from an inappropriate type of shoe is too serious to risk.”
“They don’t need to wear granny shoes,” Kenneth added, “but it’s important to make sure that the shoes they wear on both feet don’t cause them problems.”
“Shoe prescriptions” for people with diabetes
Podiatrists may need to prescribe therapeutic shoes, or protective footwear and protective inserts, if foot circulation or sensation worsens, or if patients develop ulcers, severe deformities and other serious problems.
For example, some patients need “depth shoes” combined with custom-made inserts to redistribute pressure in the foot. John says, “Most foot ulcers are pressure-related.”
The “depth shoe” gets its name from the extra depth of the shoe to accommodate the orthotic.
Patients with extremely deformed feet may need custom-made shoes, which are molded using the patient’s feet as a model. “These shoes are for patients who have very severe foot deformities and whose feet can no longer fit in any other footwear,” John said.
McGuire said diabetic patients who are prescribed medical shoes must insist on wearing such shoes. He told the story of a male patient, who had an incurable heel ulcer and was being treated for it, who changed out of his protective boots and put on regular shoes to walk around the mall on Christmas Day. “He wanted to have a nice, normal day with his wife,” McGuire said. But the patient ended up with a fracture as a result, which was difficult to heal and led to a bone infection, and eventually had to have his leg amputated.
“If he had followed the instructions, this would not have happened,” McGuire said. People with diabetes “can’t take that risk once they lose feeling in their feet.
Shoe shopping tips for people with diabetes
To keep feet healthy for people with diabetes, the Joslin Diabetes Center offers these tips for buying new shoes and throwing away old ones:
- Buy shoes made of soft, stretchable leather.
- If possible, choose lace-ups over loafers because they fit better and provide more support.
- For better shock absorption, pick shoes with padding rather than thin soles.
- Buy your shoes in the afternoon because your feet will expand over time.
- The distance between the longest toe and the toe of the shoe should be half the width of the thumb.
- Try on shoes with socks that you will use later to ensure a good fit.
- The first time you wear your new shoes for 1~2 hours, then check for cuts and blisters on your feet. On the 2nd day, wear them for 3~4 hours and gradually increase the length of wear to make sure the shoes do not hurt your feet.
Throw away your old shoes when
- The heel starts to turn sideways
- The bottom of the heel is worn
- The lining of the shoe is torn.