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

SAS diabetic shoe and tennis shoe image.

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

Tennis shoe and x-depth shoe/contour last image.

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

X-depth shoe/contour last, superdepth/rigid sole shoe, wide shank shoe, custom shoe/boot, and lower leg bracing image.

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.

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