Can Nurse Practitioners Order Diabetic Shoes?
Yes, nurse practitioners can order diabetic shoes for patients with diabetes who meet clinical criteria for therapeutic footwear, as the medical guidelines focus on clinical indications rather than prescriber type, and Medicare regulations permit qualified healthcare professionals including NPs to prescribe therapeutic footwear.
Clinical Framework for Ordering Diabetic Shoes
The decision to order diabetic shoes should be based on risk stratification and specific foot conditions rather than provider credentials. The key clinical indications include:
Patient Eligibility Criteria
Patients requiring therapeutic footwear include those with:
- Peripheral neuropathy with foot deformities (hammertoes, prominent metatarsal heads, bunions, Charcot foot) that cannot be accommodated with standard commercial shoes 1
- History of foot ulceration or amputation, who require therapeutic footwear with demonstrated plantar pressure-relieving effect (30% relief compared with standard therapeutic footwear) 1
- Pre-ulcerative signs including calluses, erythema, warmth, or evidence of increased plantar pressures 1
Risk-Based Prescription Algorithm
For patients with neuropathy but no deformities:
- Well-fitted walking shoes or athletic shoes that cushion feet and redistribute pressure are adequate 1
- No prescription therapeutic footwear required initially 1
For patients with bony deformities:
- Extra-wide or depth shoes are needed for moderate deformities 1
- Custom-molded shoes are required for extreme deformities (e.g., Charcot foot) that cannot be accommodated with commercial therapeutic footwear 1
For patients with history of plantar ulceration:
- Therapeutic footwear must demonstrate plantar pressure reduction of at least 30% compared to standard therapeutic footwear 1
- This is a strong recommendation with moderate quality evidence 1
Prescriber Qualifications
The clinical guidelines emphasize that therapeutic footwear should be prescribed by healthcare professionals with appropriate training and expertise in diabetic foot care, without specifically restricting this to physicians only 1. The Medicare therapeutic shoe demonstration program established that clinicians specializing in foot care can prescribe therapeutic shoes 2.
Key prescriber responsibilities include:
- Conducting comprehensive foot examination including neurological assessment (10-g monofilament testing), vascular assessment (pedal pulse palpation), and musculoskeletal evaluation 1
- Identifying loss of protective sensation, foot deformities, and peripheral arterial disease 1
- Documenting clinical justification for therapeutic footwear based on risk classification 1
Common Pitfalls to Avoid
Do not prescribe therapeutic shoes for:
- Patients without peripheral neuropathy, foot deformities, or ulcer history, as they can use standard off-the-shelf footwear 1
- Healing active plantar foot ulcers—conventional therapeutic shoes should not be used for ulcer healing 1
Critical documentation requirements:
- Document presence of peripheral neuropathy using objective testing (10-g monofilament with at least one other assessment) 1
- Specify foot deformities and their impact on standard footwear fit 1
- For recurrent ulcer prevention, document need for pressure-relieving footwear 1
Patient Education and Follow-up
Essential patient counseling includes:
- Instruction not to walk barefoot, in socks only, or in thin-soled slippers at home or outside 1
- Daily foot inspection and proper shoe inspection before wearing 1
- Gradual break-in period for new therapeutic shoes to minimize blister formation 1
- Adherence counseling, as patient compliance with wearing prescribed footwear is critical for ulcer prevention 1, 3
Follow-up schedule: