Best Footwear for Diabetic Foot Patients
For diabetic patients with peripheral neuropathy, prescribe therapeutic footwear with custom-made insoles that achieves at least 30% plantar pressure reduction compared to standard shoes, and strongly emphasize that the patient must never walk barefoot, in socks only, or in thin-soled slippers—whether at home or outside. 1
Risk Stratification and Footwear Selection
For Prevention of First Ulcer (No Prior Ulcer History)
Instruct all at-risk diabetic patients to wear properly fitting footwear where the shoe is 1-2 cm longer than the foot, with internal width equal to the foot width at the metatarsal phalangeal joints, and sufficient height for all toes. 1
When foot deformity or pre-ulcerative signs are present (callus, erythema, blistering), escalate to therapeutic shoes with custom-made insoles or toe orthosis. 1
Properly fitting footwear alone reduces ulcer incidence, as ill-fitting footwear is a major cause of non-plantar foot ulceration. 1
For Prevention of Recurrent Plantar Ulcer (History of Healed Plantar Ulcer)
Prescribe therapeutic footwear that demonstrates documented plantar pressure reduction of at least 30% during walking compared to standard therapeutic footwear. 1
This pressure-relieving footwear reduces recurrent plantar ulcer risk by 46-64% when patients actually wear it. 1
Cushioned therapeutic footwear with appropriate insoles reduces intercurrent foot lesions in 58% of compliant patients versus only 13% in non-compliant patients. 2
Critical Design Features for Diabetic Footwear
Based on biomechanical analysis, therapeutic footwear should incorporate:
Medial arch support to distribute pressure away from high-risk areas. 3
Wide toe box to accommodate toe deformities and prevent dorsal/lateral toe ulceration. 3
Material-specific insoles: polyurethane for forefoot areas and ethylene-vinyl acetate for heel areas to optimize offloading during walking. 3
Cushioned insoles that reduce peak plantar pressure by 50% at the forefoot compared to normal shoes. 4
Absolute Contraindications
Do NOT allow patients to walk barefoot, in socks only, or in thin-soled standard slippers at any time, whether at home or outside. 1
Do NOT prescribe conventional or standard therapeutic shoes for active plantar ulcers—these require non-removable offloading devices instead. 1
Adherence: The Critical Success Factor
Patient adherence determines effectiveness: therapeutic footwear only prevents ulcers when worn >60% of daytime hours. 4
Patients wearing protective shoes >60% of the day have 50% lower ulcer relapse rates compared to those with shorter wearing times. 4
Non-compliance is common—many patients resist bulky custom shoes before experiencing their first ulcer, despite understanding the risks. 1
Combine footwear prescription with frequent foot care visits to maximize adherence and outcomes. 4
When Therapeutic Footwear Alone Is Insufficient
If foot deformities are severe or conservative footwear fails to prevent recurrent ulceration:
Consider surgical interventions such as Achilles tendon lengthening, metatarsal head resection, or digital flexor tenotomy when conservative treatment fails. 1
For active plantar ulcers, therapeutic footwear is inadequate—use non-removable knee-high offloading devices instead. 1
Common Pitfalls to Avoid
Do not assume patients will wear prescribed footwear—explicitly assess and reinforce adherence at every visit, as non-adherence is the primary reason for therapeutic footwear failure. 4
Do not prescribe footwear without documented pressure-relieving properties for patients with prior plantar ulcers—generic "diabetic shoes" without proven 30% pressure reduction are insufficient. 1
Do not allow patients to go barefoot "just at home"—most diabetic foot injuries occur at home where patients feel safe and let their guard down. 1