What are the recommendations for a diabetic, insulin-dependent patient with circulatory problems, presenting with a bunion and redness at the first MTP, who is requesting medical shoes to prevent foot complications?

Therapeutic Footwear for Diabetic Patient with Bunion and Pre-ulcerative Signs

This patient requires immediate prescription of therapeutic footwear—specifically extra-depth shoes or custom-made footwear with custom insoles and/or toe orthoses—because the combination of diabetes, insulin dependence, circulatory problems, foot deformity (bunion), and pre-ulcerative signs (redness at first MTP) places them at high risk for foot ulceration (IWGDF Risk 2-3). 1

Risk Stratification

This patient falls into IWGDF Risk 2 or 3 (moderate to high risk) based on:

• Insulin-dependent diabetes with circulatory problems (PAD) 1
• Foot deformity (bunion at first MTP) 1
• Pre-ulcerative sign (redness at medial first MTP) 1

Patients at this risk level require screening and intervention every 1-3 months. 1

Immediate Footwear Prescription

Primary Recommendation

Prescribe therapeutic footwear with the following specifications: 1

• Extra-depth shoes or custom-made footwear to accommodate the bunion deformity 1
• Custom-made insoles designed to offload the first MTP region 1
• Toe orthoses (digital silicone orthoses) to protect the bunion and reduce pressure at the first MTP 1

Specific Fitting Requirements

The footwear must meet these criteria when evaluated with the patient standing, preferably at end of day: 1

• Length: Inside of shoe should be 1-2 cm longer than the foot 1
• Width: Internal width must equal the width of the foot at the metatarsal-phalangeal joints (or widest part of foot) 1
• Height: Sufficient room to accommodate all toes and the bunion deformity without compression 1
• Not too tight or too loose 1

Evidence Supporting This Approach

The evidence strongly supports therapeutic footwear for patients with foot deformities and pre-ulcerative signs: 1

• Digital silicone orthoses reduce first toe ulcer incidence by 69.8-92.9% in at-risk patients with pre-ulcerative lesions 1
• Therapeutic footwear reduces ulcer incidence by 52.5-70.2% compared to no prescription 1
• Ill-fitting footwear is a major cause of non-plantar foot ulceration (which includes bunion-related ulcers at the first MTP) 1

Critical Additional Instructions

What the Patient Must Do

Educate the patient on these non-negotiable behaviors: 1

• Never walk barefoot, in socks only, or in thin-soled slippers—indoors or outdoors 1, 2
• Wear the prescribed therapeutic footwear consistently (adherence is critical—ulcer prevention only works if worn) 1, 3
• Daily foot inspection for new areas of redness, warmth, or breakdown 1
• Daily foot washing with careful drying between toes 1
• Immediate contact with healthcare provider if redness worsens or skin breaks down 1

Immediate Treatment of Pre-ulcerative Sign

The redness at the first MTP requires immediate attention: 1

• Treat this pre-ulcerative lesion now to prevent progression to ulceration 1
• Consider offloading modifications to the prescribed footwear specifically targeting the first MTP region 4
• Debride any callus around the bunion area 1

Vascular Assessment Required

Given the circulatory problems, immediate vascular assessment is essential: 5, 6

• Measure ankle-brachial index (ABI), but recognize this may be falsely elevated in diabetes due to arterial calcification 5
• Toe pressure or TcPO2 measurement is preferred in diabetic patients 5
• If toe pressure <30 mmHg or TcPO2 <25 mmHg, urgent vascular evaluation and possible revascularization are needed 5, 6
• Values of toe pressure ≥30 mmHg or TcPO2 ≥25 mmHg increase likelihood of healing by at least 25% 5

Follow-up Schedule

This patient requires intensive monitoring: 1

• Re-evaluate every 1-3 months given high-risk status 1
• Assess footwear fit and adherence at each visit 1
• Monitor the pre-ulcerative lesion for progression or resolution 1

Common Pitfalls to Avoid

Do not prescribe generic "diabetic shoes" without proper specifications—the footwear must specifically accommodate the bunion deformity and offload the first MTP region. 1, 2

Do not allow the patient to wear the therapeutic shoes "only when going out"—most diabetic foot injuries occur at home where patients feel safe. 2

Do not rely solely on ABI for vascular assessment in this insulin-dependent diabetic patient—arterial calcification makes ABI unreliable. 5

Do not delay treatment of the redness—this is a pre-ulcerative sign that requires immediate intervention to prevent ulceration. 1

Integrated Foot Care Program

Provide integrated foot care including: 1

• Professional foot treatment (debridement of callus, nail care) 1
• The prescribed therapeutic footwear described above 1
• Structured education about foot self-care 1
• Repeat or re-evaluate every 1-3 months 1