Management

Stage 2 feet require multidisciplinary care.

The following components of multidisciplinary care are important at stage 2

• Mechanical control

• Vascular control

• Metabolic control

■ Educational control.

Wound control and microbiological control are not needed as the feet have intact skin.

Mechanical control

To maintain mechanical control, deformity must be accommodated by footwear and callus, dry skin and fissures treated. Common non-diabetic foot problems, already described in stage 1, will also occur in stage 2 feet and need management as described in Chapter 2.

Footwear

Deformities in the neuropathic foot may include a raised medial longitudinal arch leading to high pressure points on the sole of the foot, which develops callus and ulceration unless protected by a special insole. The insole will usually need to be accommodated in a bespoke shoe.

The neuroischaemic foot is prone to develop ulcers upon its margins, often over the side of the 1st and 5th metatarsal heads, and 5th metatarsal base. Patients should be advised to wear a sufficiently wide and deep shoe to protect the vulnerable margins of the foot.

The overall approach is to try to accommodate these deformities in properly fitting shoes. The role of prophylactic surgery is discussed in Chapter 8.

For the multidisciplinary management of deformity, close liaison is necessary between physican, podiatrist and orthotist in the provision of shoes and insoles. Some deformities may be accommodated in high-street footwear. Patients with major deformities whose shoes cause red pressure marks or callus will need either footwear adjustments or special shoes.

An outline of the shoes and insoles available is given below, and a further discussion of footwear is given in Chapter 4.

Types of shoe

There are five main categories of shoe.

• Sensible shoes of a correct size and style from the high-street shoe shop. Once patients are high risk they should not wear mail-order shoes unless they can obtain them on a sale or return basis and have them checked by a health-care professional. Athletic shoes (trainers) are a reasonable choice for most patients. Patients who have neuropathy and don't know it will be accustomed to the tactile sensation of having shoes on their feet and may progressively buy tighter-fitting shoes to reproduce that sensation. This habit can cause pressure necrosis-patients with neuropathy should be warned to avoid tight shoes, and the implications of sensory loss should be emphasized. High-street shoes are not able to accommodate significant deformity which needs to be housed within stock shoes, modular shoes or bespoke shoes

• Ready-made, off-the-shelf, stock shoes (Fig. 3.1). These are made with extra depth and width, and without prominent seams. They usually have a low opening, are

Fig. 3.1 Extra-depth stock shoe.

fully lined and contain a built-in rocker sole and flatbed insoles made of microcellular rubber. The insoles can be replaced with bespoke insoles. Stretching specific areas, or making 'balloon patches' to accommodate single small deformities may also render off-the-shelf shoes suitable

• Modular shoes, which are the stage between ready-made and bespoke shoes. The orthotist carries out a trial fit using the standard stock shoe and then details a number of fixed modifications to be carried out

• Customized or bespoke shoes. These accommodate the shape of the foot which cannot be fitted within stock or modular shoes. The more abnormal the foot shape the greater the need for bespoke shoes. These may also be necessary if previous ulceration has resulted in scarring, depletion of fibrofatty padding under the metatarsal heads, or bound down plantar tissues leading to high plantar pressures. Bespoke shoes can house moulded insoles which redistribute high plantar pressures in the neuropathic foot

• Temporary ready-made shoes (for ulcerated feet) that can accommodate dressings. They are usually fitted with flat-bed insoles but a moulded insole can be inserted.

General principles of prescription of stock and bespoke shoes

• The patient's choice of material, colour and style should always be respected as far as possible

• For young patients, shoes made in a trainer style are often acceptable

• Patients need shoes for inside and outside, and may need bespoke shoes or boots for work, sometimes with steel toecaps. Agricultural labourers may develop prob lems if they wear Wellington boots for long periods in wet climates. In tropical climates agricultural labourers are at risk of deep fungal infections without protective footwear

• Shoe soles should be thick enough to prevent puncture by nails or thorns

• Shoe fastenings should be adjustable to accommodate swelling. Patients should be taught to rest the heel of the shoe on the ground and move the foot well back in the shoe before doing up the laces

• Shoes should be checked at every clinic visit and reassessed frequently for excessive wear and the changing needs of patients

• Patients should have at least two pairs so that they are never without a pair of wearable shoes

• Each pair of shoes should, if possible, not be worn for more than 2 consecutive days at a time

• Patients should wear special shoes at all times except for bed and bathing. They should not 'keep special shoes for best'—they are for everyday use. Slippers should not be worn round the house

• Shoes which become worn down should be brought in for early repair and the orthotist should supervise repair of bespoke shoes

• There is need for regular review of footwear. If foot biomechanics are abnormal there may be uneven patterns of wear which can rapidly render the shoe likely to cause problems

• New shoes, and repaired shoes, whether bespoke, stock or from high-street stores, should be checked before the patient wears them for the first time. They should never be posted to the patient without a final fitting and check and if new problems develop the patient should be seen without delay.

Insoles

Insoles are made from a variety of polyethylene foams, microcellular rubbers and ethyl vinyl acetate foams, and can be flat-bed (usually one layer, provided in stock shoes) or moulded. Moulded insoles are usually made from two or three layers of differing densities.

Insoles are used to reduce or redistribute areas of high pressure, friction and shear in the following ways:

• By loading areas of the sole which are not normally in contact with the ground, such as the medial longitudinal arch, a total contact effect can be achieved, relieving local areas of high pressure

• By extending the insole up the sides of the foot, a cradle effect will reduce friction (so-called cradled insoles)

• Under particularly high-pressure areas, such as prominent metatarsal heads, areas of the insole can be excavated out to form a 'sink'

• Extra cushioning can be used to compensate for reduced fibrofatty padding over the metatarsal heads

• A metatarsal bar or dome can be incorporated, applying pressure behind the metatarsal heads to bring the toes down

• Silicone gel plantar inserts can be used to reduce shear and this material also comes in the form of heel cups, flat-bed insoles and sleeves for individual toes.

All insoles should be regularly checked for 'bottoming-out' or excessive wear.

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