Open access publishing The Journal of Diabetic Foot Complications

Perceptions of appropriate shoe size in diabetic patients presenting for initial podiatric evaluation.Authors:

The Journal of Diabetic Foot Complications, 2011; Volume 3, Issue 2, No. 2, Pages 40-42 © All rights reserved.

Andrew J. Meyr, DPM1 and Corine Creech, DPM2

Abstract:

Key words: Diabetic foot, shoe size, prevention

Corresponding author: Andrew J. Meyr. TUSPM Department of Surgery8th at Race Street Philadelphia, PA 19107.Phone: 215 620-8184Fax: 215 629-4904Email: ajmeyr@gmail.com

1. Assistant Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, Pennsylvania, USA

2. Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, Pennsylvania, USA

Ill-fitting shoe gear is a known risk factor for the development of foot ulceration in patients with diabetes, particularly those with neuropathy and foot deformity. The objective of this study was to evaluate shoe size perception in a cohort of diabetic patients at a large, inner-city United States clinic presenting for initial podiatric examination. A measurement of foot size was obtained from 129 consecutive patients and then compared to the size of shoe that patient presented with on that visit. Seventy-eight percent (78%; 101/129) of patients presented in a pair of shoes that were the wrong size with respect to either length or width. Sixty percent (60%; 78/129) of patients presented in a pair of shoes that were too small by an average size of 1.1. Twenty-four percent (24%; 31/129) of patients presented in a pair of shoes that were both too small and too narrow. This study provides evidence that the majority of patients presenting for initial diabetic foot assessment were in an incorrectly sized shoe, and that evaluation of foot length and width may form an important component of the preventative diabetic foot examination.

Ill-fitting shoe gear is a known risk factor for the development of foot ulceration in patients with diabetes, particularly in the setting of neu-ropathy and foot deformity. Reiber describes these factors of trauma, neuropathy and deformity as a causative pathologic triad in the development of lower-extremity ulceration1. Apelqvist et al confirmed the role of participat-ing external stresses, specifically ill-fitting shoes, as a contributing etiology to ulcer development in a series of neuropathic diabetic patients2. Nixon et al further demonstrated that patients with diabetic foot ulceration were five times as

likely to have poor fitting shoes compared to a cohort with appropriately sized shoes3. And several authors have provided evidence as to the potential protective benefits of therapeu-tic footwear with respect to the diabetic foot.4-6 Three studies have previously demonstrated prevalence rates of incorrect shoe size in spe-cialized patient populations,3,7,8 but this investi-gation aimed to evaluate shoe size perception in a previously unstudied group of patients: those with diabetes at a large, inner-city United States clinic presenting for initial foot evaluation.

Introduction

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Inclusion criteria of the population cohort consisted of new, consecutive diabetic patients presenting to the Temple University Foot and Ankle Institute who were fitted for an initial pair of diabetic shoes from Hanger Prosthetics and Orthopedics, Inc over a 3-month data collection period (June 2010-August 2010). A measurement of correct foot size was obtained with respect to length and width with a Brannock device by a certified pedorthist. (Fig. 1) This measurement was then compared to the size of shoe (length and width) that the patient presented with on that visit.

Data from 129 consecutive patients (78 female; Average age 62.2 years) was analyzed, and results are summarized in Table 1. Sev-enty-eight percent (78%; 101/129) of patients presented in a pair of shoes that were the wrong size with respect to either length or width.

(Fig 2) Sixty percent (60%; 78/129) of patients presented in a pair of shoes that were “too small” by an average size of 1.1. Twenty-four percent (24%; 31/129) of patients presented in a pair of shoes that were both “too small” and “too narrow”.

Open access publishing The Journal of Diabetic Foot Complications 2011; Volume 3, Issue 2, No. 2, Pages 40-42

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Results

Methods

Any wrong sized shoe 78% (101/129)

Wrong sized shoe “too small” with respect to length 60% (78/129)

Wrong sized shoe “too small” with respect to length and width 24% (31/129)

Figure 2A: An example of footwear worn by a study patient. Figure 2B: Mismatch between size and shape of feet and the footwear worn by this patient.

Figure 1: Two types of Brannock devices for measuring feet.

Table 1: Perceptions of appropriate shoe size in diabetic patients presenting for initial diabetic foot evaluation.

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Open access publishing The Journal of Diabetic Foot Complications 2011; Volume 3, Issue 2, No. 2, Pages 40-42

1) Reiber GE, Vileikyte L, Boyko EJ, del Aquila M, Smith DG, Lavery LA, Boulton AJ. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care. 1999 Jan; 22(1): 157-162.

2) Apelqvist J, Larsson J, Agardh CD. The influence of external precipitating factors and peripheral neuropathy on the development and outcome of diabetic foot ulcers. J Diabet Complications. 1990 Jan-Mar; 4(1): 21-5.

3) Nixon BP, Armstrong DG, Wendell C, Vazquez JR, Rabinovich Z, Kimbriel HR, Rosales MA, Boulton AJ. Do US veterans wear appropriately sized shoes?: the Veterans Affairs shoe size selection study. J Am Podiatr Med Assoc. 2006 Jul-Aug; 96(4): 290-2.

4) Chantelau E, Kushner T, Spraul M. How effective is cushioned therapeutic footwear in protecting diabetic feet? A clinical study. Diabet Med. 1990 May; 7(4): 355-9.

5) Uccioli L, Faglia E, Monticone G, Favales F, Durola L, Aldeghi A, Quarantiello A, Calia P, Menzinger G. Diabetes Care. 1995 Oct; 18(10): 1376-8.

6) Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C, Maciejewski ML, Yu O, Heagerty PJ, LeMaster J. Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. JAMA. 2002 May 15; 287(19): 2552-8.

7) Harrison SJ, Cochrane L, Abboud RJ, Leese GP. Do patients with diabetes wear shoes of the correct size? Int J Clin Pract. 2007 Nov; 61(11): 1900-4.

8) Brem H, Sheehan P, Boulton AJ: Protocol for treatment of diabetic foot ulcers. Am J Surg 187:1S–10S, 2004

References

Discussion

This investigation provides evidence that the majority of patients presenting for initial diabetic foot assessment in a large, inner-city United States clinic were in an incorrectly sized shoe. These findings mirror results of previous studies examining other patient populations. Nixon et al examined shoe size in United States veterans (58.4% of which were diabetics) at a VA Medical Center, and found that approximately 75% were in an incorrectly sized shoe3. Harrison et al studied shoe size in new and established diabetic patients at a health clinic in the United Kingdom and found that approximately 67% were in an incorrect size shoe7. Finally, Brem et al found that 72% of a group of older patients admitted to a rehabilitation center in the United

Kingdom (9% of which were diabetic) wore ill-fitting shoes8. Based on these results, one could conclude that a comprehensive diabetic foot preventative examination should include evalu-ation of both intrinsic and extrinsic patient risk factors. Objective physical examination findings of sensory neuropathy and foot deformity are certainly contributory to the causal pathway of foot ulceration, but the contribution of external stresses should be appreciated and can be quantified as well. Although the intention of this study was non-interventional and primarily de-scriptive, it supports the evaluation of foot length and width with a comparison to patient shoe size perception as part of an initial examination.