Footwear can accommodate changes in the lower limb, for ankle, foot and toe deformities.
Diabetes and inflammatory arthropathies (rheumatoid arthritis and osteoarthritis) are arguably the most common conditions that cause toe and foot deformities in the elderly patient population. Appropriate footwear is used as a therapeutic tool that can prevent lesion formation on the foot due to toe deformities such as corns, callus, blisters and ulceration.
Diabetes Mellitus is a metabolic condition that affects roughly 4.9 million people in the UK according to the 2019 diabetes statistics. Of that, 90% have type 2 diabetes and under 10% have type 1. Diabetes can be a life-changing condition and most of the effects of diabetes can be seen in the lower limbs.
Changes to diabetic feet
Some of the ways in which diabetes affects the lower limb are neuropathy, Charcot foot, poor skin viability, peripheral arterial disease/peripheral vascular disease aggravated by a history of smoking, high risk of opportunistic infections, toe deformities and ulceration.
In the diabetic population, it is generally accepted that appropriate/suitable footwear is considered part of the multifaceted intervention in preventing diabetic foot complications such as ulcers. Neuropathy can be subdivided into the motor, autonomic and sensory.
Motor neuropathy leads to:
- Muscle weakness
- Claw Toe
- Loss of joint mobility
- Foot drop
- Prominent metatarsal heads
- Hammer toes
- Leads to the loss of protective sensations such as heat, pain, vibration, and tactile and deep pressure.
- Often the causative factor for ulcers due to unperceived trauma
- Can lead to ischemic foot disease due to dysfunction of arteriovenous shunts
- Provides the pathway for bacteria to enter an ulcer
Modifications to diabetic footwear
Footwear wouldn’t be the cure to the above conditions, however, appropriate footwear can accommodate the aforementioned foot deformities. According to (Bennet, 2012) 21-76% of ulcers occur due to ill-fitting footwear, areas that need extra considerations are:
- toe box
- shoe size
- cushion support to accommodate for increased plantar pressures
Condition: Rheumatoid Arthritis, Osteoarthritis, Psoriatic arthritis and Gout (Inflammatory Arthropathies)
Inflammatory arthropathies is an umbrella term that describes a group of conditions in which the immune system mistakenly attacks your own body, common sites are knee joints, wrist joints, big toe joints and hip joints. These tend to be the most mechanical and vascular. This can lead to symptoms such as joint pain, stiffness, swelling, restricted movements, weakness and muscle wasting.
Changes to arthritic feet:
The common forms in which inflammatory arthropathy is presented are
- Gout: build-up of uric acid in the blood which gets deposited in the big toe joint, causing pain, inflammation, swelling and redness. It tends to be chronic and progressive.
- Rheumatoid Arthritis (RA): a systemic, autoimmune condition that can have articular as well as extra-articular presentations. The most common extra-articular manifestations tend to be: Rheumatoid nodules, Sjogren’s syndrome (dry eyes, mouth), peripheral neuropathy, Ischaemic heart disease, anaemia and osteoporosis. Articular manifestations tend to occur in the small joints of the hands and feet and can lead to deformities due to damage to the tendons and joint capsules. This can look like flat arches in the foot, bunion development, subluxation of smaller toes, claw toe deformity, and the development of calluses and metatarsalgia due to altered biomechanics. Posterior-tibial tendon dysfunction is often associated with RA, along with plantar fasciitis as a result of subluxation of joints and a flattening of the arch profile.
- Osteoarthritis (OA): is the progressive loss of articular cartilage and remodelling of the underlying bone, this type of arthritis primarily affects the joints, leading to joint stiffness, tenderness and a ‘grating’ sound. The older you get, the higher the chances of developing osteoarthritis. The most commonly affected areas are the small joints of the hands and feet. Often patients that suffer from big toe joint arthritis will note that it feels painful to the touch, limited movement and looks red and swollen.
- Psoriatic arthritis (PsA): is defined as seronegative inflammatory arthritis, due to the absence of Rheumatoid Factor in blood tests. Presentations can often be asymmetrical even though it affects multiple joints, ‘pencil-in-cup’ deformities, joint redness and swelling. Swelling and inflammation in the digits, and is preceded by a diagnosis of Psoriasis for at least ~ 10 years, along with red, scaly patches on the skin.
Modifications to arthritic footwear
Recommended therapeutic footwear features that have proved quite beneficial to patients with chronic conditions:
- Rocker bottom
- Extra-depth with soft soles
- Inserts with soft plugs
- Custom-made orthopaedic footwear with moulded insoles
- Running/athletic footwear
For sensory loss:
- Low heel height + suppleness in the outsole, leg + tongue
- Should not be too roomy or too tight
- Insoles with low heel height footwear, shock absorption + optimal pressure distribution (gold standard)
- Toughened outsole
- Resilient material
Condition Information External Links:
- Arthritis Information: www.versusarthritis.org
- NHS Guidance: www.nhs.uk/conditions/osteoarthritis
- Psoriatic Arthritis Information: www.hss.edu/condition-list_psoriatic-arthritis.asp
- Diabetes Information: www.diabetes.org.uk/professionals/position-statements-reports/statistics
- CDC Recommendations: www.cdc.gov/diabetes/library/features/healthy-feet.html
Ameersing, Luximong, Ganesan Balasankar, and Younus Abida. 2015. “Diabetic Foot and Footwear.” Research Journal of Textile and Apparel 19, no. 1 (February): 1-10. https://doi.org/10.1108/RJTA-19-01-2015-B001.
Boulton, Andrew J., and Edward B. Jude. 2004. “Therapeutic Footwear in Diabetes: the good, the bad, and the ugly?” Diabetes Care 27, no. 7 (July): 1832-1833. https://doi.org/10.2337/diacare.27.7.1832.
Colquhoun, Matthew, Malvika Gulati, Ziad Farah, and Maria Mouyis. 2022. “Clinical features of rheumatoid arthritis.” Medicine 50, no. 3 (March): 138-142. https://doi.org/10.1016/j.mpmed.2021.12.002.
Gladman, D. D., C. Antoni, P. Mease, D. O. Clegg, and P. Nash. 2005. “Psoriatic arthritis: epidemiology, clinical features, course, and outcome.” Annals of Rheumatic Disease 64, no. 2 (February): ii14-ii17. https://ard.bmj.com/content/64/suppl_2/ii14.citation-tools#block-system-main.
Rome, Keith, Mike Frecklington, Peter Gow, and Nicola Dalbeth. 2011. “Footwear characteristics and factors influencing footwear choice in patients with gout.” Arthritis Care & Research 63 (October): 1599-1604. https://doi.org/10.1002/acr.20582.
Silverstein, Renee N., Anita E. Williams, Nicola Dalbeth, and Keith Rome. 2010. “’Choosing shoes’: a preliminary study into the challenges facing clinicians in assessing footwear for rheumatoid patients.” Journal of Foot & Ankle Research 3, no. 24 (October). https://doi.org/10.1186/1757-1146-3-24.
Appendix: Case study: Silvester, R.N., Williams, A.E., Dalbeth, N. et al. ‘Choosing shoes’: a preliminary study into the challenges facing clinicians in assessing footwear for rheumatoid patients. J Foot Ankle Res 3, 24 (2010). https://doi.org/10.1186/1757-1146-3-24