For most people, a bad shoe day means a blistered heel or painful arch that goes away quickly. But for people with diabetes, poor footwear can trigger serious problems, such as foot ulcers, infections, and even amputation.
Foot problems aren't inevitable, though. Ralph Guanci learned the hard way to pick his shoes with care and to stick with wearing them because they're good medicine for his feet.
Guanci, 57, a businessman in Carlisle, Massachusetts, was diagnosed with type 2 diabetes 25 years ago. For the first two decades, his feet seemed fairly normal, and he gave little thought to footwear. "I wore anything I wanted," he says.
But a few years ago, he developed foot trouble: a foot bone injury that prompted recurring, infected blisters on his sole. After doctors cured the problem with surgery and antibiotics, Guanci started wearing only one brand of comfort shoes called SAS that his podiatrist had recommended.
"The only times I've violated that, I usually regret it," he says. During one business trip, he ditched his podiatrist-recommended shoes for a fancier pair. "I wanted to look dressy, so I wore an expensive pair of shoes." He wasn't planning to walk much, but after dinner, his companions sprung a surprise plan: a two-mile stroll back to the hotel.
"When I got back to my room, my sock was full of blood and there was a huge blister on my foot," Guanci says. He flew home that night and went straight from the airport to his podiatrist's office. The blister, which was on the ball of his foot, forced him onto crutches and took four months to heal, he says.
Shoes for Diabetes: Double Trouble for the Feet
Why are diabetic feet so vulnerable?
Diabetes can cause nerve damage, or neuropathy, that lessens the foot's sensitivity to pain. Guanci's nerve damage is extensive. After years of "funny, tingling feelings in my feet" -- a sign of abnormal nerve function -- he has now lost all sensation in both feet, he says. "I broke a big toe once and the only thing I noticed was that my toe was swollen. I didn't feel a thing."
Doctors see many similarly affected patients: those who have stepped on broken glass, knitting needles, syringes, or nails and never felt pain to alert them to injury.
Nor can they sense foreign objects in their shoes. James McGuire, DPM, PT, director of the Leonard S. Abrams Center for Advanced Wound Healing at Temple University's School of Podiatric Medicine, described one patient who didn't feel a jack, the star-shaped plaything, inside his shoe. "He just put the shoe on, stepped down and drove the jack into his foot and walked around all day and ended up with an infection from that."
Besides loss of sensation, diabetes can also cause poor circulation because high blood sugar can lead to narrowing of small and large blood vessels. When blood flow is reduced in the feet, wounds heal more slowly.
"Any kind of injury or damage to the foot is the main concern," says Kenneth Snow, MD, acting chief of the adult diabetes department at the Joslin Diabetes Center. "Certainly, ulcers are one such problem, but any kind of laceration injury can lead to significant problems if unrecognized and untreated, particularly in those at risk." At worst, foot complications can lead to amputation.
Most foot complications occur after a patient has had diabetes for 10-15 years, says John Giurini, DPM, chief of podiatry at Beth Israel Deaconess Medical Center. But, he adds, "For individuals who are under very poor control, the complications may occur sooner."
Shoes for Diabetes: Choose Shoes Wisely
When it comes to shoe selection, numerous factors crop up -- not just how long someone has had diabetes, Giurini says. "Do they have normal sensation in their feet? Do they have any abnormalities or deformities of their feet? That's really what should be taken into consideration when selecting shoe gear," he says.
Diabetes patients with good blood sugar control and healthy feet can wear conventional shoes, experts tell WebMD. "They're not at any greater risk for problems than the average population. They can kind of wear whatever they would usually wear, realizing that they should inspect their feet regularly," McGuire says. Experts urge all diabetes patients to check their feet carefully each day for blisters, sores, cuts, redness, warm areas, swelling, ingrown toenails, and other abnormalities and report such changes to their doctor.
For diabetic women with good foot health and no foot deformity or only minor ones, even high heels are fine. "They can certainly wear a fashionable-style shoe for short periods of time, maybe when they're not going to do a lot of walking," Giurini says. He suggests that they save high heels for the office and wear sneakers to and from work. If they slip into heels for a business presentation, they should consider wearing comfortable shoes before and after, he adds.
But women at higher risk for foot problems should eschew the high heels. "A diabetic patient who has some significant loss of sensation, poor circulation or has things like hammertoes and bunion, have to be much more careful," Giurini says.
McGuire advises patients with impaired sensation to steer clear of high heels and narrow dress shoes because they can't feel the pain and stress that such shoes place on the forefoot and toes.
Which shoes are not good for anyone with diabetes? Flip-flops, Giurini says. "They expose the toes [to injury], they're not very supportive, and the strap that goes between the toes can cause a blister or irritation."
"I'm not a really big fan of rigid leather-style shoes," he adds. "They don't give, so that if there's a blister or irritation, there's no opportunity for the shoe to expand."
As for Guanci, he takes foot safety a step further by wearing protective water shoes during swimming. Going barefoot exposes feet to injury, so wearing slippers in the house is also a good idea.
If diabetes patients do develop minor foot deformities or impaired sensation and circulation, it's smart to move from conventional footwear to buying comfort shoes or diabetic shoes, according to Giurini.
These shoes are marketed under various brands, such as CrocsRx, P.W. Minor, Drew, or Easy Spirit.
"A diabetic-style shoe is characterized by being made of soft leather, has a deep toe box, has a rounder, wider toe box that can accommodate things like hammertoes and bunions," Giurini says.
Experts also mentioned jogging shoes or walking shoes as good alternatives.
Patients have complained to McGuire that diabetes forces them to wear unfashionable shoes. "They have to change what they wear, how they look a little bit," he says. Some resist. "It's that basic desire just to remain normal, to not admit that they have diabetes or that they have to make some lifestyle changes." But the harm from improper footwear is too serious to chance, he says.
"They don't need to wear granny shoes," Snow adds. "But folks really have to make sure that what they're putting their foot into is not going to give them a problem."
'Shoe Prescription' for Diabetes Patients
If foot circulation or sensation worsens or a patient develops ulcerations, significant deformities, or other serious issues, a podiatrist may need to prescribe therapeutic shoes, or protective footwear and inserts. Medicare covers these treatments.
For example, some patients require "depth shoes" combined with custom-molded inserts to redistribute pressures on the foot. "Most ulcerations that occur on the foot are pressure-related," Giurini says.
"Depth shoes" derive their name from the extra depth to accommodate orthotics.
Patients with extreme foot deformities may need custom-molded shoes, in which the entire shoe is molded from a cast of the patient's foot. "These are for individuals with very severe foot deformities that can't possibly be accommodated in any other shoe gear," Giurini says.
Diabetes patients who are prescribed any types of medical shoes must wear them religiously, McGuire says. He tells of one man undergoing treatment for a hard-to-treat heel ulcer who cast aside his protective boot to walk around the mall in regular shoes. It was Christmastime and "he wanted to have a nice, normal day with his wife," McGuire says. The patient ended up with bone breakdown, a chronic wound, and bone infection that eventually led to amputation of his foot.
"This didn't have to happen if he had continued to follow directions," McGuire says. Diabetes patients "just can't take that risk once they have that loss of sensation."
Tips for Buying Shoes for Diabetes
To enhance diabetic foot health, the Joslin Diabetes Center offers these tips for buying new shoes and tossing old ones:
- Buy shoes made of soft, stretchable leather.
- When possible, choose laced shoes over loafers because they fit better and offer more support.
- For better shock absorption, look for a cushioned sole instead of a thin leather sole.
- Shop for shoes later in the day because feet swell as the day progresses.
- The distance between your longest toe and the shoe tip should be half of your thumb's width.
- To ensure proper fit, try on shoes while wearing the socks that you'll be using.
- Wear new shoes for 1-2 hours for the first time, then check feet for cuts or blisters. The next day, wear them 3-4 hours and gradually build up time to make sure they aren't injuring your feet.
Replace old shoes when:
- The heel begins to collapse to one side
- The bottom of the heel is worn down
- The inner lining of the shoe is torn