Custom Indoor Footwear Improves Compliance and Outcomes for People at Risk of Foot Ulcers

If you have type two diabetes, you may be at an increased risk for foot problems such as ulcers. Often, these wounds that won’t heal begin as small cuts or blisters that you may not notice at first due to decreased nerve function in the area, caused by poor circulation over time. But if the wound isn’t noticed and properly cared for, it can grow and become infected.

On top of that, collapsed arches or other deformities that are common in people with diabetes may cause normal shoes to put extra pressure on some areas of the foot, making it more likely that a person with diabetes will get a blister in the first place.

People with diabetes often also struggle with lowered immunity, meaning your body have more trouble healing itself. The issues of poor circulation, poor nerve function, lowered immunity, and malformations of the foot combine to create the perfect storm for ulcers to grow and fester.

Doctors often prescribe special, custom-made shoes or extra-depth shoes with special modifications for people with diabetes who are at risk of developing ulcers. Besides being closely fitted to the exact shape of the patient’s foot, these custom shoes typically have a stiff sole and a rocker-bottom that disperses the pressure more evenly across the bottom of the foot.

Custom shoes generally go a long way to prevent ulcers from occurring by providing an even amount of pressure on all areas of the foot and decreasing the amount of movement the foot does within the shoe. These measures help decrease the risk of blisters and can help improve circulation.

However, if patients do not wear these special shoes as instructed, they can’t do their jobs. And it seems there’s a problem in this area of patient compliance, especially for people who spend a lot of time indoors and don’t want to wear their custom footwear inside their homes.

A 2022 study explored the changes in patient adherence to their doctor’s orders and ulcer recurrence when subjects were given an extra set of indoor custom footwear in addition to the set of prescription footwear they already owned.

The researchers’ hypothesis was that many people don’t like to wear shoes in their house, both to avoid tracking dirt and other particles from outside into the home and also because it isn’t the cultural norm in many places to wear shoes inside. However, giving a person shoes that are specifically meant for indoor use might help clear both of those hurdles for many patients.

All patients in the study had diabetes and were considered at high risk for plantar foot ulceration. Their adherence to wearing their custom footwear both indoors and outdoors was measured as a percentage of their steps taken with the custom footwear. High adherence was considered to be use of the custom footwear for upwards of 80 percent of steps taken. Participants were followed for a year after being given their new footwear.

23 of the 31 participants had a low indoor adherence at the beginning of the study with a median value of 65% adherence. At one month in, median indoor adherence was up to 77%, and at 12 months it had increased to 78%. Among those whose adherence was high at baseline, it remained high for the full year.

The one-year ulcer recurrence rate was 26%, and participants’ self-reports were all positive, although some participants reported skin irritation or that the shoes were too heavy.

Based on the results and participants’ feedback, the researchers recommend a “combination of regular and indoor custom-made footwear.”

Although this was a small study, results suggest that an extra set of custom shoes meant for use indoors significantly improves overall compliance with doctors’ orders and helps people with diabetes prevent plantar foot ulcers. People aren’t used to wearing shoes in their homes and don’t want to track in dirt, but a separate pair of shoes specifically for home use encourages people to wear their custom shoes inside and allows them to keep their homes clean.

The researchers say future studies should further investigate ulcer recurrence over a longer period of time and in more participants.