Shoes and socks: everything you need to know as a diabetic

Diabetic foot ulcers are a costly complication of diabetes, reducing people’s quality of life, and increasing morbidity, mortality and healthcare expenditure. Additionally, diabetic foot ulcers are the leading cause of lower extremity amputations and cause approximately 2% of all hospitalisations. Therefore, the prevention of diabetic foot ulcers is of paramount importance. Good footwear and socks can greatly lower the risk of diabetic foot ulcers from occurring.

Shoes

Use of inappropriate footwear or walking barefoot typically increases the magnitude of the local mechanical repetitive stresses on the foot that are leading causes of the development of diabetic foot ulceration. Therefore, it is highly recommended that people with diabetes wear appropriate footwear designed to reduce repetitive stresses at all times, to help prevent diabetic foot ulceration. Below is a list of the features that all good shoes should have:

1. Length: The inner length of the footwear should be 1–2 cm longer than the foot length as measured from heel to the longest toe when a person is standing.
   
   
2. Depth: Depth should accommodate the toes to move freely without causing pressure at either the medial, lateral or the dorsal side.
   
   
3. Width: Width should equal the width of all parts of the foot. Width is good when the upper can be slightly bunched. The relation between forefoot and hindfoot is important, as accommodating a wide forefoot may result in the heel being too wide.
   
   
4. Innersole: The removable moulded insole can be pre-fabricated, adjusted or custom-made. The primary function of the insole is pressure redistribution. This is achieved via the principle of increasing the contact area between the foot and the insole, and the addition of corrective elements in the insole. Shock-absorbing, soft but sufficiently resilient and non-slippery materials should be used.
   
   
5. Outsole: Rubber, plastic, and leather can all be used in construction of footwear outsoles, but rubber outsoles are thought to be superior. Outsoles can be supple, toughened or stiff. The shoe should not be more supple than the foot, or friction between foot and shoe will develop during push-off.
   
   
6. Heel enclosure: An adequately fitting and enclosed heel is recommended, as open backed footwear or a heel enclosure that is too wide can result in injury and usually requires a person to claw their toes in order to keep them on. The heel counter needs to be free of edges protruding into the footwear.
   
   
7. Heel lift: The heel lift (or heel-forefoot difference, or pitch) should be generally 1.5–2 cm, and should not exceed 3 cm.
   
   
8. Closure:  Adequate closure (or fixation) is needed to keep the foot from sliding forward. Closure should allow secure longer-term fastening and individual adjustment. Laces have long been considered the optimal choice; however, alternatives that are easier to use while still meeting these criteria are available as well, and innovative closures continue to be developed.
   
   
9. Upper:  Uppers should be made from leather or a combination of materials (similar to sports shoes), with smooth inner lining made from a material that does not harden over time, with limited seams and preferably no seams in the vamp area as they reduce the ability of the leather to give. Uppers can be supple, toughened or stiff. 
   
   
10. Toe box: The part of the shoe that covers and protects the toes. This should be supple (unless specific requirements (e.g. for building professionals) require otherwise), and should accommodate the shape of the toes, to avoid any rubbing on the toes.

Socks

While not all diabetics are required to wear diabetic socks, people with diabetes have sensitive feet and need to protect their feet more than others. Diabetic socks are specially designed to decrease the risk of foot injury, to offer maximum blood flow, and keep the feet dry. The best diabetic socks should have the following features:

1. Seamless: Even the tiniest protrusion can have a severe impact on the diabetic foot. Socks with seams can rub against the skin and can cause blisters or ulcers, which may be harmful for diabetic feet. The best diabetic socks are seamless and knitted with inverse linking, which keeps the ends of the toe-linking thread outside rather than inside the sock.
   
   
2. Non-constricting: The fit of diabetic socks should be loose, non-constricting and have a super stretch design. In fact, they should be loose to the point where you barely feel them!.
   Tight socks can inhibit circulation, which might be challenging for those who suffer from circulatory issues.
   
   
3. Padding: Extra padding and cushioning for sensitive areas help prevent injury and enhances comfort. Normally the extra padding runs along the bottom of the sock, around the toes, and at the heel of the foot. These areas of the foot are usually susceptible to the most shock forces during activities and therefore need to be protected even more.
   
   
4. Warmth: Diabetes can cause blood vessels to restrict, decreasing circulation to the feet.
   Diabetic socks should be made from fabrics that keep feet warm and help improve blood circulation.
   
   
5. White Sole: A white sole is important for people with compromised sensation, as it helps alert wearers to a draining wound. Stains from infections, open cuts and sores that require immediate attention will be very visible on a white sole.
   
   
6. Moisture-wicking: Many socks today are knitted with special yarns that are infused with advanced technology to help maintain a healthy foot. Synthetic yarns such as polyester and nylon are able to move moisture out of the sock and quickly dry up. A dry foot environment helps prevent skin infections and keeps feet comfortable for long periods.
   
   
7. Anti-microbial: Good diabetic socks are treated with anti-microbial technology to prevent the growth of bacteria and fungi in the moisture prone regions of the foot, keeping it healthy. Eliminating bacteria and fungi also eliminates the bad odours in your feet!
   
   
8. Soft yarns: Diabetic socks are often made from finer texture fabrics that feel super soft against the skin. Bamboo fibres are an excellent option that reduce rough abrasion and shear forces on the skin.

If you have any questions or would like to discuss appropriate footwear and socks for diabetics feel free to visit us in the Marrickville clinic and we will be happy to answer your questions.

Thanks for reading and stay safe!

Richard
Sole-Lution Podiatry