The Role of Footwear in the Prevention of Diabetic Foot Complications: The State of the Art

  • Luigi Uccioli
  • Claudia Giacomozzi
Part of the Contemporary Diabetes book series (CDI)


Main goal of human foot evolution was to allow safe and effective barefoot motion on natural grounds. Footwear came afterwards, to protect the foot from extreme environmental conditions, to improve walking and running performance, and to cope with challenging surfaces also including new artificial substrates. But while on the one side shoes and insoles—i.e., footwear—act beneficially on the foot, on the other side they may limit foot function and render the foot itself more fragile and less prone to adaptation. This may lead the shod foot to unnaturally concentrate peak pressures under small areas at heel, forefoot, and hallux. Such a potentially dangerous condition may likely happen in diabetic patients with long-term complications, such as peripheral neuropathy, which deeply modify foot structure, foot function, and the resulting gait. Without proper protection, such patients are made vulnerable and at risk of foot ulceration. Unsuitable footwear may precipitate this condition and may be responsible for the new appearance or the recurrence of a foot ulcer. Research efforts during the last 50 years helped to better understand the criteria to take into account when prescribing or making proper footwear and/or plantar orthoses to: prevent diabetic foot ulceration (primary prevention); manage healing of an active ulcer; and prevent ulcer recurrences (secondary prevention). However, despite these huge advances in knowledge, recent literature still claims the lack of strong evidence about clinical efficacy of diabetic footwear especially in preventing first ulcer occurrence. Main reasons for that, among which the still poor adherence to treatment, are presented and discussed in the following, together with a literature review of the most recent peer-reviewed studies and position papers, to bring attention on the main causes for the still limited success of footwear intervention in diabetes and on a desirable improvement of diabetic foot care.


Diabetes Foot–ankle complex Footwear recommendations Ulceration Primary prevention Secondary prevention Partial amputation Charcot’s foot Foot aids Active lesions Shear stress Plantar pressures Foot orthoses Foot structure Footwear prescription Proper shoe fitting Footwear treatment Foot walker Offloading 


  1. 1.
    Vileikyte L, Rubin RR, Peyrot M, Gonzalez JS, Boulton AJ, Ulbrecht JS, Cavanagh PR. Diabetic feet. Br J Gen Pract. 2009;59:290.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Jeffcoate WJ, Lipsky BA, Berendt AR, Cavanagh PR, Bus SA, Peters EJ, et al. Unresolved issues in the management of ulcers of the foot in diabetes. Diabet Med. 2008;25:1380–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Bus SA, Valk GD, van Deursen RW, Armstrong DG, Caravaggi C, Hlavácek P, et al. The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review. Diabetes Metab Res Rev. 2008;24(Suppl 1):S162–80.CrossRefGoogle Scholar
  4. 4.
    Bus SA, Valk GD, van Deursen RW, Armstrong DG, Caravaggi C, Hlavácek P, et al. Specific guidelines on footwear and offloading. Diabetes Metab Res Rev. 2008;24(Suppl 1):S192–3.PubMedCrossRefGoogle Scholar
  5. 5.
    Ledoux W. The biomechanics of the diabetic foot. In: Harris GF, Smith PA, Marks RM, editors. Foot and ankle motion analysis (clinical treatment and technology). Boca Raton, FA: CRC Press; 2008. p. 317–401.Google Scholar
  6. 6.
    Gooding GAW, Stess RM, Graf PM. Sonography of the sole of the foot: evidence for loss of foot pad thickness in diabetes and its relationship to ulceration of the foot. Investig Radiol. 1986;21:45–8.CrossRefGoogle Scholar
  7. 7.
    Young MJ, Cavanagh PR, Thomas G, Johnson MM, Murray H, Boulton AJM. The effect of callus removal on dynamic plantar foot pressures in diabetic patients. Diabet Med. 1992;9:55–7.CrossRefGoogle Scholar
  8. 8.
    D’Ambrogi E, Giurato L, D’Agostino MA, Giacomozzi C, Macellari V, Caselli A, et al. Contribution of plantar fascia to the increased forefoot pressures in diabetic patients. Diabetes Care. 2003;26:1525–9.CrossRefGoogle Scholar
  9. 9.
    Veves A, Murray HJ, Young MJ, Boulton AJM. The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study. Diabetologia. 1992;35:660–3.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Masson EA, Hay EM, Stockley I, Veves A, Betts RP, Boulton AJM. Abnormal foot pressures alone may not cause ulceration. Diabet Med. 1989;6:426–8.CrossRefGoogle Scholar
  11. 11.
    Lavery LA, Armstrong DG, Vela SA, Quebedeax TL, Fleischli JC. Practical criteria for screening patients at high risk for diabetic foot ulceration. Arch Intern Med. 1998;158:157–62.PubMedCrossRefGoogle Scholar
  12. 12.
    Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217–28.CrossRefGoogle Scholar
  13. 13.
    IWGDF, Prevention and management of foot problems in diabetes: a Summary Guidance for daily practice 2015 based on the IWGDF Guidance documents, link:, last check November 2016.
  14. 14.
    Young MJ, Breddly JL, Veves A, Boulton AJM. The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds: a prospective study. Diabetes Care. 1994;17:557–60.CrossRefGoogle Scholar
  15. 15.
    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 Diabetes Complicat. 1990;4:21–5.CrossRefGoogle Scholar
  16. 16.
    Prompers L, Huijberts M, Apelqvist J, Jude E, Piaggesi A, Bakker K, et al. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia. 2007;50:18–25.CrossRefGoogle Scholar
  17. 17.
    Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM. Preventive foot care in people with diabetes. Diabetes Care. 1999;21:2161–77.CrossRefGoogle Scholar
  18. 18.
    Giacomozzi C, Caselli A, Macellari V, Giurato L, Lardieri L, Uccioli L. Walking strategy in diabetic patients with peripheral neuropathy. Diabetes Care. 2002;25:1451–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Payne CB. Biomechanics of the foot in diabetes mellitus. Some theoretical considerations. J Am Podiatr Med Assoc. 1998;88:285–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Uccioli L, Caselli A, Giacomozzi C, Macellari V, Giurato L, Lardieri L, et al. Pattern of abnormal tangential forces in the diabetic neuropathic foot. Clin Biomech. 2001;16:446–54.CrossRefGoogle Scholar
  21. 21.
    Uccioli L. The role of footwear in the prevention of diabetic foot problems. In: Veves A, Jurini JM, LoGerfo FW, editors. The diabetic foot. 2nd ed. New Jersey: Humana Press Inc.; 2006. p. 523–42.CrossRefGoogle Scholar
  22. 22.
    Janisse DJ, Janisse EJ. Shoes, orthoses, and prostheses for partial foot amputation and diabetic foot infection. Foot Ankle Clin North Am. 2010;15:509–23.CrossRefGoogle Scholar
  23. 23.
    American Diabetes Association. Preventive foot care in people with diabetes. Diabetes Care. 2003;26(Suppl 1):S78–9.Google Scholar
  24. 24.
    Medicare, Part B. The Official U.S. Government site for Medicare.
  25. 25.
    Armstrong DG, Todd WF, Lavery LA, Harkless LB, Bushman TR. The natural history of acute Charcot’s arthropathy in a diabetic foot specialty clinic. Diabet Med. 1997;14:357–63.PubMedCrossRefGoogle Scholar
  26. 26.
    Pinzur M. Surgical versus accommodative treatment for Charcot arthropathy of the midfoot. Foot Ankle Int. 2004;25:545–9.CrossRefGoogle Scholar
  27. 27.
    Stess RM, Jensen SR, Mirmiran R. The role of dynamic plantar pressure in diabetic foot ulcers. Diabetes Care. 1997;20:855–8.CrossRefGoogle Scholar
  28. 28.
    Armstrong DG, Lavery LA. Evidence-based options for off-loading diabetic wounds. Clin Podiatr Med Surg. 1998;15:95–104.PubMedGoogle Scholar
  29. 29.
    Caravaggi C, Faglia E, De Giglio R, Mantero M, Quarantiello A, Sommariva E, et al. Effectiveness and safety of a nonremovable fiberglass off-bearing cast versus a therapeutic shoe in the treatment of neuropathic foot ulcers: a randomized study. Diabetes Care. 2000;23:1746–51.PubMedCrossRefGoogle Scholar
  30. 30.
    Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ, Harkless LB. Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care. 2001;24:1019–22.PubMedCrossRefGoogle Scholar
  31. 31.
    Borssen B, Lithner F. Plaster casts in the management of advanced ischaemic and neuropathic diabetic foot lesions. Diabet Med. 1989;6:720–3.PubMedCrossRefGoogle Scholar
  32. 32.
    Knowles EA, Armstrong DG, Hayat SA, Khawaja KI, Malik RA, Boulton AJ. Offloading diabetic foot wounds using the scotchcast boot: a retrospective study. Ostomy Wound Manage. 2002;48:50–3.PubMedGoogle Scholar
  33. 33.
    Armstrong DG, Short B, Espensen EH, Abu-Rumman PL, Nixon BP, Boulton AJ. Technique for fabrication of an “instant total-contact cast” for treatment of neuropathic diabetic foot ulcers. J Am Podiatr Med Assoc. 2002;92:405–8.CrossRefGoogle Scholar
  34. 34.
    Lavery LA, Vela SA, Fleischli JG, Armstrong DG, Lavery DC. Reducing plantar pressure in the neuropathic foot. A comparison of footwear. Diabetes Care. 1997;20:1706–10.PubMedCrossRefGoogle Scholar
  35. 35.
    Baumhauer JF, Wervey R, McWilliams J, Harris GF, Shereff MJ. A comparison study of plantar foot pressure in a standardized shoe, total contact cast, and prefabricated pneumatic walking brace. Foot Ankle Int. 1997;18:26–33.PubMedCrossRefGoogle Scholar
  36. 36.
    Piaggesi A, Macchiarini S, Rizzo L, Palumbo F, Tedeschi A, Nobili LA, et al. An off-the-shelf instant contact casting device for the management of diabetic foot ulcers: a randomized prospective trial versus traditional fiberglass cast. Diabetes Care. 2007;30:586–90.PubMedCrossRefGoogle Scholar
  37. 37.
    Faglia E, Caravaggi C, Clerici G, Sganzaroli A, Curci V, Vailati W, et al. Effectiveness of removable walker cast versus non removable fiberglass off-bearing cast in the healing of diabetic plantar foot ulcer: a randomized controlled trial. Diabetes Care. 2010;33:1419–23.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Hunt DL. Diabetes: foot ulcers and amputations. BMJ Clin Evid. 2011. pii: 0602.Google Scholar
  39. 39.
    Bus SA. Priorities in offloading the diabetic foot. Diabetes Metab Res Rev. 2012;28(Suppl 1):54–9. Scholar
  40. 40.
    Healy A, Naemi R, Chockalingam N. The effectiveness of footwear and other removable off-loading devices in the treatment of diabetic foot ulcers: a systematic review. Curr Diabetes Rev. 2014;10(4):215–30.PubMedCrossRefGoogle Scholar
  41. 41.
    Bus SA, van Deursen RW, Armstrong DG, Lewis JE, Caravaggi CF, Cavanagh PR. Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review. Diabetes Metab Res Rev. 2016;32(Suppl 1):99–118. Scholar
  42. 42.
    Elraiyah T, Prutsky G, Domecq JP, Tsapas A, Nabhan M, Frykberg RG, et al. A systematic review and meta-analysis of off-loading methods for diabetic foot ulcers. J Vasc Surg. 2016;63(2 Suppl):59S–68S.e1–2. Scholar
  43. 43.
    Piaggesi A, Goretti C, Iacopi E, Clerici G, Romagnoli F, Toscanella F, et al. Comparison of removable and irremovable walking boot to total contact casting in offloading the neuropathic diabetic foot ulceration. Foot Ankle Int. 2016;37(8):855–61.PubMedCrossRefGoogle Scholar
  44. 44.
    Mueller MJ, Strube MJ, Allen BT. Therapeutic footwear can reduce plantar pressure in patients with diabetes and transmetatarsal amputation. Diabetes Care. 1997;20:637–41.PubMedCrossRefGoogle Scholar
  45. 45.
    Lavery LA, Armstrong DG, Wunderlich RP, Tredwell J, Boulton AJ. Predictive value of foot pressure assessment as part of a population-based diabetes disease management program. Diabetes Care. 2003;26:1069–73.CrossRefGoogle Scholar
  46. 46.
    Patry J, Belley R, Côté M, Chateau-Degat ML. Plantar pressures, plantar forces, and their influence on the pathogenesis of diabetic foot ulcers: a review. J Am Podiatr Med Assoc. 2013;103(4):322–32.PubMedCrossRefGoogle Scholar
  47. 47.
    Mueller MJ, Zou D, Lott DJ. Pressure gradient as an indicator of plantar skin injury. Diabetes Care. 2005;28(12):2908.CrossRefGoogle Scholar
  48. 48.
    Dahmen R, Haspels R, Koomen B, Hoeksma AF. Therapeutic footwear for the neuropathic foot: an algorithm. Diabetes Care. 2001;24:705–9.PubMedCrossRefGoogle Scholar
  49. 49.
    Yavuz M, Tajaddini A, Botek G, Davis BL. Temporal characteristics of plantar shear distribution: relevance to diabetic patients. J Biomech. 2008;41:556–9.PubMedCrossRefGoogle Scholar
  50. 50.
    Janisse D, Janisse E. Pedorthic management of the diabetic foot. Prosthetics Orthot Int. 2015;39(1):40–7. Scholar
  51. 51.
  52. 52.
    Owings TM, Woerner JL, Frampton JD, Cavanagh PR, Botek G. Custom therapeutic insoles based on both foot shape and plantar pressure measurement provide enhanced pressure relief. Diabetes Care. 2008;31:839–44.PubMedCrossRefGoogle Scholar
  53. 53.
    Bowling FL, Reeves ND, Boulton AJ. Gait-related strategies for the prevention of plantar ulcer development in the high risk foot. Curr Diabetes Rev. 2011;7(3):159–63.PubMedCrossRefGoogle Scholar
  54. 54.
    Actis RL, Ventura LB, Lott DJ, Smith KE, Commean PK, Hastings MK, et al. Multi-plug insole design to reduce peak plantar pressure on the diabetic foot during walking. Med Biol Eng Comput. 2008;46:363–71.PubMedPubMedCentralCrossRefGoogle Scholar
  55. 55.
    Soletech website. Link, last check Nov 2016.
  56. 56.
    Maciejewski ML, Reiber GE, Smith DG, Wallace C, Hayes S, Boyko EJ. Effectiveness of diabetic therapeutic footwear in preventing reulceration. Diabetes Care. 2004;27:1774–82.PubMedCrossRefGoogle Scholar
  57. 57.
    Cavanagh PR, Ulbrecht JS, Caputo GM. The biomechanics of the foot in diabetes mellitus. In: Bowker JH, Pfeifer MA, editors. Levin and O’Neal’s the diabetic foot. 6th ed. St Louis, MO: Mosby, Inc.; 2001. p. 125–96.Google Scholar
  58. 58.
    Owings TM, Apelqvist J, Stenstrom A, Becker M, Bus SA, Kalpen A, et al. Plantar pressures in diabetic patients with foot ulcers which have remained healed. Diabetic Med. 2009;26:1141–6.PubMedCrossRefGoogle Scholar
  59. 59.
    Giacomozzi C, Uccioli L. Learning from experience: a simple effective protocol to test footwear prescriptions for the diabetic foot by using the Pedar system. JBiSE. 2013;6:45–57.CrossRefGoogle Scholar
  60. 60.
    Bus SA, Haspels R, van Schie CHM, Mooren P. Biomechanical optimisation of orthopaedic footwear for diabetic patients using in-shoe plantar pressure measurement. In: Proceedings of the EMED scientific meeting, 26 July–28 July 2006. Munich, Germany; 2006.CrossRefGoogle Scholar
  61. 61.
    Giacomozzi C. Appropriateness of plantar pressure measurement devices: a comparative technical assessment. Gait Posture. 2010;32:141–4.PubMedCrossRefGoogle Scholar
  62. 62.
    Giacomozzi C, Keijsers N, Pataky T, Rosenbaum D. International scientific consensus on medical plantar pressure measurement devices: technical requirements and performance. Ann Ist Super Sanita. 2012;48(3):259–71.PubMedCrossRefGoogle Scholar
  63. 63.
    World Health Organization. International diabetes federation. Diabetes care and research in Europe: the Saint Vincent declaration. Diabet Med. 1990;7:360.CrossRefGoogle Scholar
  64. 64.
    Cisneros LL. Evaluation of a neuropathic ulcers prevention program for patients with diabetes. Rev Bras Fisioter. 2010;14:31–7.PubMedCrossRefGoogle Scholar
  65. 65.
    van Netten JJ, Price PE, Lavery LA, Monteiro-Soares M, Rasmussen A, Jubiz Y, et al. Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review. Diabetes Metab Res Rev. 2016 Jan;32(Suppl 1):84–98. Scholar
  66. 66.
    Robinson C, Major MJ, Kuffel C, Hines K, Cole P. Orthotic management of the neuropathic foot: an interdisciplinary care perspective. Prosthetics Orthot Int. 2015;39(1):73–81. Scholar
  67. 67.
    Lázaro-Martínez JL, Aragón-Sánchez J, Alvaro-Afonso FJ, García-Morales E, García-Álvarez Y, Molines-Barroso RJ. The best way to reduce reulcerations: if you understand biomechanics of the diabetic foot, you can do it. Int J Low Extrem Wounds. 2014;13(4):294–319. Scholar
  68. 68.
    Turns M. The diabetic foot: an overview for community nurses. Br J Community Nurs. 2012;17(9):422. 424–27, 430–3. PubMed FOCUS ON multidisciplinary process of carePubMedCrossRefGoogle Scholar
  69. 69.
    Sheridan S. The need for a comprehensive foot care model. Nephrol Nurs J. 2012;39(5):397–400. quiz 401PubMedGoogle Scholar
  70. 70.
    MacFarlane RM, Jeffcoate WJ. Factors contributing to the presentation of diabetic foot ulcers. Diabet Med. 1997;14:867–70.PubMedCrossRefGoogle Scholar
  71. 71.
    Lietzelman DK, Marriott DJ, Vinicor F. Independent physiological predictors of foot lesions in patients with NIDDM. Diabetes Care. 1997;20:156.CrossRefGoogle Scholar
  72. 72.
    Harrison SJ, Cochrane L, Abboud RJ, Leese GP. Do patients with diabetes wear shoes of the correct size? Int J Clin Pract. 2007;61:1900–4.PubMedCrossRefGoogle Scholar
  73. 73.
    Parnés A. If the shoe fits… footwear and patients with diabetes. Int J Clin Pract. 2007;61:1788–90.PubMedCrossRefGoogle Scholar
  74. 74.
    American Diabetes Association. Standards of medical care in diabetes – 2016. Diabetes Care. 2016;39(1):S4–5.CrossRefGoogle Scholar
  75. 75.
    American Diabetes Association. Microvascular complications and foot care. Diabetes Care. 2016;39(Suppl 1):S72–80. Scholar
  76. 76.
    Physical activity/exercise and diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2016;39:2065–79. Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Luigi Uccioli
    • 1
  • Claudia Giacomozzi
    • 2
  1. 1.Department of Systems MedicineTor Vergata University HospitalRomeItaly
  2. 2.Department of Cardiovascular, Dysmetabolic and Aging-Associated DiseasesItalian National Institute of HealthRomeItaly

Personalised recommendations