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Shoe Modifications for Diabetic Patients

Custom inserts ensure proper alignment from the ground up.

By Alma Deguzman, PT, CPed

Posted on: September 27, 2012

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Compared to ordinary shoes, diabetic shoes are extra deep and wide. They're designed to accommodate diabetic feet, and can help prevent foot-related complications arising from neuropathy.

Other benefits include the redistribution of pressure on the plantar aspect of both feet. The use of custom inserts or shoe modifications provides proper alignment from the ground up for a diabetic patient with flat feet or high arches, which can help relieve foot, ankle, knee, hip and back discomfort. Not only do these inserts provide biomechanical advantages, they also reduce ground reaction force to the arthritic joints of the lower extremities and spine, which decreases pain and increases tolerance to ambulation. Proper support from the ground up is essential in maintaining good body alignment and lower-extremity biomechanics, decreasing problems in the knees, hips and spine.

Many podiatrists have discontinued dispensing diabetic shoes because of the changes that Medicare instituted in their eligibility requirements. Navigating the eligibility requirements can be difficult, and knowledge of the necessary steps is required for rehabilitation professionals to assist their patients in obtaining diabetic shoes.

In 1993, Congress amended Medicare statutes to provide partial reimbursement for depth shoes, custom-molded shoes and shoe inserts or modifications to qualifying Medicare Part B patients with diabetes. What many PTs don't know is that a significant number of diabetic patients we see can benefit from this program. However, eligibility requirements must be met. To meet Medicare requirements, a pair of diabetic shoes has to have some form of closure (either Velcro or laces), have a minimum of 3/16" additional depth, be made of leather or other suitable materials, and be available in full and half sizes with a minimum of 3 widths.

Who qualifies for diabetic shoes? A patient must meet three requirements. First, the patient has a diagnosis of diabetes mellitus. Second, the patient has one or more of the following foot conditions: previous amputation of the other foot or part of either foot; history of previous foot ulceration; history of pre-ulcerative calluses; peripheral neuropathy with evidence of callus formation; foot deformity or poor circulation. Finally, the patient must be being treated under a comprehensive plan of care for diabetes by a physician.

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It's important to keep in mind that Medicare reimburses for one pair of diabetic shoes and three pairs of heat moldable or custom inserts. A shoe modification is also covered in lieu of one pair of heat moldable or custom inserts. Currently, this program is underused by physical therapists because of the lack of information regarding what's covered and what's not.

Diabetic inserts are multiple density inserts that are either custom molded or heat molded to the foot using an external heat source of 230°F or higher, and must have total contact with patient's foot, including the arch. There are also specifications on the hardness of the insert material per Medicare standards.

Shoe modifications are modifications or additions done to a shoe to support and stabilize ankle instability, accommodate a deformity or leg length discrepancy, and relieve or redistribute pressure on the foot. Some examples are lateral and medial stabilizers for ankle instabilities, sole lift for leg length discrepancies and rockers for limitation of motion on the ankle joint.

We can use this Medicare program efficiently by properly identifying patients who need diabetic shoes and inserts, and by assisting patients in obtaining them. Consulting a pedorthist can help answer questions about Medicare eligibility and requirements and help you formulate a comprehensive treatment plan.

Alma Deguzman is owner and lead physical therapist at Polaris Physical Therapy and Pedorthics, Woodridge, IL.

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