Thursday, April 23, 2009

Obtaining Proper Shoes Through Medicare

Over the years, I have found that unfortunately, one of the best kept secrets among patients with diabetes is the Medicare Therapeutic Shoe Program. People with diabetes are instructed that they need to make sure they wear proper shoes. This is a program that makes this possible! Per Medicare guidelines, patients who qualify can receive one pair of shoes per calendar year, and three pair of accomodative inserts. Three pair of inserts are allowed because over time, they lose their ability to cushion the feet. By dispensing three pair, patients can change the inserts every 4 months, thus insuring that they always have proper cushioning and support in their shoes. While not every diabetic patients on Medicare qualify for this program, the truth is that many do qualify, and there are many who qualify who are not taking advantage of this program.

For a shoe to qualify for the Medicare Therapeutic Shoe Program, it needs to meet certain criteria. These include:

  • Have more interior depth than a normal shoe, which allows for at 3/16" accomodative insert.

  • Must be made from leather or a material of equal quality

  • Must have some form of closure (usually laces or a Velcro closure)

  • Must be available in full and half sizes

  • Must be available in at least 3 widths.

Many diabetic patients are concerned that the shoes will be big, heavy or unattractive to wear. This is simply not the case. The variety of shoes styles available means that it is extremely rare not to be able to find a pair of shoes that meets your need, both medically and aesthetically. On top of that, the shoes are designed to be comfortable!

To qualify for shoes, you need to be examined by your doctor to see if you meet Medicare's guidelines for receiving the shoes. Once it's determined that you qualify, a letter will need to be received from your primary care physician who will certify that you are diabetic and would benefit from receiving the shoes. This is one of the few programs that Medicare offers that is intended to be preventative. Studies have shown that by wearing proper shoes, the risk of developing an ulceration in the foot can be greatly reduced. In other words, you don't have to already have had a foot ulcer to qualify, you just need to be at risk of developing an ulcer. You also do not have to be on insulin to qualify.

Most offices will do a fitting, then order the shoes for you. Once the shoes are shipped to the office, you will be contacted for shoe dispensing. In our office, we recommend that you wear the shoes indoors until you are certain that they are right for you. If for any reason they are not, they can be returned for a more appropriate size or style.

If you have not taken advantage of this program, talk to your podiatrist & see if it is something that you would benefit from. And if you have received a pair of shoes in the past, perhaps it's time for a new pair. Your feet will thank you!

Tuesday, April 21, 2009

Keeping the Elderly Walking

As we get older, our health continues to weaken. Every time we take a trip to the doctor’s office we pray nothing new comes up. Time and time again we hear the same old story, “you need to make sure you exercise to stay healthy.” Whether you have hypertension, diabetes, or high cholesterol, your doctor is going to prescribe exercise! So how does an elderly person stay fit? Walking is everyone’s favorite activity! It is often the safest and easiest type of physical activity to participate as we age. Here are a few tips to help you stay healthy and safe while walking.

Walking Tip #1: Warm up and Cool down

It may seem silly and useless, but taking time to warm up and cool down before walking is very important. It allows an increase of blood flow to your muscles. This increases the oxygen levels available to your muscles. As you exercise, your muscles use the oxygen to create energy. If the oxygen is depleted, your body creates lactic acid which causes pain and your muscles to get tired faster. A warm up will help prevent this from happening. Stretching is an import part of a warm up and cool down. Having tight muscles can cause many different problems and can be painful. Stretching can also help prevent injuries.

Walking Tip #2: Buy a good pair of shoes that fits!

We all want to watch our budget, but walking shoes is not a place to cut corners. You should shop for your shoes in the afternoon. Your feet will swell throughout the day; thus, to ensure you have a properly fitted shoes you should avoid buying them in the mornings. Also make sure you have ample space in the toe box. You should be able to wiggle your toes around in your shoes. Try on several different brands and different sizes and walk around with them on both feet. This is the only way to find a comfortable shoe!

Walking Tip #3: Your feet should not hurt!

You may experience some pain when you begin your new walking schedule. You should pay close attention because this is not a normal occurrence. Self treatment may lead to more significant problem. You should contact a podiatric physician who will be able to accurately asses your pain and treatment options.

Walking Tip #4: Walk on softer surfaces!

As we get older, we lose our protective fat pad on the bottom of our feet. This increases the pressure on our bones and may lead to stress fractures. These types of injuries are more common in women but can also occur in men. Try to walk on grass, or dirt paths rather than hard cement if possible. Through softer ground may be better for stress fractures, make sure the ground is even to prevent ankle sprains or falls.

Walking Tip #5: Make a plan and get a friend!

Changing your lifestyle to include exercise is a huge undertaking. It is not easy to always stay motivated. It works best to build a plan and schedule that you can adhere to the best. Talk over your plan with your doctor to make sure it is appropriate for your health concerns. Find a friend or local walking groups to join. This will make the experience more enjoyable and rewarding!

Thursday, April 16, 2009

Have Diabetes? No Bare Feet on the Beach!

People with diabetes are hammered with things they shouldn't do. Always high on the list is not to go barefoot. We always tend to over-analyze such recommendations, often to our own detriment.

In our own house? Well, yes. I've pulled all sorts of crazy things out of people's feet. Pet hair, pins, staples, glass, a toothpick. No joke! Some, of course, knew that the foreign body was in really hurt! There are those with diabetes who don't have any sensation due to peripheral neuropathy. These folks can step on a foreign body and not have any idea. They may notice bleeding on the carpet or in their shoe and find out that way. For others it can be days or more before they discover the problem.

The most universally accepted place to go barefoot is the beach. No problem, right? Wrong. Let me count the ways...

First of all, sand gets very, very hot. For those who have full sensation in their feet, they'll realize it and will protect their feet with shoes, flip-flops, Crocs, etc. For those who don't have sensation, they will have no idea about the heat of the sand. Severe burns can (and believe me often do) result. If you have any decrease in sensation, always protect your feet on the beach.

Add the heat of the sand to the multitude of foreign body's unique to the beach. Seashells can be sharp and cut into the foot easily. Coral and other natural growth can scratch and do the same. This is more dangerous than your household foreign bodies. On the beach, there are bacteria that you won't find anywhere else. So along with the danger of simply stepping on something and not feeling it, you can add the risk of infection which, of course, is exacerbated by the diabetes depressing the immune system.

So the take home message is, always be careful and always protect your feet. You need to always think about where you are and what dangers may be lurking. Even in a comfortable situation, like a day out at the beach, being proactive in protecting yourself will always keep the memories of the day pleasant.

Friday, April 3, 2009

Diabetics are losing feeling in their feet! Why?

According to the American Diabetes Association, about 15.7 million people (5.9 percent of the United States population) have diabetes. Nervous system damage (also called neuropathy) affects about 60 to 70 percent of people with diabetes and is a major complication that may cause diabetics to lose feeling in their feet or hands.  Foot problems are a big risk in diabetics. Diabetics must constantly monitor their feet or face severe consequences, including amputation.


Diabetics lose feeling in their feet.  This is called diabetic sensory neuropathy.  Grossly simplified, the nerves do not conduct sensations as well as they can.  This is due to a variety of factors, but commonly a higher level of sugar in the blood stream diminishes the nerve action potential.  Direct metabolic damage then occurs to the nerves, which results in neuropathy.  There are three types of neuropathies a diabetic can have.  Sensory, motor, and autonomic neuropathies are all possible. 

Sensory neuropathy, the most common type, usually presents as the first type before motor neuropathy.  It is classically described as a sock and glove distribution.  This means than the loss of sensation occurs in the same distribution as a sock.  That is, all feeling is lost or diminished below a certain level just above the ankle joint, in the same area where a sock would be around the lower leg.  A diabetic will not be able to detect sensation or will have difficulty detecting two points of discrimination.  A person can also have an absent protective threshold.  In other words, a diabetic may not be able to feel hot water when checking drawn bath water, whereas a non-diabetic would jump, pull their hand back reflexively, and say “ow!”  This example also clearly illustrates the lack of temperature discrimination.  Another sequella is diminished vibration sensation. 

Lastly, proprioception can also be affected.  Proprioception is the ability of the body to know where a limb is in space or what movement is being performed.  For example, when you close your eyes while walking over a curb, your bodys’ own sensing system takes over.  It knows just how much height is required to lift the foot over the curb.  It also knows when to expect your foot to land onto the ground above the curb and at what force should be expected.  We are able to perform this complex task because of small receptors that line our joints and detect tiny movements made by us.  These movements are interpreted by our brains like movement in space. 

Motor neuropathy is a deficit of motor coordination affecting the intrinsic muscles of the foot leading to biomechanical and structural changes of the foot.  These changes predispose the diabetics feet to ulcers and subsequent infections. 

 Another type of neuropathy that can occur is autonomic neuropathy.  The autonomic nervous system is responsible for regulating body temperature among other things.  It does this by creating sweat and directing blood flow to or away from an extremity.  Poor control would lead to reduced blood flow, lack of sweating, and other conditions.  It also is responsible for hair follicles reacting to reduce heat or gather warmth. 

Wednesday, April 1, 2009

Your 4 Keys To Reducing Your Diabetic Complications

People often worry about the complications that come with diabetes. Here are 4 keys to helping reduce your complication risks.

1. The best way to limit complications of diabetes (all the complications) is strict blood sugar control. You should be monitoring your blood sugar and seeking to have a A1c of 6 or lower. Spikes in blood sugar are not recommended at any time, as this provides opportunity for the complications to start. As you talk with your doctor, you can get an aggressive program to keep blood sugars managed.

2. Exercise helps control blood sugar. Exercise in a diabetic is an important part of your self care. This program should be under the direction of your physician and should include adjustments in medications as necessary, diet changes and carefully monitored exercise. Some key points include not exercising when blood sugars are highest, 30 - 60 minutes after meals and additional carbohydrates may be required to reduce hypoglycemia (low blood sugars). Talk with your doctor and get an exercise program that will work for you.

3. Examine your feet twice a day. The American Diabetes Association recommends you examine your feet daily for new areas of redness, new calluses, blisters, or skin changes. Since you are putting shoes on and taking them off, I recommend checking your feet twice a day. This provides you information on if a certain shoe or activity is causing any of these changes. If changes are noted to the feet, your feet should be checked by a foot and ankle specialist to help improve the problem before it becomes a bigger problem. As you examine your feet, you are performing the most important exercise to reduce wounds, infections and amputations.

4. Play an active part in managing your disease. No matter how good your doctor is, you are the key to good diabetic control. Learn all you can and work to reduce your diabetic foot complications (as well as other complications).

Remember in each of these keys, YOU make the difference. Preventing complications is a process not a destination and must be worked at on a regular basis.

Click here for additional information on diabetic foot complications.