Diabetic neuropathy is a common complication of diabetes that causes nerve damage, often leading to a loss of sensation in the feet. This loss of feeling means that minor injuries, like blisters, cuts, or abrasions from ill-fitting shoes, can go unnoticed for extended periods. Poor circulation often accompanies diabetes, meaning a small, unobserved wound can quickly escalate into a severe infection or a non-healing ulcer. Selecting appropriate footwear is the primary preventative measure against foot complications because the natural protective sensory feedback is compromised. The goal of specialized diabetic shoes is to shield the foot from external trauma and prevent internal pressure points that could lead to tissue breakdown.
Crucial Design Elements for Protection
Footwear designed for the neuropathic foot must provide specific attributes to prevent injury and pressure concentration. One necessary feature is a wide and deep toe box, which allows ample space to accommodate toe deformities like hammertoes or bunions, and prevents the toes from pressing against the shoe’s sides or top. Extra depth is also needed to house custom or multi-density orthotic inserts, which are thicker than standard insoles and play a significant role in pressure distribution.
The shoe’s interior construction is equally important, demanding a smooth and seamless lining. Any internal stitching, seams, or tags can create friction against the skin during movement, and this repetitive rubbing can lead to blisters and ulcers on an insensitive foot. Materials for the upper part of the shoe should be soft, breathable, and flexible, such as certain leathers or advanced stretchable synthetics, to promote air circulation and conform gently to the foot’s shape. Hard plastics or stiff, pointed toe designs must be avoided as they create dangerous pressure points.
Many therapeutic shoes incorporate a rocker-bottom sole, characterized by a thick, rigid sole that curves upward at the toe and/or heel. This design is specifically engineered to reduce high plantar pressures—the weight-bearing forces on the sole of the foot—which are a primary cause of diabetic foot ulcers. The rocker shape assists the natural rolling motion of the foot during walking, minimizing motion in the small joints. This action transfers load away from the forefoot and metatarsal heads.
A secure closure system is also a non-negotiable feature for diabetic footwear. Laces, adjustable straps, or hook-and-loop (Velcro) closures are preferred because they allow the wearer to customize the fit throughout the day to accommodate natural swelling. Slip-on shoes are generally not recommended because they cannot be adequately tightened, potentially allowing the foot to slide and cause internal shear forces and friction.
Proper Sizing and Fitting Techniques
Since individuals with neuropathy cannot rely on pain to signal a poor fit, the fitting process requires specific, objective measurements. It is recommended that feet be measured regularly by a specialist, such as a certified pedorthist or podiatrist, because foot size and shape can change over time due to swelling or deformity. Professionals use specialized measuring devices to accurately determine both the length and the width of the foot, ensuring the shoe accommodates the entire foot structure.
Feet naturally swell throughout the day, meaning they are at their largest in the afternoon or evening. To select a shoe that will remain comfortable and safe all day, fitting sessions should be scheduled during this later time window. When trying on shoes, the wearer should always use the type of specialized diabetic sock or orthotic insert they intend to wear with the footwear.
A simple but effective fitting rule is to ensure there is approximately half an inch of space—the width of a thumb—between the end of the longest toe and the inside tip of the shoe. Equally important is checking the width at the ball of the foot, which should be the widest part of the shoe, to prevent compression and rubbing on the sides. Once purchased, shoes should be introduced gradually, often starting with only one hour on the first day and increasing the duration incrementally. After each wear, the feet must be immediately inspected for any signs of pressure, such as red spots or areas of darkness, which indicate an unsafe fit that requires adjustment.
Categorizing Specialized Diabetic Footwear
Diabetic footwear is classified into categories based on the patient’s level of risk and foot condition complexity. For individuals with mild neuropathy but no history of ulcers or significant deformities, over-the-counter comfort shoes with features like extra cushioning and a roomy toe box may be suitable. These shoes offer basic protection but lack the advanced therapeutic features.
The next category involves therapeutic or extra-depth shoes, which meet specific regulatory requirements, often identified by the Healthcare Common Procedure Coding System (HCPCS) code A5500. To qualify, shoes must have a full-length, removable filler that provides at least 3/16 inch of additional depth to accommodate specialized inserts. These shoes are designed for patients with a documented diagnosis of diabetes who also have conditions such as poor circulation, foot deformity, or peripheral neuropathy with callus formation.
Custom-molded shoes, designated by code A5501, represent the highest level of specialization and are reserved for patients with severe foot deformities that cannot be safely accommodated by an off-the-shelf depth shoe. These devices are constructed over a positive mold of the patient’s foot, ensuring a perfect, non-irritating fit for complex anatomical needs or post-amputation care. The use of custom orthotics and inserts, whether prefabricated or custom-molded (A5513), works in tandem with the shoe to distribute pressure evenly and reduce shear forces.
For qualifying patients, Medicare and other insurers often provide coverage for one pair of therapeutic shoes and three pairs of custom inserts per calendar year, provided they are prescribed by a managing physician.