Diabetic Shoes are Worthless

[Adam Smasher]

I talk a lot of crap on these forums so I wanted to make an actual post for a change. We love to complain about the job market and how ridiculous schooling is. I want to zero in on something else that is deserving of our scorn: diabetic shoes.

In a nutshell, I don’t believe diabetic shoes do anything. I know a lot of ink has been spilled on papers “proving” that they are effective in preventing ulcers, just like how there were some really well designed studies backing up the Cartiva implant. So why doubt the settled science? As so often happens in academic circles, once upon a time an idea took root in someone’s head that magical shoes could prevent ulcers. And that person shared that idea with others who all thought it sounded fine and that it was too boring of a claim to bother arguing. As the number of adherents to this proposition grew, so too would grow the amount of effort needed to refute what is, at a glance, a very innocuous claim. Besides, it seems intuitive that certain shoes would be better than others for preventing ulcers. After all, how often do our patients ask us “are these the shoes I should be wearing?”

My characterization of this process might not be entirely fair. The studies might very well be truly sound research with honest investigators acting in good faith. The studies are too boring to read, so we’ll never know for sure. What we do know is that outcomes of an intervention in an academic medical setting are not always reproducible in clinical practice. So expectations need to be tempered.

In order to be eligible for diabetic shoes, the patient needs to satisfy at least one of the following criteria:

• Neuropathy WITH callus formation
• Poor circulation
• History of ulcer
• History of amputation
• Preulcerative callus
• Foot deformity

These criteria are grounded in the diabetic risk factor triad—neuropathy, trauma, and foot deformity—originally identified by some group no one cares about. What’s peculiar is that each of these risk factors on their own is extremely inclusive. It’s actually harder to disqualify someone for shoes than to qualify them.

If you routinely monofilament all patients (not just diabetics) over the age of 80, you will find many of them have idiopathic peripheral neuropathy. [This can be used to qualify patients for routine foot care, a practice @Pronation would describe as a “very podiatric”] Makes sense, people get older, they lose their vision, they lose their healing, why wouldn’t some people lose feeling in their toes too? But somehow these patients have been able to walk the earth with neuropathy and they don’t get ulcers!

Ah ha, but remember the risk factors form a triad! The patient must have callus formation as well. I’m sure some APMA stooge would argue that any callus is a preulcerative callus. You can’t predict the future. You have no way of knowing with certainty that a callus won’t ulcerate. So neuropathy ultimately doesn’t matter. Therefore any callus should qualify someone for diabetic shoes.

Even without calluses, criteria like “poor circulation” and “foot deformity” are extremely broad. What’s poor circulation? A nonpalpable pulse? A weak pulse? A pulse you don’t try very hard to feel and therefore mark it as absent? And what’s a deformity? Obviously they had Charcot in mind. Pes planus and pes cavus sound fine. Hallux valgus? An adductovarus pinky toe? As long as it’s documented, the patient gets covered.

So fine, just about anyone with diabetes can get shoes, and maybe it’s better too many patients are in them than too few. The problem is that among patients who do go on to ulcerate, the diabetic shoes do nothing to prevent it. I have patients who adamantly remind me every January that they should get a new pair of diabetic shoes and yet they still ulcerate. Perhaps it’s a question of adherence, they say you have to wear your diabetic shoes at least 60% of the time to get any benefit (how is this claim even provable?), including in your own home, but think about what you’re asking of your patient. “These are the shoes that you must spend 2/3 of every waking moment in for the next year. Have a nice day.”

Over the course of my (admittedly short) career treating ulcers and diabetic foot infections, I have come to the conclusion that shoegear doesn’t make an enormous difference. Clearly, there are shoes that will cause problems. But it’s hard to say what benefits diabetic shoes confer beyond a well-fitting pair of store-bought running shoes. Furthermore, the emphasis on diabetic shoes distracts the patient from real problems like glycemic control and untreated/undiagnosed peripheral arterial disease. It’s like talking to a wall sometimes because I want patients to be worked up for PAD or schedule some kind of bumpectomy surgery to definitively offload them, while they have convinced themselves that all efforts at limb preservation hinge on their use of magic shoes.

I will admit one nice thing about diabetic shoes: the foam inserts that come with them are really easy to modify. Because it’s such a porous material, it’s very easy to glue metatarsal pads and forefoot posts. This is another one of Pronation’s “highly podiatric practices,” but idgaf, it actually works, and smart MAs can be trained to do it. [When doing this, bill an e/m service against a diagnosis of Q66.89 or whatever fits.] But if the shoes were truly as good as they are purported to be, they wouldn’t need modifications at all!

So where do I fit in the mix? Well, patients want em, their PCP says they should have em, so does ID and vascular, Medicare wants to pay for em, and I’m just a stupid podiatrist, so what right do I have to question anything? So I sign the mountain of forms, patients receive their magic shoes with 3 pair custom (foam box, lol) inserts, patients who were never going to ulcerate to begin with get a free pair of shoes, patients who were destined to ulcerate do so anyway, and I get money for basically being a bureaucrat. Which is nice but not a tremendous source of job satisfaction for me.

Which brings me to the real problem with diabetic shoes. I have zero problem whatsoever treating patients of lesser socioeconomic status. But this service offering selects for the stupidest, most obnoxious, most entitled sub-population of that group. Because there is no skill involved, only forms to be filled out, diabetic shoes cheapen the doctor-patient relationship into a transactional one while Uncle Sam picks up the tab. I don’t enjoy dealing with these people, and my staff have better things to do as well. I wouldn’t mind if it was a medical intervention that did something. But it’s not.

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[heybrother]

Good post. One of my least favorite things in the world is that diabetics with a MSK problem are commonly told they need a "custom orthotic" and are then sold diabetic shoes. Whatever trivial value diabetic shoes offer for ulcers, they offer even less for plantar fasciitis and other motion strain conditions.

 

[HardRoadPaved]

Stop right there. I need to pay off my diabetic shoe van and my second home in Maine before you criticize one of my revenue streams.

 

[Pronation]

I talk a lot of crap on these forums so I wanted to make an actual post for a change. We love to complain about the job market and how ridiculous schooling is. I want to zero in on something else that is deserving of our scorn: diabetic shoes.

In a nutshell, I don’t believe diabetic shoes do anything. I know a lot of ink has been spilled on papers “proving” that they are effective in preventing ulcers, just like how there were some really well designed studies backing up the Cartiva implant. So why doubt the settled science? As so often happens in academic circles, once upon a time an idea took root in someone’s head that magical shoes could prevent ulcers. And that person shared that idea with others who all thought it sounded fine and that it was too boring of a claim to bother arguing. As the number of adherents to this proposition grew, so too would grow the amount of effort needed to refute what is, at a glance, a very innocuous claim. Besides, it seems intuitive that certain shoes would be better than others for preventing ulcers. After all, how often do our patients ask us “are these the shoes I should be wearing?”

My characterization of this process might not be entirely fair. The studies might very well be truly sound research with honest investigators acting in good faith. The studies are too boring to read, so we’ll never know for sure. What we do know is that outcomes of an intervention in an academic medical setting are not always reproducible in clinical practice. So expectations need to be tempered.

In order to be eligible for diabetic shoes, the patient needs to satisfy at least one of the following criteria:

• Neuropathy WITH callus formation
• Poor circulation
• History of ulcer
• History of amputation
• Preulcerative callus
• Foot deformity

These criteria are grounded in the diabetic risk factor triad—neuropathy, trauma, and foot deformity—originally identified by some group no one cares about. What’s peculiar is that each of these risk factors on their own is extremely inclusive. It’s actually harder to disqualify someone for shoes than to qualify them.

If you routinely monofilament all patients (not just diabetics) over the age of 80, you will find many of them have idiopathic peripheral neuropathy. [This can be used to qualify patients for routine foot care, a practice @Pronation would describe as a “very podiatric”] Makes sense, people get older, they lose their vision, they lose their healing, why wouldn’t some people lose feeling in their toes too? But somehow these patients have been able to walk the earth with neuropathy and they don’t get ulcers!

Ah ha, but remember the risk factors form a triad! The patient must have callus formation as well. I’m sure some APMA stooge would argue that any callus is a preulcerative callus. You can’t predict the future. You have no way of knowing with certainty that a callus won’t ulcerate. So neuropathy ultimately doesn’t matter. Therefore any callus should qualify someone for diabetic shoes.

Even without calluses, criteria like “poor circulation” and “foot deformity” are extremely broad. What’s poor circulation? A nonpalpable pulse? A weak pulse? A pulse you don’t try very hard to feel and therefore mark it as absent? And what’s a deformity? Obviously they had Charcot in mind. Pes planus and pes cavus sound fine. Hallux valgus? An adductovarus pinky toe? As long as it’s documented, the patient gets covered.

So fine, just about anyone with diabetes can get shoes, and maybe it’s better too many patients are in them than too few. The problem is that among patients who do go on to ulcerate, the diabetic shoes do nothing to prevent it. I have patients who adamantly remind me every January that they should get a new pair of diabetic shoes and yet they still ulcerate. Perhaps it’s a question of adherence, they say you have to wear your diabetic shoes at least 60% of the time to get any benefit (how is this claim even provable?), including in your own home, but think about what you’re asking of your patient. “These are the shoes that you must spend 2/3 of every waking moment in for the next year. Have a nice day.”

Over the course of my (admittedly short) career treating ulcers and diabetic foot infections, I have come to the conclusion that shoegear doesn’t make an enormous difference. Clearly, there are shoes that will cause problems. But it’s hard to say what benefits diabetic shoes confer beyond a well-fitting pair of store-bought running shoes. Furthermore, the emphasis on diabetic shoes distracts the patient from real problems like glycemic control and untreated/undiagnosed peripheral arterial disease. It’s like talking to a wall sometimes because I want patients to be worked up for PAD or schedule some kind of bumpectomy surgery to definitively offload them, while they have convinced themselves that all efforts at limb preservation hinge on their use of magic shoes.

I will admit one nice thing about diabetic shoes: the foam inserts that come with them are really easy to modify. Because it’s such a porous material, it’s very easy to glue metatarsal pads and forefoot posts. This is another one of Pronation’s “highly podiatric practices,” but idgaf, it actually works, and smart MAs can be trained to do it. [When doing this, bill an e/m service against a diagnosis of Q66.89 or whatever fits.] But if the shoes were truly as good as they are purported to be, they wouldn’t need modifications at all!

So where do I fit in the mix? Well, patients want em, their PCP says they should have em, so does ID and vascular, Medicare wants to pay for em, and I’m just a stupid podiatrist, so what right do I have to question anything? So I sign the mountain of forms, patients receive their magic shoes with 3 pair custom (foam box, lol) inserts, patients who were never going to ulcerate to begin with get a free pair of shoes, patients who were destined to ulcerate do so anyway, and I get money for basically being a bureaucrat. Which is nice but not a tremendous source of job satisfaction for me.

Which brings me to the real problem with diabetic shoes. I have zero problem whatsoever treating patients of lesser socioeconomic status. But this service offering selects for the stupidest, most obnoxious, most entitled sub-population of that group. Because there is no skill involved, only forms to be filled out, diabetic shoes cheapen the doctor-patient relationship into a transactional one while Uncle Sam picks up the tab. I don’t enjoy dealing with these people, and my staff have better things to do as well. I wouldn’t mind if it was a medical intervention that did something. But it’s not.

First of all, are you kidding me bro? I monofilament everybody as I feel like this def bumps me up to a level 5 visit

 

[heybrother]

Monofilament testing is listed nowhere in the Medicare A, B, C criteria. It is mentioned for LOPS.

Class C findings

Claudication;

Temperature changes (e.g., cold feet);

Edema;

Paresthesias (abnormal spontaneous sensations in the feet); and

Burning.

 

[newfeet]

It gets patients to change their shoes at least once a year… there are people who come with their toes sticking out. 🤷🏽‍♂️.

 

[Pronation]

It gets patients to change their shoes at least once a year… there are people who come with their toes sticking out. 🤷🏽‍♂️.

That’s a simple fix

 

[Feli]

I have had good luck with DM shoes and insoles... mountains of research say they cut ulcer risk, hospitalization risk for foot, amp risk.

I Rx them for almost anyone who fits the criteria unless they flat out tell me they don't want or won't use them.
Sure, they are no more than properly measured running shoes (custom insoles can be good), but that's critical if they don't have it already.

I think anyone with neuropathy - diabetic or not - runs into trouble with ill fit shoes or not enough cushion.
There are the rare diabetics who naturally wear wide NBalance with soft insoles, but there are many more who wear tight shoes or Western Boots or sandals... and have issues.
I see those visits too often where the neuropathy patient was doing well but started a new job and new work boots, wore dress shoes for a wedding, tried new fashion shoes, etc... and ulcerated.
That's why the research is what it is and why 99% of payers copied the MCR shoe program to spend a little to save a lot later. on DM foot problems.

It's the same with the fillers and shoes after "successful" amp or Charcot immobilize... the surgery or the diagnosis can be great, but if it's not going to last very long if it's not followed up with shoes and custom insoles/filler... re-ulcer rate is sky high.

I am so glad all that stuff is a tiny % my practice these days.

 

[Adam Smasher]

I see those visits too often where the neuropathy patient was doing well but started a new job and new work boots, wore dress shoes for a wedding, tried new fashion shoes, etc... and ulcerated.

There's the problem. People are going to attend weddings and wear dress shoes. They are going to go to rodeos in cowboy boots. We can't move in with them. We can't wrap their feet in bubble wrap. These are the people who are destined to lose their toes, and magic shoes won't stop them.

I understand there is research. I am not going to ignore the countervailing evidence before my own eyes.

 

[HardRoadPaved]

The main issue is the race to the bottom for shoes/inserts. Reimbursements keep dropping. Fitters feel the burn and tell the distributors they want lower prices to acquire shoes and inserts. Manufacturer then makes a cheaper quality device that has poorly constructed materials that dont last a year until next pair can be reimbursed.

Other issue include:
1) Fitters who only order 5512 for everyone because they can be returned
2) Manufactures who use cheap foams for the 5513/4 + 5000 that flatten in a month
3) Manufacturers who charge crazy prices for modifying their shoes and then the fitter cant get reimbursed that value because only A5500 is payable. Then fitter starts improperly billing L codes to get the shank, lift, etc paid
4) Returns... ugh the returns. Dealing with patients and their sense of fashion. "that shoe looked better in the catalog"... :"i didnt order the shoe in white"
5) The MD/DO sign-off when the patient sees the PA/NP of the practice and MD/DO gets mad when their schedule fills with BS visit so the patient can get a damn pair of free shoes.
6) Dealing with mad patients that bought orthofeet off of Amazon and the quality is better than what you ordered trying to get a fair shake on reimbursement

 

[Hybrocure]

I have for the most part had good success with diabetic shoes and inserts for my ulcer patients, but I have a good prosthetist who is able to offload them well.

In fact, the problems I run into almost are when my neuropathic patients don’t like how the custom shoes feel, so they go back to wearing Nikes or whatever for their factory job then come back in with a new ulcer.


Now custom non-diabetic inserts for which I cast in office are another hassle entirely. They pay very well but sometimes you’ll get a patient who either

A) Expects the orthotic to solve all their foot problems.

Or

B) Is the type of patient who will never get better no matter what.

And then you’re stuck in a cycle of returns, modifications that probably won’t work, and eventually refunding them.

For 95% of non-DM orthotic customs though, generally a good cast of their foot and heel cushion/lift and met pad is all you need. I rarely mess with wedges or other stuff. I’ve found when I start messing with that stuff patients tend to have more issues. Maybe it’s user error because I hate biomechanics, who knows.

 

[PeaJay]

The local places that dispense by me offer diabetic shoes that are barely big enough to fit the trilayer insole. The toe boxes are all narrow and have leather straps across the mpjs that cause trouble.

I hate…hate… hate diabetic shoes. Rather have them wear Skechers or hey dudes. They may offer the support of a wet sponge and last approximately 2 weeks, but at least they don’t attempt to sell a pipe dream.

 

[shadesofgrey]

I've also had good success with DM shoes, particularly with sub met head ulcers. Now would they have done just as well with a high quality OTC plastizote insert and a running shoe? Probably, but they would never want to pay for it.

 

[air bud]

I talk a lot of crap on these forums so I wanted to make an actual post for a change. We love to complain about the job market and how ridiculous schooling is. I want to zero in on something else that is deserving of our scorn: diabetic shoes.

In a nutshell, I don’t believe diabetic shoes do anything. I know a lot of ink has been spilled on papers “proving” that they are effective in preventing ulcers, just like how there were some really well designed studies backing up the Cartiva implant. So why doubt the settled science? As so often happens in academic circles, once upon a time an idea took root in someone’s head that magical shoes could prevent ulcers. And that person shared that idea with others who all thought it sounded fine and that it was too boring of a claim to bother arguing. As the number of adherents to this proposition grew, so too would grow the amount of effort needed to refute what is, at a glance, a very innocuous claim. Besides, it seems intuitive that certain shoes would be better than others for preventing ulcers. After all, how often do our patients ask us “are these the shoes I should be wearing?”

My characterization of this process might not be entirely fair. The studies might very well be truly sound research with honest investigators acting in good faith. The studies are too boring to read, so we’ll never know for sure. What we do know is that outcomes of an intervention in an academic medical setting are not always reproducible in clinical practice. So expectations need to be tempered.

In order to be eligible for diabetic shoes, the patient needs to satisfy at least one of the following criteria:

• Neuropathy WITH callus formation
• Poor circulation
• History of ulcer
• History of amputation
• Preulcerative callus
• Foot deformity

These criteria are grounded in the diabetic risk factor triad—neuropathy, trauma, and foot deformity—originally identified by some group no one cares about. What’s peculiar is that each of these risk factors on their own is extremely inclusive. It’s actually harder to disqualify someone for shoes than to qualify them.

If you routinely monofilament all patients (not just diabetics) over the age of 80, you will find many of them have idiopathic peripheral neuropathy. [This can be used to qualify patients for routine foot care, a practice @Pronation would describe as a “very podiatric”] Makes sense, people get older, they lose their vision, they lose their healing, why wouldn’t some people lose feeling in their toes too? But somehow these patients have been able to walk the earth with neuropathy and they don’t get ulcers!

Ah ha, but remember the risk factors form a triad! The patient must have callus formation as well. I’m sure some APMA stooge would argue that any callus is a preulcerative callus. You can’t predict the future. You have no way of knowing with certainty that a callus won’t ulcerate. So neuropathy ultimately doesn’t matter. Therefore any callus should qualify someone for diabetic shoes.

Even without calluses, criteria like “poor circulation” and “foot deformity” are extremely broad. What’s poor circulation? A nonpalpable pulse? A weak pulse? A pulse you don’t try very hard to feel and therefore mark it as absent? And what’s a deformity? Obviously they had Charcot in mind. Pes planus and pes cavus sound fine. Hallux valgus? An adductovarus pinky toe? As long as it’s documented, the patient gets covered.

So fine, just about anyone with diabetes can get shoes, and maybe it’s better too many patients are in them than too few. The problem is that among patients who do go on to ulcerate, the diabetic shoes do nothing to prevent it. I have patients who adamantly remind me every January that they should get a new pair of diabetic shoes and yet they still ulcerate. Perhaps it’s a question of adherence, they say you have to wear your diabetic shoes at least 60% of the time to get any benefit (how is this claim even provable?), including in your own home, but think about what you’re asking of your patient. “These are the shoes that you must spend 2/3 of every waking moment in for the next year. Have a nice day.”

Over the course of my (admittedly short) career treating ulcers and diabetic foot infections, I have come to the conclusion that shoegear doesn’t make an enormous difference. Clearly, there are shoes that will cause problems. But it’s hard to say what benefits diabetic shoes confer beyond a well-fitting pair of store-bought running shoes. Furthermore, the emphasis on diabetic shoes distracts the patient from real problems like glycemic control and untreated/undiagnosed peripheral arterial disease. It’s like talking to a wall sometimes because I want patients to be worked up for PAD or schedule some kind of bumpectomy surgery to definitively offload them, while they have convinced themselves that all efforts at limb preservation hinge on their use of magic shoes.

I will admit one nice thing about diabetic shoes: the foam inserts that come with them are really easy to modify. Because it’s such a porous material, it’s very easy to glue metatarsal pads and forefoot posts. This is another one of Pronation’s “highly podiatric practices,” but idgaf, it actually works, and smart MAs can be trained to do it. [When doing this, bill an e/m service against a diagnosis of Q66.89 or whatever fits.] But if the shoes were truly as good as they are purported to be, they wouldn’t need modifications at all!

So where do I fit in the mix? Well, patients want em, their PCP says they should have em, so does ID and vascular, Medicare wants to pay for em, and I’m just a stupid podiatrist, so what right do I have to question anything? So I sign the mountain of forms, patients receive their magic shoes with 3 pair custom (foam box, lol) inserts, patients who were never going to ulcerate to begin with get a free pair of shoes, patients who were destined to ulcerate do so anyway, and I get money for basically being a bureaucrat. Which is nice but not a tremendous source of job satisfaction for me.

Which brings me to the real problem with diabetic shoes. I have zero problem whatsoever treating patients of lesser socioeconomic status. But this service offering selects for the stupidest, most obnoxious, most entitled sub-population of that group. Because there is no skill involved, only forms to be filled out, diabetic shoes cheapen the doctor-patient relationship into a transactional one while Uncle Sam picks up the tab. I don’t enjoy dealing with these people, and my staff have better things to do as well. I wouldn’t mind if it was a medical intervention that did something. But it’s not.

It's podiometric. Get it right.

 

[billBOB213]

I hate the DM shoes that are carried near my practice, too narrow and toe box isn’t deep enough. BUT I do send people out for them just for the inserts, as (has been said above) I can modify them.

My two favorite ‘DM shoes’ for patients to then put their 3 pairs of inserts in are:
-Air Monarchs (kohls for $65), these babies are amazing and frickin wide
-Avia shoes at Walmart for $28, they are a Hoka copycat (can’t think of the model name off the top of my head), and I printed out a little handout so patients can buy them online

I’ve had good success with getting patients the free DM shoes/inserts and then pairing it with a store bought shoe.

 

[Feeter]

There is evidence that secondary ulceration rate is decreased with use of foam diabetic inserts. So reulveration rate is lower with use of these inserts but no value in it if pt does t not have prior history of ulcers.

 

[Hungry_Anxiety8703]

The one pair a year some of these patients get is the only thing stopping some of my patients from continuing to walk around in dirty, disgusting, ill-fitted shoes that look like a breeding ground for infection.

 

[Pronation]

The one pair a year some of these patients get is the only thing stopping some of my patients from continuing to walk around in dirty, disgusting, ill-fitted shoes that look like a breeding ground for infection.

Humanitarian

 

[HardRoadPaved]

The one pair a year some of these patients get is the only thing stopping some of my patients from continuing to walk around in dirty, disgusting, ill-fitted shoes that look like a breeding ground for infection.

Sounds like a constitutional right to give shoes for all.

https://www.usdebtclock.org/

 

[Adam Smasher]

The one pair a year some of these patients get is the only thing stopping some of my patients from continuing to walk around in dirty, disgusting, ill-fitted shoes that look like a breeding ground for infection.

At this point though it's not really about the shoes. It's about patterns of behavior. Give them prescription shoes and some other destructive habit will be this person's downfall.

 

[Hybrocure]

At this point though it's not really about the shoes. It's about patterns of behavior. Give them prescription shoes and some other destructive habit will be this person's downfall.

Like sugar?

 

[iridocyclitiss]

I love how much this guy gets triggered by the posts on SDN.

 

[Adam Smasher]

View attachment 372603
I love how much this guy gets triggered by the posts on SDN.

I just re-read my post, it wasn't even criticizing podiatry, just the shoes. You could write a post "X is worthless" about anything you want (HBOT, topical antifungals, Cartiva implant). Why does Dr Ron have a love affair with shoes?

 

[Pronation]

I just re-read my post, it wasn't even criticizing podiatry, just the shoes. You could write a post "X is worthless" about anything you want (HBOT, topical antifungals, Cartiva implant). Why does Dr Ron have a love affair with shoes?

Shoes are an extremely important aspect of complete patient care for the total toenail replacement surgeon.

 

[HardRoadPaved]

And tolcyclen

 

[Pronation]

And tolcyclen

Oh definitely. It’s like this, but instead of champagne it’s the nectar of the gods (tolcylen)

 

[heybrother]

I just re-read my post, it wasn't even criticizing podiatry, just the shoes. You could write a post "X is worthless" about anything you want (HBOT, topical antifungals, Cartiva implant). Why does Dr Ron have a love affair with shoes?

My presumption is money - there's a post on Reddit where he describes situations where owners defraud associates by scheduling the patient for their "diabetic shoe visit" with the owner and not the associate.

 

[Pronation]

My presumption is money - there's a post on Reddit where he describes situations where owners defraud associates by scheduling the patient for their "diabetic shoe visit" with the owner and not the associate.

Doctor of Puma Medicine

 

[heybrother]

The East Coast sounds like a fabulous place.

 

[Hybrocure]

View attachment 372608

The East Coast sounds like a fabulous place.

East coast big city podiatry is so weird. Very predatory and is after all the birthplace of mustache podiatry. But I guess that’s what happens when you spend decades blocked out from surgery and any power by big ortho.

 

[heybrother]

East coast big city podiatry is so weird. Very predatory and is after all the birthplace of mustache podiatry. But I guess that’s what happens when you spend decades blocked out from surgery and any power by big ortho.

The above and Feli's post about misapplied copays are unbelievable to me. If you are misapplying copays (how) or moving patients between doctors for follow-up visits - something is just wrong with your practice. You are presumably just straight making up the assignment of billing and collections.

 

[Hybrocure]

The above and Feli's post about misapplied copays are unbelievable to me. If you are misapplying copays (how) or moving patients between doctors for follow-up visits - something is just wrong with your practice. You are presumably just straight making up the assignment of billing and collections.

I’d say it’s a HCOL area that causes people to behave like this but if you look at California or Seattle DPMs from my experience an associate podiatrist (for the most part) is treated and compensated far better than say NYC PP. West coast podiatry also doesn’t have the stigma of being restricted from every dang thing over the years and fighting over the scraps too. This means a stronger, more independent culture of podiatry that treats their own better.

Ever go to an IFAF conference? They’re the best. There’s just a different mentality between west and east coast podiatry that is hard to explain.

I think a lot of it is steeped in tradition, culture, and a mindset of “This was how it was when I started so it must be this way for you too.”

 

[PatchAdamsFan]

“This was how it was when I started so it must be this way for you too.”

This is true for many MD/DO residencies, but only in podiatry does it get significantly worse as an associate.

 

[diabeticfootdr]

Extra depth shoes and insoles (+/- custom) is a covered benefit for Medicare beneficiaries passed in federal law.

Plenty of research shows good footwear prevents DFUs. Even more robust research shows that poor footwear causes ulcers.

It could be argued to be malpractice if they’re not prescribed or considered in part of your assessment/plan for a patient who qualifies.

It’s a shame that the arguments against them in this thread are due to financial motivations on behalf of the provider.

 

[Pronation]

It could be argued to be malpractice if they’re not prescribed or considered in part of your assessment/plan for a patient who qualifies.

Loooool yea ok buddy. Also let’s be realistic here, 90% of the diabetics these TFPs give the footlocker experience to don’t really qualify for diabetic shoes.

 

[Feli]

Lol... malpractice for not Rx'ing DM shoes? I have heard it all.
They'd better get buses and buses ready to take all of the PCPs to the slammer, then.

Sometimes, I can't figure out how the univ/hospital people get so out of touch with normal practice. Perhaps it's the thin air up on the high horse, which helps them manage to see 15pts/day... although I'm sure it takes much longer to accomplish things "academically."
On the other side of the coin, it'd be awesome to see shoe Rx trends and rates among DPMs/groups that disp the shoes in-office or own the DME shop (supergroups, large groups, employ a CPed) versus the DPMs who get nothing from the Rx shoes and just send it to local DME places (Hanger, etc). It would probably be just like the utilization rates of ortho groups who owned MRI versus did not own.

 

[AttackNME]

I get the frustration when people get ulcers despite using the shoes. Even more frustrating when they don’t use them at all.

Effects of Special Therapeutic Footwear on the Prevention of Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

To reduce diabetic foot ulcer (DFU) occurrence or recurrence, diabetic therapeutic footwear is widely recommended in clinical practice for at-risk patients. However, the effectiveness of therapeutic footwear is controversial. Thus, we performed a systematic ...

www.ncbi.nlm.nih.gov

It’s true that there’s a statistical benefit to using the shoes per the above review, but it’s not very palpable. If you dig through the data and divide the incidence by the sample sizes, you’ll see what they mean by variability… incidence ranging from 1.12% to 38.82% for the intervention groups and 6.67% to 58.33% for the control groups. I think we all can feel this variability when we see patients in clinic. I’ll still rx diabetic foot shoes but it’s not the golden ticket to ulcer prevention.

 

[Adam Smasher]

Loooool yea ok buddy. Also let’s be realistic here, 90% of the diabetics these TFPs give the footlocker experience to don’t really qualify for diabetic shoes.

That's the thing though, the criteria are VERY inclusive! All you need is a "foot deformity" and that can mean anything!

The paperwork is hard but once you get the workflow down, it moves along fine. I prescribe at least 5 pair shoes/week. 20% of the time it's for someone I know is a massive risk and they go on to ulcerate no matter what I do. The other 80% it's someone just hassling me who probably doesn't need the shoes but happens to tick off the right boxes. The fastest way to get them out of my exam room is to write the rx so I can move on and hopefully render actual patient care for someone else.

 

[HardRoadPaved]

That's the thing though, the criteria are VERY inclusive! All you need is a "foot deformity" and that can mean anything!

and what is "poor circulation".... arterial? venous dz? lymphedema?
is "pre-ulcerative callus" like "pre-pregnant"? I'm warning ya... it can happen... that callus could turn any minute!

The fastest way to get them out of my exam room is to write the rx so I can move on and hopefully render actual patient care for someone else.

"Doctor... I never wear an 8.5M! I dont care if they fit... I've always been a 9XW"
"This shoe looked nothing like in the catalog"
"I wore these shoes just for the weekend and they are falling apart"... (shows obvious signs they cut the grass and did gardening in them)
"Why do I have to see my endocrinologist who is an MD? I only see Sarah, his NP?"
"Should I put on the shoes before or after today's pedicure? Just make sure to get my nails short when you do or I'll know in a month"
"Maybe I'll order the Mary Jane shoe. It will look great for church when I go for X-mas mass"

 

[billBOB213]

Yes, all the hard hitting questions we field as DPMs sometimes

 

[Pronation]

and what is "poor circulation".... arterial? venous dz? lymphedema?
is "pre-ulcerative callus" like "pre-pregnant"? I'm warning ya... it can happen... that callus could turn any minute!



"Doctor... I never wear an 8.5M! I dont care if they fit... I've always been a 9XW"
"This shoe looked nothing like in the catalog"
"I wore these shoes just for the weekend and they are falling apart"... (shows obvious signs they cut the grass and did gardening in them)
"Why do I have to see my endocrinologist who is an MD? I only see Sarah, his NP?"
"Should I put on the shoes before or after today's pedicure? Just make sure to get my nails short when you do or I'll know in a month"
"Maybe I'll order the Mary Jane shoe. It will look great for church when I go for X-mas mass"

Great post. These are all important inquiries from patients that the well rounded total toenail replacement surgeon needs to take into account.

 

[Adam Smasher]

"Doctor... I never wear an 8.5M! I dont care if they fit... I've always been a 9XW"
"This shoe looked nothing like in the catalog"
"I wore these shoes just for the weekend and they are falling apart"... (shows obvious signs they cut the grass and did gardening in them)
"Why do I have to see my endocrinologist who is an MD? I only see Sarah, his NP?"
"Should I put on the shoes before or after today's pedicure? Just make sure to get my nails short when you do or I'll know in a month"
"Maybe I'll order the Mary Jane shoe. It will look great for church when I go for X-mas mass"

My MA fields all those questions. Goes back to what I wrote above about obnoxiousness and entitlement. We do 2 exchanges before we refund their insurance and tell them "sorry, diabetic shoes are not for you"

Here's a question for the shoe believers. Say a patient shows up with risk factors (say neuropathy plus callus formation). You would say they need shoes to prevent an ulcer. But they've gotten this far with these risk factors. Why haven't they ulcerated already? Why won't they ulcerate between now and the dispense date 4-6 weeks out?

 

[Feli]

...Here's a question for the shoe believers. Say a patient shows up with risk factors (say neuropathy plus callus formation). You would say they need shoes to prevent an ulcer. But they've gotten this far with these risk factors. Why haven't they ulcerated already? Why won't they ulcerate between now and the dispense date 4-6 weeks out?

It's just a matter of getting that perfect storm of hyperglycemia + neuropathy + shoe friction (edema/ activities/ new job/ shoe fit/ whatever). It's not unlike Charcot for someone with those risks: much better to have the DME in place preventative than to scramble later.

We've all seen it 100x where "stable" patient ulcerates, whether we recognized it or not. That's why the shoes are covered: they don't make probability zero, but properly measured, it cuts down on rates. I've seen many ulcerate - or callus becomes hemorrhagic - in the month or two waiting for DM shoes.

 

[Adam Smasher]

We've all seen it 100x where "stable" patient ulcerates, whether we recognized it or not. That's why the shoes are covered: they don't make probability zero, but properly measured, it cuts down on rates. I've seen many ulcerate - or callus becomes hemorrhagic - in the month or two waiting for DM shoes.

Probably you're right. I just have a hard time believing that the only thing standing between a patient and an amputation is a few layers of plastizote and rubber

 

[newfeet]

Probably you're right. I just have a hard time believing that the only thing standing between a patient and an amputation is a few layers of plastizote and rubber

I view it as one of the things. If they have bad diets, walk around barefoot all the time, wear slippers everywhere or never check their own foot ever... the shoes won't do anything at all. I have people who seem to like collecting diabetic shoes.

 

[DMEpod]

I've found that the good trilaminar inserts with proper shoes do some good for pts with chronic callus/ulceration. This is usually in those without huge deformity like charcot but often times it is better than surgery in these people that would dehisce if you look at an incision wrong. The shoes themselves are a bit hit or miss but I don't at all see them as worthless

 

[Hybrocure]

I've found that the good trilaminar inserts with proper shoes do some good for pts with chronic callus/ulceration. This is usually in those without huge deformity like charcot but often times it is better than surgery in these people that would dehisce if you look at an incision wrong. The shoes themselves are a bit hit or miss but I don't at all see them as worthless

Referral to the Goodfeet Store or your local Sketchers outlet for the Charcot

 

[DMEpod]

Referral to the Goodfeet Store or your local Sketchers outlet for the Charcot

I prefer to refer those to the local podiatrist with a laser. Usually within 10-12 treatments foot is plantigrade

 

[HardRoadPaved]

Probably you're right. I just have a hard time believing that the only thing standing between a patient and an amputation is a few layers of plastizote and rubber

rubbers do stop unwanted pregnancies

 

[p100]

I hate the DM shoes that are carried near my practice, too narrow and toe box isn’t deep enough. BUT I do send people out for them just for the inserts, as (has been said above) I can modify them.

My two favorite ‘DM shoes’ for patients to then put their 3 pairs of inserts in are:
-Air Monarchs (kohls for $65), these babies are amazing and frickin wide
-Avia shoes at Walmart for $28, they are a Hoka copycat (can’t think of the model name off the top of my head), and I printed out a little handout so patients can buy them online

I’ve had good success with getting patients the free DM shoes/inserts and then pairing it with a store bought shoe.

I went to Walmart this weekend and checked out the Avia shoes. The Hightail and Swift Trail models are pretty nice. The soles are noticeably firmer than my Brooks but similar to New Balance.