Among people with diabetes who have healed from a plantar foot ulcer, recurrence is the rule rather than the exception. Roughly 40% of patients re-ulcerate within one year, and approximately 60% within three years of healing. Because each new ulcer carries a measurable risk of infection, hospitalization, and amputation, preventing recurrence is one of the most clinically important goals in diabetic foot care. Therapeutic footwear and custom insoles, when correctly prescribed and consistently worn, are central to that effort.
Why Pressure Matters in the Insensate Foot
Diabetic peripheral neuropathy removes the protective pain feedback that normally prompts people to shift weight, change shoes, or stop walking when tissue is being injured. In this setting, repetitive mechanical stress at sites of elevated plantar pressure — most often the metatarsal heads, the hallux, and bony prominences in a deformed foot — drives both first-ever ulceration and recurrence. A 2020 comprehensive review in Diabetes/Metabolism Research and Reviews by Chatwin and colleagues documented a consistent association between higher in-shoe peak plantar pressure and ulcer risk, while also noting that no single barefoot pressure threshold reliably predicts ulceration across diverse patients. The clinical implication is that prevention should focus on relieving pressure at the wearer’s own high-risk sites, measured in the shoes they actually walk in.
What the IWGDF 2023 Prevention Guideline Recommends
The International Working Group on the Diabetic Foot (IWGDF) updated its prevention guideline in 2023, published in 2024 in Diabetes/Metabolism Research and Reviews (Bus, Armstrong, Crews, et al.). The guideline stratifies preventive intensity by IWGDF risk category and makes several specific recommendations regarding footwear:
- For people at moderate-to-high risk of ulceration (IWGDF risk 2–3), prescribe therapeutic footwear — including therapeutic shoes, custom insoles, or orthoses — that fits properly and accommodates any foot deformity.
- For people with a previously healed plantar foot ulcer (IWGDF risk 3), prescribe therapeutic footwear that has a demonstrated plantar pressure–relieving effect during walking, ideally verified by in-shoe pressure measurement.
- Encourage consistent indoor and outdoor wear, since most patients spend a large fraction of their weight-bearing time at home.
An accompanying systematic review and meta-analysis by van Netten and colleagues (2024) supported these recommendations, finding that therapeutic footwear can reduce ulcer occurrence and recurrence in at-risk patients, although effect sizes vary with the rigor of the prescription and how adherence is measured.
Pressure-Guided (“Data-Driven”) Custom Footwear
A central insight from the past decade is that footwear is most protective when it is designed and verified to lower pressure at each patient’s specific high-risk sites. In a 2020 PLOS ONE study, Arts, Bus, and colleagues demonstrated that data-driven custom-made footwear — designed using a patient’s in-shoe pressure map and adjusted iteratively — reduced peak forefoot pressures by 17% to 53% compared with non-therapeutic shoes. A 2022 systematic review and meta-analysis in the Journal of Diabetes Research reported that special therapeutic footwear, particularly designs incorporating a rigid rocker sole, reduced re-ulceration risk at the forefoot by up to 64% compared with semi-rigid alternatives. These findings underscore that the type of sole, the contour of the insole, and the offloading at metatarsal heads are not interchangeable design details — they are the mechanism by which protection is achieved.
Adherence: The Limiting Factor
Even the best-engineered shoe protects the foot only when it is on the foot. Studies summarized in the IWGDF guideline and a 2023 sensor-based analysis (Jarl et al., Sensors) show that adherence to prescribed footwear is often around 50% of waking hours and falls further indoors, where many patients walk barefoot, in socks, or in slippers. Because indoor steps can account for the majority of daily ambulation, this is exactly where many recurrent ulcers occur.
Two strategies have emerged from recent research. First, providing dedicated indoor therapeutic footwear has been shown to increase short- and long-term adherence in people with diabetes at high ulcer risk (Jarl et al., 2022; Journal of Foot and Ankle Research). Second, “smart” pressure-sensing insoles can give patients real-time feedback. A 2019 randomized proof-of-concept study in The Lancet Digital Health (Abbott et al.) found that an intelligent insole system reducing sustained high pressures was associated with fewer recurrent plantar ulcers compared with standard care, particularly in adherent users.
Clinical Summary
Preventing diabetic foot ulcer recurrence depends on more than dispensing a shoe. Current evidence supports an integrated approach: stratify patients by IWGDF risk, prescribe properly fitted therapeutic footwear with custom insoles, verify pressure relief at the patient’s high-risk sites using in-shoe measurement when feasible, address indoor walking with dedicated indoor footwear, and consistently reinforce adherence at every visit. Emerging technologies — including data-driven custom designs and pressure-sensing insoles — refine, rather than replace, this foundation. The clinical takeaway is straightforward: in the high-risk diabetic foot, footwear is not an accessory to care; it is a prescribed medical intervention whose effectiveness depends on engineering, fit, and consistent wear.
References
- Bus SA, Armstrong DG, Crews RT, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3651.
- van Netten JJ, Raspovic A, Lavery LA, et al. Prevention of foot ulcers in persons with diabetes at risk of ulceration: A systematic review and meta-analysis. Diabetes/Metabolism Research and Reviews. 2024;40(3):e3652.
- Chatwin KE, Abbott CA, Boulton AJM, Bowling FL, Reeves ND. The role of foot pressure measurement in the prediction and prevention of diabetic foot ulceration—A comprehensive review. Diabetes/Metabolism Research and Reviews. 2020;36(4):e3258.
- Arts MLJ, de Haart M, Waaijman R, et al. Data-driven directions for effective footwear provision for the high-risk diabetic foot. PLOS ONE. 2020;15(4):e0224010.
- Zhang X, Yuan Y, Xiao M, et al. Effects of Special Therapeutic Footwear on the Prevention of Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Journal of Diabetes Research. 2022;2022:9742665.
- Abbott CA, Chatwin KE, Foden P, et al. Innovative intelligent insole system reduces diabetic foot ulcer recurrence at plantar sites: a prospective, randomised, proof-of-concept study. The Lancet Digital Health. 2019;1(6):e308–e318.
- Jarl G, van Netten JJ, Bus SA, Hermansson LN. Adherence and Wearing Time of Prescribed Footwear among People at Risk of Diabetes-Related Foot Ulcers: Which Measure to Use? Sensors. 2023;23(3):1648.
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