Twenty-six bones per foot, plus two sesamoids under the first metatarsal head, forming 33 joints. They divide into three functional groups.

Rearfoot

Talus (no muscle attachments; transmits all body weight to the foot) and calcaneus (the largest bone; the Achilles inserts on its posterior surface).

Midfoot

Navicular, cuboid, and three cuneiforms (medial, intermediate, lateral). These form the arch's keystone region.

Forefoot

Five metatarsals and 14 phalanges — two in the hallux, three in each lesser toe.

Joints that govern fit and function

• Talocrural (ankle): a hinge between tibia, fibula and talus. Produces dorsiflexion and plantarflexion. Restricted dorsiflexion (equinus) drives forefoot pressure.
• Subtalar: talus on calcaneus. Inversion and eversion, and therefore the rearfoot component of pronation and supination.
• Midtarsal (Chopart's): talonavicular plus calcaneocuboid. Locks and unlocks the midfoot — the mechanism that lets the foot be a shock absorber at contact and a rigid lever at push-off.
• Tarsometatarsal (Lisfranc's): the junction between midfoot and forefoot. A common site of injury and of Charcot collapse.
• Metatarsophalangeal (MTP): where the foot bends and where the shoe must bend. The first MTP requires substantial dorsiflexion for normal roll-off.
• Interphalangeal (PIP, DIP): the joints that deform in hammer, claw and mallet toes.

Landmarks you will palpate

The arches

• Medial longitudinal — the tallest and most mobile; the one people mean when they say "arch."
• Lateral longitudinal — low, and in contact with the ground along the fifth ray.
• Transverse — across the midfoot and forefoot; flattens under load, which is why the forefoot widens when you stand.

Achilles tendon

The strongest tendon in the body, inserting on the posterior calcaneus. A tight Achilles limits dorsiflexion and shifts load forward onto the forefoot.

Tibialis posterior

Principal dynamic supporter of the medial arch. Dysfunction produces progressive flatfoot with hindfoot valgus.

Tibialis anterior

Dorsiflexes the foot; weakness produces drop foot and a slapping gait.

Peroneals (fibularis longus and brevis)

Evert the foot and stabilise it laterally. Weakness contributes to lateral instability and inversion injury.

Intrinsic muscles

Stabilise the toes against the pull of the long flexors and extensors. Motor neuropathy wastes them, which is what produces claw toes in diabetes.

Plantar fascia

A thick band from the calcaneal tuberosity fanning out to the digits. Toe dorsiflexion tightens it and raises the arch — the windlass mechanism — converting the foot into a rigid lever for push-off.

Plantar fat pad

Specialised shock-absorbing tissue under the heel and metatarsal heads. It thins with age and migrates distally in claw-toe deformity, leaving bone closer to the skin. That is why an insert has to do the job the fat pad no longer can.

Roughly 60% stance, 40% swing in normal walking, with two brief periods of double support. Stance breaks down as follows.

1. Initial contact / heel strike — posterolateral heel meets the ground; peak impact load.
2. Loading response — the foot pronates to absorb shock and adapt to the surface.
3. Midstance — body weight passes over the supporting foot; the arch is loaded.
4. Terminal stance / heel off — the heel lifts; the windlass engages; the foot begins to supinate.
5. Pre-swing / toe off — propulsion through the first MTP joint.

Pronation and supination

Both are normal and both are necessary. Pronation is the tri-planar motion combining eversion, abduction and dorsiflexion; supination combines inversion, adduction and plantarflexion. Problems arise from timing and amount, not from the motions themselves. Excessive or prolonged pronation shows up as medial upper breakdown, a collapsed medial counter and callus under the second metatarsal head. A rigid supinated foot shows lateral wear, lateral column callus and poor shock absorption.

Reading a used shoe

• Normal: posterolateral heel wear, even forefoot wear.
• Medial upper bulge or collapsed counter: pronation or an unstable rearfoot.
• Toe-box roof wear or dorsal stretching: claw or hammer toes; insufficient depth.
• Distinct wear at the first MTP only: possible hallux rigidus or a forceful late propulsive phase.
• Asymmetric heel wear between the pair: gait asymmetry or a limb-length difference worth investigating.
• Insole imprint: the darkened, compressed areas map where the load actually goes.

Skin

• Inspect the plantar surface, dorsum, heel, margins and between every pair of toes. Colour, temperature, moisture, integrity, callus, blisters, fissures and scars all get recorded.
• Callus is a record of repeated pressure. Note the site, size and whether it shows hemorrhage, maceration or a dark core — those features mark it as pre-ulcerative.
• Corns are focal, usually over a bony prominence: hard corns dorsally over the toe joints, soft corns macerated between the toes.
• Fissures, typically at the heel margin, break the skin barrier and are entry points for infection.
• Scars from previous ulcers are permanently weaker tissue and re-ulcerate readily. Map them.

Nails

• Onychomycosis — thickened, discoloured, crumbling nail. Raises dorsal toe height and affects toe-box clearance.
• Onychocryptosis (ingrown) and onychauxis (gross thickening) both create pressure points inside the shoe.
• Subungual hematoma — bleeding under the nail, usually from a shoe that is too short or the foot sliding forward.
• Nail care is not within the fitter's scope. Document and refer.

Circulation

• Pulses: dorsalis pedis (dorsum, lateral to the extensor hallucis longus tendon) and posterior tibial (behind the medial malleolus). Record present, diminished or absent.
• Capillary refill: compress the nail bed or pulp and time the return of colour. Sluggish return suggests poor perfusion.
• Arterial signs: cool foot, hair loss, thin shiny skin, thickened nails, dependent rubor with elevation pallor, claudication or rest pain, delayed healing.
• Venous signs: pitting edema, hemosiderin staining above the ankle, warm skin, ulcers typically at the medial gaiter area.
• Formal vascular studies such as an ankle-brachial index are performed and interpreted by other providers — your job is to spot the signs and refer.

Protective sensation

• Tested with the 10-gram, 5.07 Semmes-Weinstein monofilament.
• Technique: demonstrate on the patient's arm first so they know the sensation. Then, with their eyes closed, apply the filament perpendicular to the skin, press until it buckles, hold about one second and remove. Total contact roughly one to two seconds per site.
• Do not apply over callus, scar or ulcer — those areas will not respond regardless of nerve status.
• Vary the timing and include occasional sham applications so the patient cannot anticipate.
• Failure to perceive the filament at any tested site indicates loss of protective sensation. That patient cannot feel injury and needs total-contact protection and close follow-up.

Other findings worth recording

• Vibration perception with a 128 Hz tuning fork at the hallux is often lost early in peripheral neuropathy.
• Reported symptoms: burning, tingling, electric or shooting pain, numbness, nocturnal pain, a sensation of walking on cotton wool.
• Symptoms and sensory loss do not track together. A patient can have severe pain with intact sensation, or a completely silent, insensate foot. Test rather than assume.
• New or rapidly changing neurological symptoms need medical evaluation, not accommodation.

Sustained hyperglycemia damages nerves and blood vessels and impairs the immune response and wound healing. The three neuropathies each contribute a different piece of the risk.

Sensory neuropathy

Loss of protective sensation. The patient does not feel the pebble, the seam, the blister or the burn. Damage accumulates unnoticed.

Motor neuropathy

Intrinsic muscle wasting, clawing of the toes, depressed and prominent metatarsal heads, distal migration of the plantar fat pad. Plantar pressure concentrates where the padding has gone.

Autonomic neuropathy

Loss of sweating leaves skin dry, inelastic and prone to fissuring. It can also cause abnormal blood flow that leaves a warm foot with poor tissue nutrition.

The ulcer triad

Most diabetic foot ulcers arise from the combination of neuropathy + deformity + repetitive stress, frequently completed by ill-fitting footwear. Remove any one element and the chain often breaks — which is the entire clinical rationale for the therapeutic shoe programme.

Charcot neuroarthropathy

• Progressive destruction of bone and joint in a foot with intact circulation but absent protective sensation.
• Acute presentation: warm, red, swollen foot, often without a wound and often without significant pain. Frequently mistaken for cellulitis, gout or a sprain.
• Late result: midfoot collapse and a rocker-bottom deformity with a plantar prominence that ulcerates readily.
• An acute Charcot foot requires immediate referral and offloading. Do not fit it, and do not delay.

Wagner classification of foot lesions

Commonly used stratification runs on sensation, circulation, deformity and history. The higher the category, the more protective the device and the shorter the follow-up interval.

Hallux valgus

Lateral deviation of the great toe with a prominent medial first MTP eminence, often with a bursa. Accommodate: width, depth, soft seam-free upper over the eminence.

Hallux rigidus / limitus

Degenerative restriction of first MTP dorsiflexion, dorsal osteophyte, pain at toe-off. Stiff sole plus forefoot rocker; extra depth for the dorsal bump.

Hammer toe

PIP flexion. Dorsal corn over the PIP, distal callus at the tip.

Claw toe

MTP hyperextension with PIP and DIP flexion. Prominent metatarsal heads plantarly and dorsal pressure on the toes. The classic neuropathic deformity.

Mallet toe

Isolated DIP flexion; callus at the toe tip.

Morton's neuroma

Interdigital nerve irritation, most often the third interspace. Burning radiating pain, relieved by removing the shoe. Wider forefoot, met pad proximal to the heads.

Metatarsalgia

Pain under the metatarsal heads with plantar callus. Cushioning, met pad or bar, rocker sole.

Plantar fasciitis

Medial calcaneal tuberosity pain, worst with the first steps after rest. Cushioned heel, arch support, firm counter.

Achilles tendinopathy / retrocalcaneal bursitis

Posterior heel pain and swelling. Avoid pressure at the insertion; a small heel lift and a soft, non-rigid topline help.

Pes planus

Low or collapsed medial arch, often with hindfoot valgus and forefoot abduction. Medial support, firm extended counter, straight or slightly inflare last.

Pes cavus

High, rigid arch, clawed toes, lateral instability, poor shock absorption. Cushioning and total contact; do not over-post.

Tailor's bunion (bunionette)

Prominence at the fifth MTP. Lateral relief, stretched toe box, wider last.

Haglund's deformity

Posterosuperior calcaneal prominence irritated by a rigid heel counter. Soften or relieve the counter area.

Rheumatoid forefoot

MTP subluxation, clawed toes, fat pad migration, fragile skin. Maximum depth and softness; expect fluctuating volume.

Edema and lymphedema

Volume varies through the day. Fit late, choose adjustable closures, generous depth and removable layers.

Limb-length discrepancy

Measure and document. Small differences may be accommodated internally; larger ones need an external build-up.

Devices for missing toes and partial-foot amputations are coded and provided differently from standard diabetic inserts, and the more proximal levels move outside non-custom scope. Recognise the level and route the patient correctly.

Check every order for:

• Patient identification that matches the person in front of you.
• The item ordered, described specifically enough to act on, with quantity.
• Diagnosis supporting the item.
• Prescriber's signature and date.
• Any specified modifications or material requirements.

• Medical: diagnoses and duration, diabetes control, prior ulceration, prior amputation, surgery, vascular disease, renal disease, neuropathy, arthritis, recent hospitalisation.
• Medications and allergies: including latex, adhesives, dyes, nickel, and topical sensitivities.
• Prior devices: what they had, what worked, what failed, and why they stopped wearing it. Past failure predicts future failure unless you find the cause.
• Function and activity: occupation, hours on feet, terrain, driving, exercise, assistive devices, fall history.
• Self-care capacity: vision, reach, dexterity, cognition, who inspects the feet, who helps with shoes.
• Footwear habits: what they wear now, indoors and outdoors, and whether they go barefoot at home.
• Social: living situation, support, transport to appointments, ability to return for follow-up.
• The patient's own goals. Ask directly. A plan that ignores what the patient wants gets left in the closet.

Most practices structure notes as S / O / A / P.

S — Subjective

What the patient reports: symptoms, history, goals, in their terms.

O — Objective

What you measured and observed: measurements, skin findings with site and size, sensory testing results, pulses, deformity, gait, current footwear condition.

A — Assessment

Your professional evaluation within scope — fit and functional findings, risk level, suitability. Not a medical diagnosis.

P — Plan

What will be provided, what was communicated, referrals made, and the follow-up interval.

Record-keeping rules

• Legible, accurate and contemporaneous — written at or near the time of service.
• Signed and dated, with your credential.
• Objective language. “Callus 1 cm under the second metatarsal head, right” beats “bad callus.”
• Corrections by single line-through, initial and date. Never erase, obliterate or write over.
• Record what you referred, to whom, and the patient's response — including a refusal.

• Open ulcer, draining wound, odour, or surrounding cellulitis.
• Warm, red, swollen foot with no wound — suspect acute Charcot or infection.
• Pre-ulcerative callus with hemorrhage, maceration or a dark core. Do not debride.
• New, unexplained deformity or a collapsing arch.
• Signs of acute ischemia: cool, pale or mottled foot, rest pain, absent pulses of new onset.
• New or rapidly progressing neurological symptoms.
• Any presentation requiring a custom-fabricated device made from a model of the foot.

Upper

Vamp

The forward section covering instep and toes.

Quarters

The sides and back of the upper, meeting at the back seam.

Throat

The opening where the vamp meets the lacing. Its construction defines blucher versus balmoral.

Topline / collar

The upper edge of the opening. Padding here prevents malleolar and Achilles irritation.

Tongue

Protects the instep from lace pressure. Gusseted tongues also keep debris out.

Eyelet stays

Reinforcement carrying the eyelets, taking the load of the closure.

Toe box

The volume over the toes. Height, width and shape are what accommodate deformity.

Toe puff / box toe

The stiffener that holds the toe box's shape. In therapeutic footwear it is deliberately soft or omitted.

Backstay

Reinforcement over the rear seam.

Linings

The internal surface against the foot. Smooth, seam-free and moisture-managing for the at-risk foot.

Structure and sole

Last

The three-dimensional form the shoe is built over. It sets shape, volume and proportion — the reason two shoes of the same stated size fit differently.

Heel counter

The stiffener at the rear controlling the calcaneus. Firm and correctly fitted is essential; extended medially it adds midfoot control.

Shank

Reinforcement between heel breast and ball, resisting torsion and supporting the midfoot. Steel, fibreglass or composite; an extended shank stiffens the shoe for rocker soles.

Insole board

The structural platform the upper is attached to.

Sockliner / removable insole

The liner you take out to make room for the multi-density insert.

Midsole

Cushioning layer, and the place where wedges, rockers and lifts are added.

Outsole

Ground contact and traction. Its material determines slip resistance and wear rate.

Heel base and heel breast

The heel block and its forward-facing surface. A broad base adds stability.

Toe spring

The upward curve of the sole at the toe that eases roll-off.

Feather edge

Where upper meets sole. A flush feather edge avoids a pressure ridge.

Construction matters because it determines whether the shoe can accept an external modification. A shoe you intend to fit with a rocker sole or a lift must have enough sole material and the right attachment method to take one.

Last shapes

• Straight last — forefoot in line with the rearfoot. The general therapeutic default.
• Inflare last — forefoot angled medially, for a foot with an adducted forefoot.
• Outflare last — forefoot angled laterally, occasionally used post-surgically or for an abducted forefoot.
• Combination last — narrower heel with a wider forefoot, for the very common foot that needs both.

Sizing systems

Widths step in girth increments of roughly 3/16 inch. Letter designations vary by manufacturer and are not standardised, which is one more reason the number in the shoe never decides the fit.

• A depth shoe carries roughly ¼ inch or more of additional depth throughout, creating room for a multi-density insert, deformity and dressings.
• For the diabetic shoe benefit, a depth shoe is expected to have a full toe box, be made from leather or an equivalent material, be available in a range of sizes and widths, and have some means of adjustment such as laces or straps. It comes with a removable non-customised insole that the therapeutic insert replaces.
• Custom-molded shoes are fabricated from a model of the patient's foot and are reserved for deformity that a depth shoe cannot accommodate. The severity of that deformity must be documented.
• Depth is the therapeutic feature that matters most. Without it, the insert simply displaces the foot upward into the toe box.

Throat patterns

• Blucher (open throat) — quarters lace over the vamp, so the throat opens wide. Maximum adjustability, easiest entry. The therapeutic default.
• Balmoral (closed throat) — quarters stitched under the vamp. Dressier, considerably more restrictive, poor for a high instep or edema.

Choosing a closure

Upper materials

• Soft full-grain leather and deerskin — mould to deformity over time, breathe well, durable.
• Stretch fabrics and knits — conform around a fixed bony prominence without loading it. The answer when leather will not stretch enough.
• Mesh — light and breathable, but check that overlays and seams do not sit over prominences.
• Synthetics and coated materials — easy to clean but poor breathability; watch for moisture problems.
• Whatever the material: smooth, seam-free linings over anything prominent, and no internal ridges.

Durometer

Durometer measures hardness, usually on the Shore A scale for these foams. Lower number, softer material. It is not the same as density or thickness. Coverage descriptions for custom inserts specify a base layer of a stated minimum thickness and minimum durometer, which is a reminder that the base layer is doing a structural job.

Layering logic

• Top layer: soft, conforming, low friction — contacts the skin and achieves total contact.
• Intermediate layer: shock-absorbing, resists bottoming out — where a met pad or relief is usually built in.
• Base layer: firmer, structural — provides support, holds the shape and carries any posting.

A single soft material would compress out within weeks; a single firm material would not conform. That is the whole argument for a multi-density insert.

• Total contact. Pressure equals force divided by area. Spreading load across the whole plantar surface, including filling the arch, lowers peak pressure everywhere. This is the central principle for the neuropathic foot.
• Offloading. Relieve a specific site by transferring its load to adjacent tissue that can tolerate it — a met pad shifts load from the heads onto the shafts.
• Accommodation before correction. A rigid deformity is accommodated; only a flexible one can be influenced. Trying to correct a fixed deformity creates a pressure point.
• Do not create an edge. Every relief, pad and post needs a feathered transition. A sharp border becomes a new pressure ridge.
• Beware the relief hole. Cutting a hole under a lesion often raises pressure at its rim. Broad offloading around the site is safer than a window through the middle of it.
• Account for volume. Every millimetre of insert is a millimetre taken from the shoe. Design the insert and select the shoe together, never in sequence.

• Internal heel lifts are practical up to about ¼ inch; beyond that they displace the heel out of the counter and steal depth, so the correction goes external.
• External build-ups are tapered and paired with a rocker so the shoe still rolls, and the outsole must remain level and stable.
• Under the diabetic shoe benefit, modifications may be substituted for a pair of inserts rather than added on top of the annual allowance.

• State the goal in the patient's own terms: protect the skin, spread the pressure, make room for the deformity, reduce the pain, keep them walking.
• Cover before ordering: what the device will and will not do, the wear-in requirement, the follow-up schedule, and the cost or coverage position.
• Use plain language and check comprehension with teach-back — ask the patient to explain the plan in their own words. A yes/no “do you understand?” hides gaps.
• Involve the caregiver whenever the patient cannot inspect their own feet or manage the shoes, and use a qualified interpreter where language is a barrier.
• Where the patient's expectation cannot be met safely, say so honestly, explain why, and offer what can be done. Document the discussion.
• Adherence is a clinical variable. Within the constraints of the assessment, honour preferences on style and colour — a shoe that stays in the box protects nobody.

What the device reads

• Heel-to-toe length — overall foot length.
• Heel-to-ball (arch) length — heel to the first MTP joint. This determines where the ball sits relative to the shoe's flex point.
• Width — girth at the ball.

Technique

1. Measure late in the day where possible, with the patient wearing the sock they will actually use.
2. Patient standing, full weight on both feet. Loading lengthens and widens the foot.
3. Heel firmly seated in the heel cup, foot straight on the device.
4. Read length, then slide the arch pointer to the first MTP joint and read arch length.
5. Bring the width slide snug against the fifth metatarsal head — contact, not compression.
6. Measure both feet. Record both.

The numbers

• One full US size ≈ ⅓ inch; one half size ≈ ⅙ inch.
• One width grade ≈ 3/16 inch of girth.
• Men's and women's scales differ by about 1½ sizes for the same length. Read the correct scale.

Difficult feet

• A fixed deformity that will not sit flat on the device: record the device reading, add direct measurements and a tracing, and describe the deformity in the note.
• Partial-foot amputation: measure the intact side for reference and record the residual foot's dimensions directly.
• Severe edema: note the time of day the measurement was taken, since it is part of interpreting the number.

Common fit errors and what they produce

1. Read the manufacturer's instructions. They specify the temperature, dwell time and moulding method for that exact product, and they are the authority — not experience with a similar-looking material.
2. Pre-heat the low-temperature oven to the stated temperature and confirm it with a thermometer rather than trusting the dial.
3. Heat for the stated time. Overheating destroys the cell structure, causing shrinkage, scorching and permanent loss of resilience; underheating gives an incomplete mould.
4. Check the surface temperature yourself before it touches the patient. An insensate patient cannot warn you about a burn.
5. Mould as directed — commonly weight-bearing or semi-weight-bearing, with the foot in a neutral, well-supported position.
6. Hold until fully cooled and dimensionally stable before trimming.
7. Trim to the shoe's own removable sockliner as the template, then confirm it seats flat with the patient standing in the shoe.
8. Inspect for buckling at the toe, curling at the heel, and any edge that could form a ridge.

Metatarsal pad

Placed just proximal to the metatarsal heads, supporting the shafts and unloading the heads. Directly beneath the heads it becomes a pressure source.

Metatarsal bar (internal)

A transverse version of the same principle, spanning the full width proximal to the heads.

Scaphoid / navicular pad

Medial arch fill and support, referenced to the navicular tuberosity.

Tongue pad

Takes up instep volume. The first answer for heel slip in a shoe of correct length.

Heel pad or cushion

Focal shock absorption at the calcaneus.

Heel lift

Small internal elevation, practical to about ¼ inch.

Toe filler

Occupies the void left by amputated toes, preventing forward migration and shear.

Relief or accommodation

Local excavation of the insert under a prominence, with feathered edges — not a sharp-walled hole.

Feather every addition into the surrounding surface. An abrupt edge on an insert is a new pressure ridge, which is the opposite of what you were trying to achieve.

Stretching

• Ball-and-ring stretcher for a localised prominence — a bunion, a bunionette, a dorsal exostosis.
• Full-shoe stretchers for general width or instep, used sparingly.
• Stretching relieves a spot; it does not change the shoe's size or its underlying last shape. If the shoe is the wrong shape, stretching will not rescue it.
• Anything requiring permanent alteration of the shoe's structure, or a device fabricated from a model of the foot, is outside the non-custom scope.

1. Correct patient, correct item, correct quantity, matching the order.
2. Correct size and width, verified by fit assessment with the insert installed.
3. Sockliner removed, insert seated flat, no buckling.
4. Interior hand-checked for defects; exterior inspected for damage.
5. Fit assessed seated, standing and walking.
6. Patient demonstrates don, doff and fasten — watched, not assumed. If they cannot, change the closure or train the caregiver.
7. Education delivered and understanding confirmed by teach-back.
8. Written instructions provided.
9. Documentation completed and proof of delivery obtained.

Break-in schedule

• Day one: roughly 1–2 hours, indoors, then remove and inspect the skin.
• Increase gradually over one to two weeks provided the skin stays clear. Skin response, not elapsed time or comfort, is what permits the next increase.
• Applies to replacement pairs of the same model too — new materials are firmer and load differently.
• They wear their old footwear home from the fitting. The first wear is a monitored one at home.

The pressure red flag

Redness that has not faded about 20–30 minutes after removing the shoe means excessive pressure. Stop wearing that shoe and call the office.

Daily foot care

Device care

• Clean inserts per the manufacturer's instructions; never machine-wash or heat-dry.
• Replace inserts when they compress, delaminate or stop rebounding — they are consumables.
• Keep the follow-up appointment even if everything feels fine, because on an insensate foot “feels fine” proves nothing.

• Measurements taken, both feet, and the conditions under which they were taken.
• Product supplied: make, model, size, width, quantity, insert type and any modifications.
• Fit assessment findings, seated, standing and walking.
• Any adjustment performed, and why.
• Education delivered, including the wear schedule and inspection instruction, and confirmation the patient understood.
• Whether the patient can independently don, doff and fasten, and who will assist if not.
• Skin condition at delivery.
• Date, signature, credential, and proof of delivery.
• Follow-up appointment date given.

The purpose is simple: find the pressure problem while it is still redness rather than an ulcer, and find the fit problem before the patient stops wearing the device.

• See a new device early — commonly within one to two weeks — and sooner for a high-risk foot.
• Then at planned intervals set by risk, and at any time the patient reports a problem.
• Highest-risk feet (prior ulcer, prior amputation, active deformity, end-stage renal disease) get the shortest intervals.
• An intact, sensate, low-risk foot can go considerably longer.
• Annual review before reordering is a minimum, not a maximum.

1. Subjective feedback — comfort, pain, what they like and avoid, whether their stated goals are being met, any incident since delivery.
2. Wear history — actual hours per day, where, with what socks, whether the break-in schedule was followed. Ask in a way that makes an honest answer easy.
3. Skin re-assessment — both feet, plantar, dorsal, heel, margins, between every pair of toes. New callus, blisters, redness, maceration, colour change, warmth, drainage.
4. Fit re-assessment — length, width, depth, heel fit, ball position, all weight-bearing, all with the insert in place. Re-measure when anything has changed.
5. Device inspection — inserts for compression, bottoming out, delamination, cracking, soiling and wear pattern; shoes for upper stretch, counter collapse, closure failure and outsole wear.
6. Function — watch them walk; confirm they can still don, doff and fasten.
7. Adjust, re-educate, re-plan, document.

• Inserts are consumables. They compress with use and lose their protective properties before they look worn out, which is why coverage allows multiple pairs per year and why replacement is scheduled rather than reactive.
• Replace an insert when it is compressed flat, has stopped rebounding, has delaminated or cracked, has lost its moulded shape, or is contaminated beyond cleaning.
• Replace or repair a shoe when the counter has collapsed, the upper has stretched beyond adjustment, the closure has failed, or the outsole is worn enough to alter the gait.
• Heavier patients, longer hours on the feet and rougher terrain all shorten the interval. Ask about the patient's actual usage rather than assuming.
• Soiling and odour are not merely cosmetic — they can flag excessive moisture, unreported drainage or a hygiene problem worth solving.

A patient who is not wearing the device always has a reason. Find it.

• The plan belongs to the patient, not the chart. Tell them: when to return, what would bring them back sooner, who to call, and what happens next visit — and give it in writing.
• Report findings, adjustments and referrals to the referring or treating provider. You are part of the care team, not a retail transaction at the end of it.
• Document every contact, including phone calls, and what advice was given.
• A missed follow-up on a high-risk foot is a clinical event: attempt contact, document the attempts, and notify the referring provider as appropriate.
• If a patient declines a recommended referral, explain the risk clearly, document the recommendation and the refusal, and inform the referring provider.
• Clinical photographs require patient consent and are handled as protected health information under the practice's policy.

Covered under Part B as durable medical equipment, prosthetics, orthotics and supplies. Three conditions must all be met.

1. The patient has diabetes mellitus.
2. The patient has at least one qualifying foot condition.
3. A certifying physician — an MD or DO managing the patient's diabetes under a comprehensive plan of care — documents the diabetes and the qualifying condition and certifies the need for the footwear.

The six qualifying conditions

• Previous amputation of the foot or part of the foot
• History of previous foot ulceration
• History of pre-ulcerative callus
• Peripheral neuropathy with evidence of callus formation
• Foot deformity
• Poor circulation

Three roles, not interchangeable

Certifying physician

The MD or DO treating the diabetes. Cannot be the supplier.

Prescriber

Writes the order for the specific item.

Supplier

Furnishes and fits the footwear, and holds the documentation.

Annual allowance, per calendar year

• One pair of depth shoes plus three pairs of inserts (not counting the non-customised removable insole supplied with the shoes), or
• One pair of custom-molded shoes, which includes one pair of inserts, plus two additional pairs of inserts.
• A modification may be substituted for a pair of inserts — substituted, not added on top.
• Quantities beyond these are denied as non-covered.

Codes in the family

• Shoes and inserts are billed per item, not per pair — one pair of shoes is two units, three pairs of inserts is six units.
• A5500 and A5501 are mutually exclusive for the same shoe.
• These A-codes apply only to diabetic footwear. Inserts and modifications for L-coded orthopaedic footwear use L codes, and devices for missing toes or partial-foot amputation are coded separately again.
• A custom-molded shoe requires documented deformity that a depth shoe cannot accommodate.

The documentation chain the supplier keeps

• The certifying physician's statement
• The order for the specific item
• Evidence of the in-person evaluation supporting the need
• The supplier's own fitting and delivery record
• Proof of delivery
• An Advance Beneficiary Notice of Noncoverage where an item may not be covered — given in writing before furnishing, so the patient can decide whether to accept financial responsibility

• Protected health information is any individually identifiable health information — including appointment records, photographs, and the fact that someone is a patient at all.
• Minimum necessary: use and disclose only what is needed for the task. Working at the same organisation does not create a right of access.
• Disclosures for treatment, payment and healthcare operations are generally permitted; most others require the patient's authorisation.
• Before discussing a patient with a family member, verify the caller's identity and confirm the patient has authorised disclosure to that person. Record the authorisation.
• Patients have a right of access to their own records. The practice's release process governs how, not whether.
• Physical safeguards matter as much as electronic ones: charts closed, screens turned, conversations held where they cannot be overheard, a discreet area for examination and fitting.
• Loss or theft of unsecured PHI triggers breach assessment and notification. Follow the practice's documented response policy.
• Never share clinical images or details outside authorised clinical use.

OSHA requirements you will meet in practice

• Bloodborne pathogens standard — exposure control plan, training, hepatitis B vaccination offer, PPE, sharps handling, post-exposure procedure.
• Hazard communication — labelled containers, employee training, and accessible safety data sheets for adhesives, solvents, cleaners and grinding materials.
• Machine guarding and dust extraction at grinders and trimmers, with eye and respiratory protection.
• Regulated medical waste in labelled containers, per the facility's plan.

Standard precautions

• Treat all blood and body fluids as potentially infectious, regardless of known status.
• Hand hygiene before and after every patient contact is the single most effective measure. Gloves supplement it; they never replace it.
• Gloves for contact with non-intact skin, wounds, dressings or body fluids — and hand hygiene immediately after removing them.
• Clean and disinfect measuring devices, fitting stools and contact surfaces between patients.
• Dispose of contaminated dressings as regulated medical waste, not general refuse.

A safe patient environment

• Stable seating, clear circulation space, non-slip flooring, and adequate lighting for skin inspection.
• Fall prevention is part of care, particularly with patients who are neuropathic, visually impaired or unsteady.
• Incidents are documented objectively and reported per policy, whether or not an injury resulted.

ADA

Accessible facilities and effective communication for patients with disabilities — including hearing, vision and mobility accommodations.

FDA

Regulates therapeutic footwear and inserts as medical devices, with labelling requirements and adverse-event reporting.

Supplier standards

Medicare DMEPOS suppliers must meet enrolment standards covering licensure, insurance, hours, complaint handling and record retention.

Facility accreditation

Standards covering the care environment, records, safety, personnel qualifications and quality improvement. Required for DMEPOS billing.

State licensure

Some states license or register footwear and orthotic providers independently of national certification. Comply with both.

Fraud, waste and abuse

• False Claims Act — no billing for items not furnished, not delivered, or not meeting coverage criteria; no upcoding.
• Anti-Kickback Statute — no payment, gift or other value in exchange for referrals or purchasing volume. Disclosure does not cure it, and the size of the benefit does not matter.
• Beneficiary inducement — routine waiver of copayments to attract business is improper. Documented hardship handled under a formal policy is a different matter.
• Claims follow delivery. Billing before the item is furnished is a false claim regardless of intent.

• Patient welfare first. Where any other interest conflicts with it, the other interest yields.
• Practise within scope and competence. Refer when the patient's need exceeds either.
• Represent credentials accurately. Do not imply certification or a scope you do not hold. The credential is written Certified Fitter — therapeutic shoes (CFts).
• Honest recommendations. Base them on clinical need, present options and costs truthfully, and never let margin drive the choice.
• Own errors. If you make a fitting mistake, tell the patient, correct it, document it, and inform the referring provider where relevant.
• Records reflect who did the work. Signing for a service you did not perform is falsification, regardless of how well it was done or how close you were standing.
• Confidentiality, dignity and non-discrimination in every encounter, with a private area for examination and fitting.
• Maintain the credential through continuing education and compliance with the certifying body's requirements and disciplinary process.

• Legible, accurate, contemporaneous, signed and dated with credential.
• Objective language; observations rather than conclusions.
• Corrections by single line-through, initial and date — never erased or obliterated.
• Retained for the period required by applicable federal, state and payer requirements, which differ — policy should follow the longest applicable one.
• Stored securely, with access limited to those who need it.
• Every clinical contact recorded, including phone calls, missed appointments and outreach attempts.