Friends of the oppressed foot?

T he title of this editorial originates from an article in the " Herald Tribune " from 1889 entitled " Think of the Feet, " which stated that the human foot is cruelly oppressed in the civilized world. It remarked that shoes were made too tight and " in utter defiance of the shape of the foot, " resulting in " the foot being outraged from morning till night. " Readers of Diabetes Care in the new millennium may well ask, " what has changed in the last 110 years? " When Ella Fitzger-ald was interviewed in 1993 and asked what resulted in her major amputations, she replied, " I liked to wear pointy-toed evening shoes. " Today, despite major steps in our understanding of the patho-genesis of diabetic foot disease, there is no evidence of any consistent reduction in amputation rates among diabetic patients in western countries, even in the Veterans Health Administration (VA) system; May-field et al. (1) recently reported that whereas there was an overall reduction in major amputations in the VA population, such a reduction was not observed in Veterans with diabetes. Footwear is probably one of the major reasons for the lack of progress in reducing foot ulceration and amputation rates. It is well recognized that shoes are a major cause of minor trauma that features in the pathways to both ulceration (2) and amputation (3). The pivotal role of appropriate footwear was recognized in the 1999 American Diabetes Association Consensus Development Conference on Diabetic Foot Wound Care (4). In this issue of Diabetes Care, the article by Dahmen et al. (5) from Amster-dam is, therefore, a welcome addition to the literature. They propose a simple algorithm for use in the selection of appropriate shoe gear for the neuropathic foot. However, it is not perfect, because, as the authors admit (though no fault of their own), whereas some components of the algorithm are evidence-based, most are opinion-based. This highlights a major problem in the area of diabetic foot re-search— the lack of evidence-based studies (6). Of 2,348 randomized controlled trials of diabetes management identified by the Cochrane Diabetes Group, only 3% were concerned with the diabetic foot (6). Few studies have focussed solely on footwear (7). Many studies, including those recently published by Dargis et al. (8) and Faglia et al. (9), show reduced reulceration rates in patients with a previous history of ulceration that …