Therapeutic footwear in patients with diabetes: a position statement from the Italian diabetic foot study group

Prevention of diabetic foot ulcers is crucial, given the high risk of ulcer development (34%) and recurrence (> 40%), with up to 85% of amputations being preceded by ulceration. The most effective preventive intervention is the use of therapeutic footwear combined with custom-made insoles, which should be considered a true therapeutic strategy, comparable to metabolic control. Scientific evidence demonstrates that therapeutic footwear, particularly rigid-soled models with multilayer total-contact insoles, significantly reduces the risk of ulcer recurrence, provided that specific plantar pressure targets are achieved (< 200 kPa or a ≥ 30% reduction). Moreover, treatment adherence (at least 60-80% of daily active time) represents a critical determinant of effectiveness. This document aims to provide a practical approach to orthotic therapy by identifying the most appropriate prescription according to the patient's ulceration risk level (IWGDF classification) and the presence of foot deformities, while matching orthotic features to the clinical status of the foot for protective purposes. Prescriptions should be individualized and validated by a multidisciplinary team.