Steel Toe Safety Boots In Prisons – Not Always The Best Choice

Steel Toe Safety Boots In Prisons | NIH: Shear-Reducing Insoles Prevent Foot Ulceration

Medicine is both an art and a science. While the implementation of steel-toe safety boots protects the institution and the majority of persons incarcerated, there is a significant, albeit small part of their population that may be harmed – however rare that may be.

As The Bureau states in their Program Statement 6031.01, Patient Care, (Page 58), they are responsible for providing one pair of safety shoes to each inmate, suitable for their job assignment. They would make custom shoes or orthotic devices available if needed that would have to be, medically necessary to accommodate a significant foot deformity or decrease the chance of injury to feet with impaired sensation.

The caveat here is that in a large bureaucratic institution, the patient/inmate may have to either pay their co-pay to be seen immediately for an unscheduled visit or wait for staff to provide a referral – either way, once prescribed, the wait time can be expected to be at best – “a while.”

The headline image I have chosen was for several reasons. To start, safety boots with a steel-toe box will provide protection, but in my opinion, after 30+ years of practicing in this space, I believe that there are other forces of concern. To start, the inner sole at the inside bottom of the boot has to have significant padding to cushion (or protect) the foot from shear forces, that over time could wear down the skin’s protective padding. The boots in 2006, had none.

Additionally, with correct insoles, biomechanical support would be of additional long-term benefit. When I was in a BOP facility years ago, there was nothing like this available, and I was left to figure out the protection and biomechanical issues on my own.

The medicare prescription shoe P6031.04 is referencing:

o   HCPCS code A5500 for diabetics only, custom preparation, and supply of off-the-shelf depth-inlay shoe manufactured to accommodate a multi-density insert(s), per shoe as maintained by CMS

o   ICD-10 Codes for Orthotic/Prosthetic — Diabetic Shoe

Then there is the steel toe, and while available in widths, new boots being what they are, take time to break in. During that period, a person’s toe that is rubbing against the hard, leather-steel binding, is a recipe for potential problems, no matter how rare. Then, with wear, the foot through the normal gait process over time, again no matter how rare, could rub against the steel toe box.

The patient/inmate does not have to be an out-of-control Diabetic, they could be a pre-diabetic, have Peripheral Vascular Disease (PVD), or Raynaud’s (which I still have), just to mention a few. Therefore, for those few who slip between the CARE LEVEL cracks, there may be some that need to get a toe or two amputated due to infections. But here is where Murphy’s Law presents itself, (where one amputation turns into multiple, more aggressive procedures) – some of which could have been avoided, with a little prevention.

I present several cases from NIH:

I) Intermediate-term outcome of primary digit amputations in patients with diabetes mellitus who have forefoot sepsis requiring hospitalization had presumed adequate circulatory status.

Outcome.

• Out of 92 patients with 97 forefoot infections, twenty-two had foot amputations.
• Pre-op, all had presumed adequate forefoot perfusion (assumed good blood flow to their feet), as determined by noninvasive methods, was studied.

II) Midfoot amputations expand limb salvage rates for diabetic foot infections

Outcome.

• If surgery is indicated, these are likely options.
• Transtarsal amputations (removes even more of the foot – below the ankle) salvaged over half of nonhealing Transmetatarsal, Amputation (TMA)

III) Shear-reducing insoles to prevent foot ulceration in high-risk diabetic patients

Outcome.

• These results suggest that a shear-reducing insole is more effective than traditional insoles in preventing foot ulcers in high-risk persons, including those with diabetes.

Prevention In Medicine Is a Core Value

I believe that the responsibility for a client’s Mental and Physical Health should be safeguarded to protect them from themselves and others, …while providing a safe environment for the duration of their incarceration. Ultimately this is the responsibility of the Court, Defense Team, and BOP.

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Marc, Dr. Blatstein

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