Medicare may cover some of the cost for people with certain conditions who are at risk of injuries. Conditions include if you are under the active care of a MD or DO who documents your condition and if care from a non-professional would be hazardous because of the underlying systemic disease. Ask your podiatrist, NP, or PA if you qualify for coverage for routine foot care.
 
Medicare may also cover the cost of therapeutic shoes for individuals with diabetes. A podiatrist can work with your MD/DO if you have qualifying medical conditions that allow for Medicare coverage of routine foot care and/or therapeutic shoes. Your NP/PA can work with (incident to) the supervising MD/DO to create an order for therapeutic shoes. Your NP can work independently to order therapeutic shoes if he/she is enrolled in Medicare's Primary Care First Initiative.
There are many places to look for diabetic education. In a 2019 review about diabetic education, Smith et al. found that people turn to Facebook, Google, and YouTube to find answers. In their search for relevant material offered through YouTube, they found that of the first 100 videos that came up with the search diabetic foot care, over a third of them were classified as misleading. Smith et al. (2019) further identified the following topics as relevant to diabetic foot care.

 

Blood sugar: Target ranges, foods, exercise

Foot inspection: areas of friction, pressure, or injury

Exercise: fitness programs

Foot hygiene: daily washing and thorough drying

Skin care: lotions (emollients) and ointments (humectants), over the counter anti fungals

Toenails: proper length, width, and thickness

Foot protection: wearing shoes while walking

Socks: material, size, length, and form fitting to reduce wrinkles (pressure) or slack (friction)

Shoes: length, depth, width, sole, upper - breathability and give

Temperature protection: avoiding frozen toes or burnt feet

Circulation: things that help or inhibit blood flow to your toes

Seeing a podiatrist: pain, injury, balance

References:

Peter E. Smith, James McGuire, Michael Falci, Dilli Ram Poudel, Richard Kaufman, Mary Ann Patterson, Benjamin Pelleschi, Esther Shin; Analysis of YouTube as a Source of Information for Diabetic Foot Care. J Am Podiatr Med Assoc 1 March 2019; 109 (2): 122–126. doi: https://doi.org/10.7547/16-149

 

Diabetic Education

Foot with normal nails

Level 1 is basic routine foot care and can be performed by any RN. At this level, your nails are considered normal and you are able to trim your own nails. The nurse would provide an annual assessment for circulation and sensation as well as foot hygiene, footwear assessment, education, and recommendations.

Foot with toe deformities
Level 2 is intermediate routine foot care and can be performed by a podiatrist or an RN trained as a foot care nurse. At level 2, you may have one or more thick/long nails, corns/calluses, or you cannot trim your own nails. You may also have a loss of protective sensation or skin integrity issues. A foot care professional should perform an assessment every 4 months. He or she may also provide foot hygiene, trim toenails/fingernails, reduce corns and calluses, assess footwear, and provide education and recommendations.

Dystrophic Toenails
 
Level 3 is advanced routine foot care and can be performed by a podiatrist or an RN trained as a foot care nurse. At level 3, you may additionally have circulation and functional issues as well as complex nails and painful corns/calluses. A foot care professional should perform an assessment every 3 months. He or she may also provide foot hygiene, trim toenails/fingernails, thin toenails, reduce corns and calluses, assess footwear, and provide education and recommendations.
When nails grow too long, dead skin and debris are frequently under the grown out nail. There is a likely chance that live skin has grown out with the nail and debris. There is a risk of cutting this skin if the nail is cut to a normal length. For this reason, I cut nails to a length that I can differentiate the nail and skin, and I use a sanding drill to shorten the remainder of the nail. This is why thinning and shortening thick nails requires a double session. A podiatrist can stop any bleeding caused by cutting the hidden skin that grew out with the nail. If you or your loved one cannot sit for the length of a double session (1.5 hours), your best choice is to see a podiatrist who can address the risk involved with cutting nails quickly. Switching from one foot to the other is an option to rest one leg at a time, but the time requirement is necessary to reduce/eliminate the risk of injury and pain.

 
When to See a Podiatrist

Routine foot care is the thinning and trimming of nails and reduction of calluses and corns. The levels of routine foot care are described above. If there is pressure or pain caused by a nail or build up of debris, it may still be routine foot care in which a foot care nurse can help.

Infected Toe

Advanced foot care is when you are experiencing pain, redness, swelling, and blood/pus/exudate. These could be signs/symptoms of an infection and you should consult your podiatrist or primary care provider. If a nail has grown into the skin, you may benefit from a local anesthetic prior to removing that section of nail. For any wounds on the toes or feet, I recommend calling the Wound Care Center in Hyannis to see a wound care podiatrist.

 

More about Services

Risk Assessment

Circulation, skin integrity, protective sensation, gait issues, and well-being are highly influential factors that determine one's health. Pain is the greatest motivator to take action on foot and nail care, however neuropathy and loss of protective sensation will dull this sense. It is important to check sensation in your feet and toes. If you have profound loss of protective sensation, keeping skin soft and elastic is imperative, as well as inspecting your feet and shoes daily. Injury prevention is a key feature of one's well-being. Identifying potential issues and seeking help from professionals is the first step. A certified foot care nurse can assess for any potential issues and suggest when it's time to see your primary care provider or specialist. 

Toenail Trimming

Toenails grow approximately 3 mm per month. Factors affecting the growth rate include circulation, nutrition, and current health status, among others. A toenail will completely grow from start to end (matrix to free edge) by 18 months. 

 

Long toenails can rub against adjacent toes or grow into the same toe. If wounds develop, risk of infection becomes a serious concern. Infected wounds can lead to regular visits with a wound care professional or even amputation.

Nails that grow too long can also cause trauma to the nail bed if the nail rubs against the front of your shoe. Nail bed trauma can result in a callus under the nail, giving the appearance of a thick nail, but the inability to thin the nail to reduce the height. 

 

Toenail Thinning

Nails that are damaged from trauma, pressure and friction, and fungal invasion can become thick and brittle. A typical healthy nail is 0.8 mm thick. When nails thicken, it may increase a natural tendency to curve inward, causing painful ingrown nails and pincer nails. A limited study has shown the effectiveness of nail thinning and reducing nail curvature. Another benefit of nail thinning is reduced pressure and friction from footwear, which decreases nail bed trauma.

Corn and Callus Reduction

Thickened skin is evident in corns, calluses, plantar warts, and actinic keratosis (which is caused by long term sun exposure). The skin is protecting itself by building thicker layers, but these areas can 1) become pressure points, which inhibit circulation and 2) become inelastic and develop fissures, or cracks, that can be an entry point for infection.

To reduce thickened skin, reduce pressure and friction through foot and nail care as well as choice of footwear. Footwear can accommodate foot and toe deformities as well as gait issues such as overpronation. Footwear adjustments can be as simple as finding a pair of shoes with an insole that shows outside your weight bearing foot (i.e. your foot doesn't "spill over" the insole). Shoe sizing should take place at the end of the day, when your feet are the largest. Adjusting for gait issues may require custom made orthotics ordered or made by a podiatrist.

 

More about Special Features

Sterilized Tools

Cape Cod Foot Care only uses sterilized tools. Sterilization for routine foot and nail care is not required by the overseeing bodies; it is a value of Cape Cod Foot Care based on a high standard interpretation of The Center for Disease Control and Prevention (CDC) definitions of critical vs. semicritical items. I prefer dry heat sterilization, as there are fewer factors that influence successful sterilization compared to moist heat sterilization. Also, it is biologically verifiable, unlike high-level disinfectant. High-level disinfectant is typically used in U.S. based routine foot and nail care. The CDC recommends dry heat sterilization for sharp and metal instruments, as the heat can penetrate the full distance of the metal and is non-corrosive. Sterilization at Cape Cod Foot Care is accomplished through thorough manual cleaning, ultrasonic cleaning, and dry heat sterilization with three step verification (mechanical, chemical, and biological). All processes are environmentally friendly with no use of toxic chemicals.

ULPA Filter Dust Vacuum

Thinning nails, calluses, and corns with the use of a pedicure/podiatry drill creates airborne dust. ULPA (Ultra-Low Particulate Air) filtration eliminates 99.999% of dust particles that are 0.1 microns in diameter. As a comparison, HEPA (High-Efficiency Particulate Air) filters only eliminate 99.995% of dust particles that are 0.3 microns in diameter. The smaller the dust particle, the longer it remains airborne, therefore removing as many small dust particles as possible will reduce risk of breathing complications. I use an ULPA filter dust vacuum that virtually eliminates all dust created through nail, callus, and corn thinning.

 

Client Education

Peter E. Smith, James McGuire, Michael Falci, Dilli Ram Poudel, Richard Kaufman, Mary Ann Patterson, Benjamin Pelleschi, Esther Shin; Analysis of YouTube as a Source of Information for Diabetic Foot Care. J Am Podiatr Med Assoc 1 March 2019; 109 (2): 122–126. doi: https://doi.org/10.7547/16-149