Current strategies and priorities for diabetic footwear design and production: a cross-European exploratory survey of clinicians and shoemakers

Background: Therapeutic footwear plays an important role in preventing ulceration in people with diabetes. Despite guidelines recommending offloading footwear for individuals at risk of ulceration, limited data are available on the alignment between current industrial practices, clinical expectations, and evidence. This study explored current practices, priorities and challenges associated with diabetic footwear from manufacturers’ and clinicians’ perspectives across Europe. Methods: An exploratory cross-sectional survey was conducted between May and October 2025 to gather insights from diabetic footwear manufacturers and clinicians involved in diabetic foot care across Europe. A 26-item questionnaire was developed to explore product design, materials, innovation, and adherence to guidelines among manufacturers. Additionally, a separate 14-item questionnaire for clinicians examined footwear prescription, patient barriers, and industry communication. Quantitative data were analysed descriptively, and open-text responses underwent thematic analysis. Results: Nine manufacturers and twelve clinicians participated in the survey. While only half of the Manufacturers that completed the survey reported having a research and development department, most reported adopting data-driven design approaches (n = 8) and scientific literature (n = 7). Offloading, internal volume, and toe protection were the highest-ranking priorities for manufacturers, whereas aesthetics ranked lowest. Clinicians, conversely, prioritised accommodation of deformities, offloading, and comfort, and highlighted poor aesthetics and shoe weight as major limitations to adherence. Conclusions: This exploratory study suggests partial alignment between diabetic footwear manufacturers and clinicians on functional and offloading features but highlights gaps in aesthetics, materials, and sustainability. Better collaboration, data-driven innovation, and clearer product specifications could improve user adherence, prescription efficacy, and the preventive role of therapeutic footwear in diabetes care.