Zimmet, P . :Diabetes and obesity worldwide: epidemics in full flight. .Paper presented at the 60th Scientific Sessions of the American Diabetes Association,June 10, 2000,San Antonio, TX.
Singapore Ministry of Health :Clinical practice guidelines: diabetes mellitus .2006. .Available at: http://www.moh.gov.sg/mohcorp/uploadedFiles/Publications/Guidelines/Clinical_Practice_Guidelines/Diabetes%20Mellitus.pdf. .Accessed January 27, 2010.
Cockram, CS . :The epidemiology of diabetes mellitus in the Asia-Pacific region. .Hong Kong Med J 6::43. ,2000. .
Nather, A, C Bee, C Huak, et al. :Epidemiology of diabetic foot problems and predictive factors for limb loss. .J Diabetes Complications 22::77. ,2008. .
Boulton, A . :The diabetic foot: an update. .Foot Ankle Surg 14::120. ,2008. .
Boulton, AJ, CA Hardisty, RP Betts, et al. :Dynamic foot pressure and other studies as diagnostic and management aids in diabetic neuropathy. .Diabetes Care 6::26. ,1983. .
Veves, A, HJ Murray, MJ Young, et al. :The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study. .Diabetologia 35::660. ,1992. .
Frykberg, RG, LA Lavery, H Pham, et al. :Role of neuropathy and high foot pressures in diabetic foot ulceration. .Diabetes Care 21::1714. ,1998. .
Bus, SA, M Maas, A de Lange, et al. :Elevated plantar pressures in neuropathic diabetic patients with claw/hammer toe deformity. .J Biomech 38.:1918. ,2005. .
Stess, RM, SR Jensen, and R Mirmiran. :The role of dynamic plantar pressures in diabetic foot ulcers. .Diabetes Care 20::855. ,1997. .
Luger, E, M Nissan, A Karpf, et al. :Dynamic pressures on the diabetic foot. .Foot Ankle Int 22::715. ,2001. .
Viswanathan, V, S Madhavan, S Rajasekar, et al. :Limited joint mobility and plantar pressure in type 1 diabetic subjects in India. .J Assoc Physicians India 56::509. ,2008. .
Zimny, S, H Schatz, and M Pfohl. :The role of limited joint mobility in diabetic patients with an at-risk foot. .Diabetes Care 27::942. ,2004. .
Abouaesha, F, CH van Schie, DG Armstrong, et al. :Plantar soft-tissue thickness predicts high peak plantar pressure in the diabetic foot. .JAPMA 94::39. ,2004. .
Pataky, Z, JP Assal, P Conne, et al. :Plantar pressure distribution in Type 2 diabetic patients without peripheral neuropathy and peripheral vascular disease. .Diabet Med 22::762. ,2005. .
Boulton, AJ, RP Betts, CI Franks, et al. :Abnormalities of foot pressure in early diabetic neuropathy. .Diabet Med 4::225. ,1987. .
Nather, A, G Singh, XN Koo, et al. :“Footwear Habits in Diabetics With and Without Diabetic Foot Problems: The Singapore Experiece,”. inDiabetic Foot Problems. , ed byNather, A. , p547. ,World Scientific. ,Singapore. ,2008. .
Echarri, J and F Forriol. :The development in footprint morphology in 1851 Congolese children from urban and rural areas, and the relationship between this and wearing shoes. .J Pediatr Orthop B 12::141. ,2003. .
Frykberg, R, T Zgonis, D Armstrong, et al. :Diabetic foot disorders: a clinical practice guideline (2006 revision). .J Foot Ankle Surg 45::S1. ,2006. .
Walters, DP, W Gatling, RD Hill, et al. :The prevalence of foot deformity in diabetic subjects: a population study in an English community. .Practical Diabetes Int 10::106. ,1993. .
Kärvestedt, L, E Mårtensson, V Grill, et al. :The prevalence of peripheral neuropathy in a population-based study of patients with type 2 diabetes in Sweden. .J Diabetes Complications 25::97. ,2011. .
Coughlin, M . :Lesser toe abnormalities. .J Bone Joint Surg Am 84::1446. ,2002. .
Bardelli, M, L Turelli, and G Scoccianti. :Definition and classification of metatarsalgia. .Foot Ankle Surg 9::79. ,2003. .
van Schie, C, C Vermigli, A Carrington, et al. :Muscle weakness and foot deformities in diabetes: relationship to neuropathy and foot ulceration in caucasian diabetic men. .Diabetes Care 27::1668. ,2004. .
Hunter, G . :Pes planus (flat foot): discussion paper prepared for the Workplace Safety and Insurance Appeals Tribunal. .Revised June 2002. Available at: http://www.wsiat.on.ca/english/mlo/pes_planus.htm. .Accessed September 24, 2010.
McMillan, A, K Landorf, J Barrett, et al. :Diagnostic imaging for chronic plantar heel pain: a systematic review and meta-analysis. .J Foot Ankle Res 2::32. ,2009. .
Vanore, J, J Christensen, S Kravitz, et al. :Diagnosis and treatment of first metatarsophalangeal joint disorders: section 3: hallux varus. .J Foot Ankle Surg 42::137. ,2003. .
Beeson, P, C Phillips, S Corr, et al. :Hallux rigidus: a cross-sectional study to evaluate clinical parameters. .Foot (Edinb) 19::80. ,2009. .
Boffeli, T, J Bean, and J Natwick. :Biomechanical abnormalities and ulcers of the great toe in patients with diabetes. .J Foot Ankle Surg 41::359. ,2002. .
Singh, N, DG Armstrong, and BA Lipsky. :Preventing foot ulcers in patients with diabetes. .JAMA 293::217. ,2005. .
Dros, J, A Wewerinke, P Bindels, et al. :Accuracy of monofilament testing to diagnose peripheral neuropathy: a systematic review. .Ann Fam Med 7::555. ,2009. .
Armstrong, D . :The 10-g monofilament: the diagnostic divining rod for the diabetic foot. ?Diabetes Care 23::887. ,2000. .
Smieja, M, D Hunt, D Edelman, et al. :Clinical examination for the detection of protective sensation in the feet of diabetic patients: International Cooperative Group for Clinical Examination Research. .J Gen Intern Med 14::418. ,1999. .
Tan, L . :The clinical use of the 10 g monofilament and its limitations: a review. .Diabetes Res Clin Pract 90::1. ,2010. .
Xiao, HS, L Yan, LH Chen, et al. :Study of foot plantar pressure in Chinese diabetic patients [in Chinese]. .Zhonghua Yi Xue Za Zhi 87.:1825. ,2007. .
Greenman, RL, L Khaodhiar, C Lima, et al. :Foot small muscle atrophy is present before the detection of clinical neuropathy. .Diabetes Care 28::1425. ,2005. .
Crawford, F, M Inkster, J Kleijnen, et al. :Predicting foot ulcers in patients with diabetes: a systematic review and meta-analysis. .QJM 100::65. ,2007. .
Hohne, A, C Stark, and GP Bruggemann. :Plantar pressure distribution in gait is not affected by targeted reduced plantar cutaneous sensation. .Clin Biomech (Bristol, Avon) 24::308. ,2009. .
Sacco, I, T Bacarin, M Canettieri, et al. :Plantar pressures during shod gait in diabetic neuropathic patients with and without a history of plantar ulceration. .JAPMA 99::285. ,2009. .
Bus, SA and A de Lange. :A comparison of the 1-step, 2-step, and 3-step protocols for obtaining barefoot plantar pressure data in the diabetic neuropathic foot. .Clin Biomech (Bristol, Avon) 20::892. ,2005. .
Stacpoole-Shea, S, G Shea, and L Lavery. :An examination of plantar pressure measurements to identify the location of diabetic forefoot ulceration. .J Foot Ankle Surg 38::109. ,1999. .
Bus, SA, JS Ulbrecht, and PR Cavanagh. :Pressure relief and load redistribution by custom-made insoles in diabetic patients with neuropathy and foot deformity. .Clin Biomech (Bristol, Avon) 19::629. ,2004. .
We sought to establish the in-shoe plantar pressure distribution during normal level walking in type 2 diabetic patients of Chinese, Indian, and Malay descent without clinical evidence of peripheral neuropathy.
Thirty-five patients with type 2 diabetes mellitus without loss of tactile sensation and foot deformities and 38 nondiabetic individuals in a control group had in-shoe plantar pressures collected. Maximum peak pressure and peak pressure-time integral of each foot were analyzed as separate variables and were masked into 13 areas. Differences in pressure variables were assessed by analysis of covariance, adjusting for relevant covariates at the 95% confidence interval.
No significant differences were noted in maximum peak pressures after adjusting for sex, race, age, height, and body mass. However, patients with diabetes mellitus had significantly higher mean ± SD pressure-time integrals at the right whole foot (309.50 ± 144.17 kPa versus 224.06 ± 141.70 kPa, P < .05) and first metatarsal (198.65 ± 138.27 kPa versus 121.54 ± 135.91 kPa, P < .05) masked areas than did those in the control group after adjustment.
Patients without clinical observable signs of foot deformity (implying absence of motor neuropathy) and sensory neuropathy had similar in-shoe maximum peak pressures as controls. This finding supported the notion that either component of neuropathy needs to be present before plantar pressures are elevated. Patients with diabetes mellitus demonstrated greater pressure-time integrals, implying that this variable might be the first clinical sign observable even before peripheral neuropathy could be tested. (J Am Podiatr Med Assoc 101(6): 509–516, 2011)