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Plantar Pressures During Shod Gait in Diabetic Neuropathic Patients with and without a History of Plantar Ulceration

Isabel C. N. Sacco Laboratory of Biomechanics of the Human Movement and Posture; Physical Therapy, Speech and Occupational Therapy Department, School of Medicine, University of São Paulo, São Paulo, Brazil.

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Tatiana Almeida Bacarin Laboratory of Biomechanics of the Human Movement and Posture; Physical Therapy, Speech and Occupational Therapy Department, School of Medicine, University of São Paulo, São Paulo, Brazil.

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Maíra Grizzo Canettieri Laboratory of Biomechanics of the Human Movement and Posture; Physical Therapy, Speech and Occupational Therapy Department, School of Medicine, University of São Paulo, São Paulo, Brazil.

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Ewald M. Hennig Laboratory of Biomechanics, University of Duisburg-Essen, Essen, Germany.

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Background: Diabetic neuropathy leads to progressive loss of sensation, lower-limb distal muscle atrophy, autonomic impairment, and gait alterations that overload feet. This overload has been associated with plantar ulcers even with consistent daily use of shoes. We sought to investigate and compare the influence of diabetic neuropathy and plantar ulcers in the clinical history of diabetic neuropathic patients on plantar sensitivity, symptoms, and plantar pressure distribution during gait while patients wore their everyday shoes.

Methods: Patients were categorized into three groups: a control group (CG; n = 15), diabetic patients with a history of neuropathic ulceration (DUG; n = 8), and diabetic patients without a history of ulceration (DG; n = 10). Plantar pressure variables were measured by Pedar System shoe insoles in five plantar regions during gait while patients wore their own shoes.

Results: No statistical difference between neuropathic patients with and without a history of plantar ulcers was found in relation to symptoms, tactile sensitivity, and duration of diabetes. Diabetic patients without ulceration presented the lowest pressure–time integral under the heel (72.1 ± 16.1 kPa × sec; P = .0456). Diabetic patients with a history of ulceration presented a higher pressure–time integral at the midfoot compared to patients in the control group (59.6 ± 23.6 kPa × sec × 45.8 ± 10.4 kPa × sec; P = .099), and at the lateral forefoot compared to diabetic patients without ulceration (70.9 ± 17.7 kPa sec × 113.2 ± 61.1 kPa × sec, P = .0193). Diabetic patients with ulceration also presented the lowest weight load under the hallux (0.06 ± 0.02%, P = .0042).

Conclusions: Although presenting a larger midfoot area, diabetic neuropathic patients presented greater pressure–time integrals and relative loads over this region. Diabetic patients with ulceration presented an altered dynamic plantar pressure pattern characterized by overload even when wearing daily shoes. Overload associated with a clinical history of plantar ulcers indicates future appearance of plantar ulcers. (J Am Podiatr Med Assoc 99(4): 285–294, 2009)

Corresponding author: Isabel C. N. Sacco, PhD, Laboratory of Biomechanics of the Human Movement and Posture; Physical Therapy, Speech and Occupational Therapy Department, School of Medicine, University of São Paulo, R. Cipotânia, 512 São Paulo, Brazil 05360-160. (E-mail: icnsacco@usp.br)