Partanen J, Niskanen L, Lehtinen J, et al: Natural history of peripheral neuropathy in patients with non-insulin-dependent diabetes mellitus. .N Eng J Med 333::89. ,1995. .
Thomas PK: “Diabetic Neuropathy: Epidemiology and Pathogenesis,” in Textbook of Diabetes, ed by J Pickup, G Williams, p 613, Blackwell Scientific, London. ,1991. .
Macedo G: “Conduta no Pé Diabético,” in Endocrinologia Clinica, ed by L Vilar, E Castellar, E Moura, E Leal, AC Machado, L Teixeira, R Campos, p 484, Medsi, Rio de Janeiro. ,1999. .
Ctercteko GC, Dhanendran M, Hutton WC, et al: Vertical forces acting on the feet of diabetic patients with neuropathic ulceration. .Br J Surg 68::608. ,1981. .
Pham H, Armstrong DG, Harvey C, et al: Screening techniques to identify people at high risk for diabetic foot ulceration. A prospective multicenter trial. .Diabetes Care 23::606. ,2000. .
Murray HJ, Young MJ, Hollis S, et al: The association between callus formation, high pressures and neuropathy in diabetic foot ulceration. .Diabet Med 13::979. ,1996. .
Cavanagh PR, Simoneau GG, Ulbrecht JS: Ulceration, unsteadiness and uncertainty: the biomechanical consequences of diabetes mellitus. .J Biomech 26::23. ,1993. .
Salsich GB, Mueller MJ: Effect of plantar flexor muscle stiffness on selected gait characteristics. .Gait and Posture 11::207. ,2000. .
Cavanagh PR, Ulbrecht JS: “Biomechanics of the Diabetic Foot: A Quantitative Approach to the Assessment of Neuropathy, Deformity and Plantar Pressure,” in Disorders of the Foot and Ankle, ed by MH Jahss, H Melvin, p 86, WB Saunders, Philadelphia. ,1991. .
Mueller MJ: Etiology, evaluation, and treatment of neuropathic foot. .Crit Rev Phys Rehabil Med 3::289. ,1992. .
Mueller JM, Minor SD, Sahrmann SA, et al: Differences in the gait characteristics of patients with diabetes and peripheral neuropathy compared with age-matched controls. .Phys Ther 74::299. ,1994. .
Strauss MB: Diabetic foot problems: keys to effective, aggressive prevention. .Consultant 41::1693. ,2001. .
Reiber GE, Vileikyte L, Boyko EJ, et al: Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. .Diabetes Care 22::157. ,1999. .
Ahroni JH, Boyko EJ, Forsberg RC: Clinical correlates of plantar pressure among diabetic veterans. .Diabetes Care 22::965. ,1999. .
Boyko EJ, Ahroni JH, Stensel V, et al: A prospective study of risk factors for diabetic foot ulcer. .Diabetes Care 22::1036. ,1999. .
Maluf KS, Mueller MJ: Comparison of physical activity and cumulative plantar tissue stress among subjects with and without diabetes mellitus and a history of recurrent plantar ulcers. .Clin Biomech 18::567. ,2003. .
Payne C, Turner D, Miller K: Determinants of plantar pressure in the diabetic foot. .J Diabetes Complication 16::277. ,2002. .
Boulton AJM: The diabetic foot: from art to science. The 18th Camillo Golgi lecture. .Diabetologia 47::1343. ,2004. .
Shaw JE, Van Shie CHM, Carrington AL, et al: An analysis of dynamic forces transmitted through the foot in diabetic neuropathy. .Diabetes Care 21::1955. ,1998. .
Rich J, Veves A: Forefoot and rearfoot plantar pressures in diabetic patients: correlation to foot ulceration. Available at: http://www.Medscape.com/viewarticle/407554. Accessed June 8. ,2009. .
Caselli A, Pham H, Giurini JM, et al: The forefoot-to-rearfoot plantar pressure ratio is increased in severe diabetic neuropathy and can predict foot ulceration. .Diabetes Care 25::1066. ,2002. .
Reiber GE, Smith DG, Wallace C, et al: Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. .JAMA 287::2552. ,2002. .
Lavery LA, Vela SA, Fleischli JG, et al: Reducing plantar pressure in the neuropathic foot: a comparison of footwear. .Diabetes Care 20::1706. ,1997. .
Erdemir A, Saucerman J, Lemmon D, et al: Local plantar pressure relief in therapeutic footwear: design guidelines from finite element models. .J Biomech 38::1798. ,2005. .
Frykberg RG: Diabetic foot ulcers: current concepts. .J Foot Ankle Surg 4::154. ,2005. .
Burnfield JM, Few CD, Mohamed OS, et al: The influence of walking speed and footwear on plantar pressures in older adults. .Clin Biomech 19::78. ,2004. .
Cavanagh PR, Hennig EM, Rodgers MM, et al: “The Measurement of Pressure Distribution on the Plantar Surface of Diabetic Feet,” in Biomechanical Measurements in Orthopaedic Practice, ed by M Whittle, D Harris, Clarendon Press, Oxford, p 159. ,1985. .
Scarlet JJ, Blais MR: Statistics on the diabetic foot. .JAPMA 79::306. ,1989. .
Veves A, Murray HJ, Young MJ, et al: The risk of foot ulceration in diabetic patient with high foot pressure: a prospective study. .Diabetologia 35::660. ,1992. .
Raskin P: Risk factors for the development of diabetic complications. .J Diab Comp 8::195. ,1994. .
Feldman EL, Stevens MJ, Thomas PK, et al: A practical two-step quantitative clinical and electrophysiological assessment for the diagnosis and staging of diabetic neuropathy. .Diabetes Care 17::1281. ,1994. .
Michigan Neuropathy Screening Instrument (MNSI). Available at: http://www.med.umich.edu/mdrtc/profs/survey.html#mnsi. Accessed April 25. ,2005. .
Cavanagh PR, Sims JDS, Sanders LJ: Body mass is a poor predictor of peak plantar pressure in diabetic men. .Diabetes Care 14::750. ,1991. .
Wertsch JJ, Frank LW, Zhu H, et al: Plantar pressures with total contact casting. .J Rehabil Res Dev Clin S32::205. ,1995. .
Frykberg RG, Lavery LA, Pham H, et al: Role of neuropathy and high foot pressures in diabetic foot ulceration. .Diabetes Care 21::1714. ,1998. .
Perry JE, Hall JO, Davis BL: Simultaneous measurement of plantar pressure and shear forces in diabetic individuals. .Gait Posture 15::101. ,2002. .
Schmid H, Neumann C, Brugnara L: O diabetes melito e a desnervação dos membros inferiores: a visão do diabetólogo. .J Bras Vasc 2::37. ,2003. .
Cavanagh PR, Rodgers MM: The Arch Index: a useful measure from footprints. .J Biomech 20::547. ,1987. .
Hsiao H, Guan J, Weatherly M: Accuracy and precision of two in-shoe pressure measurement systems. .Ergonomics 45::537. ,2002. .
Cavanagh PR, Ulbrecht J: “Biomechanical Aspects of Foot Problems in Diabetes,” in The Foot in Diabetes, ed by A Boulton, H Connor, P Cavanagh, p 25, Wiley, Chichester, United Kingdom. ,1994. .
Quaney B, Meyer K, Cornwall MW, et al: A comparison of the dynamic pedobarograph and EMED systems for measuring dynamic foot pressures. .Foot Ankle Int 16::562. ,1995. .
Lawrence A, Lavery DG, Armstrong RP, et al: Predictive value of foot pressure assessment as part of a population-based diabetes disease management program. .Diabetes Care 26::1069. ,2003. .
Van der Leeden M, Dekker JH, Siemonsma PC, et al: Reproducibility of plantar pressure measurements in patients with chronic arthritis: a comparison of one-step, two-step, and three-step protocols and an estimate of the number of measurements required. .Foot Ankle Int 25::739. ,2004. .
Bus AS, Lange A: 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 20::892. ,2005. .
Siegel S, Castellan J Jr: Nonparametric Statistics for the Behavioral Sciences, The McGraw-Hill Companies, Inc, New York. ,1998. .
Boulton AJ, Hardisty CA, Franks CI, et al: Dynamic foot pressure and other studies as diagnostic and management aids in diabetic neuropathy. .Diabetes Care 6::26. ,1983. .
Brill LR, Cavanagh PR, Gibbons GW, et al: Prevention of lower extremity amputation in patients with diabetes. Treatment of Chronic Wounds. Available at: http://www2.curative.com/CUEBIC/CURATIVE/localdata%5CWEB%5CDATA/WEBSECTIONS%5DMATTACHMENT/CURATIVE_725/Mono7.pdf. Accessed May 2. ,2005. .
Armstrong DG, Peters EJ, Athanasiou KA, et al: Is there a critical level of plantar foot pressure to identify patients at risk for neuropathic foot ulceration?. J Foot Ankle Surg 37::303. ,1998. .
Lavery LA, Armstrong DG, Wunderlich RP, et al: Predictive value of foot pressure assessment as part of a population based diabetes disease management program. .Diabetes Care 26::1069. ,2003. .
Bus AS, Maas M, Lange A, et al: Elevated plantar pressures in neuropathic diabetic patients with claw/hammer toe deformity. .J Biomech 38::1918. ,2005. .
Cavanagh PR, Ulbrecht JS, Caputo GM: New developments in the biomechanics of the diabetic foot. .Diabetes Metab Res Rev 16::S6. ,2000. .
Maluf KS, Mueller MJ, Strube MJ, et al: Tendon Achilles lengthening for treatment of neuropathic ulcers causes a temporary reduction in forefoot pressure associated with changes in plantar flexor power rather than ankle motion during gait. .J Biomech 37::897. ,2004. .
Nurse MA, Nigg BM: The effect of changes in foot sensation on plantar pressure and muscle activity. .Clin Biomech 16::719. ,2001. .
Taylor A, Menz HB, Keenan AM: Effects of experimentally induced plantar insensitivity on forces and pressures under the foot during normal walking. .Gait Posture 20::232. 2004. .
Eils E, Nolte S, Tewes M, et al: Modified pressure distribution patterns in walking following reduction of plantar sensation. .J Biomech 35::1307. ,2002. .
Van Schie CHM: A review of the biomechanics of the diabetic foot. .Int J Low Extrem Wounds 4::160. ,2005. .
Mueller MJ, Salsich GB, Bastian AJ: Differences in the gait characteristics of people with diabetes and transmetatarsal amputation compared with age-matched controls. .Gait Posture 7::200. ,1998. .
Katoulis EC, Parry ME, Lanshammar H, et al: Gait abnormalities in diabetic neuropathy. .Diabetes Care 12::1904. ,1997. .
Sacco ICN, Amadio AC: A study of biomechanical parameters in gait analysis and sensitive cronaxie of diabetic neuropathic patients. .Clin Biomech 15::196. ,2002. .
Petrofsky J, Lee S, Bweir S: Gait characteristics in people with type 2 diabetes mellitus. .Eur J Appl Physiol 93::640. ,2005. .
Bruggemann GP, Potthast W, Goldmann J, et al: Intraarticular pressure distribution in the ankle joint. .J Biomech 39::S191. ,2006. .
Abboud RJ, Rowley DI, Newton RW: Lower limb muscle dysfunction may contribute to foot ulceration in diabetic patients. .Clin Biomech 15::37. ,200. .
Sacco ICN, Amadio AC: Influence of the diabetic neuropathy on the behavior of electromyographic and sensorial responses in treadmill gait. .Clin Biomech 18::426. ,2003. .
Kwon OY, Minor SD, Maluf K, et al: Comparison of muscle acitivity during walking in subjects with and without diabetic neuropathy. .Gait Posture 18::105. ,2003. .
Giacomozzi C, Caselli A, Macellari V, et al: Walking strategy in diabetic patients with peripheral neuropathy. .Diabetes Care 25::1451. ,2002. .
Van der Leeden M, Dekker JH, Siemonsma PC, et al: Reproducibility of plantar pressure measurements in patients with chronic arthritis: a comparison of one-step, two-step, and three-step protocols and an estimate of the number of measurements required. .Foot Ankle Int 25::739. ,2004. .
Barnett S, Cunningham JL, West S: A comparision of vertical force and temporal parameters produced by an in-shoe pressure measuring system and a force platform. .Clin Biomech 16::353. ,2001. .
Finch PM: Technology in biomedicine: the EMED pedar pressure measurement system. .The Foot 9::1. ,1999. .
Winter DA: Biomechanics and Motor Control of Human Movement, John Wiley & Sons, Inc, New York. ,1990. .
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)