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There is evidence to indicate that therapeutic footwear can help prevent lower extremity amputation in patients with diabetes. The primary means of preventing amputation is to protect the insensitive foot from unnoticed trauma and excessive plantar pressures that occur during walking. The specific prescription of the shoe will depend on many foot risk criteria, but particularly on the patient's level of sensation, history of ulceration, and the amount of foot deformity. This article describes the type of footwear recommended for each of these increasing levels of foot risk categories.
Although diabetes mellitus is a biochemical disease, it has biomechanical consequences for the lower extremity. Numerous alterations occur in the function of the foot and lower extremity in people with diabetes. This article evaluates biomechanical alterations of the foot in the presence of neuropathy in patients with diabetes in the context of several theoretical concepts. Further study of these hypotheses will result in a better understanding of how diabetes causes elevated plantar pressures and the potential of strategies to prevent these changes so that the burden of diabetic foot disease can be reduced.
Talonavicular coalitions, a rarely reported fusion between the talus and navicular, are often an incidental radiographic finding that may be asymptomatic or associated with peroneal spasm. The authors present a review of literature and case report based on clinical evaluation and instrumented gait analysis. Specifically, a patient presenting with a bilateral talonavicular coalition was objectively evaluated with kinetic, kinematic, muscle dynamometry, and pedobarographic testing to understand the biomechanical limitations related to this pathology. An excessive passive component of ankle torque, a high first metatarsophangeal joint plantar pressure, and a diminished time in the midstance portion of stance phase were measured and compared to those of healthy individuals.
This paper reviews the literature relating to foot orthoses, in particular foot orthoses that attempt to alter biomechanical function. Whilst few well-controlled studies have been performed, the findings from the available literature are generally positive. The authors provide an overview of this literature and then summarise the findings. The literature is categorised into six research outcome areas: (i) patient satisfaction, (ii) pain and deformity, (iii) plantar pressures, (iv) position and motion, (v) muscle activity, and (vi) oxygen consumption. In addition, the difficulties associated with researching foot orthoses are discussed.
The purpose of this study was to compare the ability of various modalities to reduce pressure in the plantar heel. Twenty-five patients with grade 1A plantar foot ulcerations were evaluated; a repeat measures design comparing plantar pressure was used to evaluate the total contact cast, the Aircast pneumatic walker, the DH pressure relief walker, and depth-inlay shoes. The total contact cast reduced pressure significantly better than the other modalities; however, its pressure reduction was only 33% less than a baseline sneaker. All other modalities reduced significantly more pressure than the depth-inlay shoe. The DH walker had a significantly lower pressure-time integral than other modalities. These data indicate that, while the total contact cast appears to be effective compared with other modalities, the role that limitation of transverse motion of the fat pad on compression at heel strike has yet to be fully explained.
The authors draw attention to the importance of evaluation of the contralateral limb when treating unilateral sequelae secondary to distal symmetrical polyneuropathy. Plantar pressure measurements of the contralateral limb during total contact casting are reviewed. The results of thermometric evaluation before and after initiation of repetitive stress were reviewed. The results suggest that the patient walking in a total contact cast may experience a reduced focal pressure on the contralateral limb when compared with uncasted walking and three-point walking with crutches. Dermal thermometry may be a highly sensitive tool in evaluating even mild increases in repetitive stress. To explain this decrease in contralateral stress, the authors examine the features inherent to the total contact cast and propose the concept of proprioceptive stability.
BACKGROUND: Although pilon fractures are rare, they are important for orthopedic surgeons because of the difficulty of treatment and adverse effects on gait function. The aim of the study to evaluate the relationship between the reduction quality of the fracture, functional results, ankle arthrosis and plantar pressure distribution in patients with tibia pilon fractures. METHODS: In this study, a total of 62 patients treated for an intraarticular pilon fracture in our clinic between January 2015 and January 2019 were evaluated retrospectively. Postoperative reduction qualities of the patients were evaluated with the Ovadia-Beals criteria, ankle functional scores with the Teeny-Wiss score, and ankle arthrosis with the Takakura classification. In the last follow-up of the patients, foot loading analysis was performed and the results of the patients were evaluated for their relation with postoperative reduction quality, ankle functions and ankle arthrosis. RESULTS: There were 62 patients (50 men and 12 women). The average age was 43.3 years (range 19-78). The mean follow-up was 34.3 months (range 24 - 58). The mean Ovadia-Beals score was 12.35 {plus minus} 4.6 in the postoperative plain radiographs of the patients; the mean Teeny-Wiss score in the last follow-up was 76.82 {plus minus} 17.69, and the Takakura score was 1.47 {plus minus} 1.35. Based on the pedobarographic measurements, 47.58% of the patients put weight on the anterior and 52.42% on the posterior of the foot in the anteroposterior plane. In the mediolateral plane, 42.15% loaded on the medial of the ankle and 57.85% loaded on the lateral of the foot. CONCLUSION: Intra-articular tibia pilon fractures can be demonstrated by lateralization of the walking axis and changes in gait patterns and can be associated with clinical outcome.
Background:
There are no conclusive data to support the contention that diabetic patients have an increased frequency of ankle equinus compared with their nondiabetic counterparts. Additionally, a presumed contributing cause of foot ulceration is ankle joint equinus. Therefore, we sought to determine whether persons with diabetes have a higher prevalence of ankle joint equinus than do nondiabetic persons.
Methods:
A prospective pilot survey of 102 outpatients (43 diabetic and 59 nondiabetic) was conducted. Demographic and historical data were obtained. Each patient underwent a standard lower-extremity examination, including the use of a biplane goniometer to measure ankle joint range of motion.
Results:
Equinus, defined as ankle dorsiflexion measured at 0° or less, was found in 24.5% of the overall population. In the diabetes cohort, 16 of 43 patients (37.2%) were affected compared with 9 of 59 nondiabetic participants (15.3%) (P = .011). There was a threefold risk of equinus in the diabetic population (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.28–8.44; P < .013). The equinus group had a history of ulceration in 52.0% compared with 20.8% of the nonequinus group (P = .003). Equinus, therefore, imparted a fourfold risk of ulceration (OR, 4.13; 95% CI, 1.58–10.77; P < .004). We also found a 2.8 times risk of equinus in patients with peripheral neuropathy (OR, 2.8; 95% CI, 1.11–7.09; P < .029).
Conclusions:
Equinus may be more prevalent in diabetic patients than previously reported. Although we cannot prove causality, we found a significant association between equinus and ulceration. (J Am Podiatr Med Assoc 102(2): 84–88, 2012)
Offloading Properties of a Rocker Insole
A Preliminary Study
Multiple offloading modalities are currently used in the management of diabetic plantar foot ulcerations. A relatively new device, the Rocker Insole, was tested for its ability to relieve plantar forefoot pressures when inserted into a surgical boot as compared to a patient’s customary footwear and the surgical boot alone. The Rocker Insole significantly reduced forefoot pressures by 48% when worn inside the surgical boot. Mean peak pressures unexpectedly increased 12% when the surgical boot was worn alone. This preliminary investigation suggests that when worn in conjunction with a surgical boot, the Rocker Insole can effectively offload plantar forefoot pressures and may be useful in the management of plantar metatarsal ulcerations. (J Am Podiatr Med Assoc 92(1): 48-53, 2002)
Verrucous Hyperplasia
A Common and Problematic Finding in the High-Risk Diabetic Foot
Although verrucous hyperplasia may be common in high-risk insensitive feet, the literature contains little discussion on this topic. Treatment of verrucous hyperplasia is aimed primarily at reducing the causative forces. In cases that result from edema, external compression has proved to be adequate. If verrucous hyperplasia on the foot results from frictional forces, then shoe modifications with proper fit, accommodative liners, or fillers in the case of amputation are necessary. In recalcitrant cases, excision of the affected tissue with local soft-tissue or graft coverage has been successful. We describe a 56-year-old man with verrucous hyperplasia. (J Am Podiatr Med Assoc 96(4): 348–350, 2006)
