A kinetic change in the foot such as altered plantar pressure is the most common etiological risk factor for foot ulcers in people with diabetes mellitus. Kinematic alterations in joint angle and spatiotemporal parameters of gait have also been frequently observed in participants with diabetic peripheral neuropathy (DPN). Diabetic peripheral neuropathy leads to various microvascular and macrovascular complications of the foot in type 2 diabetes mellitus. There is a gap in the literature for biomechanical evaluation and assessment of type 2 diabetes mellitus with DPN in the Indian population. We sought to assess and determine the biomechanical changes, including kinetics and kinematics, of the foot in DPN.
This cross-sectional study was conducted at a diabetic foot clinic in India. Using the purposive sampling method, 120 participants with type 2 diabetes mellitus and DPN were recruited. Participants with active ulceration or amputation were excluded.
The mean ± SD age, height, weight, body mass index, and diabetes duration were 57 ± 14 years, 164 ± 11 cm, 61 ± 18 kg, 24 ± 3 kg/m2, and 12 ± 7 years, respectively. There were significant changes in the overall biomechanical profile and clinical manifestations of DPN. The regression analysis showed statistical significance for dynamic maximum plantar pressure at the forefoot with age, weight, height, diabetes duration, body mass index, knee and ankle joint angle at toe-off, pinprick sensation, and ankle reflex (R = 0.71, R2 = 0.55, F12,108 = 521.9 kPa; P = .002).
People with type 2 diabetes mellitus and DPN have significant changes in their foot kinetic and kinematic parameters. Therefore, they could be at higher risk for foot ulceration, with underlying neuropathy and biomechanically associated problems.
Retrospective and prospective studies have shown that elevated plantar pressure is a causative factor in the development of many plantar ulcers in diabetic patients and that ulceration is often a precursor of lower-extremity amputation. Herein, we review the evidence that relieving areas of elevated plantar pressure (off-loading) can prevent and heal plantar ulceration.
There is no consensus in the literature concerning the role of off-loading through footwear in the primary or secondary prevention of ulcers. This is likely due to the diversity of intervention and control conditions tested, the lack of information about off-loading efficacy of the footwear used, and the absence of a target pressure threshold for off-loading. Uncomplicated plantar ulcers should heal in 6 to 8 weeks with adequate off-loading. Total-contact casts and other nonremovable devices are most effective because they eliminate the problem of nonadherence to recommendations for using a removable device. Conventional or standard therapeutic footwear is not effective in ulcer healing. Recent US and European surveys show that there is a large discrepancy between guidelines and clinical practice in off-loading diabetic foot ulcers. Many clinics continue to use methods that are known to be ineffective or that have not been proved to be effective while ignoring methods that have demonstrated efficacy.
A variety of strategies are proposed to address this situation, notably the adoption and implementation of recently established international guidelines, which are evidence based and specific, by professional societies in the United States and Europe. Such an approach would improve the often poor current expectations for healing diabetic plantar ulcers. (J Am Podiatr Med Assoc 100(5): 360–368, 2010)
An essential skill for podiatrists is conservative sharp debridement of foot callus. Poor technique can result in lacerations, infections and possible amputation. This pilot trial explored whether adding simulation training to a traditional podiatry clinical placement improved podiatry student skills and confidence in conservative sharp debridement, compared with traditional clinical placement alone.
Twenty-nine podiatry students were allocated randomly to either a control group or an intervention group on day 1 of their clinical placement. On day 4, the intervention group (n = 15) received a 2-hour simulation workshop using a medical foot-care model, and the control group (n = 14) received a 2-hour workshop on compression therapy. Both groups continued to learn debridement skills as opportunities arose while on clinical placement. The participants' debridement skills were rated by an assessor blinded to group allocation on day 1 and day 8 of their clinical placement. Participants also rated their confidence in conservative sharp debridement using a questionnaire. Data were analyzed using logistic regression (skills) and analysis of covariance (confidence), with baseline scores as a covariate.
At day 8, analysis showed that those in the intervention group were 16 times more likely to be assessed as competent (95% confidence interval, 1.6–167.4) in their debridement skills and reported increased confidence in their skills (mean difference, 3.2 units; 95% confidence interval, 0.5–5.9) compared with those in the control group.
This preliminary evidence suggests that incorporating simulation into traditional podiatry clinical placements may improve student skills and confidence with conservative sharp debridement.
Plantar pressure measurements are commonly used to evaluate foot function in chronic musculoskeletal conditions. However, manually identifying anatomical landmarks is a source of measurement error and can produce unreliable data. The aim of this study was to evaluate intratester reliability associated with manual masking of plantar pressure measurements in patients with gout.
Twenty-five patients with chronic gout (mean disease duration, 22 years) were recruited from rheumatology outpatient clinics. Patients were excluded if they were experiencing an acute gout flare at the time of assessment, had lower-limb amputation, or had diabetes mellitus. Manual masking of peak plantar pressures and pressure-time integrals under ten regions of the foot were undertaken on two occasions on the same day using an in-shoe pressure measurement system. Test-retest reliability was assessed by using intraclass correlation coefficients, SEM, 95% limits of agreement, and minimal detectable change.
Mean peak pressure intraclass correlation coefficients ranged from 0.92 to 0.97, with SEM of 8% to 14%. The 95% limits of agreement ranged from−150.3 to 133.5 kPa, and the minimal detectable change ranged from 30.8 to 80.6 kPa. For pressure-time integrals, intraclass correlation coefficients were 0.86 to 0.94, and SEM were 5% to 29%, with the greater errors observed under the toes. The 95% limits of agreement ranged from −48.5 to 48.8 kPa/sec, and the minimal detectable change ranged from 6.8 to 21.0 kPa/sec.
These findings provide clinicians with information confirming the errors associated with manual masking of plantar pressure measurements in patients with gout. (J Am Podiatr Med Assoc 101(5): 424–429, 2011)
Background: Neurologic screening tests are often used to identify and stratify patients at risk for diabetic foot complications such as infections, ulcers, and amputations. Two of the most commonly cited methods are the 5.07 Semmes-Weinstein monofilament (SWM) for loss of protective sensation and vibratory sensation testing. The aim of this study was to determine whether combined SWM and the timed vibration test (TVT) more effectively predicts diabetic foot ulcer (DFU) development compared with each test alone.
Methods: An electronic medical record database search was performed restricted to podiatric medical clinic patients with diabetes and DFU ICD-10 diagnosis codes. Of 200 patients who met the criteria, 24 developed DFUs. A statistical analysis was performed comparing the SWM and TVT at various cutoff times and the combined SWM/TVT in their ability to predict DFUs.
Results: Statistical analysis revealed that the TVT cutoff time of less than 4 sec was superior to the other times for prediction of DFUs. The combined SWM/TVT results at less than 4 sec were superior to each test individually: sensitivity, 87.5%; specificity, 84.7%; positive predictive value, 43.8%; and receiver operating characteristics area under the curve, 0.86.
Conclusions: The SWM combined with TVT was shown to be superior compared with either test alone in discriminating DFU risk. In addition, the TVT cutoff time of less than 4 sec proved to have greater diagnostic yield than other times, including 0 sec. This unexpected finding might impact providers relying on the absence of vibration sensation via tuning fork testing as an optimal marker of DFU risk.
We sought to show the biomechanical and morphometric properties of flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendon grafts harvested by specific surgical approaches and to assess the contribution of FHL slips to the long flexor tendons of the toes.
Thirteen fresh-frozen amputated feet (average age, 79 years) were dissected. The connections between the FHL and FDL tendons and the contribution of FHL slips to the long flexor tendons were classified. The biomechanical properties of the tendons and slips were measured using a tensile device.
The connections between the FHL and FDL tendons were reviewed in two groups. Group 1 had FHL slips (11 cases) and group 2 had cross-slips (two cases). The FHL slips joined the second and third toe long flexor tendon structures. Tendon length decreased significantly from the second to the fifth toe (P < .001). Apart from the second toe tendon being thicker than that of the fourth toe (P = .02) and Young's modulus being relatively smaller in the third versus the fourth toe tendon (P = .01), biomechanical and morphometric properties of second to fourth tendons were similar. Mechanical properties of those tendons were significantly different from fifth toe tendons and FHL slips. Morphometric and biomechanical properties of FHL slips were similar to those of the fifth toe tendon.
Herein, FHL slips were shown to have biomechanical properties that might contribute to flexor functions of the toes. During the harvesting of tendon grafts from the FHL by minimally invasive incision techniques from the distal plane of the master knot of Henry, cutting slips between FHL and FDL tendons could be considered a cause of postoperative function loss in toes.
Background: Neurologic assessments using a monofilament and a tuning fork are routinely performed to screen for peripheral neuropathy and to identify foot ulceration and amputation risks. We investigated whether assessments commonly used to monitor sensation in the feet may illuminate a more holistic perspective of a person’s overall health status.
Methods: Recruitment of 50 participants for foot health screening was facilitated via a promotional event for Foot Health Week. Participants were aged 52 to 92 years (31 women and 19 men). Monofilament and tuning fork assessments were used to determine each participant’s neurologic status. Participants also completed a modified Foot Health Status Questionnaire. Data were analyzed to identify correlations between neurologic assessment results and questionnaire responses.
Results: For participants self-reporting an “excellent” health rating, a significant relationship was identified with adequate vibration sensation (P < .01). Significant correlations were also identified between a greater number of sites detected using a 10-g monofilament assessment and a person’s experience of having a lot of energy (P = .03), limited interference with social activities (P = .03), and greater confidence completing a variety of functional tasks.
Conclusions: Significant correlations were observed between basic neurologic assessments and a participant’s perception of their overall health. Although these findings reflect a correlational rather than a causational relationship, they may provide a stimulus for clinicians to reflect on the holistic value of peripheral neurologic assessment. Although the immediate focus for a practitioner is minimizing risk and preserving tissue viability, neurologic test results may be useful to stimulate further discussion about a patient’s health outcomes by exploring issues beyond the presenting condition.
By following a systematic approach to the patient history, physical examination, and laboratory analysis in cases of infections, rapid and accurate therapeutic intervention becomes possible. This action can prevent possibly devastating infectious complications, ranging from partial amputation to death. The current litigious climate dictates thorough evaluation and documentation of all infectious diseases of the lower extremity.
A case of angiosarcoma of the lower extremity was presented. This rare but highly malignant soft tissue tumor usually presents as a raised pigmented lesion. Wide surgical excision or amputation is the treatment of choice. Radiotherapy may offer some relief in cases that are inoperable.
In this case presentation, the diagnosis was based solely on the histopathologic examination of tissue taken at the time of the first surgery. Subsequent cultures did not reveal any growth of organisms that would cause Madura foot. The patient must be monitored periodically, for it is rare that such an infection is cured with surgery other than amputation.