Modification of Footwear to Prevent Ulcerations Speaker: Alison Deacon, Podiatrist B.Sc. (Hons) MChS...

Modification of Footwear to Prevent Ulcerations

Speaker: Alison Deacon, Podiatrist B.Sc. (Hons) MChS HPC

Optimum Health Services Ltd (UK)

FACTS & FIGURES

• In the developed world 5% of people with diabetes have ulcers and use 12-15% of healthcare resources

• In DEVELOPING countries the figure could be as high as 40% of healthcare resources

Diabetic Foot Complications

Diabetic Foot

Vascular diseaseNeuropathy

Foot ulceration

Ischaemic footAutonomic Sensory/Motor

Physical stresses

Decreased sweating

Dry skin fissures

Why Do Ulcers Form?

• The complex etiology of diabetic foot ulceration requires a comprehensive management approach which includes debridement, wound dressings, oral medication along with education and support.

• Reducing plantar mechanical stress is one critical

aspect of optimising healing potential, particularly in neuropathic feet, where plantar loads and tissue stress are increased.

Changes in mechanical stresses can be due to : -

1. Skin changes - The skin and soft tissues are less pliable due to glycosylation, leading to skin breakdown and callus formation due to decreased tolerability to friction and restricted joint motion.

2. Structural (bony) abnormalities producing plantar prominences that alter the normal contact surface area of the foot e.g. bunions

3. Limited joint mobility due to age, accidents and stroke etc

4. Gait and postural abnormalities

5. Intolerance of friction

6. Abnormal shear

7. Increased body mass – Plantar pressure is equal to the weight-bearing forces divided by the total contact surface area, so a heavier person will exert more force

The Podiatrists‘ Role

Education

Routine foot care

Debriding of ulcers

Dressing wounds

Biomechanical assessment and orthotic therapy

Biomechanics

• Biomechanics is the study of the function and form of the lower limbs and the foot during gait or walking.

• Assessment of the shape and motion of the limbs.

• An examination of calluses/corns/ulcers to diagnose the cause of injuries/development of deformities.

History

• As far back as 160 AD Galen understood that the function of the body could lead to foot deformities and vice versa

 • Dr. Root in 1966 created a classification

system, based on the subtalar joint neutral position

TRI PLANE MOTION

Pronation ABduction Eversion Dorsiflexion

Supination ADduction Inversion Plantarflexion

PLANES = Transverse Frontal Saggital

Pronation & Supination

Root Paradigm

The Root Paradigm uses measuredbiomechanical positions which suggests that

the forefoot or rearfoot can have abnormalitiessuch as being perceived to being in a varus or

valgus (deviating to the lateral or medial side ofthe body) position.

Suggesting that the abnormal foot is eitherexcessively supinated or more often pronated or

OVER PRONATING – FLAT FOOT.

Technological Innovations• The science of BIOMECHANICS/PATHOMECHANICS has become

huge and modern computer –based technology/equipment allows: -

• Precise measurements of patterns of movement and forces in any type of weight bearing activity.

• Pressure plate analysis can be accurate at that time and place in

that shoe.

• Postulations or theories add value to our very large amount of evidence - but also can cause confusion.

 • BUT not one THEORY fits ALL, after all, aren’t we ALL individuals

with differing leg length, muscle strength, biological age, height, environment & nutrition?

A different shoe type and heel height will

impact differently on each step we take.

Assessment Diabetic Limb

Neuropathy

Sensory testing Motor evaluation Autonomic

10g Monofilament

Tuning fork

TipTherm

Visual

PressureStat

Neuropad

Advice on footcare Orthoses & Advice Creams & Advice

Changes in mechanical stresses can be due to : -

1. Skin changes - The skin and soft tissues are less pliable due to glycosylation, leading to skin breakdown and callus formation due to decreased tolerability to friction and restricted joint motion.

This illustrates a callus on the 5th metatarsal which could have an ulcer underneath – debridement is essential

A biomechanicalproblem CAN result in an ulcer.

Changes in mechanical stresses can be due to : -

1. Skin changes - The skin and soft tissues are less pliable due to glycosylation, leading to skin breakdown and callus formation due to decreased tolerability to friction and restricted joint motion.

2. Structural (bony) abnormalities producing plantar prominences that alter the normal contact surface area of the foot

Be aware ! Charcot foot

• Neuropathic• Non ischaemia• Swollen /hot• Trauma history• Poor glycaemic control• Renal patients

Charcot foot

Prominent metatarsal heads

Hyperextension contributes to prominent metatarsal heads along with migration of the plantar fat pad distal and dorsally, further exposing the metatarsal heads to increased pressure which especially affects the first metatarsal head.

Changes in mechanical stresses can be due to : -

1. Skin changes - The skin and soft tissues are less pliable due to glycosylation, leading to skin breakdown and callus formation due to decreased tolerability to friction and restricted joint motion.

2. Structural (bony) abnormalities producing plantar prominences that alter the normal contact surface area of the foot e.g. bunions

3. Limited joint mobility due to age, accidents and stroke etc

CLAW TOES

Claw toes are formed due to intrinsic muscle atrophy which is secondary to motor neuropathy.

Motor neuropathy can lead to unopposed hyperextension at the metatarsal phalangeal joints by the extrinsic muscles.

Changes in mechanical stresses can be due to : -

1. Skin changes - The skin and soft tissues are less pliable due to glycosylation, leading to skin breakdown and callus formation due to decreased tolerability to friction and restricted joint motion.

2. Structural (bony) abnormalities producing plantar prominences that alter the normal contact surface area of the foot e.g. bunions

3. Limited joint mobility due to age, accidents and stroke etc

4. Gait and postural abnormalities

Structural (bony) abnormalities producing plantar prominences that alter the normal contact surface area of the foot.

Changes in mechanical stresses can be due to : -

1. Skin changes - The skin and soft tissues are less pliable due to glycosylation, leading to skin breakdown and callus formation due to decreased tolerability to friction and restricted joint motion.

2. Structural (bony) abnormalities producing plantar prominences that alter the normal contact surface area of the foot e.g. bunions

3. Limited joint mobility due to age, accidents and stroke etc

4. Gait and postural abnormalities

5. Intolerance of friction

Callous

This is a typical place that someone with a bunion would get callous, which can easily progress to an ulcer.

Changes in mechanical stresses can be due to : -

1. Skin changes - The skin and soft tissues are less pliable due to glycosylation, leading to skin breakdown and callus formation due to decreased tolerability to friction and restricted joint motion.

2. Structural (bony) abnormalities producing plantar prominences that alter the normal contact surface area of the foot e.g. bunions

3. Limited joint mobility due to age, accidents and stroke etc

4. Gait and postural abnormalities

5. Intolerance of friction

6. Abnormal shear

Changes in mechanical stresses can be due to : -

1. Skin changes - The skin and soft tissues are less pliable due to glycosylation, leading to skin breakdown and callus formation due to decreased tolerability to friction and restricted joint motion.

2. Structural (bony) abnormalities producing plantar prominences that alter the normal contact surface area of the foot e.g. bunions

3. Limited joint mobility due to age, accidents and stroke etc

4. Gait and postural abnormalities

5. Intolerance of friction

6. Abnormal shear

7. Increased body mass – Plantar pressure is equal to the weight-bearing forces divided by the total contact surface area, so a heavier person will exert more force

Increased body mass – diabetics have problems losing weight!

The absolute threshold of plantar pressure which causes tissue damage is not known and likely varies among individuals thus the goal is

to gain even distribution of pressure.

This is what one of the Malaysian clinics are using

Very hard thin plastic that was being used for an arch support.

TREATMENTSThe Total Contact Cast (TCC) has been shown to

heal a higher proportion of diabetic foot wounds than other therapeutic interventions as this gives:

• Optimal weight off-loading• Decreased patient mobilization• Reduced oedema• Foot protection • Cannot be removed = ensuring compliance.

• Sinks can be made in areas to accommodate abnormalities but these cannot be changed. However TCC may be unacceptable for some patients and unrealistic to those who are already unsteady on ambulation because of peripheral neuropathy.

Custom-Moulded Orthotics

More affordable than TCC Specifically moulded to the foot of the wearer to optimally protect and cushion.

Accommodate deformityAllow some range of motionBe over the budget of many

BOTH solutions are usually used when an ulcerHAS ALREADY FORMED

Prevention is MUCH better than cure!

Studies show that the emergence of Neuropathic ulcers can be reduced by the use

of cushioned insoles made of PORON.

PORON ORTHOTICS

• The flat base, this allows many of the weight bearing or ground reaction forces can be absorbed.

• Can be sold to the RECENTLY DIAGNOSED DIABETIC and put in place by a (Podiatrist) trained foot nurse to relive pressure immediately!

• Sinks or cut-outs can be made in this item by to accommodate the deformity/ulcer & refitted later.

• The flat base makes this orthotic perfect for adding various varus/valgus pads, wedges domes etc BY THE PODIATRIST.

• Biomechanical problems can be addressed 1. An offloading device for the ulcer 2. A lifelong biomechanical adjustment

THE 50 RM SOLUTION!• In a study by Cross (2006) it was suggested that basic canvas

footwear and simple orthotic devises can significantly reduce the time over which ulcers heal.

• Studies have suggested that the expensively branded sneaker Do NOT function much better than cheap supermarket sports shoe.

• Compliance is critical - orthotics and shoes should be worn at all times.

SAVE FEET – SAVE LIVES

Quality footcare will: -1. Keep people active & contribute to their

overall health 2. Reduce the misery that diabetes is causing

today. 3. Reduce the overall cost of care to the

government and the individual.

Lead By Example!

Ladies and gentlemen whatever your role in diabetes care is PLEASE set an example with your footwear and footcare. What shoes are

you wearing today?

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