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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?
www.FeetFitForLife.Com
More details about the wonderful world of feet can be found on the
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