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 Neuropathy Vascular disease Autonomic Sensory/Motor Ischaemic foot Decreased sweating Simply divide diabetic foot problems into vascular & neuropathic manifestations . All roads can lead to foot ulceration Physical stresses Dry skin fissures Foot ulceration

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 : - 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. Structural (bony) abnormalities producing plantar prominences that alter the normal contact surface area of the foot e.g. bunions Limited joint mobility due to age, accidents and stroke etc Gait and postural abnormalities Intolerance of friction Abnormal shear 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 measured biomechanical positions which suggests that the forefoot or rearfoot can have abnormalities such as being perceived to being in a varus or valgus (deviating to the lateral or medial side of the body) position. Suggesting that the abnormal foot is either excessively 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 : - 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 biomechanical problem CAN result in an ulcer.

Changes in mechanical stresses can be due to : - 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. 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 neuroarthropathy. Osteoclastic activity increased , bone resorption weakens strength and foot collapses. In severe cases , this happens in 24-48 hours.

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 : - 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. Structural (bony) abnormalities producing plantar prominences that alter the normal contact surface area of the foot e.g. bunions 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 : - 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. Structural (bony) abnormalities producing plantar prominences that alter the normal contact surface area of the foot e.g. bunions Limited joint mobility due to age, accidents and stroke etc 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 : - 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. Structural (bony) abnormalities producing plantar prominences that alter the normal contact surface area of the foot e.g. bunions Limited joint mobility due to age, accidents and stroke etc Gait and postural abnormalities 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 : - 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. Structural (bony) abnormalities producing plantar prominences that alter the normal contact surface area of the foot e.g. bunions Limited joint mobility due to age, accidents and stroke etc Gait and postural abnormalities Intolerance of friction Abnormal shear

Changes in mechanical stresses can be due to : - 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. Structural (bony) abnormalities producing plantar prominences that alter the normal contact surface area of the foot e.g. bunions Limited joint mobility due to age, accidents and stroke etc Gait and postural abnormalities Intolerance of friction Abnormal shear 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.

TREATMENTS The 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 deformity Allow some range of motion Be over the budget of many

BOTH solutions are usually used when an ulcer HAS 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 An offloading device for the ulcer 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: - Keep people active & contribute to their overall health Reduce the misery that diabetes is causing today. 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?

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