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A Comparison of Plantar Pressure in Patients With Diabetic Foot Ulcers Using Different Hosiery
Byron Blackwell, Roy Aldridge and Shirley Jacob International Journal of Lower Extremity Wounds 2002 1: 174 DOI: 10.1177/153473460200100305 The online version of this article can be found at: http://ijl.sagepub.com/content/1/3/174

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BLACKWELL PLANTAR PRESSURE ET AL

A Comparison of Plantar Pressure in Patients With Diabetic Foot Ulcers Using Different Hosiery
Byron Blackwell,* Roy Aldridge, PT, MS,* and Shirley Jacob, PhD

*Arkansas State University, Ark, USA, and Southeastern Louisiana University, Hammond, La, USA

Abnormally high plantar pressure has been associated with the development of foot ulcers in populations with diabetes. Improved foot care includes the use of hosiery (socks) as well appropriate footwear. In this study, the Parotec System, an in-shoe plantar pressure measurement device, was used to measure the plantar pressure of the forefoot of 21 participants. All patients were diagnosed with diabetes and were as-

sessed while wearing a combination of either a diabetic sock, a dress sock, or no sock and the participants own shoe or slipper. There were no statistically significant differences between combinations of socks and footwear.

Key words: diabetes, ulcers, plantar pressures, hosiery

t is estimated that 16 million Americans suffer from diabetes. Among this population, an estimated 2.5 million people (15%) will develop foot ulcers.1 Approximately 14% to 24% of these patients will require an amputation.1 It has also been estimated that 20% of all diabetic admissions to hospitals are for foot problems. Diabetes is the most frequent cause of nontraumatic lower limb amputation in the United States each year, comprising more than 56,000 amputations.2 In 2002, the total cost of caring for persons with diabetes inclusive of loss of productivity in the United States was estimated at $98 billion annually.2 Patients with foot ulcers localized to the plantar surface of their feet experience a 15 times higher overall risk of amputation compared to nondiabetes.3 It has been reported that diabetic neurotrophic ulcers are confined almost exclusively to the plantar surfaces of the metatarsal heads and toes.4 Abnormal foot pressure is implicated in the etiology of foot ulcers. There is a need to better manage this problem as well as to prevent it, as diabetes is projected to increase to involve 29 million by the year 2050.5 The use of improved foot care programs and custom-made shoes is known to be

beneficial, leading to a 44% to 85% reduction in the rate of amputations.6 Neuropathic ulcers may be prevented in some patients. This involves reduction of increased pressure perceived on plantar surfaces using specially designed shoes.7 The patient needing extra depth and occasionally rocker soles will need additional attention. as such shoes can be unacceptable for everyday use.7 Adapting the hosiery is another step in helping the patient and is reported to reduce plantar pressure. Researchers have developed experimental hosiery for diabetic patients.8 The experimental hosiery has been shown to reduce the plantar pressure more efficiently than typical hosiery.7 The purpose of this study was to evaluate the impact of various socks (diabetic vs nondiabetic [dress socks]) on the peak plantar pressure measurements of persons with diabetes. The diabetic sock (JOBST[Germany]) is composed of 100% cotton, whereas the nondiabetic sock (basic Editions) is composed of 100% nylon. Plantar pressures were accepted as a measure of reduced risk of ulceration. BACKGROUND STUDIES Previous studies have used an optical pedobarography to collect the static and dynamic plantar pressure under barefoot as well hosiery-protected foot conditions. These studies examined subjects while walking barefoot as well as while wearing different

Correspondence should be sent to: Roy Aldridge, PT, MS, PO Box 910, State University, AR 72467; e-mail: raldridge@mail.astate.edu. 2002 Sage Publications

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PLANTAR PRESSURE support hosiery.7,9 The investigation presented in this report was limited to the dynamic plantar pressure measurements using an in-shoe measurement device (Parotec System[Germany]). The device allows 24 independent measurement sites. The diabetic sock (JOBST), dress sock, and no-sock (barefoot) conditions were examined with patients using a slipper and their own shoe. Veves et al9 studied the pressure-reducing effects of socks worn by athletes. In another study, 27 patients were studied using a computerized optical pedobarograph. Three footsteps on each side were recorded under 3 conditions: barefoot, wearing the patients own hosiery, and wearing the experimental patented padded hosiery.9 It was reported that the special hosiery designed for diabetic patients was more efficient in reducing plantar pressure.9 Veves et al7 studied the durability of these specially designed socks and reported plantar pressures of 531.702 kPa, 234.459 kPa, and 343.35 kPa obtained at baseline, 3-month follow-up, and 6-month follow-up, respectively. Socks were washed regularly during the study. The study demonstrated the pressure reduction afforded by hosiery at different time periods. METHODS AND MATERIALS Twenty-one subjects (10 men, 11 women) with a mean age of 57.4 years (20 to 83 years) were recruited from the community and previous diabetic foot studies to participate in this study, which was approved by the institutional review board at Arkansas State University. Prior informed consent was obtained from all participants. All participants were diabetic by definition (5 type I, 16 type II). Eighteen participants (85.4%) had a previous history of, or complained of, foot complications. These included perceived loss of feeling of hot/ cold (4), discoloration (1), edema (7), burning (3), pain (8), tingling (5), cramping (3), bunions (2), callus formation (7), ulceration (3), loss of protective sensation (9), and amputation (2). However, if an open ulceration was present at the time of testing or if the participant had suffered an amputation, data from that extremity were excluded. At the time of data collection, 2 (9.5%) participants had an amputation (1 below-knee and 1 removal of the third and fourth phalanges) and 1 (4.76%) participant had an open ulcer. Patients with bilateral frank ulcers were excluded from the study. Patients walked a distance of 6 m wearing a controller unit weighing 0.907 kg around their waist. They wore a 3-mm thick collecting insole in each shoe, lifted their legs while seated for 1 second to calibrate the de-

vice, and stood without support for 10 seconds to collect static measurements. Each patient (n = 18) repeated the walk. The following procedure was repeated on all participants. The first step was an oral explanation and demonstration of the collection procedures while the subject sat in view of the testing path. After history taking, body weight (using an electrical scale) and shoe size were measured. Sensation was tested with the Semmes-Weinstein monofilament (5.07 g), and the foot pulse was palpated by the examiner. All information was recorded on the intake form and filed in individual folders. Patients were asked to participate in 3 trials of each of the 6 conditions using a repeated-measures design based on previous pilot studies by the group. These conditions were wearing (1) no sock with slipper, (2) no sock with the patients own shoe, (3) dress sock with slipper, (4) dress sock with the patients own shoe, (5) diabetic sock with slipper, and (6) diabetic sock with the patients own shoe. Each trial consisted of the patient walking on a hard, level surface for a predetermined distance while wearing one of the 6 combinations of hosiery and shoe. All participants completed three 6-m trials per condition while fitted with the Parotec-Systems data collection device, which was attached to a belt and worn about the waist. The pressure sensor pads were placed directly under the hosiery or foot and directly above the insole of either the patients own shoe or slipper, depending on the combination of support and hosiery. The sensor pads were connected to the data collection device by wires. Participants were given a verbal explanation and demonstration of the procedure. Patients were instructed to lift their feet off the ground for 3 seconds while seated in order to calibrate the device. After calibration, patients stood with their feet together at the starting point of their walk for 5 seconds while the static signals were collected. The patients were then asked to walk normally at a constant speed while plantar pressure measurements were recorded. Along with the collection of the dynamic plantar pressure measurements, the time and the total number of steps during the distance covered were collected to ensure that a consistent speed and number of steps were taken with each trial. After walking, patients returned to the computer, where they sat in a chair while the data were downloaded into the individuals file. Patients were permitted to recover before performing a repeat walk. All data for each participant were collected on the same day by the same researcher, with the time of day being dependent on a mutual agreement between the schedules of the participant and examiner.

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BLACKWELL ET AL

Table 1. Plantar Pressure Measurements (kPa) of the Forefoot Region (Sensors 17 to 24) Taken During the 6 Combinations (N = 21)
Combination Mean SD SEM

Table 2. Plantar Pressure Measurements (kPa) of the Metatarsal Heads (Sensors 17 to 20) Taken During the 6 Combinations (N = 21)
Combination Mean SD SEM

Slipper with no sock Slipper with diabetic sock Slipper with dress sock Shoe with no sock Shoe with diabetic sock Shoe with dress sock

1123.5 1148.9 1161.4 1091.9 1143.5 1129.5

256.0 266.7 289.4 232.3 241.3 230.9

55.9 58.2 63.2 50.7 52.7 50.4

Slipper with no sock Slipper with diabetic sock Slipper with dress sock Shoe with no sock Shoe with diabetic sock Shoe with dress sock

195.3 182.1 187.1 171.5 176.4 177.8

60.7 72.6 72.1 43.7 42.0 38.7

13.25 15.84 15.73 9.53 9.16 8.45

NOTE: One-way repeated-measures analysis of variance showed no significant difference between the 6 combinations; F = 0.562, p = .729. Power of the performed test with = .05 is 0.0496

NOTE: One-way repeated-measures analysis of variance showed no significant difference between the 6 combinations; F = 0.933, p = .463. Power of the performed test with = .05 is 0.0496.

RESULTS The Parotec System records 24 separate sensors, but for the purpose of the study, data from sensors relating to forefoot alone (17 to 24) were considered. Each trial consisted of data collected on 5 steps. Therefore, each mean value of the 3 trials represented 15 individual steps for the particular condition of sock/no sock and shoe/slipper. Data of each individual participating were entered into Sigma Stat (US) for data analysis using 1-way repeated-measures analysis of variance. Table 1 represents the statistical analysis of the mean plantar pressure (kPa) measurements of the forefoot region taken during the 6 combinations used in the study. Figure 1 shows the descriptive statistics of the mean plantar pressure of the forefoot for each of the 6 variables used in the study. Data analysis of the forefoot region plantar pressure measurements produced no statistically significant differences between any of the 6 combinations in the study. One-way repeated-measures analysis of variance revealed that the plantar pressure measurements under the area of the metatarsal heads between the 6 combinations in the study were not statistically significant. These are presented in tabular form in Table 2. Analysis of variance of the plantar pressure measurements recorded under the toes (sensors 21 to 24) were also run for the 6 combinations in the study. A statistically significant difference (p = .0195) was shown between 5 of the combinations. The slipper combined with no sock had significantly lower pressure than the other 5 combinations. Because these data were nonnormally distributed, a Friedman repeated-measures analysis of variance on ranks was used to evaluate the measurements under the phalanges/toes. Table 3 shows the descriptive data of the phalanges/toes taken 176
LOWER EXTREMITY WOUNDS 1(3); 2002

during the 6 combinations used in the study. One-way repeated-measures analysis of variance was used to determine differences between the 6 combinations measured by sensor 20, which was located under the first metatarsal head. Again, no statistically significant differences were detected. These measurements suggest that the diabetic sock did not significantly decrease the plantar pressure measurement with either the shoe or the slipper. DISCUSSION The aim of this study was to determine differences between hosiery used by diabetic patients using plantar pressure measurements as an objective risk assessment for foot ulcer occurrence/prevention. Two different types of hosiery (socks) were compared to a nosocks condition in this study to measure plantar pressure obtained with different footwear. Lower plantar pressure or the ability to lower a high value is considered useful in reducing the risks of forefoot ulcers in persons with diabetes. This study showed that the diabetic sock (JOBST) was not different from the other types of hosiery in reducing plantar pressure. However, it was observed that the slipper/no sock combination was associated with significantly less pressure under the metatarsal heads. This interesting observation may have implications for persons with diabetes in Chinese and South Asian societies, where slippers are worn outwith the household and where diabetes is increasing. For those persons who have diabetes, finding a means of dispersing and relieving this abnormal pressure can be the difference between having healthy feet and having complications that could lead to a significantly increased risk of amputation. Many simple actions can be taken as a preventative means in caring for

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PLANTAR PRESSURE

1800

1600

1400

1200

Plantar Pressure (kPa)

1000

800

600

400

200

Shoe with no sock 659.01 1647.3 1091.919

Shoe with diabetic sock 636.64 1759.17 1143.5138

Shoe with dress sock 679.03 1662.33 1129.5048

Slipper with no Slipper with sock diabetic sock 738.2 1770.11 1123.54 743.8 1763.86 1148.8905

Slipper with dress sock 714.37 1715.6 1161.3643

Minimum Maximum Mean

Fig. 1.

Mean plantar pressure values (kPa) of the forefoot (sensors 17 to 24) for each of the 6 variables used in the study.

Table 3. Plantar Pressure Measurements (kPa) of the Phalanges/Toes (Sensors 21 to 24) Taken During the 6 Combinations (N = 21)
Combination Mean SD SEM

Slipper with no sock Slipper with diabetic sock Slipper with dress sock Shoe with no sock Shoe with diabetic sock Shoe with dress sock

85.6 105.2 103.3 101.5 109.5 104.6

52.7 54.2 64.1 40.6 43.3 46.0

11.51 11.84 13.99 8.85 9.45 10.03

NOTE: The slipper with no sock combination had significantly lower plantar pressure than the other 5 combinations; F = 2.84, p = .0195. Power of the performed test with = .05 is 0.6018.

the feet using the simple acronym KEEP: know the disease, exercise, eat right, and wear proper footwear. Many factors go into selecting the proper footwear. Shoes should provide proper arch support, pressure relief, and a large toe box; in many cases, a wide shoe can be found. Never should a person with diabetes ambulate, whether inside or out, without wearing some kind of shoe (not sandals). Footwear involves not only shoes but also the wearing of socks. White socks are preferable because any form of wound that appears can be easily noticed by the stains of the exudate on the white sock. High plantar pressures should be avoided using designed footwear and hosiery. Boulton10 has also sug-

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BLACKWELL ET AL

gested the importance of evaluating plantar pressures regularly. REFERENCES

1. Cavanagh PR, Buse JB, et al. The American Diabetes Association, Inc. Diabetes Care 1999;22:1354-60. 2. American Diabetes Association. About us. Retrieved January 12, 2002, from http://www.diabetes.org/main/health/body_care/foot/ foot_care.jsp. 3. Boulton AJM, Betts RP, Franks CI, et al. The natural history of foot pressure abnormalities in neuropathic diabetic subjects. Diabetes Res 1987;5:73-7. 4. Boulton AJM, Bowker JH, Gadia M, et al. Use of plaster casts in the management of diabetic neuropathic foot ulcers. Diabetes Care 1986;9:149-52.

5. Boyle JP, Honeycutt AA, Narayan KMV, et al. Projection of diabetes burden through 2050: impact of changing demography and disease prevalence in the US. Diabetes Care 2001;24:1936-40. 6. Bild DE, Selby JV, Sincock P, et al. Lower extremity amputation in people with diabetes: epidemiology and prevention. Diabetes Res 1987;5:73-7. 7. Veves A, Masson EA, Fernando DJS, et al. Studies of experimental hosiery in diabetic neuropathic patients with high foot pressures. Diabetic Med 1990;7:324-6. 8. Herring KM, Richie DH. Friction blisters and sock fiber composition: a double-blind study. J Am Podiatr Med Assoc 1990;80(2):63-71. 9. Veves A, Masson EA, Fernando DJS, et al. Use of experimental padded hosiery to reduce abnormal foot pressures in diabetic neuropathy. Diabetes Care 1989;12:653-5. 10. Boulton AJM. The diabetic foot. Med Clin North Am 1988;72:1513-31.

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