545422

research-article2014
POI0010.1177/0309364614545422Prosthetics and Orthotics InternationalRobinson et al.

INTERNATIONAL
SOCIETY FOR PROSTHETICS
AND ORTHOTICS

Expert Clinical View Point

Prosthetics and Orthotics International

Orthotic management of the neuropathic 2015, Vol. 39(1) 73­–81

© The International Society for
Prosthetics and Orthotics 2014
foot: An interdisciplinary care perspective Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0309364614545422
poi.sagepub.com

Christopher Robinson1, Matthew J Major1, Charles Kuffel2, Kevin

Hines2 and Pamela Cole3

Abstract
Background: Clinical management of the patient with neuropathic foot is becoming commonplace in orthotic clinics
worldwide. The presentations that can result from neuropathic foot are diverse, requiring clinicians to understand the
pathomechanics of ulceration, infection, and Charcot joint arthropathy to provide effective interventions.
Objectives: The purpose of this clinical perspective is to provide a review of the literature regarding clinical concepts
associated with orthotic management of neuropathic foot.
Study design: Literature review and clinical case study.
Methods: Relevant literature were reviewed and summarized, and a clinical case study synthesizing reviewed concepts
was presented.
Results: Given the multifactorial nature of the neuropathic foot, treatments must be multifaceted and patient-specific to
effectively address the underlying disease processes. While systemic issues such as peripheral arterial disease are treated by
physicians, local issues such as foot deformity are managed by orthotists. Orthotic interventions commonly include custom
footwear to reduce the risk of ulceration through creation of a protective environment or targeted plantar offloading. Patient
and caregiver education to encourage management compliance is equally as important to ensure successful treatment.
Conclusion: Patients with neuropathic foot benefit from an interdisciplinary care approach which engages physicians,
wound care practitioners, and orthotists to treat and manage systemic and local problems. Addressing this pathology
through interdisciplinary care may positively affect the patient’s health status while lowering associated healthcare costs
through improved treatment efficacy.

Clinical relevance
The commonality of neuropathic foot and associated complications including ulceration, infection, and Charcot joint
arthropathy requires that the patient care team have a fundamental understanding of these pathologies and common
treatment modalities. We review orthotic treatment modalities to assist clinicians with the management of patients with
neuropathic foot.

Keywords
The diabetic foot, diabetes, lower limb orthotics, orthotics, wound management, skin

Date received: 31 March 2014; accepted: 16 June 2014

Background
Diabetes affects approximately 7%–8.3% of the US popu-
lation, which equates to over 22 million people.1,2 Of
potentially greater concern is the fact that that 7 million of
the patients with diabetes in the United States are unaware
that they even have the disease.2 Diabetes is not only a
major clinical challenge in the United States, as it is esti-
mated that almost 200 million people worldwide have dia-
the immense strain that diabetes places on the resources of
our healthcare systems. The total cost to treat diabetes and
its related conditions in the United States is estimated to be
1JesseBrown VA Medical Center, Northwestern University, Chicago,
IL, USA
2Arise Orthotics & Prosthetics, Inc., Blaine, MN, USA
3Methodist Hospital Wound Clinic, St. Louis Park, MN, USA

betes and there is a potential for this number to grow as

Corresponding author:
high as 552 million by 2030 based upon population growth Christopher Robinson, Northwestern University, 680 N Lake Shore
and inadequate access to healthcare resources globally.3,4 Drive, Chicago, IL 60611, USA.
The current healthcare climate demands consideration of Email: c-robinson@northwestern.edu
74 Prosthetics and Orthotics International 39(1)
Figure 1.  Clinical algorithm describing pathways that can lead to ulceration.13
Source: reprinted with permission from John Wiley & Sons, Inc.
US$14 billion annually.5 Neuropathic foot complications
account for 20% of all inpatient days for patients with dia-
betes in the United States and is estimated to cost £252 mil-
lion annually in the United Kingdom.6,7 Treatment of each
neuropathic ulcer costs between US$7000 and US$28,000
depending on the locality and magnitude of treatment
required. If amputation is needed, the expense may be
upward of US$50,000–US$60,000.3,8,9 Despite the volume
of scholarly literature on the topic of neuropathic foot and
its support for interdisciplinary care team management, the
rate of ulceration continues to increase at approximately
2% per year.3 This increase in ulceration may ultimately
translate to increased expense and burden to the healthcare
system.3 However, interdisciplinary care teams, including
orthotists and wound care specialists, that collaboratively
manage neuropathic ulceration are a potentially effective
solution to minimizing these costs. It has been suggested
that 50%–75% of amputations are preventable with early
diagnosis of diabetes and its associated complications
combined with appropriate treatment by an interdiscipli-
nary care team including orthotics practitioners.5,10,11 A
multi-center trial in Italy using this model of management
succeeded in reducing the cost by €107,505 annually pre-
venting 55 diabetic foot ulcers per year in the population
that received orthotic management as part of their interdis-
ciplinary care.12
The multifactorial nature of foot ulceration requires the
clinician to understand the interplay between local and
systemic factors in order to design the most effective treat-
ment plan. The clinical algorithm proposed by Boulton13
(Figure 1) illustrates the interplay of the contributing fac-
tors and the pathways that can lead to ulceration.
Essentially, ulceration is a multifactorial condition that
arises from a combination of systemic and localized prob-
lems.1,3,6,8,11,14 Systemic complications of diabetes include
hyperglycemia, peripheral arterial disease, and neuropa-
thy.4,5,8,14 Hyperglycemia secondary to poorly managed
blood glucose can result in increased stiffness and reduced
elasticity of plantar tissue, compromising its ability to tol-
erate sheer forces.6 Systemic issues can increase the likeli-
hood of developing a wound and often occur in concert
with localized issues versus in isolation.6,11 Of all the sys-
temic complications of diabetes, evidence suggests that
sensory neuropathy is the most prominent risk factor for
ulceration.14 Importantly, the combination of sensory neu-
ropathy, minor foot trauma, and deformity accounts for
over 50% of diabetic ulcers.14 Local problems include the
presence of hyperkeratotic lesions, foot deformity, range-
of-motion (ROM) limitations, improper footwear, and a
history of previous ulceration.1,8 Hyperkeratotic lesions
and foot deformities create focal points for ulceration to
occur, while decreased ROM of the joints in the lower limb
and improperly fit footwear can result in greater than typi-
cal forces during weight-bearing activity.6,15,16 Furthermore,
a history of ulceration elevates the patient’s risk of sustain-
ing a new wound given that the resultant tissue after heal-
ing lacks the tensile strength of the original structure.4
Given the multifactorial nature of the neuropathic foot
and its associated complications, treatments must also be
multifaceted and tailored to each individual patient’s
needs. Regardless of the underlying factors such as neu-
ropathy or abnormality, there is a general consensus that
the underlying disease processes must be addressed if the
practitioner hopes to achieve long-term success.4
Management of the neuropathic foot requires the interdis-
ciplinary team to address both systemic and local
Robinson et al. 75

problems, while providing the patient and their caregivers Table 1.  Modified Eichenholtz19 classification.
adequate education to ensure compliance to the proposed
Stage Definition Clinical presentation
treatment plan.
A practical illustration of the interplay between sys- O Patients at risk of Diabetic neuropathy and an
temic and local factors is patients with diabetes that lack a Charcot joint acute sprain or fracture
normal immunoresponse, which enables infection to more I Development– Erythema, edema, and
easily spread and cause potentially irreparable damage if fragmentation increased warmth, usually
absence of pain
not promptly addressed.1 Tissue damage secondary to
II Coalescence Diminution of erythema,
infection, which is the second most common complication edema, and warmth; decreased
of neuropathic foot,11 can subsequently require modifica- joint mobility
tion to a patient’s treatment needs, including orthotic man- III Reconstruction– Erythema, edema, and warmth
agement if the patient’s limb volume has changed or a consolidation are no longer present; ulcers
surface-based treatment is implemented by the wound care at sites of residual deformity
team. For example, alginate or foam-based dressings can
be implemented to control the wound exudate, but they
require adequate space within the orthosis to function Table 2.  Sanders and Frykberg20 classification.
optimally.17
Another complication of neuropathic foot that will Classification Anatomical location of joint
shape the clinical decision-making process with regard to involvement
orthotic management is Charcot joint arthropathy. Charcot I Forefoot
joint arthropathy is developed by just 1% of patients with II Tarsometatarsal
neuropathic foot and is believed to be a result of combined III Naviculocuneiform, talonavicular,
sensory neuropathy, normal circulation, and preceding calcaneocuboid joints
foot trauma.1,17,18 To facilitate diagnosis and clinical deci- IV Ankle and subtalar joints
sion making, multiple classification systems have been V Calcaneus
developed to quantify and categorize Charcot joint arthrop-
athy. Classification systems for Charcot joint arthropathy
are based upon either the natural history of the disease or prevent recurrence, although more complicated cases will
affected joint structures. A common classification system require more involved orthotic management.16 There is
based on natural history is the Eichenholtz and modified evidence to support that orthotic modalities are acceptable
Eichenholtz classification systems.6,18,19 The original methods for offloading of ulceration21 and that the imple-
Eichenholtz classification system defines three stages: (I) mentation of protective footwear can reduce the incidence
acute inflammatory, (II) healing, and (III) chronic, while of future ulceration.22
the modified Eichenholtz system added an initial stage Finally, a treatment that must not be overlooked is
referred to as pre-stage I or stage 0 (Table 1).19 The Sanders effective patient and caregiver education.1,8 Although posi-
and Frykberg classification system is useful for classifying tive clinical outcomes for the management of neuropathic
the joints affected by Charcot joint arthropathy (Table 2), foot have been attributed to interdisciplinary care, patient
with locations ranging from distal/anterior to proximal/ adherence to the wear of orthotic interventions, home
anterior.1,20 For example, the most common type of Charcot wound care plans, and an understanding of their overall
joint arthropathy as defined by the Sanders and Frykberg1 health condition are all equally important in ensuring suc-
classification is “type II,” which occurs at the tarsometa- cessful treatment. The patient must have a clear under-
tarsal joints often resulting in “rocker bottom foot” standing of the aims of their treatment, be able to identify
deformity. worsening symptoms, and be proactive about communi-
While systemic issues are most often treated by physi- cating with their healthcare team to treat a new wound as
cians, local issues are addressed by a collaborative effort expeditiously as possible. However, for this treatment to
of a wound care practitioner and a prosthetist/orthotist. be successful, the patient must be informed and open to
Offloading sensitive areas to minimize applied pressure communication with their healthcare team.4
and/or sheer, while simultaneously increasing applied Diabetes and associated neuropathic foot are clinical
pressure to more tolerant areas, is often the primary goal challenges faced by practitioners worldwide. As incidence
when treating the neuropathic foot in order to decrease the of neuropathic foot and its associated complications rise,
risk of ulceration.12,13 The greater the magnitude of off- it is imperative that orthotic practitioners have a sound
loading, the more likely a wound is to heal, with common understanding of the clinical principles that underlie
orthotic modalities reducing peak plantar pressures effective management of patients with these conditions.
between 20% and 80%.15 A treatment as simple as provid- The aim of this article is to provide the clinician with a
ing properly fit footwear can facilitate wound healing and multidisciplinary perspective on the management of
76 Prosthetics and Orthotics International 39(1)
neuropathic foot, describe orthotic modalities commonly
implemented to treat ulceration and Charcot joint arthrop-
athy, provide a clinical case study of interdisciplinary care,
and generally discuss pertinent topics to consider when
managing the neuropathic foot.
Treating the neuropathic foot: an
orthotist’s perspective
The neuropathic foot is one of the most challenging clini-
cal scenarios that an orthotist can manage. The practitioner
must not only perform a comprehensive examination of
the client and formulate an individualized treatment plan
including an appropriate orthotic modality but also pro-
vide the education required to achieve an appropriate clini-
cal outcome. Failure to provide an appropriate intervention
and necessary education may preclude successful treat-
ment and further compromise the patient’s already delicate
health condition.
Preventative screening for these clinical problems is
essential to identify those individuals who are most at risk.
A common screening technique to assess for the presence
of peripheral neuropathy is the Lower Extremity
Amputation Prevention (LEAP) program.5,23 The five-step
LEAP protocol includes the following: (1) an annual foot
screening, (2) patient education, (3) daily self-inspection,
(4) proper footwear selection, and (5) management of sim-
ple foot problems.5
The annual foot screening protocol of the LEAP pro-
gram provides the orthotist with clinical information to
help identify those patients who are at risk of ulceration.
This protocol consists of two components: standardized
questionnaire and protective sensation assessment. The
questionnaire instrument assesses factors including history
of ulceration, deformity, swelling, callous, muscle weak-
ness, and the fit of the patients’ footwear. The protective
sensation assessment is completed with a 5.07 gauge
monofilament to assess the extent of sensory neuropathy.
In patients who have already lost protective sensation, the
US Health Resources and Service Administration recom-
mends an increase in frequency for the administration of
the screening exam to every 3 months given their increased
relative risk.24 Completion of the LEAP screening protocol
informs the patient’s orthotic treatment plan and will pro-
vide context for education about their condition and poten-
tial complications.
Verbal and written patient education on the manage-
ment of diabetes and associated neuropathy not only
engages the patient but also may prevent further complica-
tions.25 Through the introduction of simple self-manage-
ment techniques, the patient will assume responsibility for
their health by performing daily skin inspections, identify-
ing problems, and treating simple foot problems such as
dry skin. Early recognition of potential problems empow-
ers the patient to pursue them before they manifest into
something more serious. Patient education is not complete
unless the orthotist also stresses the importance of appro-
priate footwear and the need to wear the footwear even for
activities within the patient’s home.24
Once the neuropathic foot patient has been thoroughly
assessed and educated about their condition such that they
have been provided the information necessary to monitor
their condition, the orthotist can begin to formulate a treat-
ment plan. Orthotic management must account for internal
influences such as bony malformation or ROM limitations,
skin integrity, and the patient’s ability to implement the
selected intervention independently. In patients with no
active ulceration, long-term maintenance of the neuro-
pathic foot is often achieved through the use of depth inlay
shoes and multi-density accommodative foot orthoses.
Chronic foot ulceration and/or active Charcot joint arthrop-
athy requires more aggressive orthotic management such
as joint immobilization and unweighting to promote initial
healing. The objective of this section is to provide practi-
tioners with a fundamental understanding of the orthoses
commonly used to treat neuropathic foot and discuss their
appropriateness for managing the neuropathic patient.
A practice framework exists for the wound care practi-
tioner to affectively treat neuropathic ulceration, but it is
important to note that no single modality can address the
needs of every patient. It is essential that the wound care
practitioner create a multifaceted treatment plan to address
each patient’s unique clinical presentation. Regardless of
the chosen wound care modalities, it is the responsibility
of the orthotics practitioner to work collaboratively to cre-
ate an interface between the patient’s foot and the ground
that can enable initial healing and long-term mobility for
the patient with the neuropathic foot.
Diabetic shoes and multi-durometer foot
orthoses
Depth inlay footwear for the treatment of neuropathic foot
is designed to provide prophylactic protection and long-
term management to the at-risk neuropathic population.
The goal of depth inlay shoes is to provide a total protec-
tive environment to the dorsal and plantar aspects of the
foot, while allowing adequate internal volume to accom-
modate off-the-shelf or custom multi-durometer foot
orthoses and prevent impingement of the patient’s anat-
omy. A proper fit between the shoe and the patient’s foot
and a seamless construction on the inside of the shoe is
intended to minimize shear and pressure within this inter-
face. The addition of an extended shank or full-length car-
bon fiber insert reinforces the shoe and limits motion at the
midfoot and forefoot during stance. Depth inlay footwear
may be lace-up and/or Velcro closure depending on the
patient’s dexterity and personal preference. Diabetic shoes
may be further enhanced by pedorthic modifications to
accommodate fixed deformities or address atypical
Robinson et al. 77
Figure 2.  (a) Forefoot and (b) hindfoot offloading footwear (OrthoWedge and HeelWedge; DARCO International, Huntington,
WV, USA).
kinetics/kinematics. Common pedorthic modifications
include the application of a medial or lateral flare, sole lift,
or a rocker sole, which can be used to widen the patient’s
base of support, address atypical joint moments, accom-
modate a leg-length discrepancy, or augment stance phase
timing.8 The diabetic shoe is typically provided in con-
junction with multi-durometer foot orthoses which utilize
varying densities of materials to provide a total contact
interface between the neuropathic foot and the shoe.
Patients with neuropathic foot often sustain higher than
normal peak plantar pressures,26 and a total contact envi-
ronment reduces areas of peak pressure as a result of
increasing the affected surface area. Multi-durometer foot
orthoses are either off-the-shelf or custom in design and
are selected based on presentation of the plantar foot.
Patients with excessive callusing, ulceration, or foot
deformity often require custom-fabricated foot orthoses
due to their unique anatomy, while prophylactic care of
mild foot abnormalities is achieved through the use of off-
the-shelf foot orthoses.
Offloading footwear
An important component to comprehensive wound care
involves the minimization of pressure and/or sheer at the
site of the wound, known as offloading. Even with optimal
local wound care, debridement, and dressings, the wound
is unlikely to heal without the addition of an offloading
modality to the treatment plan. Offloading is challenging
because many modalities reduce patient function, voca-
tion, and safety due to their weight and bulk.
Various styles of offloading footwear to relieve pres-
sure sensitive areas of the neuropathic foot are commer-
cially available. The style of offloading footwear is a
function of the region of the foot that requires offloading.
Offloading footwear is rarely a definitive intervention and
often used as an interim protective measure while custom
orthoses are being fabricated. Offloading footwear is typi-
cally used as a provisional intervention as it may not facili-
tate the same level of healing observed when using other
common modalities such as the total contact cast or remov-
able cast walker.27 Offloading footwear often relies on
aggressive modifications to the sole of the footwear to
achieve its affect, but these modifications may negatively
impact gait by creating discomfort28 and encouraging
changes in joint moments and pelvic obliquity.29
Furthermore, the sole thickness of common offloading
shoe orthoses is frequently higher than the patient’s typical
footwear and may result in a leg-length discrepancy that
requires consideration.
Forefoot offloading footwear (Figure 2(a)) is designed
to provide pressure reduction in the metatarsal heads and
phalanges. This type of offloading footwear typically
places the ankle in a relatively dorsiflexed position and
effectively shortens the amount of relative time spent in
the forefoot rocker during the stance phase of gait, thereby
reducing the duration of applied pressure to this region.
Hindfoot offloading footwear (Figure 2(b)) is designed to
limit the magnitude of forces imparted on the calcaneus.
This is done by removing the sole area plantar to the hind-
foot which forces initial contact to occur anterior to the
calcaneus.
Not all offloading footwear requires the use of rocker
modifications to impart a biomechanical benefit. Various
manufacturers provide healing shoes that are offloading
footwear to allow for targeted reduction in plantar pres-
sures through the removal of pre-punched pads in the
included insert (Figure 3). Care should be taken with this
intervention as leaving a large void below an ulcerative
site can cause wound compromise as the tissues of the foot
can displace into the void during weight-bearing activity.
However, a minimal level of plantar surface pressure
78 Prosthetics and Orthotics International 39(1)
Figure 3.  Össur DH offloading insole (Össur Americas, Aliso
Viejo, CA, USA).
applied to the ulcerative area can be maintained by back-
filling the voids with a lower durometer material.
A substantial body of literature on plantar wound treat-
ment suggests that total contact casting (TCC) is the gold
standard of offloading modalities.3 TCCs distribute pres-
sure across the foot, immobilize the foot and ankle joints,
and distribute forces across a larger surface area of the
patient’s limb. TCCs are typically changed once per week
to enable the wound care practitioner to monitor, cleanse,
debride, and re-apply dressings to the wound. Should the
patient have poor ankle brachial index, heavy necrosis,
and/or an active infection, the TCC can be fabricated such
that it is removable in nature enabling more frequent
inspection and dressing changes. The dilemma with a
removable design is that it enables patients to more easily/
readily doff the TCC, which can hinder compliance and
potentially compromise healing. Rapid TCCs, which use
off-the-shelf walking boots with pneumatic bladders to
redistribute pressure, are becoming a popular offloading
solution as they require minimal customization and fabri-
cation time. However, rapid TCCs lack the total contact
throughout the patient’s limb as they are not contoured to
the patient’s unique anatomy. If a bivalved TCC or rapid
TCC is used for treatment, the patient must clearly under-
stand that walking even a few steps without the support of
the device may compromise the wound healing process
and potentially cause the development of new wounds.
Custom orthotic management
Comprehensive orthotic management for patients with
Charcot joint arthropathy, active ulceration, or moderate-
to-severe bony deformity cannot often be addressed with
an off-the-shelf intervention. Custom orthoses allow the
orthotist to utilize appropriate materials and design
principles for the individual patient’s needs. Commonly
implemented custom orthotic modalities are the Charcot
restraint orthotic walker (CROW) orthosis, patellar ten-
don-bearing (PTB) orthosis, and conventional ankle–foot
orthosis (AFO) with molded calf lacer.
The CROW orthosis is a custom-fabricated bivalve
orthosis designed to provide total contact to the plantar
aspect of the foot, ankle, and calf designed to treat Charcot
joint arthropathy and diabetic foot ulcers. Given that the
CROW is custom fabricated, it can accommodate a wide
array of foot and ankle deformities often seen when treat-
ing the patient with neuropathic foot.30 The CROW ortho-
sis is worn to provide offloading, tri-planar restriction
motion of the foot and ankle. The CROW is contraindi-
cated for patients with large volume fluctuation as these
changes can compromise the fit and functionality of the
orthosis. The ease of doffing of the CROW orthosis allows
easy dressing changes and monitoring of the wound area.
In practice, the CROW orthosis is used for long-term man-
agement of Charcot joint arthropathy and ulceration where
a TCC or off-the-shelf intervention is inappropriate.
A PTB orthosis is designed to provide offloading of
the plantar aspect of the foot by suspending the limb via
pressure tolerant structures around the knee, such as the
patellar tendon (ligament), popliteal fossa, and medial
tibial flare. The proximal portion is fabricated from a
thermoplastic or thermoset material and is attached to a
conventional AFO with alloy sidebars and double action
joints. Depth inlay shoes with multi-density inserts are
installed distally to provide total contact to the plantar
aspect of the foot. This type of orthosis better accommo-
dates volumetric changes than the CROW orthosis as its
relatively open design can accommodate volumetric
increase while a volumetric decrease is accommodated
with the application of sock ply prior to donning the
orthosis. The integration of double action joints enables
the practitioner to tune the orthosis to optimize kinemat-
ics for the minimization of forces applied to the patient’s
neuropathic limb.5
The conventional AFO with molded calf lacer is custom
fabricated from a cast of the patient’s limb. The objective
of this orthosis is to provide unloading of the plantar aspect
of the patient’s foot by circumferential loading of the calf
musculature.31 Similar to the PTB-style AFO, the conven-
tional orthosis will accommodate volume fluctuation of
the limb as the molded calf lacer can be adjusted circum-
ferentially by simply loosening or cinching the closer
while donning. The distal portion of the orthosis consists
of alloy sidebars and double action joints to attach the
orthosis to depth inlay footwear with a multi-density insert.
The conventional AFO with molded calf lacer is an effec-
tive modality during acute, sub-acute, and long-term man-
agement of plantar ulceration.
Regardless of the orthotic modality, the interdiscipli-
nary care team must work closely to ensure the patient is
phased into the appropriate intervention. Potentially
Robinson et al. 79
Figure 4.  (a) Wound on the lateral aspect of the patient’s left lower limb status post partial resection of the calcaneus and fifth
metatarsal and (b) initial wound closure after the implementation of a PTB orthosis.
PTB: patellar tendon bearing.
cumbersome interventions such as the CROW should be
discontinued when the patient is a candidate for a less
restrictive intervention such as custom shoes and inserts.
Simply observing wound closure is not adequate justifi-
cation as it takes 3 months for scar tissue to remodel and
achieve 80% of its original tensile strength.32 Application
of excess pressure on a recently closed wound from pre-
mature weaning into diabetic shoes could increase the
risk for re-ulceration as the tissues have only 20% of its
final tensile strength at 3 weeks following the scarring
onset.
Clinical case study
Patient history
The patient was a 49-year-old female (165 cm, 102 kg)
with type 2 diabetes, bilateral plantar sensory neuropathy,
and type III Charcot joint arthropathy with a recently
debrided diabetic foot ulcer on the right lower limb and a
wound spanning the lateral aspect of the calcaneus, cuboid,
and fifth metatarsal that was recently closed with a split-
thickness skin graft. The patient stated that the ulcer on the
right limb developed 7 months prior to the consultation
and the Charcot joint arthropathy was diagnosed 10 months
prior, although they stated that they were initially misdiag-
nosed with cellulitis. The wound on the left foot developed
after the patient sustained a hematoma from striking their
foot against the orthosis on the right foot, which eventually
resulted in the need to perform a partial resection of the
calcaneus and fifth metatarsal (Figure 4). The wound beds
were clear and the edges were free from necrotic tissue.
Previous orthotic management included an off-the-shelf
pneumatic walking boot with a custom multi-density foot
orthosis and a healing sandal with practitioner adjustable
multi-density insole (Figure 3) on the right limb. The left
lower limb had not been managed with an orthotic inter-
vention and the patient utilized a kneeling scooter for
unweighting of the left foot skin graft area at the time of
consultation.
Patient evaluation
Hammer toes were observed bilaterally at digits 2–3 and
the skin appeared to be dry and flaky with callous present
on the plantar aspect of the calcaneus bilaterally and proxi-
mal to the Charcot joint at the midfoot of the right limb.
The patient’s left foot presented in forefoot adduction
likely due to changes associated with the recent osseous
resections. A 5.07 gauge monofilament was used to assess
for the presence of neuropathy, and findings were consist-
ent with the presence of peripheral neuropathy as the
patient could not identify the presence of the monofila-
ment at any point on the plantar aspect of their foot. The
patient’s lower limb passive ROM and strength were
assessed bilaterally in a seated non-weight-bearing posi-
tion. Both lower limbs were found to have hip and knee
ROM within functional limits. Ankle ROM was assessed
with the knee in terminal extension, and a plantar grade or
neutral position was achieved bilaterally, but no additional
dorsiflexion was available. Decreased mobility was noted
at the midfoot joints bilaterally secondary to surgical inter-
vention on the right limb and Charcot joint arthropathy on
the left side. Bilateral manual muscle test findings revealed
right–left symmetric muscle strength, with all lower
extremity muscle groups demonstrating strength at a level
of 4/5, apart from ankle dorsiflexor and plantar strength
which were scored as 3/5.
Treatment
Bilateral impressions were taken in a non-weight-bearing
position with the knees in terminal extension to better
reflect ankle alignment during ambulation for the fabrica-
tion of bilateral CROW orthoses. The positive model was
rectified with 3-mm build-ups placed over the Charcot joint
80 Prosthetics and Orthotics International 39(1)

at the midfoot of the right limb and the skin graft over the
lateral aspect of the foot on the left limb. The orthoses were
fabricated from 3/16″ copolymer with a soft-density poly-
ethylene foam liner and removable multi-durometer insole.
The reliefs were back-filled with pink Plastazote (Algeos
USA, Santa Monica, CA, USA) to restore total contact with
the limb and then covered with ShearBan (Tamarack
Habilitation Technologies Inc., Blaine, MN, USA) to mini-
mize friction over the compromised areas. A rocker bottom
sole was fabricated from crepe to enable adjustments to the
rocker profile and height during the fitting process.

Follow-up
The patient was closely followed with bi-monthly visits to
the orthotics team and wound care specialist over a
6-month period of time. Adjustments were made to the
CROW boots to maintain total contact throughout the
patient’s lower limbs due to volumetric or anatomical con-
tour changes. The wound on the plantar aspect of the right
foot was healed during the 6 months of immobilization in
the CROW. The wound on the lateral aspect of the foot
increased in diameter and was migrating over the foot
perimeter to the plantar aspect. This was further compro-
Figure 5.  Side view of the leather unweighting orthosis.
mised by excessive wound exudate which resulted in skin
maceration and the need for increased frequency of dress-
ing changes.
Conclusion
Secondary treatment The clinical management of the neuropathic foot requires
Six months after the CROW orthoses were provided, the careful consideration of each patient’s unique needs to
clinical team decided to transition the patient into bilat- effectively address the systemic and local issues for ensur-
eral leather unweighting orthoses attached to a conven- ing successful intervention. Effective management facili-
tional AFO with alloy sidebars and double action joints tates wound healing and prevention to avert further
locked at 90° (Figure 5). The AFOs were attached to a complications and subsequent amputation. Given the mul-
pair of custom-made shoes, and the patient was instructed tifactorial nature of the pathology, there is no single model
to wear the AFOs full time during weight-bearing activ- for interdisciplinary care. However, a collaborative effort
ity. After 3 months of management with the unweighting between relevant healthcare providers may positively
orthoses, the right plantar wound remained healed, but affect the patient’s health status while lowering associated
the wound on the left foot demonstrated minimal costs under certain circumstances.
improvement. The left foot wound had deepened in the
area of the base of fifth metatarsal and forcing the Acknowledgements
patient’s vascular surgeon to pursue the removal of the The ideas presented in this article would not have been possible
base of the fifth metatarsal to better facilitate wound without the insights of and discussions with colleagues Marty
healing. The leather unweighting AFOs were used full Carlson, MS, CPO, and Wieland Kaphingst, Dipl.-Ing., CPO,
FAAOP.
time for ambulation after the resection of the base of the
fifth metatarsal in conjunction with continued wound
debridement and dressing changes. The wound on the Author contribution
lateral aspect of the left foot closed 7 months after the All authors contributed equally in the preparation of this
resection of the base of the fifth metatarsal. The patient manuscript.
continued to utilize the conventional AFOs with molded
calf lacers after the successful wound closure in order Declaration of conflicting interests
for the scar tissue to maturate and continue to remodel Charles Kuffel is a paid consultant of Tamarack Habilitation
with type I collagen fibers. Technologies Inc. (Blaine, MN, USA).
Robinson et al. 81
Funding
This research received no specific grant from any funding agency
in the public, commercial, or not-for-profit sectors.
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