PLANTAR PRESSURE

RELIEF IN THE DIABETIC

FOOT USING FOREFOOT
OFFLOADING SHOES
Sicco A. Bus, Robert W.M. van Deursen Rajani V. Kanade, Marieke
Wissink, Erik A. Manning, Jeff G. van Baal, Keith G. Harding
Gait & Posture 29 (2009) 618–622
INTRODUCTION
 Foot ulcers in patient with DM precede 85%
of all non-traumatic lower limb amputations
 Most plantar foot ulcers are caused by a
combination of loss of protective sensation
due to peripheral neuropathy, a complication
of the disease, and elevated levels of
mechanical stress as a result of change in
foot structure
 Forefoot and toe region  plantar ulcers>>
INTRODUCTION
 Management of diabetic foot ulcers centers
on adequately offloading the affected area of
the foot which essentially is achieved by
redistribution of pressure to other foot
region.
 Forefoot offloading shoes (FOS) are
commonly used in clinical practice for
treatment of plantar forefoot ulcers in
diabetic foot
INTRODUCTION
 Mechanism of FOS  redistribution of load
from forefoot to proximal regions by a rocker
bottom outsole and a negative heel
configuration
 The aim of this study was to assess the
offloading efficacy of four different FOS
models in comparison with cast shoe and
control shoe in a group of diabetic patients
with peripheral neuropathy
Methods, subject
 24 neuropathic diabetic patients (20 men, 4
women) at high risk for plantar foot
ulceration
 The mean (SD) age, height, weight and
body-mass index of the subjects was 60.0
(7.0) years, 1.72 (0.07) m, 92.0 (15.2) kg,
and 30.9 (4.3) kg/m2
 5 patients had diabetes type 1, 19 patients
type 2
Methods, subject
 Loss of protective sensation due to neuropathy
was confirmed by the inability to sense a 10-g
Semmes–Weinstein monofilament at one of
the four plantar foot sites tested (hallux, first
and fifth metatarsal head, and heel) or the
inability to sense a vibration of 25 V at the
great toe as measured with a
Neurothesiometer (Horwell Scientic Laboratory
Supplies, Wilford, Nottingham, UK).
 Each patient had at least one foot deformity
Methods, subject
 Excluded were patients with a current foot ulcer,
inability to walk a distance of 20 m repeatedly without
walking aid, lower-extremity amputation, active
neuro-osteoarthopathy or Charcot deformity, equinus
foot deformity, and treatment for serious medical
conditions or injuries other than diabetes mellitus that
may interfere with lower limb function (walking).
 The study protocol was approved by the Local
Research Ethics Committee and each subject gave
written informed consent before the start of the study.
Methods, Footwear
 Methods, protocol
 Data were recorded on health history, neuropathic and
vascular status, foot deformities, and previous ulceration, and
photographs of the foot were taken
 The six footwear conditions were then tested in random order.
Patients were asked to walk to across an 18-m long walkway
Walking speed was measured using a stopwatch and was
standardized between trials within a footwear condition
(maximum 10% deviation) but not between footwear conditions.
In-shoe dynamic plantar pressures were measured at 50 Hz
sampling rate using the Pedar system (Novel, Munich, Germany)
which consisted of 2-mm thick capacitance insoles each with a
99-sensor matrix placed between the insole and the sock of the
patient. A minimum of 20 midgait footsteps for each foot in three
walking trials were collected per condition.
Comfort of walking was assessed using a VAS (0 to 10)
Methods, data analysis
 Each foot was divided into six anatomical regions: heel, midfoot, first
metatarsal heads, second-to-fifth metatarsal heads, hallux, and lesser
toes. For each region, peak pressure, pressure–time integral (PTI),
and force–time integral (FTI) were calculated
 Load transfer was calculated between the offloading footwear and the
control shoe.
 Statistical analysis was using SPSS (Version 14.0)
 For all normally distributed data  ANOVA
 Bonferroni post hoc testing was used for multiple pairwise
comparisons between footwear conditions.
 For data that was not normally distributed  Wilcoxon signed-
rank test
 A significance level of P < 0.05 was adopted for all analyses.
Result
 Result

Fig. 2. Load transfer diagrams showing the mean regional differences and inter-
regional load transfer in normalized FTI between each of the five offloading
footwear conditions and the control shoe. Diagram A, Thanner Cabrio FOS; B,
Rattenhuber Talus FOS; C, Fior&Gentz Hannover FOS; D, Fior&Gentz Luneburg
FOS; and E, Mabal cast shoe. The breadth of the arrows is proportional to the
absolute amount of load transfer. MTH; metatarsal heads.
Result
 Perceived walking comfort varied
substantially between footwear
 conditions with the control shoe
perceived as most comfortable (VAS
score 8.2) and the Fior&Gentz Luneburg
shoe as least comfortable shoe (VAS
score 2.7)
Discussion
 The results of this study show that the four FOS models tested were
effective in offloading the forefoot in at-risk neuropathic diabetic
patients.
 Substantial reductions in peak pressure compared to a control shoe
were achieved in the regions where most frequently ulcers develop:
51–58% at the metatarsal heads and 38–49% at the hallux.
Significant reductions in these regions were also found for the PTIs.
 All four FOS models tested were equally effective in offloading the
forefoot, with small differences present between the different models
in most foot regions. The peak pressure reductions found in this
study are of the same magnitude as those reported in an earlier
study of a group of ulcer patients tested in several offloading
devices, including a similar type FOS
Discussion
 Significant differences in metatarsal head peak pressures
found between the FOS and Mabal cast shoe were not
mimicked by differences in metatarsal head PTIs. PTI is
defined by the area under the peak pressure time curve.
Apparently, longer contact times or more flattened and
broader peak pressure curves at these regions in the FOS
explained this difference in pattern between peak pressure
and PTI results
 The mechanism of action of the FOS, as assessed using the
load transfer diagrams shown in Fig. 2, was clearly a large
transfer of load from the forefoot to the midfoot region. On
average 40% of the total force impulse present in the forefoot
and toe regions was transferred to proximal foot regions
Discussion
 The load transfer diagrams also show
that only small portions of load were
transferred from the midfoot to the heel
in the offloading footwear.
Discussion
 All FOS models were perceived as
significantly less comfortable to walk in
when compared with the control shoe and
the Mabal cast shoe. Most likely, the
design features of the FOS that caused
substantial pressure relief in the forefoot
were also responsible for more walking
discomfort in this group of patients who
already have sensory loss in their feet and
therefore more difficulty with walking
Discussion
Conclusions
 The data showed that all FOS models were
effective in their primary goal, relieving
forefoot pressure in at-risk neuropathic
diabetic patients.
 Therefore, these shoes may be effective in
offloading and healing plantar forefoot ulcers,
although the low comfort scores should be
considered as this may potentially affect
adherence to treatment
 Thank you ◙