ORTHOTI MANAGEMENT

OF DIABETIC FEET

Tarun Kumar Kulshreshtha,

Clinical Prosthetist & Orthotist,

Guest Facutly, University of Delhi,

New Delhi,

India

INTRODUCTION

Diabetic Melitus is a group of metabolic diseases

in which a persons has high blood sugar.

Globally as of 2011, 285 million people had

diabetes and its incident is increasing.

By 2030, the number is estimated to be double.

The greatest prevalence is expected to occur in

Asia and Africa.

Global Diabetic Hall of F/(Sh)ame – Top 10

1. India: 20m in 2004 to 58m by 2020

2. China 3. USA 4. Russian Fed 5. Japan 6. Brazil 7. Indonesia 8. Pakistan 9. Mexico 10. Ukraine

Prevalence of Diabetes (35-64 Years)

ABOUT DIABETES

TYPES OF DIABETES

Type 1 diabetes can occur at any age. However, it is most

often diagnosed in children, adolescents, or young adults.

Exact cause is unknown, most likely autoimmune disorder

Type 2 diabetes is a lifelong (chronic) disease in which there

are high levels of sugar (glucose) in the blood. Type 2

diabetes is the most common form of diabetes. When sugar

cannot enter cells, high levels of sugar build up in the blood.

Family history and genes play a large role in type 2 diabetes.

Low activity level, poor diet, and excess body weight around

the waist increase your risk.

WHY SO MUCH TALK ABOUT

DIABETES?

Diabetic Neuropathy

Diabetic Neuropathy is the impact of

diabetes on the nervous system, most

commonly causing numbness, tingling and

pain the feet and increasing the risk of skin

damage due to altered sensation, leading to

ulceration and in some cases amputation.

What is Diabetic Foot

WHO DEFINITION:-

The foot of a diabetic patient that has a potential risk of pathologic consequences including infection, ulceration and or destruction of deep tissue associated with neurological abnormalities, various degree of peripheral vascular disease and/ or metabolic complications of diabetes in the lower limb.

• Any foot pathology that results directly from diabetes or its long- term complications (

Boulton 2002).

Symptoms of Type 2 Diabetes

Often, people with type 2 diabetes have no symptoms at first.

They may not have symptoms for many years.

The early symptoms of diabetes may include:

• Bladder, kidney, skin, or other infections that are more frequent or heal slowly

• Fatigue

• Hunger

• Increased thirst

• Increased urination

• The first symptom may also be:

• Blurred vision

• Erectile dysfunction

• Pain or numbness in the feet or hands

Warnings Signs

• Skin discoloration

• Elevated temperature

• Swelling

• Pain

• Open sores

• Ingrown nails

• Bleeding corn, blister, calluses

• Dry skin

CALLOUS / CORN

INGROWN NAILS

FUNGAL TOENAIL

Fungal Infection which caused ingrown nail Thickened curled nails caused by fungus

HAMMERTOE

• Digital Contracture

• Usually PIPJ

• May have MPJ dorsiflexion

• May have clavus

• Pre-ulcerative in patients with diabetes

CLINICAL GRADING OF ULCERS

By Wagner

Grade 0 : Foot at risk.

Grade I : Skin and superficial fascia

involved.

Grade II : deep fascia involved.

Grade III : osteomyelitis present.

Grade IV : forefoot gangrene.

Grade V : entire foot gangrenous

Orthotic Management,

Total Contact & Off-loading

devices

Excision of infected bone

Wound allowed to granulate Grafting (skin or bone) not generally effective

Amputation

level ?

Natural history of the diabetic foot Edmonds 2006

• Stage 1 : Normal Foot

• Stage 2 : A High Risk Foot

• Stage 3 : An Ulcerated Foot

• Stage 4 : An Infected Foot

• Stage 5 : A Necrotic Foot

KEY PEDORTHIC GOALS

• Reduce Shock, Friction,

Shear

• Transfer Forces From

Sensitive to Tolerant

Areas

• Accommodate Fixed

Deformities

• Limit Motion of Painful

or Unstable Joints

• Improve Foot Function

1. Prevention of

ulceration by

providing off-

loading devices.

2. Application Orthotic

devices in

conjunction with

medical treatment

to improve wound

healing.

PATIENT EVALUATION

19

PATIENT EVALUATION

• Review Prescription and Medical

History

• Inspect Footwear

• Inspect Foot

• Select Corrective Modalities

• Educate Patient

• Follow-Up

FOOTWEAR INSPECTION

• Fit

• Upper

• Counter

• Outsole

• Insole

• Lining

TALES OF THE HEELS…

SOLES HAVE A LOT TO

TELL………

NORMAL RANGE OF

MOTION

WHERE

IS THE

TOE?

c CHECKING

FIT AT

BALL

JOINT

Testing for Sensation

• USE MONOFILAMENT TO TEST FOR NEUROPATHY

• TEMPERATURE ALSO IMPORTANT

USING

RITZ STICK

FOOT

MEASUREMENT WITH A BRANNOCK

Foot Pressure Analysis,

Traditional Ink Imprinter

RESULTS

EASY

TO

VISUALIZE

AND

EXPLAIN:

VALUE OF

A PICTURE

Digital Foot Pressure

Analysis Measures pressure and foot

Size

Advantages of Digital Scanning

1.Select the Right Shoe the 1st Time 2.Select Shoes from Existing Inventory in Your

Practice 3.Use the Pre-formed Inserts-Faster & Quicker 4. More effective communication with Patient 5. State of Art Image to Referral Sources. 6. Demonstrate efficacy of Treatment. 7. Mail, E-mail or Deliver Information to Referrals

Orthotic Management of the diabetic foot

Pressure reduction is the main treatment.

Neuropathy is irreversible.

Surgery is expensive and invasive.

Pressure reducing modalities

Footwear

Foot orthosis (Both functional & Accommodative)

Total Contact Foot Orthoses / Insoles

Bi-Valve Orthoses / Total Contact Casting

PTB Braces

FOOT WEAR & OBJECTIVES

• Protection

• Stability

• Facilitâtes ambulation

• Reduce & redistribute plantar pressure

• Provide shock absorption.

• Balance Limb Length Discrepancy

• Accommodate foot deformity & edema

• Accommodate orthosis or prostheses

• Maintain foot function

• Easy to get on & off

• Essential long term Management

OPTIONS AVAILABLE

RESULTS AFTER 2 WEEKS

Foot condition on 3/9/11 Foot condition on 16/9/11

Modified Insole provided with Shearban on 31/8/11

Special footwear

FOOT WEAR- MODIFICATION

• Rocker sole

Reduce plantar pressure

Increase propulsion

• Medial or lateral flare gives Stability

• Steel shank / broad base shoes gives stability

• Heel raise equalize limb length discrepancy

• Shear ban/Teflon can be pasted in shoes with areas of more friction.

• 54 year old male.

• Poorly controlled type II diabetes (25 years).

• Patient was on an insulin (2 years).

• Left grade 3 ulcer at unhealed Heel (4 years).

CASE STUDY 1

CASE STUDY 1

CASE STUDY 2

• 62 years, Male.

• Case of Peripheral Neuropathic ulcer in between plantar

surface of 2nd & 3rd MT head.

• Had underwent debridement in Feb2011.

•Ulcer recovered , however using insole for prevention of

further ulceration.

• Recurrence of ulcer in August 2011.

CASE STUDY 2 RESULTS AFTER 2 WEEKS

Foot condition on 3/9/11 Foot condition on 16/9/11

Modified Insole provided with Shearban on 31/8/11

CASE STUDY 2

• Wore depth inlay shoes and customised insole made of

plastozote with the application of a shear reducing material

(Shearban).

• Shown tremendous improvement after two weeks of fitment.

• Recurrence of ulcer begin after 2 months.

• Provided MT bar on the shoe.

• Patient comfortable in recurrence till Dec’11.).

• 44 year old male

•Approached to us on Jan 2011

• Right 3rd, 4th and 5th ray amputation secondary to

diabetic

complications with callus at the plantar surface of 1 st

MT head

• Has been wearing depth inlay shoes and custom

accommodative

arch supports for years.

• History of recurrent callous formation .foot.

CASE STUDY 3

Feb 2011 April 2011

CASE STUDY 3

•Patient was fitted with new depth inlay shoes with

forefoot and hindfoot rockers with custom

accommodative arch supports in Feb 2011.

• Arch supports and filler with Plastazote were

fabricated with the application of a shear reducing

material (Shearban).

• Patient has been callous free since April 2011.

CASE STUDY 3

A study in Kings’ College in London showed that

while patients who wore therapeutic shoes and

insoles had an ulcer recurrence rate of only 17%,

those who returned to wearing regular shoes had an

83% recurrence rate.

Follow-up

• Regular follow up is needed for proper management of Neuropathic foot.

• Check for Skin colour.

• Check footwear for worn out sole or compensation if given.

• provision of regular foot examinations and reinforcement of the educational message on foot care should be given to the patient.

• Educate to maintain proper lifestyle.

ACKNOWLEDGEMENT

Mr. Achille Otou-Essono for his

continuous motivation and support,

without which it would not have been

possible for me to do presentation in this

conference.

Mr. Sohan Pal, Mr. Praveen Verma, Mr.

P.S. Sidhu and Mr. Sandeep Shukla, (all

CPOs).

CONCLUSION

For ages foot care has been neglected.

Total Contact Foot Orthoses and Orthotics play an

important role in order to prevent / treat ulcers and

avoid amputations.

Compliance with the orthotics and appropriately fitted

shoes and follow-up of the patients are critical for the

care of diabetic foot.

Prevention is always better than cure.

THANKS