ORTHOTICS AND OFFLOADINGEmma Davidson MSciOrthotist

INTRODUCTION

Causative Factors

Biomechanics and Gait

Offloading Factors

Offloading Approaches

Challenges

Key Referral Information

DIABETIC MDT

“The primary objective in managing diabetic foot problems is to promote mobilisation. This

involves managing both medical and surgical problems and involving a range of medical

experts in related fields.”

(Bridges et al, 1994).

NICE GUIDELINES

Determine the need for interventions to prevent the

deterioration and development of Achilles tendon contractures

and other foot deformities

Perform an orthotic assessment and treat to prevent recurrent

disease of the foot.

People in hospital who are at moderate or high risk of

developing a diabetic foot problem should be given a

pressure redistribution device to offload heel pressure.

Nice inpatient guideline 2011

THE FOOT AND ANKLE

28 bones 55 articulations

Often subdivided into:

Rear-foot

Mid-foot

Fore-foot

Interface with ground for entire kinetic chain.

CAUSATIVE FACTORS

Peripheral Neuropathy

Deformity

Ischemia

Trauma

Shear Stress

Peak Plantar Pressure

Abnormal Biomechanics

“For us to effectively prevent ulcers, we need to have a better understanding of why they occur, and try to integrate the

implications of pressure, shear, temperature, physical activity, skin properties, and even moisture.”

PERIPHERAL NEUROPATHY Sensory

Loss of protective sensation

Motor Intrinsic muscle imbalance, atrophy

Autonomic Dry, fragile skin, fissure – route in for infection

DEFORMITY

Unopposed intrinsic muscle

pull.

Limited joint mobility.

Migration of plantar fat pads

due to excessive bony

pressures.

Callus formation.

Footwear challenges

ISCHEMIA

Intermittent claudication.

Decreased rate of capillary return.

Cooler temperature.

Absent Pulses

Discolouration

TRAUMA Increased risk

Delay in treatment

Potential infection

Foreign objects

Ill fitting footwear

Thermal

PEAK PLANTAR PRESSURE

SHEAR FORCE

Horizontal component of Ground Reaction Force

Under researched as difficult to measure

AP Force component

ML Force component

Environmental Friction

Surface next to skin.

BIOMECHANICS

Sagittal Plane Facilitation theory (Dananberg 1986)

Three rockers of gait. Sagittal plane blockades:

Ankle Equinus Forefoot Equinus Loss of motion at MTPJs specifically 1st

Structural Hallux Limitus / Rigidus Functional Hallux Limitus

GAIT ABNORMALITIES

Decreased walking speed

Increased single and double support time

Decreased proprioception

Compensatory gait deviations due to sagittal

blockades.

Drop foot and / or compensations

CHARCOT ARTHROPATHY

Immediate offloading if suspected.

Maintain integrity of bony alignment whilst active.

Prevent secondary rocker bottom deformities.

Move into custom insoles and protective footwear

once stable.

If rocker bottom mid foot already developed offload

to prevent secondary ulceration.

TYPE OF ULCER

OFFLOADING FACTORS Location of ulcer

Presence of infection

Vascular function

Volume of exudate

Oedema

Deformity

Skin integrity

History of amputation

Balance and mobility

Activity levels

Compliance

Socioeconomic factors

TYPES OF OFFLOADING

Debridement

Upper limb walking aids

Wheelchair/bed rest

Surgery

ORTHOSES

GOLD STANDARD

Below knee total contact cast

Slipper cast

Inpatient Care

PRAFO

Inflatable gutter

Heel Pro

CUSTOM BRACES

OFFLOADING SHOES

LONG TERM PRESCRIPTION

Footwear

Stock Modular Bespoke

Shape Capture

Draft / measures Cast Scan

Insoles

Stock Simple Total Contact Insoles Functional Foot Orthosis

Shape Capture

Draft Impression Box Cast Scan

INSOLES Multi – layer construction

Material properties.

Redistribute plantar pressures

Interface between soft tissue and shoe

Prevent plastic deformation of soft tissue

Restore joint moment equilibrium

FOOTWEAR

DIABETIC SPECIFICATION

ROCKER SOLES

THE FUTURE

Emerging technologies -

SurroGait Rx

Improvement in measuring

shear forces.

Early inclusion of orthotics in

treatment

More accurate pre-cursers for

ulceration

CHALLENGES

Compliance

Patient education

Re-ulceration

ORTHOTICS REFERRAL

Reason for referral

Previous ulcer history

Cause of ulcer

Location / Duration of

ulcer.

Risk factors

MDT clinic treatment

Socioeconomic issues

Previous offloading tactics

THANK YOU

FOR LISTENING

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