Orthotic Treatment of The Neuropathic Diabetic Foot

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Orthotic Treatment of The Neuropathic Diabetic
Foot

• David Kingston
• BSc. (Hons) MBAPO SR P/O
• Senior Orthotist
• IDS
• Cappagh Hospital

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Orthotist

• Four year B.Sc.(Hons)
• Dual qualified
• BAPO
• State Registered

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Training
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Introduction

• Foot complications are one of the most serious
  and costly complications of NIDDM.
• Amputation of (or part of) a lower limb is
  usually preceded by a foot ulcer
• A strategy which includes prevention, patient and
  staff education, multi-disciplinary treatment of
  foot ulcers and close monitoring can reduce
  amputation rates by 49-85
• In May 1999 the WHO and International Diabetes
  Federation set goals to reduce the rate of
  amputations by 50 in five years
• They (We) have failed

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Pathophysiology

• Spectrum of foot lesions varies across the world
• Pathways are almost identical
• Up to 50 of NIDDM patients have neuropathy and
  at-risk feet
• Neuropathy leads to an insensitive and
  subsequently deformed foot with possibly an
  abnormal gait
• Trauma can lead to a chronic ulcer
• Loss of sensation, foot deformities and limited
  joint mobility can lead to abnormal biomechanical
  loading of the foot

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• As a normal response to pressure a callous is
  formed
• The skin finally breaks down
• Frequently preceded by a subcutaneous haemorrhage
• The patient continues to walk on the insensate
  foot impairing healing
• Lack of treatment can lead to the need for
  amputation
• Once a patient has an ulcer they are 77 times
  more likely to get a second ulcer after treatment
  of the first has healed the ulcer
• Once amputation has occurred then the pressures
  on the remaining limb increase

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Five Cornerstones of the Management of the
Diabetic Foot

• Regular inspection and examination of the foot at
  risk
• Identification of the foot at risk
• Education of patient, family and healthcare
  providers
• Appropriate footwear
• Treatment of non-ulcerative pathology

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Regular Inspection and Examination of the Foot at
Risk
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Foot Deformities

• Rearfoot Valgus
• Rearfoot Varus
• Forefoot Valgus
• Forefoot Varus
• Hallux Valgus
• Hallux Limitus
• Hallux Rigidus
• FHL

• Claw Toes
• Hammer Toes
• Mallet Toes
• First Ray Dysfunction
• Prom Met Heads
• Mortons Syndrome
• Tailors Bunion
• Forefoot Ab/Adductus

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Sensory loss due to diabetic polyneuropathy can
be assessed using the following techniques
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Monofilament Testing
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Tuning Fork Testing
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Metatarsal Pressure
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Peak Pressures
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Risk Categories
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Treatment of non-ulcerative pathology

• Skin care
• Regular Chiropody
• Nail care
• Diabetic Footwear
• Diabetic Socks
• Diabetic Insoles
• Oedema control

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Orthotic Treatment - Low Risk

• Education
• Socks
• Footwear Stock
• Insoles

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Patient Education

• Take care of your diabetes control
• Check your feet daily
• Wash your feet daily
• Keep your skin soft and smooth
• Smooth corns and calluses gently
• Trim your toenails regularly and carefully
• Wear socks and shoes at all times
• Protect your feet from heat and cold
• Keep the blood flowing to your feet
• Be more active
• Consult your GP

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Socks
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Appropriate Footwear

• Good leather
• Lace up
• Solid one piece sole
• Padded collars
• Soft toe puff
• Good lining
• No stitching or intricate designs
• Low heels
• No tapered heels
• Regular soling
• Good fit

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Shoe Fit
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Parts of a Shoe
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Stock Footwear
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Footwear Objectives

• Relieve areas of plantar pressures
• Reduce shock
• Reduce shear
• Accommodate deformities
• Stabilize and support deformities
• Limit motion of joints

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TCI Insole
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Orthotic Treatment - Medium Risk

• Education
• Socks
• Footwear Stock or Bespoke
• Insoles

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Orthotic Treatment - High Risk

• Education
• Socks
• Footwear Stock or Bespoke
• Insoles

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Treatment of Ulcers

• Relief of pressures
• Restoration of skin perfusion
• Treatment of infection
• Metabolic control (lt10 mmol)
• Local wound care
• Instruction of patient and relatives
• Determination of the cause and preventing
  recurrence

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Orthotic Treatment - Ulceration

• Footwear Bespoke
• Insoles
• PRAFO
• CROW Walker
• Total Contact Cast
• Pneumatic Walker
• Rest

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TCI Insole
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Total Contact Insole
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Toe-Off Pressure
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Rocker Soles
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Rocker Sole Action
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PRAFO
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CROW Walker
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Total Contact Cast
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Diabetic Aircast Pneumatic Walker
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Neuropathic Ulcers

• Sensory Loss
• Trauma
• Callous
• Ulceration

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Lesion Pathway
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Areas of Risk
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Ulcer Sites
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Ulcer Formation
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Sesamoid Pressure
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Heel Lesion
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Mid Metatarsal Head Lesion
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Hallux Lesion
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Charcot Foot

• Neuro-arthropathy that affects the joints in the
  foot
• Rapidly progressive degenerative arthritis that
  results from neuropathy
• Pain perception and the ability to sense the
  position of the joints in the foot are severely
  impaired or lost
• Muscles lose their ability to support the
  joint(s) properly.
• Loss of these motor and sensory nerve functions
  allow minor traumas such as sprains and stress
  fractures to go undetected and untreated
• Leads to ligament laxity, joint dislocation, bone
  erosion, cartilage damage, and deformity of the
  foot
• Joint effusions, large osteophytes, fractures,
  bone fragments, and joint misalignment and/or
  dislocation

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Charcot Foot Six Key Points

• The acute Charcot foot can mimic cellulitis or,
  less commonly, deep venous thrombosis
• The existence of little or no pain can often
  mislead the patient and the physician
• Findings on plain x-rays can be normal in the
  acute phase of the Charcot foot
• Strict immobilization and protection of the foot
  is the recommended approach to managing the acute
  Charcot process
• A careful program of patient education,
  protective footwear and routine foot care is
  required to prevent complications such as foot
  ulceration
• Reconstructive surgery is reserved for patients
  who have recurrent ulceration despite compliance
  with the previously mentioned regimen

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Charcot Foot Types

• 3 types
• Type 1 Forefoot
• Type 2 Midfoot
• Type 3 Hindfoot
• When active, joint destruction is very rapid,
  orthoses must be fairly aggressive and promptly
  supplied

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Midfoot Charcot Joint
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Talar Dislocation in Charcot
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Charcot Joint Foot
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Charcot Joint Lesion
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Charcot Foot Orthotic Treatment

• Rest
• Total Contact Cast
• Pneumatic Walker
• Bespoke Footwear

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Diabetic Aircast Pneumatic Walker
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Total Contact Cast
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Referral Procedure

• Referral letter to IDS, Cappagh Hospital,
  Finglas, Dublin 11
• Clinic at Croom Orthopaedic Hospital once a month
• Include Long Term Illness Booklet Number
• davidkingston_at_idsltd.ie

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• Thank You