An analysis of dynamic forces transmitted through the foot in diabetic neuropathy.

Shaw, Jonathan E.; Schie, Carine H.M. van; Carrington, Anne L.; Abbott, Caroline A.; Boulton, A. J. M.

doi:10.2337/diacare.21.11.1955

Cited by 96 publications

(74 citation statements)

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“…In agreement with our hypothesis, in a large cross-sectional study, a significant correlation between measurements of sensory neuropathy and heel peak pressures, but not forefoot pressure, was described (17). Furthermore, increased forces during the heel contact rather than during the push-off phase of the gait cycle have already been described in diabetic neuropathic patients (18). In healthy subjects, available data also suggest that peak pressure at the rearfoot is mostly affected by events before or during heel-strike (19).…”

Section: Discussionsupporting

confidence: 87%

The Forefoot-to-Rearfoot Plantar Pressure Ratio Is Increased in Severe Diabetic Neuropathy and Can Predict Foot Ulceration

et al. 2002

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OBJECTIVE -We have previously demonstrated that high plantar pressures can predict foot ulceration in diabetic patients. The aim of the present study was to evaluate both the relationship between forefoot and rearfoot plantar pressure in diabetic patients with different degrees of peripheral neuropathy and their role in ulcer development. RESEARCH DESIGN AND METHODS-Diabetic patients of a 30-month prospective study were classified according to the neuropathy disability score: scores of 0, 1-5, 6 -16, and 17-28 are defined as absent (n ϭ 20), mild (n ϭ 66), moderate (n ϭ 95), and severe (n ϭ 57) neuropathy, respectively. The F-Scan mat system was used to measure dynamic plantar pressures. The peak pressures under the forefoot and the rearfoot were selectively measured for each foot, and the forefoot-to-rearfoot ratio (F/R ratio) was calculated.RESULTS -Foot ulcers developed in 73 (19%) feet. The peak pressures were increased in the forefoot of the severe and moderate neuropathic groups compared with the mild neuropathic and nonneuropathic groups (6.2 Ϯ 4.5 and 3.8 Ϯ 2.7 vs. 3.0 Ϯ 2.1 and 3.3 Ϯ 2.1 kg/cm 2 [mean Ϯ SD], respectively; P Ͻ 0.0001). The rearfoot pressures were also higher in the severe and moderate neuropathic groups compared with the mild neuropathic and nonneuropathic groups (3.2 Ϯ 2.0 and 3.2 Ϯ 1.9 vs. 2.5 Ϯ 1.3 and 2.3 Ϯ 1.0, respectively; P Ͻ 0.0001). The F/R ratio was increased only in the severe group compared with the moderate and mild neuropathic and nonneuropathic groups (2.3 Ϯ 2.4 vs. 1.5 Ϯ 1.2, 1.3 Ϯ 0.9, and 1.6 Ϯ 1.0, respectively; P Ͻ 0.0001). In a logistic regression analysis, both forefoot pressure (odds ratio 1.19 [95% CI 1.11-1.28], P Ͻ 0.0001) and the F/R ratio (1.37 [1.16 -1.61], P Ͻ 0.0001) were related to risk of foot ulceration, whereas rearfoot pressure was not.CONCLUSIONS -Both the rearfoot and forefoot pressures are increased in the diabetic neuropathic foot, whereas the F/R ratio is increased only in severe diabetic neuropathy, indicating an imbalance in pressure distribution with increasing degrees of neuropathy. This may lend further evidence toward the concept that equinus develops in the latest stages of peripheral neuropathy and may play an important role in the etiology of diabetic foot ulceration.

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Section: Discussionsupporting

confidence: 87%

The Forefoot-to-Rearfoot Plantar Pressure Ratio Is Increased in Severe Diabetic Neuropathy and Can Predict Foot Ulceration

et al. 2002

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“…As for the loading time, we observed a significant increase of the absolute values in patients with peripheral neuropathy, as reported in previous studies (23,24). More specifically, the major increases were recorded at the heel and at the metatarsal area, whereas loading time was significantly reduced at the hallux area.…”

Section: Giacomozzi and Associatessupporting

confidence: 72%

Walking Strategy in Diabetic Patients With Peripheral Neuropathy

et al. 2002

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OBJECTIVE -Diabetic neuropathic patients show a peculiar loading pattern of the foot, which led us to hypothesize that a substantial modification exists in their deambulatory strategy. The aim of the present study was to support this hypothesis by quantifying the changes of the loading patterns and by monitoring the excursion of center of pressure (COP) during gait. RESEARCH DESIGN AND METHODS-A total of 21 healthy volunteers (C) and 61 diabetic patients were evaluated: 27 diabetic subjects without neuropathy (D), 19 with neuropathy (DN), and 15 with previous neuropathic ulcer (DPU). A piezo-dynamometric platform was used to record the foot-to-floor interaction by measuring loading time and the instantaneous COP position during the stance phase of gait.RESULTS -Loading time was significantly longer in neuropathic patients than in control subjects (DPU: 816.8 Ϯ 150 ms; DN: 828.6 Ϯ 152 ms; D: 766.5 Ϯ 89.9 ms; C: 723.7 Ϯ 65.7 ms; P Ͻ 0.05). COP excursion along the medio-lateral axis of the foot clearly decreased from C to DPU groups (C: 6.41 Ϯ 0.1 cm; D: 4.88 Ϯ 0.2 cm; DN: 4.57 Ϯ 0.1 cm; DPU: 3.36 Ϯ 0.1 cm; P Ͻ 0.05) as well as COP excursion along the longitudinal axis for the DPU group only (C: 26.6 Ϯ 1 cm; D: 26.9 Ϯ 1 cm; DN: 27.2 Ϯ 1 cm; DPU: 24.2 Ϯ 1 cm; P Ͻ 0.05). COP integrals were significantly reduced for all pathological classes (DPU: 14.2 Ϯ 8 cm 2 ; DN: 25.8 Ϯ 6 cm 2 ; D: 27.7 Ϯ 3 cm 2 ; C: 38.6 Ϯ 6 cm 2 ; P Ͻ 0.05).CONCLUSIONS -The accurate quantification of loading patterns and of COP excursions and integrals highlights changes of foot-to-floor interaction in diabetic neuropathic patients. The decreased medio-lateral and longitudinal COP excursions and corresponding changes of loading times and patterns support our hypothesis that a change in the walking strategy of diabetic patients with peripheral neuropathy does occur. Diabetes Care 25:1451-1457, 2002A bnormal plantar pressures are considered the main cause of neuropathic foot ulceration (1-5). However, high pressures are only the last ring of a chain to which several factors contribute, including peripheral neuropathy and limited joint mobility. It is worth emphasizing that those factors may influence not only the foot loading, but, more widely, the whole performance of the lower limb during gait.A few authors have suggested that patients with peripheral neuropathy develop a change in their walking strategy, shifting from an ankle to a hip strategy (6,7). In a recent article, our group also hypothesized this kind of change by analyzing the foot loading pattern (8). The aim of the present work was to further support this hypothesis by using a different parameter, namely the evolution of the center of pressure (COP) that is the point of application of the ground reaction force (GRF). COP records the succession of instantaneous positions during the entire period of contact between foot and floor and is plotted as a sequence of points on the ground plane. It takes into account the displacement of load throughout the foot during the stance phase of a wal...

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“…The casts, if not particularly reinforced, broke down after a few days, which suggests abnormally high foot-to-ground forces. Concordantly, increased peak forces Fabrin, Larsen, and Holstein during heel strike in diabetic patients with peripheral neuropathy have recently been documented (6). The stress is increased by the presence of foot deformities and by rigidity of the joints (7,8) as evidenced by abnormally high peak plantar pressures (9).…”

Section: Increased Stressmentioning

confidence: 89%

Long-term follow-up in diabetic Charcot feet with spontaneous onset.

2000

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A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Long-Term Follow-Up in Diabetic Charcot Feet With Spontaneous OnsetOBJECTIVE -To assess the long-term results after Charcot breakdown with spontaneous onset in diabetic feet.RESEARCH DESIGN AND METHODS -This study was retrospective. A total of 115 patients (140 feet), 107 with acute deformity and 8 with chronic Charcot deformity, were followed for a median of 48 months (range 6-114). The routine treatment for acute cases was a weight-off regimen with crutches and foot protection with therapeutic shoes until skin temperature had normalized followed by increased weightbearing and the use of bespoke shoes or modification of conventional shoes.RESULTS -The incidence of Charcot deformity was 0.3%/year in the diabetic population investigated. About half of the patients were active in their jobs. Major complications were encountered in 5 (4%) of the patients that required surgical intervention: arthrodesis for unstable malaligned ankles in 3 subjects (1 bilaterally) and major amputation in 2 subjects for unstable ankle and pressure sores. Minor complications were recorded in 43% of subjects: new attacks of Charcot breakdown in 41 patients (36%) and/or foot ulceration in 43 patients (37%) that required minor surgical procedures for 11 patients. All healed except in 2 patients: 1 patient died before the Charcot fractures had healed, and 1 patient died with an unhealed ulcer. No patient lost the ability to walk independently.CONCLUSIONS -Major surgical procedures in only 4% were particularly related to patients with Charcot deformities in the ankle. Minor complications were recorded in about half of the patients. Lifelong foot care is required for diabetic patients with Charcot feet.

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An analysis of dynamic forces transmitted through the foot in diabetic neuropathy.

Cited by 96 publications

References 0 publications

The Forefoot-to-Rearfoot Plantar Pressure Ratio Is Increased in Severe Diabetic Neuropathy and Can Predict Foot Ulceration

The Forefoot-to-Rearfoot Plantar Pressure Ratio Is Increased in Severe Diabetic Neuropathy and Can Predict Foot Ulceration

Walking Strategy in Diabetic Patients With Peripheral Neuropathy

Long-term follow-up in diabetic Charcot feet with spontaneous onset.

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