1. Orthotic Treatment of The Neuropathic Diabetic Foot David Kingston BSc. (Hons) MBAPO SR P/O Senior Orthotist IDS Cappagh Hospital

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

3. Training

4. 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

5. 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

6. 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

7. 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

8. Regular Inspection and Examination of the Foot at Risk History Previous ulceration  Previous education  Social isolation  Poor access to healthcare  Barefoot walking Neuropathy Tingling  Pain  Loss of sensation Vascular Status Claudication  Rest pain  Pedal pulses  Hair on toes

9. SkinColour Temperature Oedema Nail pathology Ulcer Callous Dryness Cracked skin Interdigital maceration Bone/JointDeformities Footwear/SocksAssessment both inside and outside Tourniquet Sock marks

10. 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 Morton’s Syndrome Tailors Bunion Forefoot Ab/Adductus

11. Sensory loss due to diabetic polyneuropathy can be assessed using the following techniques Pressure perceptionMonofiliment 10 gram Vibration perception128 Hz tuning fork on hallux DiscriminationPin prick on dorsum of foot Tactile sensationCotton wool on dorsum of foot ReflexesAchilles tendon reflexes Spatial awarenessMovement of Hallux

12. Monofilament Testing

13. Tuning Fork Testing

14. Metatarsal Pressure

15. Peak Pressures

16. Risk Categories Low Risk No sensory neuropathy Medium Risk Sensory neuropathy and one foot deformity High Risk Sensory neuropathy Two or more foot deformities Signs of peripheral ischemia Previous ulceration

17. Treatment of non-ulcerative pathology Skin care Regular Chiropody Nail care Diabetic Footwear Diabetic Socks Diabetic Insoles Oedema control

18. Orthotic Treatment - Low Risk Education Socks Footwear – Stock Insoles

19. 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

20. Socks

21. 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

22. Shoe Fit

23. Parts of a Shoe

24. Stock Footwear

25. Footwear Objectives Relieve areas of plantar pressures Reduce shock Reduce shear Accommodate deformities Stabilize and support deformities Limit motion of joints

26. TCI Insole

27. Orthotic Treatment - Medium Risk Education Socks Footwear – Stock or Bespoke Insoles

28. Orthotic Treatment - High Risk Education Socks Footwear – Stock or Bespoke Insoles

29. Treatment of Ulcers Relief of pressures Restoration of skin perfusion Treatment of infection Metabolic control (<10 mmol) Local wound care Instruction of patient and relatives Determination of the cause and preventing recurrence

30. Orthotic Treatment - Ulceration Footwear – Bespoke Insoles PRAFO CROW Walker Total Contact Cast Pneumatic Walker Rest

31. TCI Insole

32. Total Contact Insole

33. Toe-Off Pressure

34. Rocker Soles

35. Rocker Sole Action

36. PRAFO

37. CROW Walker

38. Total Contact Cast

39. Diabetic Aircast Pneumatic Walker

40. Neuropathic Ulcers Sensory Loss Trauma Callous Ulceration

41. Lesion Pathway

42. Areas of Risk

43. Ulcer Sites

44. Ulcer Formation

45. Sesamoid Pressure

46. Heel Lesion

47. Mid Metatarsal Head Lesion

48. Hallux Lesion

49. 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

50. 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

51. Charcot Foot Types 3 types  Type 1Forefoot  Type 2Midfoot  Type 3Hindfoot When “active”, joint destruction is very rapid, orthoses must be fairly aggressive and promptly supplied

52. Midfoot Charcot Joint

53. Talar Dislocation in Charcot

54. Charcot Joint Foot

55. Charcot Joint Lesion

56. Charcot Foot Orthotic Treatment Rest Total Contact Cast Pneumatic Walker Bespoke Footwear

57. Diabetic Aircast Pneumatic Walker

58. Total Contact Cast

59. 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@idsltd.ie

60. Thank You