1. Orthotics and Offloading
Emma Davidson MSci
Orthotist

2. Introduction Causative Factors Biomechanics and Gait
Offloading Factors
Offloading Approaches
Challenges
Key Referral Information

3. 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).

4. Nice Guidelines Nice inpatient guideline 2011
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

5. The Foot and ankle 28 bones 55 articulations Often subdivided into:
Rear-foot
Mid-foot
Fore-foot
Interface with ground for entire kinetic chain.

6. Causative factors
“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
Deformity
Ischemia
Trauma
Shear Stress
Peak Plantar Pressure
Abnormal Biomechanics

7. Peripheral Neuropathy
Sensory
Loss of protective sensation
Motor
Intrinsic muscle imbalance, atrophy
Autonomic
Dry, fragile skin, fissure – route in for infection

8. Deformity Unopposed intrinsic muscle pull. Limited joint mobility.
Migration of plantar fat pads due to excessive bony pressures.
Callus formation.
Footwear challenges

9. Ischemia Intermittent claudication.
Decreased rate of capillary return.
Cooler temperature.
Absent Pulses
Discolouration

10. Trauma Increased risk Delay in treatment Potential infection
Foreign objects
Ill fitting footwear
Thermal

11. Peak plantar pressure

12. 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.

13. 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

14. 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

15. 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.

16. Type of Ulcer

17. 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

18. Types of Offloading ORTHOSES Debridement Upper limb walking aids
Wheelchair/bed rest
Surgery
ORTHOSES

19. Gold Standard Below knee total contact cast Slipper cast
Inpatient Care
PRAFO
Inflatable gutter
Heel Pro

20. Custom Braces

21. Offloading Shoes

22. 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

23. 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

24. Footwear

25. Diabetic Specification

26. Rocker Soles

28. The Future Emerging technologies - SurroGait Rx
Improvement in measuring shear forces.
Early inclusion of orthotics in treatment
More accurate pre-cursers for ulceration

29. Challenges
Compliance
Patient education
Re-ulceration

30. 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

31. Thank you
FOR LISTENING

32. References
Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 1998; 21(5):
Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996; 35:
Armstrong DG, Lavery LA, Kimbriel HR,et al. Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure offloading regimen. Diabetes Care 2003; 26:
Armstrong DG, Lavery LA, Nixon BP, et al. It’s not what you put on, but what you take off: techniques for debriding and off-loading the diabetic foot wound. Clin Infect Dis 2004; 39(Suppl 2): S92-S99.
Brown, D., Wertsch, J.J., Harris, G.F., Klein, J., Janisse, D., Effect of rocker soles on plantar pressures. Archives of Physical Medicine and Rehabilitation 85, 81–86.
Armstrong DG, Peters EJ, Athanasiou KA, Lavery LA: Is there a critical level of plantar foot pressure to identify patients at risk for neuropathic foot ulceration? J Foot Ankle Surg 37:303–307,
Lavery LA, Armstrong DG, Wunderlich RP, Tredwell J, Boulton AJ: Predictive value of foot pressure assessment as part of a population-based diabetes disease management program. Diabetes Care 26: 1069–1073, 2003

33. References
Van Deursen, Mechanical Loading and Off-Loading of the Plantar Surface of the Diabetic Foot. Clinical Infectious Diseases 2004; 39:S87–91
International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers. Wounds International, 2013.
NICE clinical guideline 119 Inpatient management of diabetic foot problems
NICE Clinical Guidelines for Type 2 Diabetes Prevention and management of foot problems
Meijer et al, The vertical component of the ground reaction force does not reflect horizontal braking or acceleration per se. Clinical Biomechanics, Vol 24, Issue 6, July 2009, Pages 527–528.
Schaff PS, Shoes for the insensitive foot: the effect of a "rocker bottom" shoe modification on plantar pressure distribution. Foot Ankle, 1990 Dec;11(3):
F. B. Van De Weg et alwith diabetic foot ulceration Wound healing: Total contact cast vs. custom-made temporary footwear for patients, Prosthet Orthot Int : 3
Jan S. Ulbrecht,Prevention of Recurrent Foot Ulcers With Plantar Pressure–Based In-Shoe Orthoses: The CareFUL Prevention Multicenter Randomized Controlled Trial Diabetes Care 2014;37:1982–1989 | DOI: /dc
Terrier et al. Do orthopaedic shoes improve local dynamic stability of gait? An observational study in patients with chronic foot and ankle injuries. BMC Musculoskeletal Disorders 2013, 14:94

34. References
A. Caselli, H. Pham, J.M. Giurini, D.G. Armstrong, A. Veves The forefoot-to-rearfoot plantar pressure ratio is increased in severe diabetic neuropathy and can predict foot ulceration Diabetes Care, 25 (6) (2002), pp. 1066–1071
S.O. Oyibo, E.B. Jude, I. Tarawneh, H.C. Nguyen, D.G. Armstrong, L.B. Harkless, A.J. Boulton The effects of ulcer size and site, patient's age, sex and type and duration of diabetes on the outcome of diabetic foot ulcers Diabetic Medicine, 18 (2) (2001), pp. 133–138
SICCO A. BUS, Effect of Custom-Made Footwear on Foot Ulcer Recurrence in Diabetes A multicenter randomized controlled trial. Diabetes Care 36:4109–4116, 2013
Welsh et al. A case-series study to explore the efficacy of foot orthoses in treating first metatarsophalangeal joint pain. Journal of Foot and Ankle Research 2010, 3:17
Zifchock et al, A comparison of semi-custom and custom foot orthotic devices in
high- and low-arched individuals during walking. Clinical Biomechanics 23 (2008) 1287–1293
Yavuz M, Botek G, Davis BL: Plantar shear stress distributions: comparing actual and predicted frictional forces at the footground interface. J Biomechanics. 40 (2007) 3045–3049