Orthotics and Offloading Emma Davidson MSci Orthotist

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 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

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 “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

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 ORTHOSES 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

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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): 855-9. Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996; 35: 528-31. 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: 12595-97. 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., 2004. 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, 1998 3. 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

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):129-40. 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 2008 32: 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: 10.2337/dc13-2956 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

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