Submit manuscript...
Journal of
eISSN: 2473-0831

Analytical & Pharmaceutical Research

Review Article Volume 3 Issue 3

The Importance of Plantar Pressure Measurements and Appropriate Footwear for Diabetic Patients

Saleh S Altayyar

Correspondence: Saleh S Altayyar, Biomedical Technology Department, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia, Tel 505456035

Received: October 13, 2016 | Published: October 18, 2016

Citation: Altayyar SS (2016) The Importance of Plantar Pressure Measurements and Appropriate Footwear for Diabetic Patients. J Anal Pharm Res 3(3): 00057. DOI: 10.15406/japlr.2016.03.00057

Download PDF

Abstract

Diabetic Mellitus results from failure of the endocrine system to regulate blood glucose level, approximately 15% of the population over the age of 65 in developed countries are diagnosed with diabetes. The number of people with diabetes is expected to reach 228 million by 2025. Foot is the most frequent site of ulceration in individuals hospitalized for diabetes and infection. Neuropathic plantar ulcerations result from repetitive stress over areas of high pressure associated with deformity or joint limitations. Twenty to fifty percent of people with diabetes of more than 10 years will experience symmetrical distal sensory neuropathy resulting in loss of sensation in lower extremity.

Footwear contributes greatly to the pressure distribution on the plantar surface of the foot. Insoles and appropriate footwear were shown to reduce pressure and prevent plantar ulceration. Studies showed a recurrence rates for chronic wounds in adults to be between 13% and 83%. Studies showed a reduction in the recurrence rate of diabetic ulcer from 83% to 17% by using offloading technique using orthopedic shoe. Insoles were found to have significant impact on the plantar pressure distribution; they reduced the peak pressures, and maximized the contact area compared with shoe-only condition.

Plantar pressure measurements look at the pressure distribution between the foot plantar surface and the supporting surface. Recent advances enable us to measure the pressures between the shoe or insole and the plantar foot during various activities. This was proven useful in the diagnosis and management of pressure related foot problems. This review article will look at the importance of plantar pressure measurements for identifying foot at risk of developing ulcer; it will also look at the role of plantar pressure measurements in assessing the effect of proper footwear and insoles in dispersing the plantar pressure on the plantar surface of the foot. Therefore, reducing the probability of occurrence of ulcer and the recurrence of healed ulcers.

Introduction

Diabetic Mellitus affects approximately 15% of the population over the age of 65 in developed countries.1 However, the number of people with diabetes is expected to reach 228 million by 2025.2 Twenty to fifty percent of people with diabetes of more than 10 years will experience symmetrical distal sensory neuropathy resulting in loss of sensation in lower extremity.3 This will lead to weight bearing abnormality under the foot in the long run resulting in ulcerations.

The complications of foot ulcers in diabetic patients are a major cause of morbidity and mortality. Studies show 1% to 4% annual incidence of foot ulcers in population with 5% to 10% prevalence of diabetes.4 Diabetic patients who undergo lower limb non traumatic amputation have mortality rate following amputation ranging from 39% to 80% at 5 years.4 Foot ulceration is the most common cause of amputation in diabetic patients.5 Eighty five percent (85%) of diabetes related lower extremity amputations are preceded by ulceration.6 Increased dynamic foot pressures are among the identified risk factors in the formation of diabetic foot ulcer.7–14 It is estimated that 15% of people with diabetes experience a foot ulcer during their life.15 Foot care and patients education on footwear are the initial standard treatment protocol for diabetic feet at risk.16

Plantar pressure

Foot is the most frequent site of ulceration in individuals hospitalized for diabetes and infection. Neuropathic plantar ulcerations result from repetitive stress over areas of high pressure associated with deformity or joint limitations.17–21 Studies have also shown that ulcers on the margin of the foot were due to abnormally high plantar pressure.22

Biomechanical measurements of pressure distribution concentrate on the pressures between the foot plantar surface (sole) and the supporting surface16 they are useful for assessing the pathomechanics of foot. Plantar callus can cause increase in the plantar pressure by 30%.23 Various pressure systems are available for the measurements of the pressures inside the shoe (pressure between the shoe or insole and the plantar foot during various activities). Such assessment has proven to be very useful in the diagnosis and management of pressure related foot problems. Plantar pressure may or may not be influenced by some factors such as body weight, velocity, stride length, and shoe type and construction.

Footwear and insoles

Diabetic patients with neuropath have higher risk of developing ulcer specially when using ill-fitting shoes because of loss of sensory feedback.24 This highlights the importance of choosing the appropriate and well-fitting shoes. Shoes must be well fitting, with lace-up or Velcro fasteners in order to hold the foot and prevent it from slipping forward which may risk putting pressure on the toes. They must be wide and deep enough to accommodate the foot comfortably, without subjecting any part of the foot to unnecessary pressure; the bottom of the shoe should be flat with a gentle slope upward under the toes and heel (rocker bottom). It is important that the lining (inside the shoe) be smooth and without seems. A rocker-bottom shoe has been shown to reduce the pressure on the feet; it enhances the normal heel-to-toe rolling motion.24 A study showed rocker bottom shoes to achieve a 35-65% reduction in the dynamic plantar pressure of the heel and central metatarsal heads of diabetic patients with neuropathy.25 Examples of different type of shoes are shown in Figures 1-3 Ambulatory biomechanical shoes, urban walker shoes, and off the shelf shoes.

Figure 1 Ambulatory Biomechanical Footwear.

Figure 2 Urban Walker Footwear.

Figure 3 Off the Shelf Footwear.

Insoles are designed with soft elastic materials, molded insoles and/or rigid rocker soles have been recommended to reduce pressure and prevent plantar ulceration in leprosy [26-30]. Studies showed that all footwear except the extra depth shoe without an insole had significantly lower peak pressures compared to barefoot walking.31 A study conducted by James A. Bike and others on comparing the plantar pressure in leprosy patients while walking barefoot with that when walking using6 types of footwear and patient prescribed footwear, barefoot walking have the highest pressure (1194.4 Kpa), and walking using footwear have lower pressure ranging from 985.5 to 359.5 Kpa, with the patient prescribed footwear having the lowest plantar pressure (359.5 Kpa).32 Thick insoles were found to be most significantly associated with lower pressure.31 There was no significant relationship between sole stiffness and peak pressure.32 Studies showed extra depth shoes alone do not reduce foot plantar pressures unless they are used with insoles.33 A study conducted by Saleh S. Altayyar on the impact of custom made insoles on the plantar pressure of diabetic foot showed a significant reduction in the planar pressure when walking using custom made insoles compared to that when walking barefoot, the reduction was 84.7% and 84.5% for female subjects right and left foot respectively, and 77.6% and 76.5% for male subjects right and left foot respectively.34

Rigid insoles were found to help reduce areas of increased plantar pressures and increase total contact area.16 More flexible sole shoes were found to have more decreased plantar pressure than the less flexible sole shoes.16 Proper insoles are very important in restoring foot proper shape and function. Example of low- flat, unsupported arch and ankle, compared to restored foot arch and properly supported ankle using appropriate insoles are shown in Figure 4a & 4b respectively.

Figure 4a low - flat unsupported arch and ankle.

Figure 4b Restored foot arch and properly supported ankle.

Ulcers

It is estimated that 15% of diabetic patients will develop a foot ulcer.35 The recurrence rates for chronic wounds in adults is estimated between 13% and 83%,36–39 Insoles were found to have significant impacton the plantar pressure distribution, they reduced the local peak pressures, and maximized the contact area compared with shoe-only condition.40. A study showed a reduction in the recurrence rate of diabetic ulcer from 83% to 17% by offloading technique using orthopedic shoes.41 Therefore, it is imperative that the patient be fitted for a pair of custom manufactured insoles and shoes once a wound healing is achieved to prevent recurrence of the ulceration after.

Conclusion

The shoes we wear are very important for the health of our feet. However, they are very critical for diabetic patient’s health. Proper footwear is very important for diabetic patients. It helps redistribute the pressure and reduce the risk of ulcer development and the recurrence of healed ulcer. Patients prescribed insoles (custom designed) are the most appropriate insoles and were shown to have significant reduction in the plantar pressure. Diabetic patient should be advised to never walk barefoot, or wear sandals which leave the toes exposed, because of the risk of injury. Women are advised to wear a more “foot friendly” shoes for regular everyday wear, and limit the use of fashion shoes to special occasions.It is highly recommended that diabetic patients plantar pressure be assessed in order to provide them with the most appropriate footwear for their condition to reduce the risk ulceration and / or recurrence of healed ulcer.

Acknowledgments

None.

Conflicts of interest

The authors declare no conflict of interest.

Funding

None.

References

  1. Stephen FA, Wendy YC. Rigid Foot Orthoses in the Treatment of the Neuropathic Diabetic Foot. Low Extremity. 1996 3(2):97–105.
  2. Aboderin I, Kalache A, Shlomo BY, et al. Life course perspectives on coronary heart disease: key issues and implications for policy and research. Geneva:World Health Organization. 2002. p. 1–43.
  3. Cavanagh PR, Simoneau GG, Ulbrecht JS. Ulceration, unsteadiness, and uncertainty: The biomechanical consequence of diabetes mellitus. J Biomech. 1992;26(1):23–40.
  4. Reiber GE, Edward JB, Douglas GS. Epidemiology of Foot Ulcerations and Amputations in Diabetes. 6th ed. Seattle, USA; 2001.
  5. Catanzariti AR, Haverstock BD, Grossman P, et al. Off–Loading Techniques in the Treatment of Diabetic Plantar Neuropathic Foot Ulceration. Advance in Wound Care. 1999;12(9).
  6. Larsson J, Agardh CD, Apelqvist J, et al. Long term prognosis after healed amputation in patients with diabetes. Clin Orthop Rel Res. 1998;350:149–157.
  7. Armstrong DG, Lavery LA, Vela SA, et al. choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration. Arch Intern Med. 1998;158(3):289–292.
  8. LoGerfo FW. Vascular disease, matrix abnormalities, and neuropathy; implications for limb salvage in diabetes mellitus. J Vasc Surg. 1987;5(5):793–796.
  9. Payne CB. Biomechanics of the foot in diabetes mellitus:some theoretical considerations. J Am Podiatr Med Assoc. 1998;88(6):285–289.
  10. Veves A, Sarnow MR, Giurini JM, et al. Differences in joint mobility and foot pressures between black and white diabetic patients. Diabet Med. 1995;12(7):585–589.
  11. Stess RM, Jensen SR, Mirmiran R. The role of dynamic plantar pressures in diabetic foot ulcers. Diabetes Care. 1997;20(5):855–858.
  12. Hill MN, Feldman HI, Hilton SC, et al. Risk of foot complications in long term diabetic patients with and without ESRD: a preliminary study. ANNA J. 1996;23(4):381–386.
  13. Helm PA, Walker SC, Pulliam GF. Recurrence of neuropathic ulceration following healing in a total contact cast. Arch Phys Med Rehabil. 1991;72(12):967–970.
  14. Moss SE, Klein R, Klein BEK. The prevalence and incidence of lower extremity amputation in a diabetic population. Arch Intern Med. 1992;152(3):610–616.
  15. Reiber GE, Lipsky BA, Gibbons GW. The burden of diabetic foot ulcers. Am J Surg. 1998;176(2A):5S–10S.
  16. Stephen FA, Lenore CC. Diabetic Foot Pressure Studies. Comparison Study of Patient–selected Shoes versus Clinician–selected Shoes. The Lower Extremity. 1994;1(1).
  17. Hall OC, Brand PW. The etiology of the neuropathic ulcer. J Am Podiatry Assoc. 1979;69(3):173–177.
  18. Brand PW. The insensitive foot (including leprosy) Disorders of the Foot In: Jahss M, editor. Philadelphia: WB. Saunders, USA; 1982. p. 1266–1286.
  19. Ctercteko GC, Dhanendran M, Hutton WC, et al. Vertical forces acting on the feet of diabetic patients with neuropathic ulceration. Br J Surg. 1981;68(9):608–614.
  20. Veves A, Fernando DJS, Walewiski P, et al. A study of plantar pressures in a diabetic clinic population. The Foot. 1991;1(2):89–91.
  21. Fernando DJS, Masson EA, Veves A, et al. Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration. Diabetes Care. 1991;14(1):8–11.
  22. Pitei DL, Lord M, Foster A, et al. Plantar Pressures Are Elevated in the Neuroischemic and the Neuropathic Diabetic Foot. Diabetes Care. 1999;22(12):1996–1970.
  23. Young MJ, Cavanagh PR, Thomas G, et al. The effect of callus removal on dynamic plantar foot pressures in diabetic patients. Diabetic Med. 1992;9(1):55–57.
  24. Roy HL. How to choose Footwear. Diabetes Self management. 2007.
  25. Praet SF, Louwerens JW. The influence of shoe design on plantar pressure in neuropathic feet. Diabetes Care. 2003;26(2):441–445.
  26. Fritchi EP. Surgical Reconstruction and Rehabilitation in Leprosy and other neuropathies. Lepr Rev. 1986;76:184–185.
  27. Ross WF. Footwear and the prevention of plantar ulcers. Lepr Rev. 1962;33:202–206.
  28. Ward D. Footwear in leprosy. Lepr Rev. 1962;33:94–105.
  29. Enna CD, Brand PW, Reed JK, et al. Orthotic care of the denervated foot in Hansen’s disease. Othotics and Prosthetics. 1976;30(1):33–39.
  30. Hampton GS. Therapeutic footwear for the insensitive foot. Phys Ther. 1979;59(1):23–29.
  31. Cavanagh PR, Hewitt FG, Perry JE. In–shoe plantar pressure measurement: A review. The Foot. 1992;2(4):185–194.
  32. Birke JA, Foto JG, Deepak S, et al. Measurement of pressure walking in footwear used in leprosy. Lepr Rev. 1994;65(3):262–271.
  33. Rose NE, Feiwell LA, Cracchiolo A. A method of measuring foot pressures using a high resolution, computerized insole sensor: the effect of heel wedges on plantar pressure distribution and center of force. Foot & Ankle. 1992;13(5):263–270.
  34. Altayyar SS. The impact of custom made insoles on the plantar pressure of diabetic foot. Majmaah Journal of Health Sciences. 2016;4(1):25–32.
  35. Boulton A. The diabetic foot:from art to science. The 18th Camillo Golgi lecture. Diabetologia. 2004;47(8):1343–1353.
  36. Becky Carroll. Guideline for Prevention and Management of Pressure Ulcers. Wound Ostomy Continence Nurses Society. 2003.
  37. Relander M, Palmer B. Recurrence of surgically treated pressure sores. Scand J Plast Reconstr Surg Hand Surg. 1988;22(1):89–92.
  38. Schryvers OI, Stranc MF, Nance PW. Surgical treatment of pressure ulcers:20–year experience. Archives of Physical Medicine and Rehabilitation. 2000;81(12):1556–1562.
  39. Thomas DR. Prevention and Treatment of Pressure Ulcers. J Am Med Dir Assoc. 2006;7(1):46–59.
  40. Tsung BY, Zhang M, Mak AF, et al. Effectiveness of insoles on plantar pressure redistribution. J Rehabil Res Dev. 2004;41(6A):767–774.
  41. David T. Recurrence of Chronic Ulcers – SAM Medical Products. AMDA Convention. 2001.
Creative Commons Attribution License

©2016 Altayyar. This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and build upon your work non-commercially.