Footnote September 2017 by issuuluchendrickx

footnote THE NEWSLETTER • September 2017

New D-Foot Board member

Meet Wim van Dyck Stakeholder relations

D-Foot International and the International Federation of Podiatrists join forces Congresses

Meetings in the Dominican Republic and Bulgaria Picture quiz

Another clinical brain teaser Paper trail

Recent diabetic foot publications And more …

EDITOR’S NOTE Neil Baker

Dear Readers Welcome to another “Footnote” D-Foot International newsletter. I hope you all managed to have some kind of break over the summer. As I mentioned in the Editors note last time we have been undergoing some structural changes most of which are now nearing completion. Please take the time to read the profile of our important newly appointed Board member Wim van Dyck. We will keep you updated on further organisational issues as they occur. We try to have items that will be of interest to all our readers so we hope you will not only enjoy reading the items but be inspired too. As Editor, I would make a personal request that you please share this Newsletter with your foot team colleagues and ask them to visit our website www.d-foot.org to see what D-Foot is doing, subscribe for future issues and maybe consider getting involved. Happy reading! Neil

CONTENT NEW BOARD MEMBER As D-Foot International is progressing we have now managed to secure a new board member who will be responsible for the accounting aspects of our new non-profit making organisation, please read his profile and I think you will agree the board has made a good and wise appointment. COMMENTARIES OF RECENT PUBLISHED PAPERS •

Susceptibility patterns of Staphylococcus aureus biofilms in diabetic foot infections.

•

Consensus on surgical aspects of managing osteomyelitis in the diabetic foot.

•

One week of bed rest leads to substantial muscle atrophy and induces whole-body insulin resistance in the absence of skeletal muscle lipid accumulation.

•

Adherence to wearing therapeutic shoes among people with diabetes: a systematic review and reflections.

•

Delay between onset of symptoms and seeking physician intervention increases risk of diabetic foot complications: results of a crosssectional population-based survey.

•

The incidence of confounding factors in patients with diabetes mellitus hospitalized for diabetic foot ulcers.

I think that there is something to be learnt from each of these and cleverly Andy has only selected from papers that are fully available free on line so that you can read any of the full papers. 1ST PODIATRY CONFERENCE IN RUMANIA Norina Gavan (author of publication 5 above) reports on the amazing achievement of not only starting Podiatry in Romania but organising their first conference.

TRAIN-THE-FOOT-TRAINER As we reported in January this year a Train the Foot trainer programme was run for the Western Pacific countries. As part of these programmes D-Foot requires that all participants give scheduled progress reports. In this edition of the Newsletter you can read an overview of the 3-6 activity report. COLLABORATION D-FOOT AND FIP We previously reported that we were starting to work with the International Federation of Podiatrists to try to develop a common goal towards standardised foot care for people with diabetes and foot disease. You can read a brief report from their President regarding the progress. NEJM DIABETIC FOOT PUBLICATION I know that there are two features in the newsletter relating to published literature, however I would please draw your attention to the very recently published article in NEJM. I have attached a copy of the full paper for you to read. DOMINICAN REPUBLIC CONGRESS FOR DIABETIC FOOT PATIENTS AND FAMILIES Since the Train-the-Foot-Trainer took place in Latin America the Dominican Republic has run Step-by-Step courses every year, however Dr Nalini Campillo, who has been instrumental in this initiative, recognised the need for active patient education. She organised a national training event for patients and families. PICTURE QUIZ Foot prints in the sand â&#x20AC;Ś

D-FOOT INTERNATIONAL ELECTS A VICE-PRESIDENT FINANCE At its meeting last August, the Board of D-Foot International elected Wim van Dyck as Director and Vice-President Finance for an initial term of office until May 2019, after which the appointment may be renewed. The role of the Vice-President Finance is to assist and guide the leadership in developing appropriate financial business procedures, including budget, cash flow and investment policies, interact with the external auditor as a member of the Audit and Risk Management Committee and advise on wider business, legal and financial affairs of the association. Wim van Dyck holds a Master in Mathematical Economics and Econometrics from Leuven University in Belgium and a Master of Business Administration from Cornell University in New York. He offers a full career in banking and financial services, from financial auditor with one of the ”Big Four” accounting firms to ship financing, credit risk analysis, equity derivatives and equity sales with various international banks in different continents. He’s currently retired from the banking profession but keeps up to speed with the financial world as a member of the Board of Directors of a smaller private bank in Belgium. For a number of years, Wim volunteered for Medics without Vacation, an NGO working mainly in Africa, where he was part of the financial team responsible for liaison and financial project reporting at government level. Amidst a D-Foot Board of which all other members are foot specialists, Wim brings to the table not only a personal understanding of what makes a nonprofit association tick and a sharp eye for its strengths and weaknesses, but also valuable financial and business expertise and experience: an essential piece of the governance puzzle in a relatively small but growing organisation. Welcome, Wim! • The D-Foot Board now counts 9 Directors and is complete as required by its Articles of Association.

t c a r t s b A n a c S Diabet Med. 2017 May 19. doi: 10.1111/dme.13387. [Epub ahead of print] A case series of verrucae vulgares mimicking hyperkeratosis in individuals with diabetic foot ulcers. Quast DR (1), Nauck MA (1), Bechara FG (2), Meier JJ (1). Author information: (1) Diabetes Division, Department of Medicine I, St. Josef-Hospital, Ruhr-University Bochum. (2) Department of Dermatology, St. Josef-Hospital, RuhrUniversity Bochum, Germany. BACKGROUND: Diabetic foot ulcers are a common complication in the advanced stages of diabetes mellitus. Certain lesions may be refractory to usual treatments with prolonged healing. In these cases, differential diagnoses to classical ulcers should be considered. Although plantar warts are a common and easy-to-diagnose finding in the general population, diagnosis can be challenging in people with diabetic foot ulcers, as they mimic hyperkeratosis in these people. CASE REPORT: We report seven cases of people with diabetic foot ulcers and verrucae vulgares mimicking treatment-refractory hyperkeratosis, presenting to our centre between 2014 and 2016. Diagnosis was aided by the clinical presentation, followed by dermoscopy and punch biopsy. Treatment included topical application of 5-fluoruracil and salicylic acid (four people), cryotherapy (three people) and surgical excision (three people), all in combination with local pressure offloading. In five people, the verrucae were completely removed after a mean treatment period of 9.4Â months; two individuals were lost to follow-up. CONCLUSION: Verrucae may be more common in people with diabetic foot lesions and polyneuropathy than generally assumed. Typical findings include small, pinhead-sized bleedings within and surrounding hyperkeratous lesions. These findings should alert the clinician for the potential presence of a verruca. In such cases, biopsy should be performed to enable specific diagnosis and treatment. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved. DOI: 10.1111/dme.13387 PMID: 28523836 â&#x20AC;¨

Acta Med Okayama. 2017 Apr;71(2):143-149. doi: 10.18926/AMO/54983. Toe Pinch Force in Male Type 2 Diabetes Mellitus Patients. Kataoka H (1), Miyatake N, Kitayama N, Murao S, Tanaka S. Author information: (1) Rehabilitation Center, KKR Takamatsu Hospital, Kagawa 760-0018, japan.h.kataoka59@gmail.com. We compared the toe pinch force in men with and without type 2 diabetes mellitus (T2DM). Sixty-eight male T2DM patients and 35 apparently healthy men matched for age, sex, and body mass index (BMI) were enrolled in this cross-sectional study. We compared the toe pinch force between the subjects with and without T2DM, and we evaluated the effect of diabetic polyneuropathy on toe pinch force in the patients. The toe pinch force of the T2DM patients was significantly lower than that of the subjects without diabetes (3.12±1.22 kg vs. 4.40±1.19 kg, p<0.001). Multiple regression analysis showed that T2DM was a determinant of reduced toe pinch force. In addition, the toe pinch force of patients with diabetic polyneuropathy was significantly lower than that of patients without diabetic polyneuropathy (2.31±0.93 kg vs. 3.70±1.07 kg, p<0.001). Multiple regression analysis showed that diabetic polyneuropathy was a determinant of the toe pinch force in men with T2DM, even after adjusting for age, BMI, HbA1c, and duration of diabetes. Reduced toe pinch force is a fundamental feature of motor dysfunction in men with T2DM, and diabetic polyneuropathy might be associated with toe pinch force in these patients. DOI: 10.18926/AMO/54983 PMID: 28420896 Conflict of interest statement: No potential conflict of interest relevant to this article was reported.

J Foot Ankle Surg. 2017 May - Jun;56(3):573-576. doi: 10.1053/j.jfas.2017.01.043.

Diabetic Driving Studies-Part 2: A Comparison of Brake Response Time Between Drivers With Diabetes With and Without Lower Extremity Sensorimotor Neuropathy. Spiess KE(1), Sansosti LE(1), Meyr AJ(2). Author information: (1)Resident, Surgical Residency Program, Temple University Hospital, Philadelphia, PA. (2)Associate Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA. Electronic address: ajmeyr@gmail.com. We have previously demonstrated an abnormally delayed mean brake response time and an increased frequency of abnormally delayed brake responses in a group of neuropathic drivers with diabetes compared with a control group of drivers with neither diabetes nor lower extremity neuropathy. The objective of the present case-control study was to compare the mean brake response time between 2 groups of drivers with diabetes with and without lower extremity sensorimotor neuropathy. The braking performances of the participants were evaluated using a computerized driving simulator with specific measurement of the mean brake response time and the frequency of the abnormally delayed brake responses. We compared a control group of 25 active drivers with type 2 diabetes without lower extremity neuropathy and an experimental group of 25 active drivers with type 2 diabetes and lower extremity neuropathy from an urban U.S. podiatric medical clinic. The experimental group demonstrated an 11.49% slower mean brake response time (0.757 ± 0.180 versus 0.679 ± 0.120 second; p < .001), with abnormally delayed reactions occurring at a greater frequency (57.5% versus 35.0%; p < . 001). Independent of a comparative statistical analysis, diabetic drivers with neuropathy demonstrated a mean brake response time slower than a suggested safety threshold of 0.70 second, and diabetic drivers without neuropathy demonstrated a mean brake response time faster than this threshold. The results of the present investigation provide evidence that the specific onset of lower extremity sensorimotor neuropathy associated with diabetes appears to impart a negative effect on automobile brake responses. Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved. DOI: 10.1053/j.jfas.2017.01.043 PMID: 28476388

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DIABETES CONGRESS FOR PATIENTS IN THE DOMINICAN REPUBLIC "No patient deserves an ulcer on their feet … " In the care of patients with diabetes, foot evaluation is a key factor in preventing future ulcers. An ulcer can trigger an amputation. If we emphasize the education of the physician, patient and family members about diabetes control and care of their feet, no patient should have an ulcer. It is a shame that in the Dominican Republic only 8% of patients with diabetes had their feet checked in the routine outpatient visit. This may happen for two reasons: 1- lack of training and awareness by the doctor to do the review 2- ignorance of the patient about the care of his feet. Because of this, we currently do the “Step-by-Step” diabetic foot training courses twice a year to train doctors and nurses in diabetic foot prevention. In addition, we also run an annual congress for patients and their families. In developing countries, lower limb amputation rates are high. One way to try to help prevent them is by doing prevention education courses for patients and their families.

PATIENT CONGRESS It is a priority for the Dominican Republic to create a patient education model for preventing diabetic foot problems based on international consensus guidelines, which have already shown worldwide, to help decrease lower limb amputation rates. The congress is run voluntarily by local diabetic foot experts, using very simple language due to the high degree of illiteracy. They are deliberately fun courses that include contests and prizes, to teach that â&#x20AC;&#x153;diabetes should be your best friendâ&#x20AC;?, not your enemy. This year 200 patients and their families participated in our Patient Congress. Our fight is to create this model of prevention to be accepted by the authorities of public health and to create prevention units for the diabetic foot, with a multidisciplinary approach, in each Dominican hospital all around the island. Thanks to the training received by the D -Foot International, 5 years ago, not only Dominican Republic, but, all of Latin American countries, today have a hope: to be free of amputations, we believe firmly, that nobody deserves an ulcer Nalini Campillo

NATIONAL CONGRESS OF PODIATRY IN BUCHAREST A few weeks after the National Congress of Podiatry in Bucharest, my feelings are divided. I remember both the theoretical knowledge shared by renowned speakers as well as their reflections, words of spirit which come back to my mind just like a favorite song. This congress was more than a gathering of brilliant minds in the field, it was also an attestation that Romania is on the international map of podiatry. Why am I saying this? The activity of the Association for Podiatry creates a favorable context for the development of this profession both in Romania and outside its boundaries. So, as organizers of this congress, we were glad to see that our eﬀorts were rewarded by a large number of participants. This indicates that the science of foot and especially of diabetic foot care is rising in Romania. At this congress, we’ve been honored by the presence of numerous international specialists in podiatry and its associated sciences, as well as Romanian specialists. On the first day of the congress, on the opening ceremony guest speakers such as David Armstrong or Alfred Gatt took the floor. I gladly remember the words of David Armstrong. In short, he stated that this congress is a great first step for podiatry in Romania and to quote him: “It’s just like someone stepped for the first time on the Moon”.

His name has a resonance in that sense, isn’t it? On the second day, the interaction between the public and the guests has been facilitated by scientific discussions and an open session of questions. Topics such as the medical management of diabetic foot infections, peripheral arterial disease, Charcot foot or foot in rheumatology practice have been approached. Additionally, workshops on foot biomechanics or hydrotherapy for non-healing wounds have created an interdisciplinary framework from which everyone can learn. Mark Tagoe from The University of Southampton said that “the day you stop learning is probably they day you have to step back”. The diversity of topics was complemented by a medical thematic exhibition available throughout the whole congress. Going forward, the third day of the congress brought to the foreground other themes about the valuable care provided by a podiatrist, the screening of peripheral arterial disease, the necessity of the podiatrist profession or the foot and ankle exam. I remember what Frank Bowling said at one point and that is: “the participants at this congress have received knowledge which will exponentially increase their value as professionals”.

It is important to underline that each topic addressed at this congress is of great importance in the prevention and treatment foot conditions. Yes, podiatry is at first in Romania, but this is a promising beginning. There is a need for involvement both from the professionals and the general public. After all, the effects of footlessness are economic and social and concern us all. As Kristien van Acker said at this congress: “If you are passionate about this profession of podiatrist, you can make the difference in your country. The other steps will follow naturally”. The Association of Podiatry wants to open the door to podiatry and the profession of podiatrist in Romania. The mission of the association is to promote the profession of podiatrist in the society and, implicitly, to reduce the numbers of amputations due to diabetic foot. It’s the only possible way that patients suffering from this condition can have a highquality life instead of feeling demoralized when receiving the bad news. I consider that few things can compare to an amputation of a body part that is, among others, the bond between you and the next step to a normal and fully enjoyed life. Before I finish this communication with you, allow me a few more words about this particular condition – diabetic foot. David Armstrong’s study, recently published in New England Journal of

Medicine, reveals that diabetic foot is a common complication for millions of diabetics and should be treated just like cancer is. Detected early there are more chances for the patient to heal. At the same time, this study indicates that foot ulcer remission is to be taken into account. It is estimated that 40% of the patients with foot ulcer will have a remission within the first year after healing. From this point of view, foot ulcer and cancer are similar. Studies published in 2016 show that in Romania there are approximately 1,7 million people suffering from diabetes. Out of these, 67% declare they have diabetic neuropathy, 17% have had at least one ulceration until the study was completed in 2012 and 4,7% suffered amputation. Our data shows that results of 2016 aren’t very much different. In Romania, every 22 minutes an amputation takes place because of diabetic foot. To conclude on a more positive note, all of the activities which took place at the National Congress of Podiatry I spoke to you about were aimed at increasing the importance of podiatry and podiatrist. This new medical branch and, implicitly, this specialist, are the liaison which help diabetic foot patients to live more and better. Norina Gavan President of the Association of Podiatry

Mottola C, Matias CS, Mendes JJ, Melo-Cristino J, Tavares L, Cavaco-Silva P, Oliveira M. Susceptibility patterns of Staphylococcus aureus biofilms in diabetic foot infections. BMC Microbiol. 2016 Jun 23; 16(1): 119. Pubmed ID#: 27339026; Free PMC full text article. Although Staphylococcus aureus is almost certainly the most frequently identified bacterial organism from diabetic foot infections, we are now beginning to understand the clinical significance of the polymicrobial nature of these infections. This is specifically relevant to both biofilm formation and eradication. The authors of this investigation sought to study the minimum inhibitory concentration (MIC), minimum biofilm inhibitory concentration (MBIC) and minimum biofilm eradication concentration (MBEC) of commonly prescribed antibiotics in bacterial isolates from diabetic foot infections. Results demonstrated that incredibly high concentrations of antibiotics are required to inhibit and eradicate biofilm, and that single agent therapy was rarely sufficient. These findings might highlight the importance of adjuvant, non-pharmacologic therapy in treating diabetic foot infections and might even call into question the practice of treating infections with a narrow antibiotic spectrum to some degree.

Dirks ML, Wall BT, van de Valk B, Holloway TM, Holloway GP, Chabowski A, Goossens GH, van Loon LJ. One week of bed rest leads to substantial muscle atrophy and induces wholebody insulin resistance in the absence of skeletal muscle lipid accumulation. Diabetes. 2016 Oct; 65(10): 2862-75. Pubmed ID#: 27358494; Free PMC full text article. Sir Francis Bacon’s renowned quotation “The remedy is worse than the disease” comes to mind while reviewing the hypothesis and results of this investigation. These authors found that one week of bed rest in young, healthy subjects led to substantial skeletal muscle atrophy and a 29% decrease in whole-body insulin sensitivity. I’m not sure a day goes by in my own clinical practice where I don’t expound patients to “stay off of” their feet and describe in no uncertain terms the deleterious effects of prolonged and/or unprotected weight-bearing. It would be interesting to consider a shift in thinking towards a more “functional” offloading of the diabetic foot. Could this potentially obviate the negative effects observed here, or can the neuropathic foot not be effectively protected while maintaining a degree of functional independence? These are questions that might hopefully be answered as medicine transitions toward a focus on functional outcome measures.

Allahabadi S, Haroun KB, Musher DM, Lipsky BA, Barshes NR. Consensus on surgical aspects of managing osteomyelitis in the diabetic foot. Diabet Foot Ankle. 2016 Jul12; 7:30079. Pubmed ID#: 27414481; Free PMC full text article. This investigation sought to derive â&#x20AC;&#x153;best practiceâ&#x20AC;? guidelines with respect to the management of diabetic foot osteomyelitis. A group of 14 panelists utilized the modified Delphi method and a Likert scale on a series of 63 statements relating to the clinical care of diabetic foot osteomyelitis. Panelists consisted of podiatric, orthopedic, vascular and general surgeons. Consensus (defined as a mean score of greater than or equal of 7.0) was reached on 38 of these statements ranging throughout the perioperative course. The results of this article might provide practitioners with insight on current expert practices in the United States.

Jarl G, Lundqvist LO. Adherence to wearing therapeutic shoes among people with diabetes: a systematic review and reflections. Patient Prefer Adherence. 2016 Aug 8; 10: 1521-8. PubMed ID# 27540284; Free MPC full text article. An important contemporary emphasis within the diabetic foot literature has been the concept of recurrance and prevention of recurrance. One factor that plays a role in this is the use of and adherence to protective shoegear. Unfortunately, it is well established that adherence rates to this intervention are less than desired. These authors undertook a systematic review of the medical literature in an attempt to determine which factors might (or might not) be associated with patient adherence to use of protective shoegear. Although their results were somewhat equivocal, they do demonstrate that adherence is multifactorial and likely cannot be ascribed to a single patient-, therapy-, or condition-related factor.

Gavan NA, Veresiu IA, Vinik EJ, Vinik AI, Florea B, Bondor CI. Delay between onset of symptoms and seeking physician intervention increases risk of diabetic foot complications: results of a cross-sectional population-based survey. J Diabetes Res. 2016: 1567405. PubMed ID#: 28018920; Free PMC full text article. This interesting study evaluated the results of a questionnaire of self-reported symptoms sent to 25000 Romanians in 2012. They further followed these subjects with respect to when they sought medical care after completion of the survey. Those patients who self-reported neuropathy and sought medical care within 1 month of filling out the survey were less likely to experience foot ulcerations, gangrene and amputations. Fairly consistently, patients had worse outcomes the further out they sought medical care from completion of the survey. The authors appropriately conclude that these findings point to the need for and positive effect of education of diabetic patients with respect to seeking medical care.

Strauss MB, Moon H, La S, Craig A, Ponce J, Miller S. The incidence of confounding factors in patients with diabetes mellitus hospitalized for diabetic foot ulcers. PubMed ID#: 27560472; Free PMC full text article. The authors of this investigation sought to quantify the incidence of what they considered to be the three most significant confounding variables influencing outcome of diabetic foot disease: deformity, infection and ischemia. Specifically they found that greater than 90% of patients hospitalized for a diabetic foot ulceration had the presence of at least one of these variables requiring intervention. Beyond these specific results, however, this article brings to the forefront the important concept of confounding variables in the diabetic foot medical literature, and more specifically, how we study them. With an eye to the critical analysis of the medical literature, it is likely that some of the wide range of healing/amputation/recurrance rates observed are attributable to the presence of confounding variables and the fact that they are most often analyzed as a categorical outcome. For example, this study defined the presence of lower extremity ischemia are categorical, in other words it was either present or it was not present in patients. In fact, however, there is likely a wide clinical range of lower extremity chronic ischemia with variable healing potentials. This is an example of how we often substitute statistical ease for clinical reality within our literature.

Read the full abstract here

TRAIN-THE-FOOT-TRAINER BANGKOK, NOVEMBER 2016 A 6-months’ follow-up report The follow-up is planned as a 5-step process. Western Pacific Train-the-Foot-Trainer follow-up news As part of the Train-the-Foot-Trainer programme we aim to get regular feedback from the participating countries to ascertain where implementation is succeeding and also where help and support is required. The progress reporting phase is scheduled at 3, 6, 12, 18 and 30 months. Please read below a progress summary at 3 and 6 months. At 3 months A Google-based form was circulated to all 54 delegates with directed questions to see how their initial implementation planning was proceeding. Only 17 of the delegates replied with a range of responses including: “not started yet” “Train-the-Foot-Trainer already implemented” “data collection planned to start soon” “Ministry of Health already contacted”. Further contact showed that many of the Chinese delegates could neither read nor fill out the Google form, or use the Train-the-Foot-Trainer website as these were in English only. This was on reflection predictable but overlooke…. a hard lesson learnt.

At 6 months A meeting took place including all but two countries (South Korea and Singapore) in a regional foot project meeting that was organized by Shigeo Kono (AASD) at Nagoya, Japan, in May 2017. Each representing country gave a presentation of their progress thus far and a questionnaire was completed by each. Five countries (Philippines, China, Japan, Vietnam, Mongolia) reported plans to collaboratively collect hard endpoints, including: death, major amputation, ulcer relapse, etc, on a joint database. This would hopefully help to demonstrate some of the eďŹ&#x20AC;ects of implemented Step-by-Step courses in these countries. The future The reporting plans are outlined as follows: At the 12-month follow-up we hope to receive a implementation business plan and initiation of data collection. At the 18-month follow-up: information and numbers of established and sustained Step-by-Step programmes workshops and initial data collection At the 30-month follow-up: results of data collection on endpoints for example ulcer occurrence, relapse, major amputation and mortality rates, and final reports of all activity.

Q ui z CLINICAL PICTURE “QUIZ”

Welcome to this clinical picture quiz in your newsletter. One of the key components to successful diabetic foot ulcer management and prevention is off-loading deleterious forces that the insensate and vascular comprised foot are subjected to. Identifying these and where they occur on the foot is an essential starting point. There are many pressure/force measurement platforms and insole devices with common and differing attributes. Of course, these are expensive and are not generally available to the everyday clinician around the world. Equally a lot of training is required to fully understand all the different components and complexities of their data analysis. With this in mind I thought it would be a good idea to show you a foot print obtained simply using carbonised paper and to see if you can analyse it. I have no doubt you will be able to. Here goes …! QUESTIONS Please take a look at this foot print that was obtained by a patient with sensory neuropathy walking over a simple carbonised sheet of paper to indicate the areas of high and low pressure/ force. The range of colour is black high pressure/ force – white no pressure/force. 1. Describe the shape of the foot print 2. Identify where the highest areas of pressure are 3. Identify where the lowest areas of pressure are 4. How would describe the relationship between the areas of identified high pressure and the pressures in the surrounding areas? 5. Try to relate your answer in question 4 to how you think the foot is loading in the phases of gait (heel strike, mid-stance, forefoot loading and toe off)? Which areas do you think are the highest risk for ulceration? 6. How would you try to off -load your identified high- risk areas?

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ANSWERS/COMMENTS

It is true that this simple pedograph is limited in the amount of information that is gives and in its subjective analysis, unlike the force/pressure plates that are commercially available. However, a good clinician is one who is observant and combining this pedograph and watching gait can give you valuable insight regarding therapeutic interventions especially insole and shoe design. Remember this is a simple footprint and cannot give data such as time pressure integrals etc but if you apply your mind like “Sherlock Holmes” examine carefully and cross reference with the real foot … ”Elementary my dear Watson”! I thought that rather than answer each of the questions above I would give what I consider to be the important observations from this pedograph and then a few suggestions. I will start from the heel and move forward. 1. You can notice several things regarding the heel area: a. The shape of the heel strike is slightly abnormal with a bulging towards the medial side, so that it appears as a reverse “D” shape. This would suggest that at heel-strike the direction and magnitude of force is directed medially so that impact and duration of contact is taken more on the medial side. b. The highest density of tone (black) is likewise initially at the medial heel margin but then moves more towards the central heel area more distally. c. However, the overall loading at heel strike does not appear to be heavy, i.e. small amount of black compared with grey and white. d. So the overall impression may indicate that the heel comes into contact with the ground uniformly posteriorly but moves quickly to the medial margin then centrally indicating shear stress and increase pressure in these areas. However overall looking at the density of colour I would anticipate this patient have an early heel light and thus degree of ankle equinus. 2. Moving forward from the heel to the midfoot: a. The overall shape of the midfoot pedograph would suggest that the loading occurs on the lateral border thus it is not a flat foot. It could possibly be a high arch foot but one would expect there to be a higher loading on the lateral border than there is in this print. b. The proximal half is very light in colour compared with the distal half. This would signify a quick transference towards the forefoot, which would be in keeping with an early heel lift and ankle equinus.

a. You will also notice the shape and distribution of colour. The area close to the heel is narrower broadening latero- medially joining the forefoot area proximal to the 3rd metatarsal area. b. Maximum loading appears to be in the distal third just proximal towards the 5th metatarsal head. 3. The forefoot area a. The focus of loading is very clear with high pressure concentrating over the 2nd,3rd reducing over of the 4th and then moderate over the 5th metatarsal head. The 1st metatarsal head has very little pressure over it although a small concentrated area over the proximal edge near the metatarsal neck. b. Observing this pattern gives a little clue as to the transference of pressure and possibly its duration. It hints that the direction of loading is from the 5th and 4th moving moderately quickly to the 2nd and 3rd metatarsal heads where it remains for the longest duration moving anteriorly to toe contact . 4. The toe area a. The first toe is loaded highest medially over the interphalangeal joint area reducing laterally. Notice there is a very faint loading area over the medial proximal phalanx area suggestive of hallux limitus/rigidus b. The 2nd, 3rd and 4th toes are all show high pressure areas at their apices with the 2nd having the highest amount of pressure. c. The 5th toe is deviated medially showing the peak pressure is not at its apex but over the lateral aspect of the distal interphalangeal joint. Additionally, loading can be seen over the entire length of the toe. d. It is clear that this patient is clawing their toes to assist the propulsion phase. 5. Thus, it is clear from this pedograph that the areas of highest risk for ulceration are: •

2nd metatarsal head area

•

Medial plantar surface of the great toe and the apex of the 2nd and 5th toes.

Obviously therapeutic footwear including pressure and shear relieving insoles will be required. Bearing in mind the overloading of the metatarsal heads, toe apices and hallux rigidus/limitus ideally a rocker sole shoe would be ideal. If the rocker is optimally placed and the shoes fit very well it may be possible to suﬀice with a 7-9mm simple flat cushioning insole with an anti-shear/friction top cover. Otherwise it would be sensible to use a total contact insole made of at least two diﬀerent density materials.

D-Foot

International D-Foot International Stepping out in front â&#x20AC;Ś

D-Foot International