ORTHOTI MANAGEMENT OF DIABETIC FEET. Tarun Kumar Kulshreshtha, Clinical Prosthetist & Orthotist, Guest Facutly, University of Delhi, New Delhi, India

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1 ORTHOTI MANAGEMENT OF DIABETIC FEET Tarun Kumar Kulshreshtha, Clinical Prosthetist & Orthotist, Guest Facutly, University of Delhi, New Delhi, India

2 INTRODUCTION Diabetic Melitus is a group of metabolic diseases in which a persons has high blood sugar. Globally as of 2011, 285 million people had diabetes and its incident is increasing. By 2030, the number is estimated to be double. The greatest prevalence is expected to occur in Asia and Africa.

3 Global Diabetic Hall of F/(Sh)ame Top India: 20m in 2004 to 58m by China 3. USA 4. Russian Fed 5. Japan 6. Brazil 7. Indonesia 8. Pakistan 9. Mexico 10. Ukraine

4 Prevalence of Diabetes (35-64 Years)

5 ABOUT DIABETES

6 TYPES OF DIABETES Type 1 diabetes can occur at any age. However, it is most often diagnosed in children, adolescents, or young adults. Exact cause is unknown, most likely autoimmune disorder Type 2 diabetes is a lifelong (chronic) disease in which there are high levels of sugar (glucose) in the blood. Type 2 diabetes is the most common form of diabetes. When sugar cannot enter cells, high levels of sugar build up in the blood. Family history and genes play a large role in type 2 diabetes. Low activity level, poor diet, and excess body weight around the waist increase your risk.

7 WHY SO MUCH TALK ABOUT DIABETES?

8 Diabetic Neuropathy Diabetic Neuropathy is the impact of diabetes on the nervous system, most commonly causing numbness, tingling and pain the feet and increasing the risk of skin damage due to altered sensation, leading to ulceration and in some cases amputation.

9 What is Diabetic Foot WHO DEFINITION:- The foot of a diabetic patient that has a potential risk of pathologic consequences including infection, ulceration and or destruction of deep tissue associated with neurological abnormalities, various degree of peripheral vascular disease and/ or metabolic complications of diabetes in the lower limb. Any foot pathology that results directly from diabetes or its long- term complications ( Boulton 2002).

10 Symptoms of Type 2 Diabetes Often, people with type 2 diabetes have no symptoms at first. They may not have symptoms for many years. The early symptoms of diabetes may include: Bladder, kidney, skin, or other infections that are more frequent or heal slowly Fatigue Hunger Increased thirst Increased urination The first symptom may also be: Blurred vision Erectile dysfunction Pain or numbness in the feet or hands

11 Warnings Signs Skin discoloration Elevated temperature Swelling Pain Open sores Ingrown nails Bleeding corn, blister, calluses Dry skin

12 CALLOUS / CORN

13 INGROWN NAILS

14 FUNGAL TOENAIL Fungal Infection which caused ingrown nail Thickened curled nails caused by fungus

15 HAMMERTOE Digital Contracture Usually PIPJ May have MPJ dorsiflexion May have clavus Pre-ulcerative in patients with diabetes

16 CLINICAL GRADING OF ULCERS By Wagner Grade 0 : Foot at risk. Grade I : Skin and superficial fascia involved. Grade II : deep fascia involved. Grade III : osteomyelitis present. Orthotic Management, Total Contact & Off-loading devices Excision of infected bone Wound allowed to granulate Grafting (skin or bone) not generally effectiv Grade IV : forefoot gangrene. Grade V : entire foot gangrenous Amputation level?

17 Natural history of the diabetic foot Edmonds 2006 Stage 1 : Normal Foot Stage 2 : A High Risk Foot Stage 3 : An Ulcerated Foot Stage 4 : An Infected Foot Stage 5 : A Necrotic Foot

18 KEY PEDORTHIC GOALS 1. Prevention of ulceration by providing offloading devices. 2. Application Orthotic devices in conjunction with medical treatment to improve wound healing. Reduce Shock, Friction, Shear Transfer Forces From Sensitive to Tolerant Areas Accommodate Fixed Deformities Limit Motion of Painful or Unstable Joints Improve Foot Function

19 PATIENT EVALUATION 19

20 PATIENT EVALUATION Review Prescription and Medical History Inspect Footwear Inspect Foot Select Corrective Modalities Educate Patient Follow-Up

21 FOOTWEAR INSPECTION Fit Upper Counter Outsole Insole Lining

22 TALES OF THE HEELS

23 SOLES HAVE A LOT TO TELL

24 NORMAL RANGE OF MOTION

25 WHERE IS THE TOE?

26 c CHECKING FIT AT BALL JOINT

27 Testing for Sensation USE MONOFILAMENT TO TEST FOR NEUROPATHY TEMPERATURE ALSO IMPORTANT

28 USING RITZ STICK

29 FOOT MEASUREMENT WITH A BRANNOC

30 Foot Pressure Analysis, Traditional Ink Imprinter

31 RESULTS EASY TO VISUALIZE AND EXPLAIN: VALUE OF A PICTURE

32 Digital Foot Pressure Analysis Measures pressure and foot Size

33 Advantages of Digital Scanning 1.Select the Right Shoe the 1 st Time 2.Select Shoes from Existing Inventory in Your Practice 3.Use the Pre-formed Inserts-Faster & Quicker 4. More effective communication with Patient 5. State of Art Image to Referral Sources. 6. Demonstrate efficacy of Treatment. 7. Mail, or Deliver Information to Referrals

34 Orthotic Management of the diabetic foot Pressure reduction is the main treatment. Neuropathy is irreversible. Surgery is expensive and invasive. Pressure reducing modalities Footwear Foot orthosis (Both functional & Accommodative) Total Contact Foot Orthoses / Insoles Bi-Valve Orthoses / Total Contact Casting PTB Braces

35 FOOT WEAR & OBJECTIVES Protection Stability Facilitâtes ambulation Reduce & redistribute plantar pressure Provide shock absorption. Balance Limb Length Discrepancy Accommodate foot deformity & edema Accommodate orthosis or prostheses Maintain foot function Easy to get on & off Essential long term Management

36 OPTIONS AVAILABLE Foot condition on 3/9/11 Foot condition on 16/9/11 Modified Insole provided with Shearban on 31/8/11

37 Special footwear

38 Rocker sole FOOT WEAR- MODIFICATION Reduce plantar pressure Increase propulsion Medial or lateral flare gives Stability Steel shank / broad base shoes gives stability Heel raise equalize limb length discrepancy Shear ban/teflon can be pasted in shoes with areas of more friction.

39 CASE STUDY 1 54 year old male. Poorly controlled type II diabetes (25 years). Patient was on an insulin (2 years). Left grade 3 ulcer at unhealed Heel (4 years).

40 CASE STUDY 1

41 CASE STUDY 2 62 years, Male. Case of Peripheral Neuropathic ulcer in between plantar surface of 2 nd & 3 rd MT head. Had underwent debridement in Feb2011. Ulcer recovered, however using insole for prevention of further ulceration. Recurrence of ulcer in August 2011.

42 CASE STUDY 2 RESULTS AFTER 2 WEEKS Foot condition on 3/9/11 Foot condition on 16/9/11 Modified Insole provided with Shearban on 31/8/11

43 CASE STUDY 2 Wore depth inlay shoes and customised insole made of plastozote with the application of a shear reducing material (Shearban). Shown tremendous improvement after two weeks of fitment. Recurrence of ulcer begin after 2 months. Provided MT bar on the shoe. Patient comfortable in recurrence till Dec 11.).

44 CASE STUDY 3 44 year old male Approached to us on Jan 2011 Right 3 rd, 4 th and 5 th ray amputation secondary to diabetic complications with callus at the plantar surface of 1 st MT head Has been wearing depth inlay shoes and custom accommodative

45 CASE STUDY 3 Feb 2011 April 2011

46 CASE STUDY 3 Patient was fitted with new depth inlay shoes with forefoot and hindfoot rockers with custom accommodative arch supports in Feb Arch supports and filler with Plastazote were fabricated with the application of a shear reducing material (Shearban). Patient has been callous free since April 2011.

47 A study in Kings College in London showed that while patients who wore therapeutic shoes and insoles had an ulcer recurrence rate of only 17%, those who returned to wearing regular shoes had an 83% recurrence rate.

48 Follow-up Regular follow up is needed for proper management of Neuropathic foot. Check for Skin colour. Check footwear for worn out sole or compensation if given. provision of regular foot examinations and reinforcement of the educational message on foot care should be given to the patient. Educate to maintain proper lifestyle.

49 ACKNOWLEDGEMENT Mr. Achille Otou-Essono for his continuous motivation and support, without which it would not have been possible for me to do presentation in this conference. Mr. Sohan Pal, Mr. Praveen Verma, Mr. P.S. Sidhu and Mr. Sandeep Shukla, (all CPOs).

50 CONCLUSION For ages foot care has been neglected. Total Contact Foot Orthoses and Orthotics play an important role in order to prevent / treat ulcers and avoid amputations. Compliance with the orthotics and appropriately fitted shoes and follow-up of the patients are critical for the care of diabetic foot. Prevention is always better than cure.

51 THANKS