Sergio Puigcerver (1) ; Juan Carlos González (1) ; Roser Part (1) ; Eduardo Brau (1) ; Ana León (2), Juan Ignacio Acosta (2) (1) Instituto de Biomecánica de Valencia, UPV. Valencia, Sapin; ibv@ibv.upv.es ; www.ibv.org (2) Asociación de Empresas de Ortopedia Técnica de Andalucía. Sevilla, Sapin; asociados@asoan.com ; www.asoan.com Case Report: Diabetic Foot Personal data intake and anamnesis A medium-height, overweight 76-year-old lady goes to the specialist s office. The reason for the consultation is painful feet, especially on the forefoot s area (metatarsal heads) and on the centre of the heel (bilateral). She also mentions that she has been using insoles with internal longitudinal arch support of a soft material and bespoke shoes for about 5 years. The patient was diagnosed with type II diabetes mellitus and generalized osteoarthritis. That is associated to hypertension and presence of varicose veins in the legs, which are even more affected by the weight. She does not do any sporting activity, she only walks about half an hour a day to make purchases and, furthermore, she makes the housework very slowly. Regarding the presenting pain, the patient told us: My feet, hurt a lot, especially the heels. I feel more pain in the morning and, when I get up after sitting for a long time, I have trouble for walking. Then the pain goes away slightly but it hurts again after a while. Analysis of footwear The footwear wore by the patient is customized and handcrafted (Figure 1). It is observed that it is made of natural leather and has a square 25mm high heel. Figure 1. Custom footwear It can also be seen that the wear on both the forefoot and the hindfoot are located in the external area and, as a consequence, the shoe upper is deflected towards the external side of both feet (Figure 2 and Figure 3). Figure 2.Rearfoot upper wear out Figure 3. Forefoot upper wear out.
Furthermore, the forefoot is deformed in its medial area as a consequence of a bilateral hallux valgus and also at the top because it has a 2 nd hammertoe. Non weight-bearing exploration When non weight-bearing exploration techniques are performed, it can be seen that the patient presents a decreased tibiofibular articulation, both in extension and flexion of the knee, in comparison to the normal movement that it should present (about 15º in dorsal flexion and from 40º to 70º in plantar flexion). Due to the presented that has been observed, a significant degeneration of the tibial plateau in the joints of both knees, which prevents the proper movement of the knee, is observed in the radiographies. The first ray is plantar-flexed equally in both feet. The pattern of hyperkeratosis occuring in the plantar area is in the central metatarsal heads and in fleshy part of the 5th finger, bilaterally. The subtalar joint axis is medial in both feet. Scanning load When the patient stands upright, it can be seen that he presents the left iliac crest lower than the opposite, and his right shoulder higher than the left. The support base of the patient is decreased. Finally, the digital deformities are presented, bilaterally, in the 2nd and 3rd hammertoe and bunion (Figura 1): Figura 1. Hallux valgus y dedos en martillo. When making the bisecting line of the calcaneus on both feet, they do not yield an angle of approximately 6 º of Varus, what indicates that it is just within the normal range. In a lateral view, it is shown a decrease of the medial longitudinal arch (Figura 2) and a knee flexion.
Footwear Analysis Figura 2. Disminución ALI. The type of footprint presented by the patient is a normal trace, but there are signs of overpressure zones on the central metatarsal heads and on the heels, as shown in the weight bearing foot prints taken from the patient (Figura 3). Gait analysis Figura 3. Pedigrafías. Seeing the patient walking in his normal gait, it is observed that she does not do a movement of the pelvic waist with the movement of the blades. Also width and step cadence patterns, as well and the angle of progression of gait, are diminished. All this contributes to a rigid gait. Because of that, changes in plantar pressures in static and dynamic are observed. Specific exploration for diabetics Because the patient presents an important systemic disease like diabetes mellitus, it was decided to do a sensory examination, in which all parameters resulted normal, and a motor examination, in which it was observed that the reflexes were slightly diminished, but the other parameters were within the normal range. Diagnostic Flat feet caused by bilateral forefoot varus causing painful calcaneal spur, abductus hallux valgus and 2nd hammer toe at both feet. Treatment Insole with 6mm, medium density, thermoformed EVA shell up to the subcapital area of the metatarsal heads with reinforcement in the medial longitudinal arch and in the outer longitudinal arch. Furthermore, it also includes a metatarsal download
area with Swiss subcapital ball and low-density Poron ahead of the subcapital ball, in order to accommodate more the metatarsal heads (Figura 4). It is also set a low density, coma-shaped material under the heel, in its central and internal area (Figure 8). Figura 4. Pelota retrocapital suiza. Mold Figura 5. Ortesis Plantar. In this case, since we want the plantar insole to carry out an accommodative function on the plantar structures, rather than rearfoot control, we decided to take a weight-bearing cast with phenolic foam and, thus, obtain the total expansion underwent by the foot. Production of the insole The weight-bearing cast is taken with phenolic foam, simulating the normal step phases: Heel strike Load on the external edge of the foot Load on the inner edge of the foot Take off with the 1st finger (medial forefoot) The foam negative is filled with plaster to obtain a positive mould, it is rectified correcting subtlely the position of the rearfoot and providing a support for both arches. The positive cast is polished and covered with a tubular cotton bandage, then it is placed in the vacuum machine and heated with a piece of EVA with the measures of the patient's foot (from heel to metatarsal heads). Once it is ready, the EVA is placed on the positive mould and the vacuum is applied. When it is adapted and cooled, the bottom of the EVA shell is flattened, lowering it to cero in the metatarsal heads area and approximately to 3mm in the heel area, for the spur relief. The central and medial areas of the EVA piece are milled on its lower face, forming a coma whose vertex faces the body s medial line. This space is filled with a low density material (Poron, in this case). The insole is lined with 1mm Pelite on the inner side. A 1mm Poron sheet is placed in the forefoot area and the Swiss subcapital ball is placed behind the metatarsal heads. The patient tests the insole and the specialist
marks the hyperpressure zones, which will be slightly milled in order to provide the needed selective pressure relieves. Then, the top face of the insole is lined with natural skin. Initial Validation When the first validation of the patient s treatment was carried out, several pain points were detected in both feet. These painful points are: Moderate pain: Lumbar area. Mild pain: Internal area of the heel (tibial). Toes back. External midfoot. Hallux abductus valgus. Internal heel area of the plant. Centre in the heel area of the footplant. First metatarsal head. Middle metatarsal heads. Severe pain: Instep area. Medial-internal plant. Fifth metatarsal head. From the questionnaire it was also detected that the custom footwear produced for the patient was some heavy and not very flexible for her, so that she preferred it to be lighter and more flexible. After having completed the validation questionnaire, since it was expected that the pain would go down with the use, it was considered appropriate to deliver the shoes and the plantar orthoses to the patient. She was advised that pain should not increase and, otherwise, she would have to go to the consultation. Validation during the review After wearing the footwear and the orthoses for 15 days, the patient did not feel pain in either of both feet. Regarding the problems identified in the first validation, the patient remarked: "At first they seemed a little hard, but then they became very tender and are soft inside, they look like elastic at front". This indicates that the material of the shoe and the plantar orthoses are correct as they have adapted and have not produced any kind of ailment or injury.