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Orthotic Treatment of The Neuropathic Diabetic Foot

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Orthotic Treatment of The Neuropathic Diabetic Foot David Kingston BSc. (Hons) MBAPO SR P/O Senior Orthotist IDS Cappagh Hospital Orthotist Four year B.Sc.(Hons) Dual ... – PowerPoint PPT presentation

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Title: Orthotic Treatment of The Neuropathic Diabetic Foot


1
Orthotic Treatment of The Neuropathic Diabetic
Foot
  • David Kingston
  • BSc. (Hons) MBAPO SR P/O
  • Senior Orthotist
  • IDS
  • Cappagh Hospital

2
Orthotist
  • Four year B.Sc.(Hons)
  • Dual qualified
  • BAPO
  • State Registered

3
Training
4
Introduction
  • Foot complications are one of the most serious
    and costly complications of NIDDM.
  • Amputation of (or part of) a lower limb is
    usually preceded by a foot ulcer
  • A strategy which includes prevention, patient and
    staff education, multi-disciplinary treatment of
    foot ulcers and close monitoring can reduce
    amputation rates by 49-85
  • In May 1999 the WHO and International Diabetes
    Federation set goals to reduce the rate of
    amputations by 50 in five years
  • They (We) have failed

5
Pathophysiology
  • Spectrum of foot lesions varies across the world
  • Pathways are almost identical
  • Up to 50 of NIDDM patients have neuropathy and
    at-risk feet
  • Neuropathy leads to an insensitive and
    subsequently deformed foot with possibly an
    abnormal gait
  • Trauma can lead to a chronic ulcer
  • Loss of sensation, foot deformities and limited
    joint mobility can lead to abnormal biomechanical
    loading of the foot

6
  • As a normal response to pressure a callous is
    formed
  • The skin finally breaks down
  • Frequently preceded by a subcutaneous haemorrhage
  • The patient continues to walk on the insensate
    foot impairing healing
  • Lack of treatment can lead to the need for
    amputation
  • Once a patient has an ulcer they are 77 times
    more likely to get a second ulcer after treatment
    of the first has healed the ulcer
  • Once amputation has occurred then the pressures
    on the remaining limb increase

7
Five Cornerstones of the Management of the
Diabetic Foot
  • Regular inspection and examination of the foot at
    risk
  • Identification of the foot at risk
  • Education of patient, family and healthcare
    providers
  • Appropriate footwear
  • Treatment of non-ulcerative pathology

8
Regular Inspection and Examination of the Foot at
Risk
History Previous ulceration Previous education Social isolation Poor access to healthcare Barefoot walking
Neuropathy Tingling Pain Loss of sensation
Vascular Status Claudication Rest pain Pedal pulses Hair on toes
9
Skin Colour Temperature Oedema Nail pathology Ulcer Callous Dryness Cracked skin Interdigital maceration
Bone/Joint Deformities
Footwear/Socks Assessment both inside and outside Tourniquet Sock marks
10
Foot Deformities
  • Rearfoot Valgus
  • Rearfoot Varus
  • Forefoot Valgus
  • Forefoot Varus
  • Hallux Valgus
  • Hallux Limitus
  • Hallux Rigidus
  • FHL
  • Claw Toes
  • Hammer Toes
  • Mallet Toes
  • First Ray Dysfunction
  • Prom Met Heads
  • Mortons Syndrome
  • Tailors Bunion
  • Forefoot Ab/Adductus

11
Sensory loss due to diabetic polyneuropathy can
be assessed using the following techniques
Pressure perception Monofiliment 10 gram
Vibration perception 128 Hz tuning fork on hallux
Discrimination Pin prick on dorsum of foot
Tactile sensation Cotton wool on dorsum of foot
Reflexes Achilles tendon reflexes
Spatial awareness Movement of Hallux
12
Monofilament Testing
13
Tuning Fork Testing
14
Metatarsal Pressure
15
Peak Pressures
16
Risk Categories
Low Risk No sensory neuropathy
Medium Risk Sensory neuropathy and one foot deformity
High Risk Sensory neuropathy Two or more foot deformities Signs of peripheral ischemia Previous ulceration
17
Treatment of non-ulcerative pathology
  • Skin care
  • Regular Chiropody
  • Nail care
  • Diabetic Footwear
  • Diabetic Socks
  • Diabetic Insoles
  • Oedema control

18
Orthotic Treatment - Low Risk
  • Education
  • Socks
  • Footwear Stock
  • Insoles

19
Patient Education
  • Take care of your diabetes control
  • Check your feet daily
  • Wash your feet daily
  • Keep your skin soft and smooth
  • Smooth corns and calluses gently
  • Trim your toenails regularly and carefully
  • Wear socks and shoes at all times
  • Protect your feet from heat and cold
  • Keep the blood flowing to your feet
  • Be more active
  • Consult your GP

20
Socks
21
Appropriate Footwear
  • Good leather
  • Lace up
  • Solid one piece sole
  • Padded collars
  • Soft toe puff
  • Good lining
  • No stitching or intricate designs
  • Low heels
  • No tapered heels
  • Regular soling
  • Good fit

22
Shoe Fit
23
Parts of a Shoe
24
Stock Footwear
25
Footwear Objectives
  • Relieve areas of plantar pressures
  • Reduce shock
  • Reduce shear
  • Accommodate deformities
  • Stabilize and support deformities
  • Limit motion of joints

26
TCI Insole
27
Orthotic Treatment - Medium Risk
  • Education
  • Socks
  • Footwear Stock or Bespoke
  • Insoles

28
Orthotic Treatment - High Risk
  • Education
  • Socks
  • Footwear Stock or Bespoke
  • Insoles

29
Treatment of Ulcers
  • Relief of pressures
  • Restoration of skin perfusion
  • Treatment of infection
  • Metabolic control (lt10 mmol)
  • Local wound care
  • Instruction of patient and relatives
  • Determination of the cause and preventing
    recurrence

30
Orthotic Treatment - Ulceration
  • Footwear Bespoke
  • Insoles
  • PRAFO
  • CROW Walker
  • Total Contact Cast
  • Pneumatic Walker
  • Rest

31
TCI Insole
32
Total Contact Insole
33
Toe-Off Pressure
34
Rocker Soles
35
Rocker Sole Action
36
PRAFO
37
CROW Walker
38
Total Contact Cast
39
Diabetic Aircast Pneumatic Walker
40
Neuropathic Ulcers
  • Sensory Loss
  • Trauma
  • Callous
  • Ulceration

41
Lesion Pathway
42
Areas of Risk
43
Ulcer Sites
44
Ulcer Formation
45
Sesamoid Pressure
46
Heel Lesion
47
Mid Metatarsal Head Lesion
48
Hallux Lesion
49
Charcot Foot
  • Neuro-arthropathy that affects the joints in the
    foot
  • Rapidly progressive degenerative arthritis that
    results from neuropathy
  • Pain perception and the ability to sense the
    position of the joints in the foot are severely
    impaired or lost
  • Muscles lose their ability to support the
    joint(s) properly.
  • Loss of these motor and sensory nerve functions
    allow minor traumas such as sprains and stress
    fractures to go undetected and untreated
  • Leads to ligament laxity, joint dislocation, bone
    erosion, cartilage damage, and deformity of the
    foot
  • Joint effusions, large osteophytes, fractures,
    bone fragments, and joint misalignment and/or
    dislocation

50
Charcot Foot Six Key Points
  • The acute Charcot foot can mimic cellulitis or,
    less commonly, deep venous thrombosis
  • The existence of little or no pain can often
    mislead the patient and the physician
  • Findings on plain x-rays can be normal in the
    acute phase of the Charcot foot
  • Strict immobilization and protection of the foot
    is the recommended approach to managing the acute
    Charcot process
  • A careful program of patient education,
    protective footwear and routine foot care is
    required to prevent complications such as foot
    ulceration
  • Reconstructive surgery is reserved for patients
    who have recurrent ulceration despite compliance
    with the previously mentioned regimen

51
Charcot Foot Types
  • 3 types
  • Type 1 Forefoot
  • Type 2 Midfoot
  • Type 3 Hindfoot
  • When active, joint destruction is very rapid,
    orthoses must be fairly aggressive and promptly
    supplied

52
Midfoot Charcot Joint
53
Talar Dislocation in Charcot
54
Charcot Joint Foot
55
Charcot Joint Lesion
56
Charcot Foot Orthotic Treatment
  • Rest
  • Total Contact Cast
  • Pneumatic Walker
  • Bespoke Footwear

57
Diabetic Aircast Pneumatic Walker
58
Total Contact Cast
59
Referral Procedure
  • Referral letter to IDS, Cappagh Hospital,
    Finglas, Dublin 11
  • Clinic at Croom Orthopaedic Hospital once a month
  • Include Long Term Illness Booklet Number
  • davidkingston_at_idsltd.ie

60
  • Thank You
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