This document provides an overview of podiatric medicine with an emphasis on treating diabetic patients. It discusses why feet are important, details about diabetes and how it affects gait and plantar pressure. It presents two case studies, one on plantar pressure distribution in diabetic neuropathy patients with a history of foot ulcers, and another on the effectiveness of insoles in redistributing plantar pressure. It concludes that gait analysis and innovative treatments from podiatrists can help reduce amputation rates in diabetic patients.

1. 
Podiatric Medicine
Emphasis on Diabetic Patients
Karla De La Mata
Department of Biological Sciences
East Stroudsburg University
Spring 2014

2. Overview
 Why feet?
 Diabetes Mellitus
 Gait Analysis & Plantar Pressure
 Case Studies
 Conclusion
2

3. Why Feet?...
 Amazing podiatric medical schools
 Increasing need for Doctors of Podiatric Medicine
(DPM)
 Expert in the lower extremity
 Conservative approach
 Option to perform surgeries
3

4. Diabetes is…
 Type 1 (juvenile diabetes)
- Approximately 10% are affected – not common
- Immune system attacks β cells that produce insulin
- Daily administration of insulin required
 Type 2 (adult-onset diabetes)
- Approximately 90% are affected
- Characterized by insulin resistance and/or relative insulin
deficiency ~ due to receptor
- Being overweight/obese may play a role
4

5. Facts About Diabetes
 Age, family history, and ethnicity play a role in
diabetes susceptibility
 According to the International Diabetes Federation,
there are 382 million people in the world with diabetes;
37 million in North America
 By 2035 an estimated 592 million may be affected
 North America spends an estimated 263 billion on
diabetic care
 Global killer – every 7 seconds someone dies
5

6. Is there any good news..?
 Many inexpensive and cost-effective
interventions exist!
Proven strategies for improving the living environment, changing
diet and increasing physical activity can reverse the pandemic.
6

7. Gait
 Walking is an unconscious effort, but requires symmetry
and reproducible timing
 Deviations from normal gait can hint at multiple disease
pathologies
 Diabetes affects feet through its impact on circulation and
sensation  a lack thereof leads to complications
 Gait analysis studies for patients with diabetes vary
 Results can be confusing and contradictory, BUT clear
trends emerge
7

8. Gait Analysis Diagram
comprised of 2 phases
A series of “controlled” falls
*point of reference is the
right foot*
8

9. Gait: Stance Phase
foot is in contact with the ground
4 Components
1 Heel Contact – R.heel contact,
ends with tow off of L.foot
2 Midstance – toe off of L.foot and
ends with heel lift of R.foot
3 Active Propulsion – heel lift of
R.foot and ends with heel contact of
L.foot
4 Passive Propulsion – heel contact
of L.foot and ends with toe off of
R.foot
9

10. Gait: Swing Phase
foot is NOT grounded
 During 2/3 of the stance phase,
the opposite leg is in swing phase
1 Acceleration – provides foot
clearance away from ground
2 Midswing – swing leg advances
through and in front of the stance
leg
3 Deceleration – leg in the swing
phase must be slowed before heel
strike
10

11. Other Points of Analysis
1 Pelvic Tilt
2 Pelvic Rotation
3 Lateral Shift
4 Width of Base
5 Stride Length
6 Step Length
11

12. Plantar Pressure & Gait
 Repetitive mechanical stress & loss of protective
sensation on the plantar surface of the foot are
considered relevant factors in skin breakdown resulting
in foot ulcerations…so let’s reduce the peak plantar
pressure (PPP)…
 Traditional view is that high PPP is bad and low PPP
is good…is it this cut and dry ?
12

13. Figure. Medial
longitudinal
arch functions
during stance
phase.
Plantar Pressure
13

14. How a Diabetic’s Gait Differs
 Decreased walking speed
 Decreased step length
 Decreased single limb support
time
 Decreased plantarflexion
moments
 Decreased step variability
 Decreased knee and ankle
mobility
 Decreased ground reactive
forces
 Decreased joint angles
 Increased width of base
 Increased double stance support
time
 Increased time needed to
complete gait cycle
 Overall increase in energy
expenditure
14

15. Why does it differ?
 Research has not confirmed casual relationships between
gait and diabetes, but there are suspects – Neuropathy #1
 Possible that proprioceptive deficits cause diabetics to walk
more carefully
 Studies comparing patients with and without diabetes aren’t
clear regarding which gait alterations are specific to
neuropathy and which affect those without neuropathy
 The presence of other factors also impinge on normal gait
15

16. How DPM’s help…
 Comprehensive foot care programs reduce amputation
rates by 45 – 85%
 Use innovative treatments (i.e. HBOT)
 Dedicated in executing treatments that are multi-faceted
- guidelines must be followed
 Podiatry assessments/treatments can be all-inclusive
 Amount of research completed and in-progress is
impressive
16

17. Case 1: PLANTAR PRESSURE DISTRIBUTION
IN DIABETIC NEUROPATHY PATIENTS WITH
A HISTORY OF FOOT ULCERS
 Hypothesis: Even with healed ulcers, diabetic neuropathy patients with a
history of ulceration would still show an altered distribution of plantar
pressure
 Method: PP distribution recorded during barefoot gait to avoid influence
of compounding factors (i.e. shoes)
CG: n=20 DN: n=17 DNU: n=10
 Result: Velocities amongst the 3 groups were NOT significantly different.
Peak pressure, especially the pressure-time integral, was different in all
groups – highest in DNU sample
17

18. Case 2: EFFECTIVENESS OF INSOLES ON
PLANTAR PRESSURE REDISTRIBUTION
Figure. Definitions of foot
regions. MTH=metatarsal head
 Methods: Analyze gait in non-diabetic control
group (n=8) and in a diabetic group (n=7)
using various insoles
- Types of Insoles: shoe-only, flat insole, and
three contoured insoles (non-weight, semi-
weight, and full-weight-bearing)
 Result: Insoles are affective! Peak pressure
and pressure-time integral were highest in
diabetic group. Semi-weight bearing insole
was immediately effective.
18

19. Improvements To Be Made
 Make gait analysis more accessible and
“user-friendly”
 Try “ideal approach” when identifying the
relationship between plantar pressure and
ulceration
 Increased patient education

20. QUESTIONS?...
Thank You!

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<http://lowerextremityreview.com/article/gait-alterations-associated-with-diabetic-neuropathy>.
Ko, Mansoo. "Plantar pressure and gait in patients with diabetes." Lower Extremity Review Oct. 2010. Web. 2 Apr. 2014.
<http://lowerextremityreview.com/article/plantar-pressure-and-gait-in-patients-with-diabetes>.
Liu, Rui, Ling Li, Mengliu Yang, Guenther Boden, and Gangyi Yang. "Systemic Review of the Effectiveness of Hyperbaric Oxygenation Therapy in the
Management of Chronic Diabetic Foot Ulcers." Mayo Clinic 88.2 (2013): 166-75. Web. 6 Apr. 2014.
Normal and Abnormal Gait Series. YouTube, 2013. Web. 1 Apr. 2014. <http://www.youtube.com/watch?v=VYVyoFdJHdU>.
Tsung, Bonne, Ming Zhang, Arthur Mak, and Margaret Wong. "Effectiveness of insoles on plantar pressure redistribution." Journal of Rehabilitation Research &
Development 41.6A (2004): 767-73. Web. 1 Apr. 2014.
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and Risk Management 3.1 (2007): 65-76. Web. 20 Apr. 2014. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1994045/>.
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