Orthotic Treatment of The Neuropathic Diabetic Foot - PowerPoint PPT Presentation

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Orthotic Treatment of The Neuropathic Diabetic Foot

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  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

  9. 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 Morton’s Syndrome Tailors Bunion Forefoot Ab/Adductus Foot Deformities

  10. Sensory loss due to diabetic polyneuropathy can be assessed using the following techniques

  11. Monofilament Testing

  12. Tuning Fork Testing

  13. Metatarsal Pressure

  14. Peak Pressures

  15. Risk Categories

  16. Treatment of non-ulcerative pathology • Skin care • Regular Chiropody • Nail care • Diabetic Footwear • Diabetic Socks • Diabetic Insoles • Oedema control

  17. Orthotic Treatment - Low Risk • Education • Socks • Footwear – Stock • Insoles

  18. 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

  19. Socks

  20. 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

  21. Shoe Fit

  22. Parts of a Shoe

  23. Stock Footwear

  24. Footwear Objectives • Relieve areas of plantar pressures • Reduce shock • Reduce shear • Accommodate deformities • Stabilize and support deformities • Limit motion of joints

  25. TCI Insole

  26. Orthotic Treatment - Medium Risk • Education • Socks • Footwear – Stock or Bespoke • Insoles

  27. Orthotic Treatment - High Risk • Education • Socks • Footwear – Stock or Bespoke • Insoles

  28. Treatment of Ulcers • Relief of pressures • Restoration of skin perfusion • Treatment of infection • Metabolic control (<10 mmol) • Local wound care • Instruction of patient and relatives • Determination of the cause and preventing recurrence

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

  30. TCI Insole

  31. Total Contact Insole

  32. Toe-Off Pressure

  33. Rocker Soles

  34. Rocker Sole Action

  35. PRAFO

  36. CROW Walker

  37. Total Contact Cast

  38. Diabetic Aircast Pneumatic Walker

  39. Neuropathic Ulcers • Sensory Loss • Trauma • Callous • Ulceration

  40. Lesion Pathway

  41. Areas of Risk

  42. Ulcer Sites

  43. Ulcer Formation

  44. Sesamoid Pressure

  45. Heel Lesion

  46. Mid Metatarsal Head Lesion

  47. Hallux Lesion

  48. 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

  49. 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