ORTHOTICS AND OFFLOADINGEmma Davidson MSciOrthotist
INTRODUCTION
Causative Factors
Biomechanics and Gait
Offloading Factors
Offloading Approaches
Challenges
Key Referral Information
DIABETIC MDT
“The primary objective in managing diabetic foot problems is to promote mobilisation. This
involves managing both medical and surgical problems and involving a range of medical
experts in related fields.”
(Bridges et al, 1994).
NICE GUIDELINES
Determine the need for interventions to prevent the
deterioration and development of Achilles tendon contractures
and other foot deformities
Perform an orthotic assessment and treat to prevent recurrent
disease of the foot.
People in hospital who are at moderate or high risk of
developing a diabetic foot problem should be given a
pressure redistribution device to offload heel pressure.
Nice inpatient guideline 2011
THE FOOT AND ANKLE
28 bones 55 articulations
Often subdivided into:
Rear-foot
Mid-foot
Fore-foot
Interface with ground for entire kinetic chain.
CAUSATIVE FACTORS
Peripheral Neuropathy
Deformity
Ischemia
Trauma
Shear Stress
Peak Plantar Pressure
Abnormal Biomechanics
“For us to effectively prevent ulcers, we need to have a better understanding of why they occur, and try to integrate the
implications of pressure, shear, temperature, physical activity, skin properties, and even moisture.”
PERIPHERAL NEUROPATHY Sensory
Loss of protective sensation
Motor Intrinsic muscle imbalance, atrophy
Autonomic Dry, fragile skin, fissure – route in for infection
DEFORMITY
Unopposed intrinsic muscle
pull.
Limited joint mobility.
Migration of plantar fat pads
due to excessive bony
pressures.
Callus formation.
Footwear challenges
ISCHEMIA
Intermittent claudication.
Decreased rate of capillary return.
Cooler temperature.
Absent Pulses
Discolouration
TRAUMA Increased risk
Delay in treatment
Potential infection
Foreign objects
Ill fitting footwear
Thermal
PEAK PLANTAR PRESSURE
SHEAR FORCE
Horizontal component of Ground Reaction Force
Under researched as difficult to measure
AP Force component
ML Force component
Environmental Friction
Surface next to skin.
BIOMECHANICS
Sagittal Plane Facilitation theory (Dananberg 1986)
Three rockers of gait. Sagittal plane blockades:
Ankle Equinus Forefoot Equinus Loss of motion at MTPJs specifically 1st
Structural Hallux Limitus / Rigidus Functional Hallux Limitus
GAIT ABNORMALITIES
Decreased walking speed
Increased single and double support time
Decreased proprioception
Compensatory gait deviations due to sagittal
blockades.
Drop foot and / or compensations
CHARCOT ARTHROPATHY
Immediate offloading if suspected.
Maintain integrity of bony alignment whilst active.
Prevent secondary rocker bottom deformities.
Move into custom insoles and protective footwear
once stable.
If rocker bottom mid foot already developed offload
to prevent secondary ulceration.
TYPE OF ULCER
OFFLOADING FACTORS Location of ulcer
Presence of infection
Vascular function
Volume of exudate
Oedema
Deformity
Skin integrity
History of amputation
Balance and mobility
Activity levels
Compliance
Socioeconomic factors
TYPES OF OFFLOADING
Debridement
Upper limb walking aids
Wheelchair/bed rest
Surgery
ORTHOSES
GOLD STANDARD
Below knee total contact cast
Slipper cast
Inpatient Care
PRAFO
Inflatable gutter
Heel Pro
CUSTOM BRACES
OFFLOADING SHOES
LONG TERM PRESCRIPTION
Footwear
Stock Modular Bespoke
Shape Capture
Draft / measures Cast Scan
Insoles
Stock Simple Total Contact Insoles Functional Foot Orthosis
Shape Capture
Draft Impression Box Cast Scan
INSOLES Multi – layer construction
Material properties.
Redistribute plantar pressures
Interface between soft tissue and shoe
Prevent plastic deformation of soft tissue
Restore joint moment equilibrium
FOOTWEAR
DIABETIC SPECIFICATION
ROCKER SOLES
THE FUTURE
Emerging technologies -
SurroGait Rx
Improvement in measuring
shear forces.
Early inclusion of orthotics in
treatment
More accurate pre-cursers for
ulceration
CHALLENGES
Compliance
Patient education
Re-ulceration
ORTHOTICS REFERRAL
Reason for referral
Previous ulcer history
Cause of ulcer
Location / Duration of
ulcer.
Risk factors
MDT clinic treatment
Socioeconomic issues
Previous offloading tactics
THANK YOU
FOR LISTENING
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