**The Temporary Orthesio-Therapy for Diabetic Foot**

Richard Florence *Podiatrist, Peyrehorade, Pédicure – Podologue D.E. France* 

### **1. Introduction**

82 Global Perspective on Diabetic Foot Ulcerations

Wilde S, Roglig G, Green A, Sicree R, King H, (2004). Global prevalence of diabetes. *Diabetes* 

Williams C, (1997). Wound-measuring methods. *Nurse Prescriber /Community Nurse,* Sept,

*Care* 27, pp. 1047-1053

pp. 46-48.

I was taught Temporary Orthesio-therapy by Dr Robert van Lith, a Dutch Podiatrist, who wrote a book called: "Podologie Appliquée"1.

This therapy technique is used after a very careful examination of the foot, and of the fitting qualities of shoes; an analysis of the involved pathologies and the right use of the tools. It is thus possible to take out the mechanical trauma of the conflicting areas. The knowledge of the foot "biomechanic", together with the knowledge of TOT allows relieving and curing a "keratopathy".

Mechanical stresses are one of the reasons of the foot ulceration appearance; this therapy represents therefore a relevant one for a diabetic patient.

### **2. Materials and methodology**

My purpose is not to deliver a lesson on TOT: it was thoroughly explained in the author's book. As its name says, this technique has to be used just before the permanent orthosis setting up. It is used during the scarring phase.

Doctor Margreet van Putten, Fontys Paramedische Hogeschool manager in Eindhoven, wrote: "*Almost 80% of diabetic ulcers will be cured by offloading the ulcer pressure. Then, you should never take other actions than "unloading the pressure!"(Drôme seminary2* ).

The list below is not exhaustive but it presents the necessary materials to prepare a temporary orthosis (TO) for the clinical cases described.

#### **2.1 Materials**

#### **2.1.1 Adhesive pressure deflection materials**

Used products are made by Cuxson Gerrard & Co. Ltd Company, located in England.

<sup>1</sup> Van Lith Robert, July 2003, Podologie appliquée, Edition du Lau, ISBN : 2 84750 052 9, Page 67.

<sup>2</sup> Van Putten Margreet, van Lith Marie-Josée, van Lith Robert, The diabetic foot, Montelimar Seminary (Drôme, France), March 2002.

The Temporary Orthesio-Therapy for Diabetic Foot 85

We need to discover what kind of stress is responsible for the pathology (chafing stress,

Mechanical stresses are responsible for kerathonic pathology. They give skin irritation,

3 The International Working Group on the Diabetic Foot, may 1999, International Consensus on the Diabetic Foot, Copyright by the International Working Group on the Diabetic Foot, ISBN : 90-9012716-

accelerate cellular mitosis and enhance hyperkeratosis appearance.

The association of all these factors makes the diabetic foot a risky foot.

Pathway to the diabetic foot ulceration3:

Fig. 1.

pression or compression, twisting).

x. (page 29: Pathways to diabetic foot ulceration.)

These products are :


### **2.1.2 Non - adhesive pressure deflection materials**


#### **2.1.3 Attachment materials**


#### **2.1.4 Bandages**


#### **2.2 Methodology**

The medical examination is essential to find the first cause of the infection (keropathy, wound or ulceration).

One should observe :


One should look for :


The association of all these factors makes the diabetic foot a risky foot.

Pathway to the diabetic foot ulceration3:

84 Global Perspective on Diabetic Foot Ulcerations





The medical examination is essential to find the first cause of the infection (keropathy,




Company to be used on sensitive feet. - Moleskin ®: thin fleece-lined non stretch cotton


doesn't cause contact allergy.

porus and transversally strecht. - Oper fix ®: (Iberhospitex S.A.) strecht tape.








**2.1.3 Attachment materials** 

**2.1.2 Non - adhesive pressure deflection materials**  - Plastazote ®: thermoformable polyurethane rubber. - Walk-line ®: non-rigid thermoformable material.

These products are :

strecht.

**2.1.4 Bandages** 

**2.2 Methodology** 

wound or ulceration). One should observe :


stiloïd. - Dynamic troubles, - Limited joints mobility

#### Fig. 1.

We need to discover what kind of stress is responsible for the pathology (chafing stress, pression or compression, twisting).

Mechanical stresses are responsible for kerathonic pathology. They give skin irritation, accelerate cellular mitosis and enhance hyperkeratosis appearance.

<sup>3</sup> The International Working Group on the Diabetic Foot, may 1999, International Consensus on the Diabetic Foot, Copyright by the International Working Group on the Diabetic Foot, ISBN : 90-9012716 x. (page 29: Pathways to diabetic foot ulceration.)

The Temporary Orthesio-Therapy for Diabetic Foot 87

In case of a risky foot and when it is hard to find convenient shoes, suitable for the foot out

After the medical examination, I use to make a prevention assessment, I explain all the different treatment steps (correction, protection, contention with a disease if necessary) and I

Felt TO is put on to offload the hyper-pressured area in order to eliminate the mechanical

The offloading zone delimitation will be found after the palpation of the zone to be protected, apart from the cellulitis (presence of swelling, erythema and heat indication an

shaping, we need to ask an orthopedist to make made to measure shoes.

This treatment is carried out after the instrumental gesture

The TO shape is adaptable according to the recovery step.5 There is no limit: one has just to be inventive and creative.

Nothing is left to chance because everything can be explained.

patient to put on shoes again without feeling any risk.

the injured part during all the scarring time.

CHU de Nîmes, Le Grau du Roi.

The TO is taped on the skin.

inflammatory reaction).

better pressure distribution.

OT will be bigger.

stresses of chafing (static and dynamic)

try to make the patient understand that he or she needs to respect his or her feet.

Hapla Felt is used in 2 mm size, 5 mm or 7 mm to offload the conflicted area.. One needs to take into account the loading capacity of the product (half of it)

In order to make the TO easy to wear, it is essential to bevel the external sides.

In case the patient would suffer neuropathy, the TO would assure scarring.

the foot is a fundamental measure without which scarring is impossible.6

5 Richard, F., Transitory TOT: 28th Podiatry discussions seminary, Paris, 2003.

The felt can be doubled, or even triple according to the area which needs to be isolated.

The more important the deformation is, the more material will be needed (felt) to allow a

If the inflammation is important, it is absolutely necessary to totally stop walking and so the

The immediate elimination of mechanical stress caused by chafing and pressure allows the

But this will only be possible provided that everything has been made to constantly offload

As Jean-Louis Richard, Denyse Vannareau et Claire Parer-Richard underlined: offloading

6 Richard, J.L. et al. Article : le pied diabétique, Service des maladies de la nutrition et de la diabétologie,

The basic rules and a good knowledge of the materials allow getting a spectacular result.

The used materials allow the therapist to adjust himself to the different clinical cases.

It is absolutely necessary to know what kind of stress is responsible for the pathology appearance4

It is also necessary to analyze the shoes.

Shoes wearing advice :


It must be confortable.

When compression stress is responsible of the pathology, I use a pair of clips to put out of shape locally the leather.

Fig. 2.

Treatment pattern


**Conclusion: My aim is to enhance the patient autonomy by protecting his or her walking possibilities.** 

<sup>4</sup> Richard, F., TOT training session notes, Nantes, September, 1998.

In case of a risky foot and when it is hard to find convenient shoes, suitable for the foot out shaping, we need to ask an orthopedist to make made to measure shoes.

After the medical examination, I use to make a prevention assessment, I explain all the different treatment steps (correction, protection, contention with a disease if necessary) and I try to make the patient understand that he or she needs to respect his or her feet.

This treatment is carried out after the instrumental gesture

The used materials allow the therapist to adjust himself to the different clinical cases.

The TO is taped on the skin.

86 Global Perspective on Diabetic Foot Ulcerations

It is absolutely necessary to know what kind of stress is responsible for the pathology


When compression stress is responsible of the pathology, I use a pair of clips to put out of

Cure the conflictual zone by make the stresses disappear (chafing, pressure and twisting),

**Conclusion: My aim is to enhance the patient autonomy by protecting his or her walking** 


appearance4

Shoes wearing advice :

It must be confortable.

shape locally the leather.

Fig. 2.

Treatment pattern

**possibilities.** 

Correct if possible or protect,

 Give a normal function to the articulations again If needed, fit with prosthesis to ease step development.

4 Richard, F., TOT training session notes, Nantes, September, 1998.

It is also necessary to analyze the shoes.


regarding to the back part of it).

Felt TO is put on to offload the hyper-pressured area in order to eliminate the mechanical stresses of chafing (static and dynamic)

The offloading zone delimitation will be found after the palpation of the zone to be protected, apart from the cellulitis (presence of swelling, erythema and heat indication an inflammatory reaction).

The TO shape is adaptable according to the recovery step.5

There is no limit: one has just to be inventive and creative.

Hapla Felt is used in 2 mm size, 5 mm or 7 mm to offload the conflicted area..

One needs to take into account the loading capacity of the product (half of it)

The felt can be doubled, or even triple according to the area which needs to be isolated.

In order to make the TO easy to wear, it is essential to bevel the external sides.

The more important the deformation is, the more material will be needed (felt) to allow a better pressure distribution.

If the inflammation is important, it is absolutely necessary to totally stop walking and so the OT will be bigger.

The basic rules and a good knowledge of the materials allow getting a spectacular result.

Nothing is left to chance because everything can be explained.

The immediate elimination of mechanical stress caused by chafing and pressure allows the patient to put on shoes again without feeling any risk.

In case the patient would suffer neuropathy, the TO would assure scarring.

But this will only be possible provided that everything has been made to constantly offload the injured part during all the scarring time.

As Jean-Louis Richard, Denyse Vannareau et Claire Parer-Richard underlined: offloading the foot is a fundamental measure without which scarring is impossible.6

<sup>5</sup> Richard, F., Transitory TOT: 28th Podiatry discussions seminary, Paris, 2003.

<sup>6</sup> Richard, J.L. et al. Article : le pied diabétique, Service des maladies de la nutrition et de la diabétologie, CHU de Nîmes, Le Grau du Roi.

The Temporary Orthesio-Therapy for Diabetic Foot 89

I would like to highlight this methodology by exposing several clinical cases: domiciliary

I wanted to present different situations because one can notice that ulceration is different

**3. Results** 

Fig. 4.

care, in my podiatric office or in hospital.

regarding to the place and to the limitation of our skills10.

The invasive treatment has to be appropriate for the patient's condition.

joint (big toe) reducing and preventing the patient from walking

present a wide range of this technique, that is to say:




The follow-up is different when the podiatrist is alone or in a multidisciplinary medical team. The described cases present treatments on different conflicted areas which helps us to


10 The International Working Group on the Diabetic Foot, may 1999, Practical Guidelines on the Management and the prevention of the Diabetic Foot, Copyright by the International Working Group on the Diabetic Foot, ISBN : 90-9012716-x.) page 2 :Illustration of ulcer due to repetitive stress.)

Dr Ha Van Georges wrote about this : « the perforating pain cannot be cured if the patient is still walking on it » 7.

The TO will allow the uninterrupted protection of the conflicting zone while the foot is mobilized during the walk.

And this will retain the walking radius, not to say increase it).

Even when confined to bed, the patient's foot is relieved of stress pressures.

That is why I would like to quote again Robert Van Lith's book "Podologie appliquée"8

Thanks to the scientific research team, the Cuxson Gerrard & Co. Offers materials with an unique adhesive system.

We are lucky to enjoy an amazing material technological advancement.9



Fig. 3.

<sup>7</sup> Dr. Georges Ha Van (Paris), Equilibre N°197 1996 –Qu'est-ce qu'un mal perforant et comment le prévenir ?

<sup>8</sup> Van Lith Robert, July 2003, Podologie appliquée, Edition du Lau, ISBN : 2 84750 052 9 (Pages 70-71 & 108)

<sup>9</sup>Etude éditée par Cuxson et Gerrard montrant le résultat obtenu avec antimicrobial treatment de l'Hapla glod all felt.

### **3. Results**

88 Global Perspective on Diabetic Foot Ulcerations

Dr Ha Van Georges wrote about this : « the perforating pain cannot be cured if the patient

The TO will allow the uninterrupted protection of the conflicting zone while the foot is

That is why I would like to quote again Robert Van Lith's book "Podologie appliquée"8

Thanks to the scientific research team, the Cuxson Gerrard & Co. Offers materials with an

7 Dr. Georges Ha Van (Paris), Equilibre N°197 1996 –Qu'est-ce qu'un mal perforant et comment le

8 Van Lith Robert, July 2003, Podologie appliquée, Edition du Lau, ISBN : 2 84750 052 9 (Pages 70-71 &

9Etude éditée par Cuxson et Gerrard montrant le résultat obtenu avec antimicrobial treatment de

And this will retain the walking radius, not to say increase it).

Even when confined to bed, the patient's foot is relieved of stress pressures.

We are lucky to enjoy an amazing material technological advancement.9

is still walking on it » 7.

mobilized during the walk.

unique adhesive system.

Fig. 3.

prévenir ?

l'Hapla glod all felt.

108)

I would like to highlight this methodology by exposing several clinical cases: domiciliary care, in my podiatric office or in hospital.

I wanted to present different situations because one can notice that ulceration is different regarding to the place and to the limitation of our skills10.

Fig. 4.

The invasive treatment has to be appropriate for the patient's condition.

The follow-up is different when the podiatrist is alone or in a multidisciplinary medical team.

The described cases present treatments on different conflicted areas which helps us to present a wide range of this technique, that is to say:


<sup>10</sup> The International Working Group on the Diabetic Foot, may 1999, Practical Guidelines on the Management and the prevention of the Diabetic Foot, Copyright by the International Working Group on the Diabetic Foot, ISBN : 90-9012716-x.) page 2 :Illustration of ulcer due to repetitive stress.)

The Temporary Orthesio-Therapy for Diabetic Foot 91

A-10 : After two weeks treatment : skin is totally healthy. Apply Hydra-defense balm or Akildia balm (Asepta-Akiléine laboratory). Which delays the keratin implantation.

**metatarsal-phalangeal joint (big toe) reducing and preventing the patient from walking** 

(7 mm felt with two layers)

B-5 : Enucleation B- 6: TO fitting and

B- 3 : Fixation with Haplaband with an opening to allow wound access.

Moleskiine fitting.

**3.1.2 CASE B: Treated patient with plantar keratopathy with a bruise on the** 

B-1 : First consultation B-2 : TO installing

B-4 : Medicinal dressing (Biatain) , which has to be changed every 48 hours by the nurse in charge. After the debridement, new offloading is necessary every one or two weeks by the podiatrist.

Fig. 5.

Here are some results achieved during some consultations:


### **3.1 Domiciliary care**

### **3.1.1 CASE A: Treated patient for a plantar keratopathy, right heel**


A-10 : After two weeks treatment : skin is totally healthy. Apply Hydra-defense balm or Akildia balm (Asepta-Akiléine laboratory). Which delays the keratin implantation.

Fig. 5.

90 Global Perspective on Diabetic Foot Ulcerations


**3.1.1 CASE A: Treated patient for a plantar keratopathy, right heel** 

Here are some results achieved during some consultations:

A-1: first consultation A-2: debridement and total

enucleation

A-5: after two weeks

A-8: End of the instrumental

treatment

work.

A-3: felt TO installing

A-6 et A-7: two steps enucleation with a set with diamonds cracks burrs

A-9: Moleskine installing. Which covers the back part of

the foot.

(5 mm felt with an offloading of the conflicted area).


**3.1 Domiciliary care** 

A-4: Bandage installing and fixation with Hapla-band

A-6 et A-7: two steps enucleation with a set with diamonds cracks burrs

### **3.1.2 CASE B: Treated patient with plantar keratopathy with a bruise on the metatarsal-phalangeal joint (big toe) reducing and preventing the patient from walking**


The Temporary Orthesio-Therapy for Diabetic Foot 93

**3.2.2 CASE D: A diabetic patient grade one (September 2004), she is under oral medication. She presents a bad ulceration on the external side of her third toe, regarding to the distal articulation, due to a too long nail and to the shoes she is** 

bad shoes D-2 : angiopathy ulcer D-3 : TO installing on

after four days. D-5 : On October 8th D-6 : debridement

**wearing (this kind of shoes are to be proscribed for diabetic patients)** 

C 5 : silicone device.

September 24th (5 mm felt)

C 4 : after one month. The temporary removable orthosis has been lost. Felt offloading TO installing (offloading M5 and P2/P3 articulation on the fifth toe). Recommendation for a silicone device , equivalent to an TOT but which can

be removed.

D-1 : First consultation with

D-4 : TO on September 28th

Fig. 7.

Fig. 6.

### **3.2 In my podiatrist office**

#### **3.2.1 CASE C: A diabetic patient grade zero, with a fifth metatarsal pain, on the external side**

Fig. 7.

92 Global Perspective on Diabetic Foot Ulcerations

B-8 : After eleven weeks,

B-8 : New felt offloading TO fitting. Extra explanation about the importance of this TOT treatment with orthotis device just after the total scarring. Device confection perpetuates

the treatment results.

**3.2.1 CASE C: A diabetic patient grade zero, with a fifth metatarsal pain, on the** 

C- 2 : TO installing Metatarsis head is totally offloaded (5 mm felt)

B-9 : Moleskine installing.

C- 3 : OT fixation with Hapla

Band

debridement

B-7 : After nine weeks, debridement and Moleskine

B-10 : After one month. Without any protection and with an increase of the walking area, skin is

**3.2 In my podiatrist office** 

C- 1 : first consultation

wounded.

**external side** 

Fig. 6.

installing.

**3.2.2 CASE D: A diabetic patient grade one (September 2004), she is under oral medication. She presents a bad ulceration on the external side of her third toe, regarding to the distal articulation, due to a too long nail and to the shoes she is wearing (this kind of shoes are to be proscribed for diabetic patients)** 

The Temporary Orthesio-Therapy for Diabetic Foot 95

This patient's diabete (Diabete Mellitus) comes up to grade 2 in 2009; from then she's insulin-dependent. She has to cope with an angiopathy and suffers a severe neuropathy.

Thanks to a regular medical follow up and to a healthy life, this patient has still got all her toes. Since 2010, she wears made-to-measure shoes with an appropriate interior shape, seamless. To avoid an ulceration relapse a under- diaphysis protective and corrective orthosis is

With a regular following and a good care of the nails every two months, the patient feet are

enucleation E-3 : 7 mm TO fitting

Moleskine. E-6 : Orthotic plantar device

installed.

protected.

Fig. 10.

**3.2.3 CASE E: A patient with a Charcot foot** 

E – 1 : foot print E-2 : Debridement and

E-4 : after one week. E-5 : Felt TO installing and


Fig. 8.


D-11 : the patient has bought a

D-14 : Silicone sub-digital device and Fleecy web under P1/P2 to avoid hyper-

keratosis.

new pair of shoes (17/12/2004).

D-9 : On November 29th, Moleskine fitting to avoid suction with felt TO

D-12 : orthopaedic shoes in

This patient has now diabete,

D- 15 : Ortho-plastic surgery with second toe protection.

2011.

grade two.

D-7 : TO on October 15th D-8 : debridement

D-10 : TO has been unsticked and returned, then sticked on a neighbor toe to show how the wound has scarred.

D-13 : Plastazote TO

Fig. 8.

Fig. 9.

This patient's diabete (Diabete Mellitus) comes up to grade 2 in 2009; from then she's insulin-dependent. She has to cope with an angiopathy and suffers a severe neuropathy.

Thanks to a regular medical follow up and to a healthy life, this patient has still got all her toes.

Since 2010, she wears made-to-measure shoes with an appropriate interior shape, seamless. To avoid an ulceration relapse a under- diaphysis protective and corrective orthosis is installed.

With a regular following and a good care of the nails every two months, the patient feet are protected.


### **3.2.3 CASE E: A patient with a Charcot foot**

Fig. 10.

The Temporary Orthesio-Therapy for Diabetic Foot 97

G-5: A new wound appeared.

G-7: This picture has been made three or four days before the death. Hand distal phalanx

**3.3.2 CASE H: The patient suffers a toes deviation. Big toe infraductus and total claw of the second toe. This patient is old, diabetic with a kidney insufficiency. He's only** 

H-2: On May the 27th 2004.

Fifteen days later.

are bare-skined and the patient is now totally blind. No surgery.

**treated by a podiatrist. He has very painful angiopathic wounds** 

G-4: Wounds were almost totally healed . Some holes made in the TO allows the nurses to dress the wounds every two days (Actisorb Ag+ covered with Cellosorb).

Fig. 12.

H-1: On May 13th 2004. First corrective Hapla Band TO and one inter-digital felt TO.

installing, sticked with Oper fix bandage but which will be changed only every 8 days.

G-6: On April the 14th , after incision of the hyperkeratosis. Skin started to worsen. The general patient's

H-3: Actisorb Ag+ application used all the treatment long.

state is declining.

### **3.2.4 CASE F: The patient had her third toe amputated**

Fig. 11.

### **3.3 In hospital**

Lots of clinical cases are presented in Dr van Lith's book (Podologie appliquée).

The pictures below have been made and interpreted by Mrs. Marie José van Lith. She works in a podiatric office with a multidisciplinary medical team in the Romans hospital's endocrinology department (Drôme, France).

She was kind enough to take part in this article writing.

#### **3.3.1 CASE G: The patient here suffered a diabetic retinopathy which stucked her blind. She also had a kidney insufficiency (she was on dialysis twice a week). She died five within the five years**

*While she was on hospital, first x-rays show a foot which can't be mobilized therefore no corrective TO is possible, only the protective one can be installed.* 

G-7: This picture has been made three or four days before the death. Hand distal phalanx are bare-skined and the patient is now totally blind. No surgery.

Fig. 12.

96 Global Perspective on Diabetic Foot Ulcerations

fixed with band-aid F-9: Plantar view

F-10 : front view

**3.2.4 CASE F: The patient had her third toe amputated** 

F - 7: First consultation F-8: Non-rigid Plastazote TO

endocrinology department (Drôme, France).

**died five within the five years** 

She was kind enough to take part in this article writing.

*TO is possible, only the protective one can be installed.* 

Lots of clinical cases are presented in Dr van Lith's book (Podologie appliquée).

The pictures below have been made and interpreted by Mrs. Marie José van Lith. She works in a podiatric office with a multidisciplinary medical team in the Romans hospital's

**3.3.1 CASE G: The patient here suffered a diabetic retinopathy which stucked her blind. She also had a kidney insufficiency (she was on dialysis twice a week). She** 

*While she was on hospital, first x-rays show a foot which can't be mobilized therefore no corrective* 

G-1 : The first x-rays G-2 : On August 29th 2002 G-3 : After debridement of

both wounds, felt TO

Fig. 11.

**3.3 In hospital** 

**3.3.2 CASE H: The patient suffers a toes deviation. Big toe infraductus and total claw of the second toe. This patient is old, diabetic with a kidney insufficiency. He's only treated by a podiatrist. He has very painful angiopathic wounds** 


The Temporary Orthesio-Therapy for Diabetic Foot 99

J-2: Offloading thermoformed TO, with felt

K-3: Offloading orthosis confection with Bland Rose ® from Fresco silicone, directly cast on the stump in the shoe.

inside, directly sticked in the shoe.

**3.3.4 CASE J: Where creativeness is needed…** 

J-1: Fistulisation of a plantar ulceration in the inter-digital space of the fourth and fifth toes.

**3.3.5 CASE K: Total transmetatarsal amputation** 

K-2: Inside shoe fitting : Plastazote has been used to fill in anterior part of the shoe. A silicone orthosis to avoid all

The TOT used for this diabetic patient, helps us to understand the specialist's aim: he

stump frictions.

wanted to educate and hand-hold this patient in his decease's evolution.

Fig. 15.

K-1 : Total amputation.

Fig. 16.

Fig. 13.

The protective TO was possible to fit after the articulations softening obtained by the Hapla-Band TO installing. It is held with Micrope. The silicone permanent orthosis couldn't be made because the patient couldn't reach his own feet.

Only the TO was replaced every 2 or 3 weeks.

### **3.3.3 CASE I: TO for an ulceration in order to amputate the fifth toe**

**3.3.4 CASE J: Where creativeness is needed…** 

J-1: Fistulisation of a plantar ulceration in the inter-digital space of the fourth and fifth toes. J-2: Offloading thermoformed TO, with felt inside, directly sticked in the shoe.

Fig. 15.

98 Global Perspective on Diabetic Foot Ulcerations

The protective TO was possible to fit after the articulations softening obtained by the Hapla-Band TO installing. It is held with Micrope. The silicone permanent orthosis couldn't be

I-2 : Thermoformed Plastazote

TO, with felt inside. I-3 : Offloading TO.

made because the patient couldn't reach his own feet.

**3.3.3 CASE I: TO for an ulceration in order to amputate the fifth toe** 

Only the TO was replaced every 2 or 3 weeks.

I-1 : Non-rigid thermoformed

material TO.

Fig. 14.

H-5: Front view H-6: Plantar view

H-4 : On June 24th 2004, corrective thermoformable latex foam TO allowing to treat wounds et corrective sub-digital latex foam and a inter-digital device (dorsal

view).

Fig. 13.

### **3.3.5 CASE K: Total transmetatarsal amputation**


Fig. 16.

The TOT used for this diabetic patient, helps us to understand the specialist's aim: he wanted to educate and hand-hold this patient in his decease's evolution.

The Temporary Orthesio-Therapy for Diabetic Foot 101

In the near future, I hope that this technique will be part of the teaching curriculum for French Podiatrists. I wish the words *Temporary Orthesio-therapy* and *temporary orthosis* will

TOT should be officially recognized as beneficial to the public at large... to ensure a less

Temporary orthesio-therapy (Dr Robert van Lith): This technique is called erroneously *Padding* in France. This name was brought in France by Franklin Charlesworth. This is a very inventive technique to achieve an immediate relief, before the use of a permanent

[1] Van Lith Robert, July 2003, Podologie appliqué, Edition du Lau, ISBN : 2 84750 052 9.

[2] Van Putten Margreet, van Lith Marie-José, van Lith Robert, The diabetic foot,

[3] The International Working Group on the Diabetic Foot, may 1999, International

[4] The International Working Group on the Diabetic Foot, may 1999, Practical Guidelines

[5] Richard Florence, L'orthésiothérapie transitoire. Conférence aux 28èmes Entretiens de

[6] Ha Van Georges (Paris), Equilibre N°197 1996 –Qu'est-ce qu'un mal perforant et

[7] Sanders Joan, Goldstein Barry, Leotta Daniel, Journal of Rehabilitation Research and

Adaptation rather than breakdowm- A rewiew of the literature. (page 223). [8] Boulton Andrew, Cavanagh Peter, Rayman Gerry, May 2006, The Foot Diabetes, Fourth

[9] Sanders, J.E., et al., skin response to mechanical stress : adaptation rather than

[10] Granier-Delamare, Dictionnaires des termes de médecine ; 24èmes éditions, Maloine,

(page 67: ORTHESIOTHERAPIE TRANSITOIRE/ Une Thérapeutique de choix

Consensus on the Diabetic Foot, Copyright by the International Working Group on the Diabetic Foot, ISBN : 90-9012716-x. (page 29: Pathways to diabetic foot

on the Management and the prevention of the Diabetic Foot, Copyright by the International Working Group on the Diabetic Foot, ISBN : 90-9012716-x.)page 2

Development Vol. 32 N° 3. October 1995, Skin response to mechanical stress:

Edition, Chapter 5, The Pathway to ulceration : Aetiopathogenesis. ISBN

breakdown – a review of the literature, University of Washington, Journal of

This therapeutic technique should be transmitted to all our foot specialists' colleagues.

find their definition in the medical terms dictionary (Garnier Delamare).

pour la suppression immédiate du Stress Mécanique.)

Montelimar Seminary (Drôme, France), March 2002.

:Illustration of ulcer due to repetitive stress.)

Rehabilitation and Development , vol. N° 32, 1995.

harrowing future to the diabetic patients.

**6. Definition** 

**7. References** 

silicone or plantar orthosis.

ulceration.)

Podologie à Paris 2003.

comment le prévenir ?

9780470015049.

1995, ISBN : 2-224-02381-2.

The issues of protection and correction in this treatment are essential to make him accept the installing of a digital or plantar orthosis. The podiatrist helps his patient to have a therapeutic behavior to delay as long as possible the amputation.

### **4. What instances does the TOT method fail?**

It is not the TOT method which presents a failure risk but the patient when he or she stops his or her treatment. When the work is properly done, there is no failure.

Precaution to be taken when installing a TO are those of any other treatment:


Pressures repartition thanks to the TO installed on safe areas offloads the irritated area. Pressure is quite often the aggravating factor.

TOT is a very good therapeutic method in biomechanical pathology of foot.This is a quick technique aiming a immediate relief. This is the best treatment in severe pathologies.

The podiatrist will always try to correct but if it is impossible then, he will choose the TO and the silicone protection devices or the offloading plantar devices).

### **5. Conclusion**

I hope this technique will be found essential to handle ulceration on a high-risk foot of a diabetic patient.

Having used this technique during twenty years now, I still discover the cleverness of this therapeutic methodology.

And as Mrs. Marie-José van Lith said: "*One has to be creative for each medical case he has to deal with*". It is for me a real pleasure to do so.

During all his career, my teacher (Dr. Robert van Lith) tried to transmit this technique to our colleagues and students.

In 2001, I thought and I told to Dr van Lith that this would be possible by taking the diabetic foot treatment into account (we were on a world- congress of Podiatry in Paris and Dr Margreet van Putten and Mrs. Marie-José van Lith were there).

In 2010, during the Podiatrist International Federation world conference in Amsterdam, Dr van Putten wanted to pay tribute to my teacher, an exceptional man, and when his wife, Marie-José van Lith received this tribute, she announced that she had succeeded in launching TOT in several endocrinology departments; she said: "*This technique is based on medical laws which makes it a real treatment. To treat the wounds of the diabetic foot, this treatment is essential, before all permanent silicone or plantar orthosis which could be necessary after the complete wound recovery".*

This therapeutic technique should be transmitted to all our foot specialists' colleagues.

In the near future, I hope that this technique will be part of the teaching curriculum for French Podiatrists. I wish the words *Temporary Orthesio-therapy* and *temporary orthosis* will find their definition in the medical terms dictionary (Garnier Delamare).

TOT should be officially recognized as beneficial to the public at large... to ensure a less harrowing future to the diabetic patients.

### **6. Definition**

100 Global Perspective on Diabetic Foot Ulcerations

The issues of protection and correction in this treatment are essential to make him accept the installing of a digital or plantar orthosis. The podiatrist helps his patient to have a

It is not the TOT method which presents a failure risk but the patient when he or she stops

Pressures repartition thanks to the TO installed on safe areas offloads the irritated area.

TOT is a very good therapeutic method in biomechanical pathology of foot.This is a quick

The podiatrist will always try to correct but if it is impossible then, he will choose the TO

I hope this technique will be found essential to handle ulceration on a high-risk foot of a

Having used this technique during twenty years now, I still discover the cleverness of this

And as Mrs. Marie-José van Lith said: "*One has to be creative for each medical case he has to deal* 

During all his career, my teacher (Dr. Robert van Lith) tried to transmit this technique to our

In 2001, I thought and I told to Dr van Lith that this would be possible by taking the diabetic foot treatment into account (we were on a world- congress of Podiatry in Paris and Dr

In 2010, during the Podiatrist International Federation world conference in Amsterdam, Dr van Putten wanted to pay tribute to my teacher, an exceptional man, and when his wife, Marie-José van Lith received this tribute, she announced that she had succeeded in launching TOT in several endocrinology departments; she said: "*This technique is based on medical laws which makes it a real treatment. To treat the wounds of the diabetic foot, this treatment is essential, before all permanent silicone or plantar orthosis which could be necessary after the* 

technique aiming a immediate relief. This is the best treatment in severe pathologies.

therapeutic behavior to delay as long as possible the amputation.

his or her treatment. When the work is properly done, there is no failure.

Precaution to be taken when installing a TO are those of any other treatment:

The TO helps scarring because of the offloading of the conflicted area.

 The TO is installed on safe areas and out of the irritated ones. The TO shape is adapted according to the recovery step. The TO opening will be as wide as the conflicted area requires.

and the silicone protection devices or the offloading plantar devices).

Margreet van Putten and Mrs. Marie-José van Lith were there).

**4. What instances does the TOT method fail?** 

The TO must not hurt, it is made to relief the patient.

Pressure is quite often the aggravating factor.

**5. Conclusion** 

diabetic patient.

therapeutic methodology.

colleagues and students.

*complete wound recovery".*

*with*". It is for me a real pleasure to do so.

Temporary orthesio-therapy (Dr Robert van Lith): This technique is called erroneously *Padding* in France. This name was brought in France by Franklin Charlesworth. This is a very inventive technique to achieve an immediate relief, before the use of a permanent silicone or plantar orthosis.

#### **7. References**


*The Foot Typing Center,NYC, Outreach Program, Surgical Attending,* 

*Presbyterian Healthcare System, Brooklyn, New York* 

*Department of Podiatry, Wyckoff Heights Medical Center, Member, New York* 

The importance of the physician's role in examining and assessing the diabetic foot is hard to overstate.1-2 Fifteen percent of the 16 million diabetic patients in the United States will develop foot ulcers.3,4 The diabetic foot is responsible for more than half of the 67,000 annual non-traumatic lower extremity amputations in the developed world.5 Lower extremity amputation is 15 times more likely to occur in a patient with diabetes.6 The annual cost of amputations is \$600 million and lost wages and morbidity are estimated at \$1 billion, annually.7 Finally, studies have shown that primary care physicians are rarely performing

**The underlying reasons that the foot is the number one location for comorbidities in diabetes places peripheral neuropathy and its sequellae that include Loss of Protective Sensation (LOPS) and Loss of Proprioception atop the list9** with Peripheral Arterial Disease (PAD) ranking a distant second. These risk factors magnify preexisting biomechanical risk factors that function in closed chain (Table 1) into often overlooked loss of balance, function, productivity and quality of life that precede or are adjacent to the more obvious presentations of wounds, infections, hospitalizations and amputations that are, in

Podiatry, as a profession and by degree, is the only profession armed with an underlying Functional Lower Extremity Biomechanics (FLEB) core. Three years of Undergraduate FLEB courses followed by up to three years of Residency that includes applying biomechanics to non operative and surgical decisions and the chief complaints of diabetic patients. This is

foot examinations on their diabetic patients during routine visits.8

reality, end stage events for more and more diabetic patients.

Table 1. Underlying Biomechanical Risk Factors In Diabetes

3. Underlying Biomechanical Pathology

1. Ground Reactive Forces 2. Hard, Unyielding Shoes

4. Body Mass and Weight

5. Activity Level 6. Fitness Level 7. Health State

**1. Introduction** 

Dennis Shavelson

*USA* 

[11] Richard, F., compte-rendu de séminaire de la journée de formation sur l'OTT, Nantes, septembre 1998. **7** 

### Dennis Shavelson

*The Foot Typing Center,NYC, Outreach Program, Surgical Attending, Department of Podiatry, Wyckoff Heights Medical Center, Member, New York Presbyterian Healthcare System, Brooklyn, New York USA* 

### **1. Introduction**

102 Global Perspective on Diabetic Foot Ulcerations

[11] Richard, F., compte-rendu de séminaire de la journée de formation sur l'OTT, Nantes,

The importance of the physician's role in examining and assessing the diabetic foot is hard to overstate.1-2 Fifteen percent of the 16 million diabetic patients in the United States will develop foot ulcers.3,4 The diabetic foot is responsible for more than half of the 67,000 annual non-traumatic lower extremity amputations in the developed world.5 Lower extremity amputation is 15 times more likely to occur in a patient with diabetes.6 The annual cost of amputations is \$600 million and lost wages and morbidity are estimated at \$1 billion, annually.7 Finally, studies have shown that primary care physicians are rarely performing foot examinations on their diabetic patients during routine visits.8

**The underlying reasons that the foot is the number one location for comorbidities in diabetes places peripheral neuropathy and its sequellae that include Loss of Protective Sensation (LOPS) and Loss of Proprioception atop the list9** with Peripheral Arterial Disease (PAD) ranking a distant second. These risk factors magnify preexisting biomechanical risk factors that function in closed chain (Table 1) into often overlooked loss of balance, function, productivity and quality of life that precede or are adjacent to the more obvious presentations of wounds, infections, hospitalizations and amputations that are, in reality, end stage events for more and more diabetic patients.


Table 1. Underlying Biomechanical Risk Factors In Diabetes

Podiatry, as a profession and by degree, is the only profession armed with an underlying Functional Lower Extremity Biomechanics (FLEB) core. Three years of Undergraduate FLEB courses followed by up to three years of Residency that includes applying biomechanics to non operative and surgical decisions and the chief complaints of diabetic patients. This is

to preventing and treating foot ulcers, gait and balance problems and neuropathic foot syndromes. The use of straps, pads, foot orthotics, muscle strengthening and training programs and therapeutic footwear before considering surgery has been shown to reduce foot ulcers, foot infections, amputation and hospitalizations in a diabetic population while allowing the patient to maintain and improve walking and active functioning with a high

**The Biomechanical Anatomy of the Foot.** Biomechanically, the foot can be divided into functional segments in two main ways. The first divides it at the Midtarsal Joint into a rearfoot and forefoot and the second divides the foot at the second and third rays into

Fig. 1. Functional anatomy of the foot. (Adapted from Glick JB. Dynamics of the foot in

The medial arch is composed of the calcaneus, talus, navicular, the three cuneiforms and the first, second and third metatarsals. The lateral arch is composed of the calcaneus, the cuboid and the fourth and fifth metatarsals.9 These two arches are connected by a transverse roof of bone. The surface underneath these osseous supports, architecturally, is known as The Vault of The Foot (Figure 2).23 This Vault, when centered and supported by healthy soft tissues, provides a lifetime foundation for upright weightbearing and function. In contrast if The Vault is allowed to become off-centered exhibiting excess stiffness, flexibility, collapse or arch, on a case to case basis, the resulting stressful compensations in pedal and postural bones, joints, muscles, tendons, ligaments and integumentary organs provides an ever

locomotion. Pod Management 4:136, 2001, with permission).

increasing burden to society as we live longer and more active lives.

Fig. 2. The Vault of The Foot

level of efficiency and minimal injury and disability22.

medial and lateral arch segments (Figure 1).

then followed by Continuing Medical Education and most importantly, every Doctor of Podiatric Medicine (DPM) has an Evidence Based Practice Rooted in Biomechanics that includes orthotics and active and passive therapies that have been practiced for generations by the podiatric community.

It is my opinion that the medical community, weak in closed chain medicine, is not prepared to diagnose, treat and manage their patients biomechanically. This single fact is the reason that Podiatry plays such an important role in the medical community and the life of every diabetic.

### **2. Biomechanics of the foot**

Definition: Biomechanics is the art and science of applying the scientific laws of Physics, Architecture, Engineering and Mechanics principles to living subjects. Although not a pure science and therefore, difficult to research and quantify, committed practitioners of Functional Lower Extremity Biomechanics (FLEB) have prepared themselves to conduct interpersonal practices by amassing foundational knowledge, professional experience and use the applicable evidence that has surfaced to produce, for each practitioner, his/her version of an Evidence Based Biomechanics Practice10-13.

Unlike pure science that focuses on inanimate objects, living subjects often do not obey Primary Scientific Laws. This is offset by the Biomechanical Literature which contains over 200 additions providing evidence that foot orthotics work14-18 in addition to continued research and study being called for and conducted but like other aspects of medicine, such as foot surgery, biomechanics remains as much an art as a science19-20. The Podiatry community has accepted as its responsibility, the closed chain foundation of our functional lives and in the case of the diabetic population, sits as educators, mentors and front line practitioners as no other specialist can when it comes to biomechanics and Closed Chain Medicine.

Understanding the biomechanics of the foot is an important component in the evaluation of the diabetic foot probably deserving greater focus than it has received. **The successful compensation of underlying foot type-specific biomechanical pathology cannot be underestimated as one of the most important adjacent preventive and treatment models in the health history of the diabetic.** 

FLEB focuses on the human body from the low back down, in c*losed* c*hain* (standing [stance] or active [gait] and weighted upon the ground. Alternatively, Allopathic Medicine studies subjects in o*pen chain kinetics* (on an examining table or not weighted) 21.

The etiological forces that must be overcome in managing a patient biomechanically can be reviewed using Table 1. Since they differ for each individual, unless a patient encounter during which a biomechanical evaluation is performed as well as a historical interview to assess coexisting etiological factors is performed by a biomechanically oriented Podiatrist, the resultant orthotic and treatment plan may fall short of its potential benefits.

Removing pathological forces from the weightbearing surface of the foot, balancing and supporting the posture, leveraging the muscle-tendon units and training them to perform and providing functional and safe footwear for the diabetic foot are the biomechanical keys

then followed by Continuing Medical Education and most importantly, every Doctor of Podiatric Medicine (DPM) has an Evidence Based Practice Rooted in Biomechanics that includes orthotics and active and passive therapies that have been practiced for generations

It is my opinion that the medical community, weak in closed chain medicine, is not prepared to diagnose, treat and manage their patients biomechanically. This single fact is the reason that Podiatry plays such an important role in the medical community and the life

Definition: Biomechanics is the art and science of applying the scientific laws of Physics, Architecture, Engineering and Mechanics principles to living subjects. Although not a pure science and therefore, difficult to research and quantify, committed practitioners of Functional Lower Extremity Biomechanics (FLEB) have prepared themselves to conduct interpersonal practices by amassing foundational knowledge, professional experience and use the applicable evidence that has surfaced to produce, for each practitioner, his/her

Unlike pure science that focuses on inanimate objects, living subjects often do not obey Primary Scientific Laws. This is offset by the Biomechanical Literature which contains over 200 additions providing evidence that foot orthotics work14-18 in addition to continued research and study being called for and conducted but like other aspects of medicine, such as foot surgery, biomechanics remains as much an art as a science19-20. The Podiatry community has accepted as its responsibility, the closed chain foundation of our functional lives and in the case of the diabetic population, sits as educators, mentors and front line practitioners as no other specialist can when it comes to biomechanics and Closed Chain

Understanding the biomechanics of the foot is an important component in the evaluation of the diabetic foot probably deserving greater focus than it has received. **The successful compensation of underlying foot type-specific biomechanical pathology cannot be underestimated as one of the most important adjacent preventive and treatment models** 

FLEB focuses on the human body from the low back down, in c*losed* c*hain* (standing [stance] or active [gait] and weighted upon the ground. Alternatively, Allopathic Medicine studies

The etiological forces that must be overcome in managing a patient biomechanically can be reviewed using Table 1. Since they differ for each individual, unless a patient encounter during which a biomechanical evaluation is performed as well as a historical interview to assess coexisting etiological factors is performed by a biomechanically oriented Podiatrist,

Removing pathological forces from the weightbearing surface of the foot, balancing and supporting the posture, leveraging the muscle-tendon units and training them to perform and providing functional and safe footwear for the diabetic foot are the biomechanical keys

subjects in o*pen chain kinetics* (on an examining table or not weighted) 21.

the resultant orthotic and treatment plan may fall short of its potential benefits.

by the podiatric community.

**2. Biomechanics of the foot** 

**in the health history of the diabetic.** 

version of an Evidence Based Biomechanics Practice10-13.

of every diabetic.

Medicine.

to preventing and treating foot ulcers, gait and balance problems and neuropathic foot syndromes. The use of straps, pads, foot orthotics, muscle strengthening and training programs and therapeutic footwear before considering surgery has been shown to reduce foot ulcers, foot infections, amputation and hospitalizations in a diabetic population while allowing the patient to maintain and improve walking and active functioning with a high level of efficiency and minimal injury and disability22.

**The Biomechanical Anatomy of the Foot.** Biomechanically, the foot can be divided into functional segments in two main ways. The first divides it at the Midtarsal Joint into a rearfoot and forefoot and the second divides the foot at the second and third rays into medial and lateral arch segments (Figure 1).

Fig. 1. Functional anatomy of the foot. (Adapted from Glick JB. Dynamics of the foot in locomotion. Pod Management 4:136, 2001, with permission).

The medial arch is composed of the calcaneus, talus, navicular, the three cuneiforms and the first, second and third metatarsals. The lateral arch is composed of the calcaneus, the cuboid and the fourth and fifth metatarsals.9 These two arches are connected by a transverse roof of bone. The surface underneath these osseous supports, architecturally, is known as The Vault of The Foot (Figure 2).23 This Vault, when centered and supported by healthy soft tissues, provides a lifetime foundation for upright weightbearing and function. In contrast if The Vault is allowed to become off-centered exhibiting excess stiffness, flexibility, collapse or arch, on a case to case basis, the resulting stressful compensations in pedal and postural bones, joints, muscles, tendons, ligaments and integumentary organs provides an ever increasing burden to society as we live longer and more active lives.

Fig. 2. The Vault of The Foot

The supporting structure of the lateral side of The Vault of The Foot, composed of bones that when healthy, has an architecture that allows it to lock when weighted without the need for much muscular and ligamentous support. This enables the lateral Vault to be primarily strong, stable, supportive and capable of assuming an Optimal Functional Position (OFP) without much ligamentous and muscular primary or compensatory assistance in both the rearfoot and the forefoot that is different for all individuals. When the lateral column functions from Optimal Functional Position, there is little compensatory tissue stress of the bones and supporting structures or compensatory muscle engine energy on both a

In opposition, the bony architecture of the medial side of The Vault of The Foot lacks the ability to lock on its own when weighted without the assistance of a large number of primary muscle engines and ligamentous systems. This means that without strong and trained muscle engines and a well developed and conditioned ligamentous supporting system, the medial Vault of the Foot is not capable of maintaining its Optimal Functional Position and so it serves as the anatomical location for much of the biomechanical pathology that exists in both the rearfoot and forefoot (figures 4) for most feet. Collapse of the bony position of the medial side of the foot from its OFP results in stretching and reduced leverage of the ligaments and muscles that are mandated to lock and support the vault in OFP (figure 5). This creates a subclinical vicious closed chain biomechanical cycle early on that stresses the tissues on a cellular level that when repeated over and over as we live our lives eventually rises to clinical events like pain and overuse syndromes, foot and postural deformities and irreversible degenerative changes. **Summarily, inherited medial vault weakness serves as the biomechanical etiology for FLEB and unless diagnosed and treated, guarantees compensatory degeneration, overuse, deformity and structural and** 

**functional breakdown in the feet and throughout the posture, in closed chain**.

Fig. 4. The Ligamentous Tie Beam Supports The Bony Truss in the Medial Column

Fig. 5. The Longitudinal and Vertical Collapse of The Medial Column Deforming the OFP

The current gold standard, known as Subtalar Joint (STJ) Neutral Examination was developed thirty years ago by Podiatrist Merton Root et al.25 In this system, all feet are cast for orthotics in subtalar joint neutral position to develop orthotic shells which are then

microscopic or macroscopic level.

### **The gait cycle**

Human stance and activity is comprised of many patterns or cycles in order to maintain us erect and move us in all directions as we live our lives. Movement can be forward, backward, side-to-side or it may rock, sway or move us up or down. Each of these movements has a totally different Activity Cycle that makes different demands upon the body biomechanically. The Walking Cycle (moving forward) and The Backward Walking Cycle challenge the bones, muscles, tendons and ligaments very differently. The fact that we have so many different biomechanical tasks to accomplish combined with the variations in stress that each of them has on the structures performing them makes it impossible to present biomechanics in an understandable manner to inexperienced minds unless we focus on one specific Activity Cycle.

Historically, in order to understand biomechanics foundationally, educators, researchers and practitioners have universally chosen The Activity Cycle of Forward Movement (walking) as the cycle to use when demonstrating, researching and monitoring FLEB. This cycle is known as "The Gait Cycle".24 It is important to note that there are variations in The Gait Cycle that include Midstance Contact Gait and Forefoot Contact Gait that impact the foot and posture differently than The Heel Contact Gait Cycle.

The Gait Cycle defines a complete step from heel contact to heel contact using one limb, either left or right. The gait cycle is first divided into a Stance Phase (60%), when the foot is in contact with the ground, and a Swing Phase (40%), when the foot is free floating. The stance phase is further divided into a contact phase (10%), a midstance phase (40%) and a propulsive phase (10%) (See Figure 3). Since pathology develops most when the foot is touching the ground, FLEB concentrates on the stance phase of gait.

#### Fig. 3. The Stance Phase of Gait

Because the tendo Achilles is medially inserted on the calcaneus, it places the foot in an inverted position when the stance phase of gait begins and so the heel strikes the ground on the lateral side of the vault. As foot function cascades forward, the heel everts (pronates) in order to place the medial surface of the foot upon the ground. Because of pronation, the ball of the foot contacts the ground (midstance) with the metatarsals hitting in order of 5,4,3,2 and finally 1 as the medial side of the vault begins to support weight. Then, as the leg moves forward over the planted foot, the heel comes off the ground (Heel Rise) and when muscular power leverages to the point where they are stronger than the ground reactive forces and the metatarsal heads are firmly planted, the foot pushes off the ground (Propulsion) beginning the Float Phase of Gait. That is then repeated as we move from point A to point B.

Human stance and activity is comprised of many patterns or cycles in order to maintain us erect and move us in all directions as we live our lives. Movement can be forward, backward, side-to-side or it may rock, sway or move us up or down. Each of these movements has a totally different Activity Cycle that makes different demands upon the body biomechanically. The Walking Cycle (moving forward) and The Backward Walking Cycle challenge the bones, muscles, tendons and ligaments very differently. The fact that we have so many different biomechanical tasks to accomplish combined with the variations in stress that each of them has on the structures performing them makes it impossible to present biomechanics in an understandable manner to inexperienced minds unless we focus

Historically, in order to understand biomechanics foundationally, educators, researchers and practitioners have universally chosen The Activity Cycle of Forward Movement (walking) as the cycle to use when demonstrating, researching and monitoring FLEB. This cycle is known as "The Gait Cycle".24 It is important to note that there are variations in The Gait Cycle that include Midstance Contact Gait and Forefoot Contact Gait that impact the

The Gait Cycle defines a complete step from heel contact to heel contact using one limb, either left or right. The gait cycle is first divided into a Stance Phase (60%), when the foot is in contact with the ground, and a Swing Phase (40%), when the foot is free floating. The stance phase is further divided into a contact phase (10%), a midstance phase (40%) and a propulsive phase (10%) (See Figure 3). Since pathology develops most when the foot is

Because the tendo Achilles is medially inserted on the calcaneus, it places the foot in an inverted position when the stance phase of gait begins and so the heel strikes the ground on the lateral side of the vault. As foot function cascades forward, the heel everts (pronates) in order to place the medial surface of the foot upon the ground. Because of pronation, the ball of the foot contacts the ground (midstance) with the metatarsals hitting in order of 5,4,3,2 and finally 1 as the medial side of the vault begins to support weight. Then, as the leg moves forward over the planted foot, the heel comes off the ground (Heel Rise) and when muscular power leverages to the point where they are stronger than the ground reactive forces and the metatarsal heads are firmly planted, the foot pushes off the ground (Propulsion) beginning the Float Phase of Gait. That is then repeated as we move from point A to point B.

foot and posture differently than The Heel Contact Gait Cycle.

touching the ground, FLEB concentrates on the stance phase of gait.

**The gait cycle** 

on one specific Activity Cycle.

Fig. 3. The Stance Phase of Gait

The supporting structure of the lateral side of The Vault of The Foot, composed of bones that when healthy, has an architecture that allows it to lock when weighted without the need for much muscular and ligamentous support. This enables the lateral Vault to be primarily strong, stable, supportive and capable of assuming an Optimal Functional Position (OFP) without much ligamentous and muscular primary or compensatory assistance in both the rearfoot and the forefoot that is different for all individuals. When the lateral column functions from Optimal Functional Position, there is little compensatory tissue stress of the bones and supporting structures or compensatory muscle engine energy on both a microscopic or macroscopic level.

In opposition, the bony architecture of the medial side of The Vault of The Foot lacks the ability to lock on its own when weighted without the assistance of a large number of primary muscle engines and ligamentous systems. This means that without strong and trained muscle engines and a well developed and conditioned ligamentous supporting system, the medial Vault of the Foot is not capable of maintaining its Optimal Functional Position and so it serves as the anatomical location for much of the biomechanical pathology that exists in both the rearfoot and forefoot (figures 4) for most feet. Collapse of the bony position of the medial side of the foot from its OFP results in stretching and reduced leverage of the ligaments and muscles that are mandated to lock and support the vault in OFP (figure 5). This creates a subclinical vicious closed chain biomechanical cycle early on that stresses the tissues on a cellular level that when repeated over and over as we live our lives eventually rises to clinical events like pain and overuse syndromes, foot and postural deformities and irreversible degenerative changes. **Summarily, inherited medial vault weakness serves as the biomechanical etiology for FLEB and unless diagnosed and treated, guarantees compensatory degeneration, overuse, deformity and structural and functional breakdown in the feet and throughout the posture, in closed chain**.

Fig. 4. The Ligamentous Tie Beam Supports The Bony Truss in the Medial Column

Fig. 5. The Longitudinal and Vertical Collapse of The Medial Column Deforming the OFP

The current gold standard, known as Subtalar Joint (STJ) Neutral Examination was developed thirty years ago by Podiatrist Merton Root et al.25 In this system, all feet are cast for orthotics in subtalar joint neutral position to develop orthotic shells which are then

Types or FFT's. These shared structural, functional and compensatory tendencies for those that test a particular foot type provide a platform from which to provide improved custom care for every patient. Within each subgroup, each subject shares similarities with respect to weightbearing position, segmental ranges of motion, predictable areas of strengths and weaknesses and certain precursor signs and symptoms that can help predict past, present

Starting from Root's well defined position of pedal neutrality (Figure 7) 43, two simple open chain tests are performed for the rearfoot and two tests for the forefoot determine

the Supinatory End Range of Motion (SERM) and Pronatory End Range of Motion (PERM) of each segment defining a rearfoot type and forefoot type for every foot. These two segmental foot types then combine to produce a Functional Foot Type (FFT) that serves as a

and future foot and postural breakdown and performance issues.

Fig. 6. Architectural vs. Pedal Arches

Fig. 7. Root's Neutral Position.

modified using Orthotic Reactive Postings and Modifications such as suggested by McPoil and Hunt27 in order to reduce tissue stress in areas of complaint. Rootian Biomechanics evolved what was known as orthopedics and the prescribing of custom arch supports in the colleges of podiatry into the current biomechanics and custom foot orthotics in the 1970's. Low level research proving that STJ Neutral casted shells and prescription orders for rearfoot and forefoot corrections when ordering custom foot orthotics were beneficial are difficult to deny14-18. Unfortunately, Rootian Biomechanics is being shown to lack scientific merit and a lack of reproducibility and evidentiary proof.28-30 This may be because research is showing that in reality, most of the problems facing us in daily life involve lengthening, widening and collapse of the fore part of the foot on the sagittal and transverse planes and not the subtalar joint as Root and his followers preach.30-33

In response to this fact, modern theories are surfacing that when practiced by a new wave of biomechanically committed podiatrists are returning the podiatrist to the top of a Biomechanical Pyramid and exposing the claims of others to be exaggerated.

The doctor-patient relationship that only exists between a podiatrist using modern biomechanics to diagnose and treat the diabetic foot biomechanically using custom casting and prescribing techniques as well as individually tailored "Boot Camp" type training of the patient expands care beyond the "get sick and come to me" model of Kirby and Scherer34 and Fuller35 into more of a wellness model offered by Dananberg31, Glaser33 and Shavelson38 that includes prevention, intervention and quality of life expansion as part of care using varied casting techniques and treatment for underlying pathology that includes prevention, intervention and quality of life expansion as part of care using varied casting prescribing and training techniques, not just complaints. One such theory gaining in popularity is called The Foot Centering Theory of Biomechanics or Wellness Biomechanics invented and U.S. Patented by this author38-42

#### **The foot centering theory of biomechanics**

When it comes to understanding the foot as a supportive structure, in The Foot Centering Theory of Biomechanics, the dynamic arches of the foot and The Vault of the Foot are compared to architectural arches and vaults applying the principles and terminology of architectural engineering to the positional structure of the foot (figure 6). The use of architectural language reduces the previous difficult language of physics and mechanical engineering that has distanced practitioners, patients and the foot suffering public investigating and applying biomechanics.

The architectural arches as structures have one function and that is to support. They are symmetrical (no back or front). Their pillars are equal in size, their component bricks are equal or proportional in size and shape and their keystones are centered. They resist wear and tear but fail as adaptive, functional and shock absorbing entities because they cannot provide leverage to ropes and pulleys trying to move it when attached. In opposition, pedal arches are assymetrical (they have a back and front). Their pillars are disproportional, their bones are of different size and shape and their keystones are off-centered. This means that pedal arches and vaults, in order to succeed as an adaptive, shock absorbing and mobile entities, are destined to fail as supporters (figure 6).

In Foot Centering, rather than treat all feet from a Subtalar Joint Neutral platform, feet are profiled into subgroups or types that share common characteristics called Functional Foot

modified using Orthotic Reactive Postings and Modifications such as suggested by McPoil and Hunt27 in order to reduce tissue stress in areas of complaint. Rootian Biomechanics evolved what was known as orthopedics and the prescribing of custom arch supports in the colleges of podiatry into the current biomechanics and custom foot orthotics in the 1970's. Low level research proving that STJ Neutral casted shells and prescription orders for rearfoot and forefoot corrections when ordering custom foot orthotics were beneficial are difficult to deny14-18. Unfortunately, Rootian Biomechanics is being shown to lack scientific merit and a lack of reproducibility and evidentiary proof.28-30 This may be because research is showing that in reality, most of the problems facing us in daily life involve lengthening, widening and collapse of the fore part of the foot on the sagittal and transverse planes and

In response to this fact, modern theories are surfacing that when practiced by a new wave of biomechanically committed podiatrists are returning the podiatrist to the top of a

The doctor-patient relationship that only exists between a podiatrist using modern biomechanics to diagnose and treat the diabetic foot biomechanically using custom casting and prescribing techniques as well as individually tailored "Boot Camp" type training of the patient expands care beyond the "get sick and come to me" model of Kirby and Scherer34 and Fuller35 into more of a wellness model offered by Dananberg31, Glaser33 and Shavelson38 that includes prevention, intervention and quality of life expansion as part of care using varied casting techniques and treatment for underlying pathology that includes prevention, intervention and quality of life expansion as part of care using varied casting prescribing and training techniques, not just complaints. One such theory gaining in popularity is called The Foot Centering Theory of Biomechanics or Wellness Biomechanics invented and U.S.

When it comes to understanding the foot as a supportive structure, in The Foot Centering Theory of Biomechanics, the dynamic arches of the foot and The Vault of the Foot are compared to architectural arches and vaults applying the principles and terminology of architectural engineering to the positional structure of the foot (figure 6). The use of architectural language reduces the previous difficult language of physics and mechanical engineering that has distanced practitioners, patients and the foot suffering public

The architectural arches as structures have one function and that is to support. They are symmetrical (no back or front). Their pillars are equal in size, their component bricks are equal or proportional in size and shape and their keystones are centered. They resist wear and tear but fail as adaptive, functional and shock absorbing entities because they cannot provide leverage to ropes and pulleys trying to move it when attached. In opposition, pedal arches are assymetrical (they have a back and front). Their pillars are disproportional, their bones are of different size and shape and their keystones are off-centered. This means that pedal arches and vaults, in order to succeed as an adaptive, shock absorbing and mobile

In Foot Centering, rather than treat all feet from a Subtalar Joint Neutral platform, feet are profiled into subgroups or types that share common characteristics called Functional Foot

Biomechanical Pyramid and exposing the claims of others to be exaggerated.

not the subtalar joint as Root and his followers preach.30-33

Patented by this author38-42

**The foot centering theory of biomechanics**

investigating and applying biomechanics.

entities, are destined to fail as supporters (figure 6).

Types or FFT's. These shared structural, functional and compensatory tendencies for those that test a particular foot type provide a platform from which to provide improved custom care for every patient. Within each subgroup, each subject shares similarities with respect to weightbearing position, segmental ranges of motion, predictable areas of strengths and weaknesses and certain precursor signs and symptoms that can help predict past, present and future foot and postural breakdown and performance issues.

Fig. 6. Architectural vs. Pedal Arches

Starting from Root's well defined position of pedal neutrality (Figure 7) 43, two simple open chain tests are performed for the rearfoot and two tests for the forefoot determine

Fig. 7. Root's Neutral Position.

the Supinatory End Range of Motion (SERM) and Pronatory End Range of Motion (PERM) of each segment defining a rearfoot type and forefoot type for every foot. These two segmental foot types then combine to produce a Functional Foot Type (FFT) that serves as a

In the **stable forefoot type**, the SERM position of the 1st met horizontal bisection plantarflexed to the 5th met horizontal bisection and the PERM position of the 1st met

In the **flexible forefoot type,** the SERM position of the 1st met horizontal bisection is plantarflexed to the fifth metatarsal head horizontal bisection and the PERM position of the

In the **flat forefoot type**, both the SERM and PERM position of the 1st met horizontal

Every pair of feet can be profiled as a specific rearfoot type and forefoot type. After a subject has been diagnosed with a Functional Rearfoot Type and a Functional Forefoot Type the Functional Foot Type is determined by combining both entities. The Functional Foot Typing

**(cavus) Rigid/Stable Rigid/Flex** 

**Flat Flat/Rigid Flat/Stable Flat/Flex Flat/Flat** 

When the four functional rearfoot types are plotted horizontally and the four functional forefoot types are plotted vertically, a matrix composed of sixteen boxes is created, each box representing a possible functional foot type (figure 7). This means that there are 16 possible FFT's, however for the purposes of this chapter, 90% of all feet classify into one of five

After diagnosing a subject's foot type, a podiatrist can fabricate a positional prop in the form of a foot orthotic casted in the Optimal Functional Position (OFP) replacing his/her existing footbeds, foot type-specific. This reduces the need for the muscles to overcome

**Functional Forefoot Type** 

**Rigid Stable Flexible Flat** 

**(bunion) Rigid/Flat** 

**(pronated) Flex/Flat** 

**(flat)** 

**(normal) Stable/Flex Stable/Flat** 

horizontal bisection is online with the 5th met horizontal bisection.

bisection is dorsiflexed to the fifth met horizontal bisection.

**Stable Stable/Rigid Stable/Stable** 

**Rigid Rigid/Rigid** 

Fig. 9. The Functional Foot Typing Matrix

Common Foot Types (see figure 9)

**Functional Rearfoot Type** 

1st met horizontal bisection is dorsiflexed to the 5th met horizontal bisection.

System allows every foot to be classified into one of sixteen possible FFT's.

**Flexible Flex/Rigid Flex/Stable Flex/Flex** 

starting platform to develop a plan of biomechanical care in the hands of a skilled professional.37

### **The functional foot typing system**

In The Functional Foot Typing system, the total range of motion and the positional relationships within the rearfoot (the subtalar joint) and the forefoot (the midtarsal joint) gathered in open chain can be used to describe specific foot types and how they will compensate when placed in closed chain against the ground.

The RF SERM Test represents subtalar joint position in the contact phase of The Gait Cycle and the RF PERM Test represents subtalar joint position in the midstance phase of gait. The FF SERM Test represents the first ray position at the midstance phase of The Gait Cycle and the FF PERM Test represents the first ray at the heel lift phase of propulsion (figure 8).

#### Fig. 8. The SERM-PERM Positions in Gait

The Rearfoot SERM-PERM and the Forefoot SERM-PERM tests each have four possible types that are designated Rigid, Stable, Flexible and Flat.

In trying to present functional foot typing in three paragraphs, we will begin by defining the four possible functional rearfoot types and four functional forefoot types.

#### **The rearfoot foot types**

In the **rigid rearfoot type**, the rearfoot total range of motion is less than 15 degrees with the calcaneus inverted to the lower leg at both SERM and PERM.

In the **stable rearfoot type**, the rearfoot total range of motion is 15 degrees with the calcaneus inverted to the lower leg at SERM and perpendicular to the lower leg at PERM.

In the **flexible rearfoot type,** the rearfoot total range of motion is greater than 15 degrees with the calcaneus inverted to the lower leg at SERM and everted to the lower leg at PERM.

In the **flat rearfoot type**, the rearfoot total range of motion is greater than 15 degrees in both SERM and PERM.

#### **The forefoot foot types**

In the **rigid forefoot type**, both the SERM and PERM position of 1st met horizontal bisection is plantarflexed to the 5th met horizontal bisection.

starting platform to develop a plan of biomechanical care in the hands of a skilled

In The Functional Foot Typing system, the total range of motion and the positional relationships within the rearfoot (the subtalar joint) and the forefoot (the midtarsal joint) gathered in open chain can be used to describe specific foot types and how they will

The RF SERM Test represents subtalar joint position in the contact phase of The Gait Cycle and the RF PERM Test represents subtalar joint position in the midstance phase of gait. The FF SERM Test represents the first ray position at the midstance phase of The Gait Cycle and the FF PERM Test represents the first ray at the heel lift phase of propulsion (figure 8).

The Rearfoot SERM-PERM and the Forefoot SERM-PERM tests each have four possible

**FF SERM FF PERM** 

In trying to present functional foot typing in three paragraphs, we will begin by defining the

In the **rigid rearfoot type**, the rearfoot total range of motion is less than 15 degrees with the

In the **stable rearfoot type**, the rearfoot total range of motion is 15 degrees with the calcaneus inverted to the lower leg at SERM and perpendicular to the lower leg at PERM. In the **flexible rearfoot type,** the rearfoot total range of motion is greater than 15 degrees with the calcaneus inverted to the lower leg at SERM and everted to the lower leg at PERM. In the **flat rearfoot type**, the rearfoot total range of motion is greater than 15 degrees in both

In the **rigid forefoot type**, both the SERM and PERM position of 1st met horizontal bisection

professional.37

**The functional foot typing system** 

Fig. 8. The SERM-PERM Positions in Gait

**The rearfoot foot types** 

SERM and PERM.

**The forefoot foot types** 

types that are designated Rigid, Stable, Flexible and Flat.

calcaneus inverted to the lower leg at both SERM and PERM.

is plantarflexed to the 5th met horizontal bisection.

four possible functional rearfoot types and four functional forefoot types.

compensate when placed in closed chain against the ground.

In the **stable forefoot type**, the SERM position of the 1st met horizontal bisection plantarflexed to the 5th met horizontal bisection and the PERM position of the 1st met horizontal bisection is online with the 5th met horizontal bisection.

In the **flexible forefoot type,** the SERM position of the 1st met horizontal bisection is plantarflexed to the fifth metatarsal head horizontal bisection and the PERM position of the 1st met horizontal bisection is dorsiflexed to the 5th met horizontal bisection.

In the **flat forefoot type**, both the SERM and PERM position of the 1st met horizontal bisection is dorsiflexed to the fifth met horizontal bisection.

Every pair of feet can be profiled as a specific rearfoot type and forefoot type. After a subject has been diagnosed with a Functional Rearfoot Type and a Functional Forefoot Type the Functional Foot Type is determined by combining both entities. The Functional Foot Typing System allows every foot to be classified into one of sixteen possible FFT's.


Fig. 9. The Functional Foot Typing Matrix

When the four functional rearfoot types are plotted horizontally and the four functional forefoot types are plotted vertically, a matrix composed of sixteen boxes is created, each box representing a possible functional foot type (figure 7). This means that there are 16 possible FFT's, however for the purposes of this chapter, 90% of all feet classify into one of five Common Foot Types (see figure 9)

After diagnosing a subject's foot type, a podiatrist can fabricate a positional prop in the form of a foot orthotic casted in the Optimal Functional Position (OFP) replacing his/her existing footbeds, foot type-specific. This reduces the need for the muscles to overcome

Each FFT is associated with a certain profile of features that as a whole unite the members of that FFT. These include lesion pattern, x-ray presentation, shoe wear pattern, foot

This means that if given the characteristics of a given patient, a biomechanically practiced

Since some foot type characteristics are shared by more than one type, some patients may resemble each other and not be in the same FFT but when profiled, the foot type can be confirmed by its overall characteristics. For example, the presence of a range of motion of the 1st ray to fifth of lets say, 35 degrees in a patient diagnosed as a rigid forefoot type probably reflects poor typing since that would definitely place that subject into the flexible

Since they are foot type specific, pathological foot type characteristics, even if not yet evident for a given patient can be reduced or prevented by introducing OFP and

As an example, please review the characteristics of The Rigid Rearfoot/Rigid Forefoot FFT

**The Rigid Rearfoot/Rigid Forefoot Functional Foot Type Characteristics**

In closed chain, when an area of the foot is overloaded with weight, shear or torque, there

**Rigid-Rigid FFT Characteristics**

**The characteristics of the Functional Foot Types (FFT's) 44** 

podiatrist can place that patient into one of the FFT's.

compensatory threshold training as part of care.

**Pedal Problems**

**Lesion Pattern**

**Postural Problems**

**X-ray Presentation**

**Shoe Wear Pattern**

Fig. 11. The Rigid Rearfoot/Rigid Forefoot FFT Characteristics

are two possible reactive occurrences in the skin.

**Protective callus formation1,39** 

forefoot subgroup.

(figure 11).

deformities, foot pain and postural pain and fatigue symptoms.

pathological collapse allowing them to concentrate on balance and movement. Stress risers within the foot are reduced or eliminated due to healthy redistribution of weight, preventing biomechanical sequelae and preparing each patient to be trained for a better performance, efficiency and quality of life. The goal for success is strong feet and posture that performs efficiently with an end goal of reducing or eliminating the prop orthotic.

This means that by knowing the foot type of a diabetic, the location of future ulcerations and infections can be predicted and prevented utilizing biomechanical treatment to balance and distribute weight, pressure and shear away from areas these predictable areas while expanding the functional quality of life so important to the longevity and fitness of the patient.

### **The common functional foot types**

As stated previously, we are going to focus on The Five Common Functional Foot Types that 90% of all feet profile into (Figure 10) and the forefoot biomechanics that leads to most of the biomechanical pathology seen in practice, including many ulcers and wounds that develop in the feet of diabetics.

Fig. 10. The Common Functional Foot Types

The goals for success in Foot Centering are strong feet and posture that perform efficiently with reduced deformity, degeneration and suffering. In the case of the diabetic patient, we add the prevention, improved healing, reduction of invasive procedure needed and improved functional life when dealing with closed chain ulcers, wounds and infections.

pathological collapse allowing them to concentrate on balance and movement. Stress risers within the foot are reduced or eliminated due to healthy redistribution of weight, preventing biomechanical sequelae and preparing each patient to be trained for a better performance, efficiency and quality of life. The goal for success is strong feet and posture that performs efficiently with an end goal of reducing or eliminating the prop

This means that by knowing the foot type of a diabetic, the location of future ulcerations and infections can be predicted and prevented utilizing biomechanical treatment to balance and distribute weight, pressure and shear away from areas these predictable areas while expanding the functional quality of life so important to the longevity and fitness of the

As stated previously, we are going to focus on The Five Common Functional Foot Types that 90% of all feet profile into (Figure 10) and the forefoot biomechanics that leads to most of the biomechanical pathology seen in practice, including many ulcers and wounds that

The goals for success in Foot Centering are strong feet and posture that perform efficiently with reduced deformity, degeneration and suffering. In the case of the diabetic patient, we add the prevention, improved healing, reduction of invasive procedure needed and improved functional life when dealing with closed chain ulcers, wounds and

orthotic.

patient.

**The common functional foot types** 

develop in the feet of diabetics.

Fig. 10. The Common Functional Foot Types

infections.

### **The characteristics of the Functional Foot Types (FFT's) 44**

Each FFT is associated with a certain profile of features that as a whole unite the members of that FFT. These include lesion pattern, x-ray presentation, shoe wear pattern, foot deformities, foot pain and postural pain and fatigue symptoms.

This means that if given the characteristics of a given patient, a biomechanically practiced podiatrist can place that patient into one of the FFT's.

Since some foot type characteristics are shared by more than one type, some patients may resemble each other and not be in the same FFT but when profiled, the foot type can be confirmed by its overall characteristics. For example, the presence of a range of motion of the 1st ray to fifth of lets say, 35 degrees in a patient diagnosed as a rigid forefoot type probably reflects poor typing since that would definitely place that subject into the flexible forefoot subgroup.

Since they are foot type specific, pathological foot type characteristics, even if not yet evident for a given patient can be reduced or prevented by introducing OFP and compensatory threshold training as part of care.

As an example, please review the characteristics of The Rigid Rearfoot/Rigid Forefoot FFT (figure 11).

Fig. 11. The Rigid Rearfoot/Rigid Forefoot FFT Characteristics

### **Protective callus formation1,39**

In closed chain, when an area of the foot is overloaded with weight, shear or torque, there are two possible reactive occurrences in the skin.

Figure 14 introduces the reader to the predictable sites of excess closed chain weight forming callus. Although the body's desire is to protect these areas from injury, like the fingertips of a guitar player, continued ground and shoe reactive forces cascades the clinical

After diagnosing a subject's foot type, a podiatrist can fabricate a positional prop in the form of a foot orthotic casted in the Optimal Functional Position (OFP) for that type. This reduces the need for the muscles to overcome pathological collapse allowing them to concentrate on balance and movement. Stress risers within the foot are reduced or eliminated preventing biomechanical sequelae and preparing each patient to be trained for a better foundational positioning and muscle engine performance. In addition, the need for protective callus

**Stable/Stable FFT Callus Hallux IP Joint, 2nd Met If Stressed, No Ulcer** 

All of us inherits a functional foot type and are prone to accept its strengths and weaknesses. This inevitably leads us to suffer predictable quality of life issues due to biomechanical wear and tear and inefficient compensatory mechanisms that are impacted by concomitant factors such as weight, body type, age, activity level, health state, ground surfaces, equipment and

**First Met Callus, 5th Met Callus** 

**IP Hallux Callus, 2nd Met Callus** 

**or Wound Formation** 

**Medial First Met Callus, Rolloff Hallux IP Callus, 2nd,3rd, 4th met callus** 

**Fifth Met Callus** 

**The common functional foot type/ callus-ulcer patterns** 

picture to that of the very injury it is attempting to prevent .

**Functional Foot Type Callus/Ulcer Pattern** 

formation reduces or is eliminated42.

**Rigid/Rigid FFT** 

**Rigid/Flexible FFT** 

**Flexible/Flexible** 

Fig. 14. Callus-Ulcer patterns of the Common FFT's **Why is the diabetic foot so prone to problems?** 

**Flat/Flat** 

vocation.

The first results from an overwhelming acute force that gives the skin no time to protect itself from injury. This acute injury is known as blistering. The skin separates into two layers, a base and a roof that then fills up with body fluid or blood depending on which organs are involved.

The second event occurs when there is subclinical repetitive microtrauma in the form of shear, pressure or torque to a weightbearing area of the foot and this results in reactive compression and thickening of the epidermal layers in that area presenting itself as a cascade of changes that occur ranging from protective callus (figure 12) to ulceration and wounding (figure 13). The level of change depends on how strong and how long the microtrauma continues.

Fig. 12. Protective Callus

#### Fig. 13. Pressure Ulcer with Deep Wound

This means that if protective callus develops Functional Foot Type-Specific due at least in part to underlying, inherited biomechanical pathology, then foot typing diabetic patients, monitoring their protective calluses and treating them biomechanically utilizing Foot Centering so that they don't advance into ulcers and wounds defines the important role of The Podiatrist as an integral part of the health care team of every diabetic.

#### **Ulcer, wound and amputation prevention in diabetics utilizing foot typing**

The application of Functional Foot Typing that best serves the diabetic is to look at the functional forefoot type and state the location of forefoot callus for each of the Common Foot Types. Whether these calluses exist or not on a patients biomechanical timeline, these areas are accepting greater than normal tissue stress which will cascade to ulceration unimpeded in the face of diabetic neuropathy and must be decompensated biomechanically. 45-49

The first results from an overwhelming acute force that gives the skin no time to protect itself from injury. This acute injury is known as blistering. The skin separates into two layers, a base and a roof that then fills up with body fluid or blood depending on which

The second event occurs when there is subclinical repetitive microtrauma in the form of shear, pressure or torque to a weightbearing area of the foot and this results in reactive compression and thickening of the epidermal layers in that area presenting itself as a cascade of changes that occur ranging from protective callus (figure 12) to ulceration and wounding (figure 13). The level of change depends on how strong and how long the

This means that if protective callus develops Functional Foot Type-Specific due at least in part to underlying, inherited biomechanical pathology, then foot typing diabetic patients, monitoring their protective calluses and treating them biomechanically utilizing Foot Centering so that they don't advance into ulcers and wounds defines the important role of

The application of Functional Foot Typing that best serves the diabetic is to look at the functional forefoot type and state the location of forefoot callus for each of the Common Foot Types. Whether these calluses exist or not on a patients biomechanical timeline, these areas are accepting greater than normal tissue stress which will cascade to ulceration unimpeded in the face of diabetic neuropathy and must be decompensated

The Podiatrist as an integral part of the health care team of every diabetic.

**Ulcer, wound and amputation prevention in diabetics utilizing foot typing** 

organs are involved.

microtrauma continues.

Fig. 12. Protective Callus

biomechanically. 45-49

Fig. 13. Pressure Ulcer with Deep Wound

### **The common functional foot type/ callus-ulcer patterns**

Figure 14 introduces the reader to the predictable sites of excess closed chain weight forming callus. Although the body's desire is to protect these areas from injury, like the fingertips of a guitar player, continued ground and shoe reactive forces cascades the clinical picture to that of the very injury it is attempting to prevent .

After diagnosing a subject's foot type, a podiatrist can fabricate a positional prop in the form of a foot orthotic casted in the Optimal Functional Position (OFP) for that type. This reduces the need for the muscles to overcome pathological collapse allowing them to concentrate on balance and movement. Stress risers within the foot are reduced or eliminated preventing biomechanical sequelae and preparing each patient to be trained for a better foundational positioning and muscle engine performance. In addition, the need for protective callus formation reduces or is eliminated42.


Fig. 14. Callus-Ulcer patterns of the Common FFT's

#### **Why is the diabetic foot so prone to problems?**

All of us inherits a functional foot type and are prone to accept its strengths and weaknesses. This inevitably leads us to suffer predictable quality of life issues due to biomechanical wear and tear and inefficient compensatory mechanisms that are impacted by concomitant factors such as weight, body type, age, activity level, health state, ground surfaces, equipment and vocation.

the lower extremity. This results in stress in ligaments and tendons and joints such as the tendo Achilles, plantar fascia and great toe joint, especially in those foot types that are hypermobile such as the rearfoot and forefoot stable and flexible types. This in turn produces enlargement and fibrosis as well as subsequent contractures and weakness in the foot due to the sum of the repetitive micro injuries to the soft tissues, ligaments, muscles,

Examples of where functional foot typing predicts locations for wounds, infections and ulcers would be the 2nd toe hammertoe prevalent in the rigid rearfoot-flexible forefoot FFT, The fifth met head lesions and wounds of the flat rearfoot-flat forefoot foot type, the hallux IP Rolloff Ulcers that cause hallux amputations are allied to the flexible rearfoot-flexible forefoot functional foot type and the severe ulceration of the plantar 1st metatarsal head that often leads to osteomyelitis of that area is linked to the rigid rearfoot-rigid forefoot FFT.

In diabetes, Loss of Protective Sensation (LOPS), the end stage of proprioceptor pathology, by eliminating the pain protection response from the equation, leads to overwhelming integumentary tissue stress that is not decompensated due to the fact that the body cannot recognize its existence. This leads to pressure callus, pressure ulcers and wounds, amputations and limb loss because of a lack of proprioceptive warning. Proprioceptive pathology is an early and common finding in the polyneuropathy peripheral neuropathy associated with the disease and may even precede the presence of high fasting blood sugars

Summarily, insufficient information supplied by Proprioceptive Sensors reduces efficiency of movement, causes pathologic tissue stress, injury, problems with postural coordination and/or joint alignment and chronic, un-resolving pain in sensate areas as well as skin and

The most important sensory nerve organs for controlling the muscular system are the

Muscle spindle fibers are found interspersed within the contractile fibers of all skeletal muscles, with the highest concentration in the central portion (belly) of each muscle. Muscle spindles respond to changes in muscle length and stress. Without this basic "wiring," proper

Golgi tendon organs are located in the junctions of muscles and their tendons. These protective nerve endings exert an inhibitory effect on contraction of muscle fibers (figure

joint alignment can't be maintained and closed chain stance is almost impossible. 58-59

tendons, joints and bones. 52-55

(prediabetics).

15).

soft tissue wounds and ulcers in advanced cases.

muscle spindle fibers and the Golgi tendon organs.

**Locations of nerve receptors** 

Fig. 15. A Golgi Tendon Organ

However, **no one factor is so overwhelmingly important to consider when rating the importance of podiatry care in the form of functional lower extremity biomechanics than Diabetes Mellitus**. This is because diabetics inheriting these very same FFT's end up with greater quality of life issues including ulcerations, infections, deformities and amputations than their non diabetic counterparts due to the devastating comorbidities of peripheral neuropathy and PAD. The most devastating component comorbidity of DM relates to the fact that neuropathic diabetics lose what is known as proprioception or the ability to "feel and react to the road and navigate through it".

Walking and many other tasks require daily closed chain sensory input to adapt and modify motor patterns and muscle output to carry out the desired task. Fully functioning joints and bones, combined with adequate muscle strength, are needed. The result of this activity is also coupled with local soft tissue compensations affecting the foot–ground interface. These can be affected by the frictional properties of the sole, internal muscle activity as well as the inherited underlying biomechanics of each subject that can be improved with foot orthotics.50

#### **Proprioception**

Proprioception is defined as "sensing the motion and position of the body. Knowing where we are in space and judging how we should navigate that space is a biological quality that when combined with our intelligence, elevates us from the rest of the animal kingdom.

Specialized nerve endings called Proprioceptors are present throughout the soft tissues of the musculoskeletal system. They interact with the central nervous system and coordinate our body movements, our postural alignment, and our balance. We rely on this delicately controlled and finely-tuned system of receptors and feedback loops and the validity and reliability of the information which is sent into the spinal cord tens of thousands of times every day.

Proprioceptive health allows us to "read" our environment in order to generate appropriate motor responses to perform the motions, actions, tasks and functional skills that we must perform. A reduction of Proprioception impacts our ability to stand weighted without sway as well as our ability to perform artistic and athletic physical activity efficiently and to move from point "A" to point "B".

Over time, areas of the body without adequate proprioception are exposed to increased tissue stress that weaken, deform, degenerate and eventually break down the skin, connective and supportive soft tissue, ligaments, tendons, muscles, bones and joints in those areas as well as in other areas of the body that must compensate secondarily in order keep the body performing.

The current scientific literature supports the following changes in the diabetic foot as a result of peripheral neuropathy: limited joint range of motion, glycosylation of tendons and soft tissue leading to restriction of motion, diminished plantar fat padding, and intrinsic muscle wasting with resultant clawing deformity of toes and contractures of the forefoot.45-51

Although it cannot be stated with certainty in all cases, there is evidence to state that underlying biomechanical pathology results in reductions in joint range of motion (functional hallux limitus, functional hallux extensus and ankle equinus to name a few) in

However, **no one factor is so overwhelmingly important to consider when rating the importance of podiatry care in the form of functional lower extremity biomechanics than Diabetes Mellitus**. This is because diabetics inheriting these very same FFT's end up with greater quality of life issues including ulcerations, infections, deformities and amputations than their non diabetic counterparts due to the devastating comorbidities of peripheral neuropathy and PAD. The most devastating component comorbidity of DM relates to the fact that neuropathic diabetics lose what is known as proprioception or the ability to "feel

Walking and many other tasks require daily closed chain sensory input to adapt and modify motor patterns and muscle output to carry out the desired task. Fully functioning joints and bones, combined with adequate muscle strength, are needed. The result of this activity is also coupled with local soft tissue compensations affecting the foot–ground interface. These can be affected by the frictional properties of the sole, internal muscle activity as well as the inherited underlying biomechanics of each subject that can be improved with foot

Proprioception is defined as "sensing the motion and position of the body. Knowing where we are in space and judging how we should navigate that space is a biological quality that when combined with our intelligence, elevates us from the rest of the animal kingdom.

Specialized nerve endings called Proprioceptors are present throughout the soft tissues of the musculoskeletal system. They interact with the central nervous system and coordinate our body movements, our postural alignment, and our balance. We rely on this delicately controlled and finely-tuned system of receptors and feedback loops and the validity and reliability of the information which is sent into the spinal cord tens of thousands of times

Proprioceptive health allows us to "read" our environment in order to generate appropriate motor responses to perform the motions, actions, tasks and functional skills that we must perform. A reduction of Proprioception impacts our ability to stand weighted without sway as well as our ability to perform artistic and athletic physical activity efficiently and to move

Over time, areas of the body without adequate proprioception are exposed to increased tissue stress that weaken, deform, degenerate and eventually break down the skin, connective and supportive soft tissue, ligaments, tendons, muscles, bones and joints in those areas as well as in other areas of the body that must compensate secondarily in order keep

The current scientific literature supports the following changes in the diabetic foot as a result of peripheral neuropathy: limited joint range of motion, glycosylation of tendons and soft tissue leading to restriction of motion, diminished plantar fat padding, and intrinsic muscle wasting with resultant clawing deformity of toes and contractures of the forefoot.45-51 Although it cannot be stated with certainty in all cases, there is evidence to state that underlying biomechanical pathology results in reductions in joint range of motion (functional hallux limitus, functional hallux extensus and ankle equinus to name a few) in

and react to the road and navigate through it".

orthotics.50

every day.

from point "A" to point "B".

the body performing.

**Proprioception** 

the lower extremity. This results in stress in ligaments and tendons and joints such as the tendo Achilles, plantar fascia and great toe joint, especially in those foot types that are hypermobile such as the rearfoot and forefoot stable and flexible types. This in turn produces enlargement and fibrosis as well as subsequent contractures and weakness in the foot due to the sum of the repetitive micro injuries to the soft tissues, ligaments, muscles, tendons, joints and bones. 52-55

Examples of where functional foot typing predicts locations for wounds, infections and ulcers would be the 2nd toe hammertoe prevalent in the rigid rearfoot-flexible forefoot FFT, The fifth met head lesions and wounds of the flat rearfoot-flat forefoot foot type, the hallux IP Rolloff Ulcers that cause hallux amputations are allied to the flexible rearfoot-flexible forefoot functional foot type and the severe ulceration of the plantar 1st metatarsal head that often leads to osteomyelitis of that area is linked to the rigid rearfoot-rigid forefoot FFT.

In diabetes, Loss of Protective Sensation (LOPS), the end stage of proprioceptor pathology, by eliminating the pain protection response from the equation, leads to overwhelming integumentary tissue stress that is not decompensated due to the fact that the body cannot recognize its existence. This leads to pressure callus, pressure ulcers and wounds, amputations and limb loss because of a lack of proprioceptive warning. Proprioceptive pathology is an early and common finding in the polyneuropathy peripheral neuropathy associated with the disease and may even precede the presence of high fasting blood sugars (prediabetics).

Summarily, insufficient information supplied by Proprioceptive Sensors reduces efficiency of movement, causes pathologic tissue stress, injury, problems with postural coordination and/or joint alignment and chronic, un-resolving pain in sensate areas as well as skin and soft tissue wounds and ulcers in advanced cases.

#### **Locations of nerve receptors**

The most important sensory nerve organs for controlling the muscular system are the muscle spindle fibers and the Golgi tendon organs.

Muscle spindle fibers are found interspersed within the contractile fibers of all skeletal muscles, with the highest concentration in the central portion (belly) of each muscle. Muscle spindles respond to changes in muscle length and stress. Without this basic "wiring," proper joint alignment can't be maintained and closed chain stance is almost impossible. 58-59

Golgi tendon organs are located in the junctions of muscles and their tendons. These protective nerve endings exert an inhibitory effect on contraction of muscle fibers (figure 15).

Fig. 15. A Golgi Tendon Organ

help them understand the reasons you are recommending they wear in-shoe orthotics and

Except for the spine, the foot is the anatomical region that contains the most proprioceptive sensory receptors. Because of the magnitude of sensory input, the feet are quick to produce problems when denied proprioception. These are magnified by the fact that the foot must additionally deal with ground reactive forces and hard, unyielding shoe boxes. Loss of balance, missteps, falls and a reduced ability to navigate efficiently and accurately are just some of the sequelae accompanying proprioceptive disease. Underlying foot type-specific biomechanical pathology impacts pedal posture, pedal muscle engine efficiency and the ability to perform tasks such as walking, lifting and recreational activities and when they

The six specialized nerve sensors are found throughout the musculoskeletal system, in all skeletal muscles and in every ligament, joint capsule, and articular connective tissue. However, the feet are particularly well-supplied with proprioceptive nerve endings. Mechanoreceptors in the joints, along with the muscle spindles of the foot muscles are responsible for the positive support reflexes and a variety of automatic reflexive reactions71. These include the flexor/extensor reflex, which converts the lower limb into a firm, yet compliant pillar. Weightbearing compresses the joints and muscles, evoking reflexive

Second only to glucose control when it comes to managing diabetes is the need to be active and exercise. Increased metabolic disease via peripheral neuropathy causes a reduction in sensory perception of soft touch, pinprick, vibration, and pain eliminating a diabetic from recognizing and reacting to them. Proprioceptive deficits, on the other hand reduce a diabetics ability to know where they are, where they are going and how they are positioned in closed chain. It is the reduced proprioception causes diabetics to live their lives at a slower pace and reduced activity. This in turn allows the metabolic disease to become

It is the job of the health care team to foster diabetics to increase their activity levels efficiently for the long term. In a foundational sense, this begins with pedal support, improved proprioception, healthy compensation of underlying biomechanical pathology and the incorporation of monitored training and exercise programs into the lives of all diabetics. Until this is accomplished, diabetes will continue to fester in greater portion when compared to the rest of the population and the economic and social drain that diabetes

Like other paradigms of functional lower extremity biomechanics and foot orthotic use, there is little high level evidence available for practitioners to apply in using foot typing as a starting platform. OFP casting and Foot Type-specific prescribing anecdotally allow for more organized and predictable diagnosis and treatment of underlying biomechanical pathology. By preventing postural collapse and reducing the need for primary muscle engines to participate in postural alignment and efficiency, they foster all other aspects of

train their muscle-tendon units to a higher fitness level.

**Pedal involvement**

exist in a diabetic, cause escalation of its musculoskeletal comorbidities.

activity in the extensors and inhibition of the flexor muscles.

places on society will continue to mount73.

**The vicious cycle of proprioceptive loss and peripheral neuropathy** 

progressively worse causing advancement of the peripheral neuropathy.72

### **Joint mechanoreceptors (Table 2)**

Surrounding and protecting all joints are tough, fibrous tissues that contain a variety of sensory nerve endings. The input from these specialized sensors keeps the nervous system informed as to the location of the joint, and also their degree of stress they are under by monitoring stretch, compression, tension, acceleration, and rotation.

**Type I mechanoreceptors** are found in higher densities in the proximal joints. They sense the position of a joint by signaling the joint angle through normal ranges of motion. These help determine postural (tonic) muscle contractions.

**Type II nerve endings** adapt to changes in position, and are most active at onset and termination of movement. These are more densely distributed though the distal joints, and affect phasic muscle actions.

**Type III mechanoreceptors** are high-threshold, which means they require considerable joint stress at end ranges before firing. These receptors serve a protective function similar to the Golgi tendon organs.

**Type IV receptors** are free nerve endings located in the ligaments, joint capsules, and articular fat pads which respond to pain stimulus. They can generate intense, non-adapting motor responses in all muscles related to a joint, resulting in the protective muscle contractions that restrict joint movement.


Table 2. Sensory Organs for Proprioception

In addition, stretch-sensitive receptors in the skin known as Ruffini ending, the Merkel cells in hairy skin and field receptors also signal postural and sensory information.

#### **The biomechanics of proprioception in the diabetic foot**

There are over 200 additions to the literature showing that custom orthotic support can help improve structural alignment, balance, gait, and athletic performance. 66-69 In addition, therapeutic shoes and orthotics have been shown to be effective in treating and preventing wound and ulcer formation and they are approved by U.S. Medicare for annual dispensing to diabetics as a cost saving to the health care budget.70

It has been suggested that this universe of improvements is due primarily to upgrades in the sense of proprioception.66 A quick review of the mechanisms and components of proprioception will help us comprehend how patients can demonstrate such a large variety of improvements. Being able to explain this to patients (using simpler terms, of course) will

Surrounding and protecting all joints are tough, fibrous tissues that contain a variety of sensory nerve endings. The input from these specialized sensors keeps the nervous system informed as to the location of the joint, and also their degree of stress they are under by

**Type I mechanoreceptors** are found in higher densities in the proximal joints. They sense the position of a joint by signaling the joint angle through normal ranges of motion. These

**Type II nerve endings** adapt to changes in position, and are most active at onset and termination of movement. These are more densely distributed though the distal joints, and

**Type III mechanoreceptors** are high-threshold, which means they require considerable joint stress at end ranges before firing. These receptors serve a protective function similar to the

**Type IV receptors** are free nerve endings located in the ligaments, joint capsules, and articular fat pads which respond to pain stimulus. They can generate intense, non-adapting motor responses in all muscles related to a joint, resulting in the protective muscle

muscles and tendons muscle spindle fibers

In addition, stretch-sensitive receptors in the skin known as Ruffini ending, the Merkel cells

There are over 200 additions to the literature showing that custom orthotic support can help improve structural alignment, balance, gait, and athletic performance. 66-69 In addition, therapeutic shoes and orthotics have been shown to be effective in treating and preventing wound and ulcer formation and they are approved by U.S. Medicare for annual dispensing

It has been suggested that this universe of improvements is due primarily to upgrades in the sense of proprioception.66 A quick review of the mechanisms and components of proprioception will help us comprehend how patients can demonstrate such a large variety of improvements. Being able to explain this to patients (using simpler terms, of course) will

in hairy skin and field receptors also signal postural and sensory information.

Golgi tendon organs

type I - low threshold, slow-adapting type II - low threshold, fast-adapting type III - high threshold, slow-adapting type IV - nociceptive (pain endings)

monitoring stretch, compression, tension, acceleration, and rotation.

help determine postural (tonic) muscle contractions.

**Joint mechanoreceptors (Table 2)**

affect phasic muscle actions.

contractions that restrict joint movement.

joint ligaments and capsules (mechanoreceptors)

Table 2. Sensory Organs for Proprioception

**The biomechanics of proprioception in the diabetic foot** 

to diabetics as a cost saving to the health care budget.70

Golgi tendon organs.

help them understand the reasons you are recommending they wear in-shoe orthotics and train their muscle-tendon units to a higher fitness level.

Except for the spine, the foot is the anatomical region that contains the most proprioceptive sensory receptors. Because of the magnitude of sensory input, the feet are quick to produce problems when denied proprioception. These are magnified by the fact that the foot must additionally deal with ground reactive forces and hard, unyielding shoe boxes. Loss of balance, missteps, falls and a reduced ability to navigate efficiently and accurately are just some of the sequelae accompanying proprioceptive disease. Underlying foot type-specific biomechanical pathology impacts pedal posture, pedal muscle engine efficiency and the ability to perform tasks such as walking, lifting and recreational activities and when they exist in a diabetic, cause escalation of its musculoskeletal comorbidities.

#### **Pedal involvement**

The six specialized nerve sensors are found throughout the musculoskeletal system, in all skeletal muscles and in every ligament, joint capsule, and articular connective tissue. However, the feet are particularly well-supplied with proprioceptive nerve endings. Mechanoreceptors in the joints, along with the muscle spindles of the foot muscles are responsible for the positive support reflexes and a variety of automatic reflexive reactions71. These include the flexor/extensor reflex, which converts the lower limb into a firm, yet compliant pillar. Weightbearing compresses the joints and muscles, evoking reflexive activity in the extensors and inhibition of the flexor muscles.

#### **The vicious cycle of proprioceptive loss and peripheral neuropathy**

Second only to glucose control when it comes to managing diabetes is the need to be active and exercise. Increased metabolic disease via peripheral neuropathy causes a reduction in sensory perception of soft touch, pinprick, vibration, and pain eliminating a diabetic from recognizing and reacting to them. Proprioceptive deficits, on the other hand reduce a diabetics ability to know where they are, where they are going and how they are positioned in closed chain. It is the reduced proprioception causes diabetics to live their lives at a slower pace and reduced activity. This in turn allows the metabolic disease to become progressively worse causing advancement of the peripheral neuropathy.72

It is the job of the health care team to foster diabetics to increase their activity levels efficiently for the long term. In a foundational sense, this begins with pedal support, improved proprioception, healthy compensation of underlying biomechanical pathology and the incorporation of monitored training and exercise programs into the lives of all diabetics. Until this is accomplished, diabetes will continue to fester in greater portion when compared to the rest of the population and the economic and social drain that diabetes places on society will continue to mount73.

Like other paradigms of functional lower extremity biomechanics and foot orthotic use, there is little high level evidence available for practitioners to apply in using foot typing as a starting platform. OFP casting and Foot Type-specific prescribing anecdotally allow for more organized and predictable diagnosis and treatment of underlying biomechanical pathology. By preventing postural collapse and reducing the need for primary muscle engines to participate in postural alignment and efficiency, they foster all other aspects of

from worsening. In the advanced stages of peripheral neuropathy, there is an absence of these cellular and tissue alarms allowing injuries to progress to a much higher level before becoming clinically evident. This phenomenon is known as Loss of Protective Sensation or

This phenomenon, when present in a diabetic that has inherent underlying biomechanical pathology, instead of presenting with painful bunions, stress injuries or ligamentous stresses such as plantar fasciitis, presents with a pathological collapse of the foot, involving insensate joints that have lost proprioception in their end nerve organs that is

In the Functional Foot Typing System, it is the stable and flexible rearfoot and forefoot foot types that are most commonly involved in Charcot Foot. The rigid and flat rearfoot and forefoot foot types, on the other hand resist collapse and the type of injury that may be a

More specifically, advanced flexible rearfoot types tend to lead to ankle CJD while moderate ones tend more towards a medial collapse under the navicular that leads to cuboidal ulcers and wounds. In contrast, the flexible forefoot foot types lead to 1st MP Joint neuroarthropathy and transfer ulceration under the 2nd metatarsal head, the IP Hallux and

When discussing the Charcot foot, the literature consistently points to the existence of peripheral neuropathy and a loss of protective sensation as necessary in order to develop a Charcot Foot and the presence of patent, healthy circulation in order for the hyperemia of

Finally, whether primary or secondary, trauma or repetitive micro-trauma is necessary in order for CJD to progress. This trauma is exacerbated by closed chain factors such as obesity and an active lifestyle that must be appreciated and overcome by the examiner in order to

In summary we have defined the pre-Charcot foot as a clinical entity displaying the

The presence of inherited, underlying biomechanical pathology is almost universal in the development of CJD. It is indeed rare to find a foot with normal mechanics go on to develop CJD probably because those diabetics find it easier to navigate through lives

CJD to occur. If ischemia is present, wet or dry gangrene, rather than CJD develops.

LOPS.

The Charcot Foot.

precursor of CJD.

sub 5th metatarsal head.94

**The pre-charcot foot80** 

treat CJD successfully.

2. Patent Circulation

more actively.

following quartet of signs and symptoms: 1. Loss of Protective Sensation (LOPS)

(Functional Foot Typing) 4. Excessive Closed Chain Factors (obesity, over-activity, etc.)

3. Underlying Pedal Biomechanical Pathology and Weakness

**Inherent pedal biomechanical pathology and weakness** (see biomechanics)

lifestyle upgrading and therefore it should be considered in the care of diabetics that suffer from underlying biomechanical pathology in the face of the dilution that has occurred for the current Rootian standard.

### **The biomechanics of Charcot Joint Disease**

To site an example of the application of functional foot typing and Foot Centering Biomechanics to the ever-present factors in the development and progression of the comorbidities of diabetes and how podiatric closed chain diagnosis and treatment of these entities needs to be a part of the health care team one needs only to inspect Charcot Joint Disease (CJD).

#### **Charcot Joint Disease (CJD)**

Any physician treating patients with diabetes is aware that on any visit a patient can present with a foot or ankle that is red, hot, and swollen that is not infected. This presentation signals the beginning of a destructive process affecting the soft tissues and bone structure of the foot and ankle called Charcot Joint Disease (CJD). It leads to joint and osseous collapse and degeneration, functional disability, ulceration, infection and eventual loss of limb. Understanding the etiology and progression of this process should be one of the goals of all members of the diabetes health care team, especially those involved in primary care.

Although there is significant literature related to the diagnosis and treatment of Charcot joint once it develops74,76, there has been little discussion as to the predisposing Biomechanical Risk Factors that precede the development of Charcot foot and the need for preventive biomechanical treatment once it exists.

**The Precursors of Charcot Joint Disease (CJD)** The pathophysiology of Charcot joint disease (CJD) remains unknown. One prevalent theory (Volkmann and Virchow) is named the neurotraumatic theory.77 This theory proposes that the joint destruction of CJD is due to a neuropathic foot that leads to loss of proprioception and pain sensation, thereby permitting joints to be exerted to the point of collapse and destruction.78 The neurotraumatic theory finds support in studies which demonstrate that plantar pressures are higher in the metatarsophalangeal joints of the forefoot in patients with acute CJD compared to patients with distal sensorimotor neuropathy or neuropathic ulceration.75 In addition, the motor neuropathy in the diabetic lower extremity tends to precipitate a weakness of muscle groups in the lower extremity, creating dynamic and functional imbalances that either initiate or compound deformities within the foot.

Whether there is feeling the foot or not, the level of underlying biomechanical pathology that exists will determine the level and rate of progression of the cascade of degeneration, deformity, disuse and injury that an individual suffers.

We all suffer from subclinical injury that is of a biomechanical nature. Cellular and tissue stress that goes beyond physiological tolerance. These injuries repair and may even stimulate the development of stronger and more capable cells and tissues. However, once these stresses pass certain thresholds, clinical injury occurs accompanied by various signs and symptoms. These signs and symptoms alert one to address the injury so as to keep it from progressing. Pain, heat, pressure and pinching present early in injury and send a message to change ones lifestyle, environment or metabolism in order to prevent an injury

lifestyle upgrading and therefore it should be considered in the care of diabetics that suffer from underlying biomechanical pathology in the face of the dilution that has occurred for

To site an example of the application of functional foot typing and Foot Centering Biomechanics to the ever-present factors in the development and progression of the comorbidities of diabetes and how podiatric closed chain diagnosis and treatment of these entities needs to be a part of the health care team one needs only to inspect Charcot Joint

Any physician treating patients with diabetes is aware that on any visit a patient can present with a foot or ankle that is red, hot, and swollen that is not infected. This presentation signals the beginning of a destructive process affecting the soft tissues and bone structure of the foot and ankle called Charcot Joint Disease (CJD). It leads to joint and osseous collapse and degeneration, functional disability, ulceration, infection and eventual loss of limb. Understanding the etiology and progression of this process should be one of the goals of all

Although there is significant literature related to the diagnosis and treatment of Charcot joint once it develops74,76, there has been little discussion as to the predisposing Biomechanical Risk Factors that precede the development of Charcot foot and the need for

**The Precursors of Charcot Joint Disease (CJD)** The pathophysiology of Charcot joint disease (CJD) remains unknown. One prevalent theory (Volkmann and Virchow) is named the neurotraumatic theory.77 This theory proposes that the joint destruction of CJD is due to a neuropathic foot that leads to loss of proprioception and pain sensation, thereby permitting joints to be exerted to the point of collapse and destruction.78 The neurotraumatic theory finds support in studies which demonstrate that plantar pressures are higher in the metatarsophalangeal joints of the forefoot in patients with acute CJD compared to patients with distal sensorimotor neuropathy or neuropathic ulceration.75 In addition, the motor neuropathy in the diabetic lower extremity tends to precipitate a weakness of muscle groups in the lower extremity, creating dynamic and functional imbalances that either initiate or

Whether there is feeling the foot or not, the level of underlying biomechanical pathology that exists will determine the level and rate of progression of the cascade of degeneration,

We all suffer from subclinical injury that is of a biomechanical nature. Cellular and tissue stress that goes beyond physiological tolerance. These injuries repair and may even stimulate the development of stronger and more capable cells and tissues. However, once these stresses pass certain thresholds, clinical injury occurs accompanied by various signs and symptoms. These signs and symptoms alert one to address the injury so as to keep it from progressing. Pain, heat, pressure and pinching present early in injury and send a message to change ones lifestyle, environment or metabolism in order to prevent an injury

members of the diabetes health care team, especially those involved in primary care.

the current Rootian standard.

**Charcot Joint Disease (CJD)** 

Disease (CJD).

**The biomechanics of Charcot Joint Disease** 

preventive biomechanical treatment once it exists.

compound deformities within the foot.

deformity, disuse and injury that an individual suffers.

from worsening. In the advanced stages of peripheral neuropathy, there is an absence of these cellular and tissue alarms allowing injuries to progress to a much higher level before becoming clinically evident. This phenomenon is known as Loss of Protective Sensation or LOPS.

This phenomenon, when present in a diabetic that has inherent underlying biomechanical pathology, instead of presenting with painful bunions, stress injuries or ligamentous stresses such as plantar fasciitis, presents with a pathological collapse of the foot, involving insensate joints that have lost proprioception in their end nerve organs that is The Charcot Foot.

In the Functional Foot Typing System, it is the stable and flexible rearfoot and forefoot foot types that are most commonly involved in Charcot Foot. The rigid and flat rearfoot and forefoot foot types, on the other hand resist collapse and the type of injury that may be a precursor of CJD.

More specifically, advanced flexible rearfoot types tend to lead to ankle CJD while moderate ones tend more towards a medial collapse under the navicular that leads to cuboidal ulcers and wounds. In contrast, the flexible forefoot foot types lead to 1st MP Joint neuroarthropathy and transfer ulceration under the 2nd metatarsal head, the IP Hallux and sub 5th metatarsal head.94

### **The pre-charcot foot80**

When discussing the Charcot foot, the literature consistently points to the existence of peripheral neuropathy and a loss of protective sensation as necessary in order to develop a Charcot Foot and the presence of patent, healthy circulation in order for the hyperemia of CJD to occur. If ischemia is present, wet or dry gangrene, rather than CJD develops.

Finally, whether primary or secondary, trauma or repetitive micro-trauma is necessary in order for CJD to progress. This trauma is exacerbated by closed chain factors such as obesity and an active lifestyle that must be appreciated and overcome by the examiner in order to treat CJD successfully.

In summary we have defined the pre-Charcot foot as a clinical entity displaying the following quartet of signs and symptoms:


#### **Inherent pedal biomechanical pathology and weakness** (see biomechanics)

The presence of inherited, underlying biomechanical pathology is almost universal in the development of CJD. It is indeed rare to find a foot with normal mechanics go on to develop CJD probably because those diabetics find it easier to navigate through lives more actively.

[4] Manes J, Papazoglou J, Sossidou E, Soulis, K; D. Milarakis; Prevalence of Diabetic

[5] Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of

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reconstruction of a limb-threatening injury. J Bone Joint Surg Am. Aug

behaviors related to diabetes mellitus in the U.S: Physician adherence to consensus

#### **Excessive closed chain factors**

The lifestyle and quality of life of each individual varies in many ways when in closed chain. A careful history revealing the existence and extent of closed chain factors will assist a practitioner to determine their impact on the need to actively treat a subject's functional foot type. A person who is morbidly obese, very active and wearing worn out athletic shoes may need treatment even if he/she has a stable foot type. Conversely, in the face of LOPS, patent circulation and biomechanical pathology, a healthy and fit, light weight person, who is not very active and wear well fitted shoes and socks that are not outworn has much less of a chance to develop a Charcot Foot.

### **3. Discussion**

Biomechanically, we would like individuals to have a lifestyle that includes exercise along with varied daily activities that promote aerobic health and functional fitness. Our goal should not be to reduce patients from being active and living a healthy lifestyle but instead to promote an active lifestyle for all while supporting them and training them biomechanically, injury, deformity and wound free.

Even though podiatry has become more and more an acceptable part of the diabetes health care team, there remains a poor understanding of functional lower extremity biomechanics and the need for diagnosing and treating underlying biomechanical pathology before, during and after the devastating comorbidities of diabetes reveals itself clinically. It is the hope of the author that all readers will be stimulated to increase their knowledge base regarding the needs of the diabetic patient when it comes to their feet so that foot suffering diabetics can be better cared for.

The podiatrist, skilled in closed chain medicine, biomechanical pathology and the diagnosis and treatment of the functional foot types is a necessary part of the health care team involved in treating diabetics. An annual foot exam and necessary follow-up that includes functional lower extremity biomechanics should be a mandatory part of the care of every diabetic and capable of being delivered by all members of the health care team.

### **4. References**


The lifestyle and quality of life of each individual varies in many ways when in closed chain. A careful history revealing the existence and extent of closed chain factors will assist a practitioner to determine their impact on the need to actively treat a subject's functional foot type. A person who is morbidly obese, very active and wearing worn out athletic shoes may need treatment even if he/she has a stable foot type. Conversely, in the face of LOPS, patent circulation and biomechanical pathology, a healthy and fit, light weight person, who is not very active and wear well fitted shoes and socks that are not outworn has much less of a

Biomechanically, we would like individuals to have a lifestyle that includes exercise along with varied daily activities that promote aerobic health and functional fitness. Our goal should not be to reduce patients from being active and living a healthy lifestyle but instead to promote an active lifestyle for all while supporting them and training them

Even though podiatry has become more and more an acceptable part of the diabetes health care team, there remains a poor understanding of functional lower extremity biomechanics and the need for diagnosing and treating underlying biomechanical pathology before, during and after the devastating comorbidities of diabetes reveals itself clinically. It is the hope of the author that all readers will be stimulated to increase their knowledge base regarding the needs of the diabetic patient when it comes to their feet so that foot suffering

The podiatrist, skilled in closed chain medicine, biomechanical pathology and the diagnosis and treatment of the functional foot types is a necessary part of the health care team involved in treating diabetics. An annual foot exam and necessary follow-up that includes functional lower extremity biomechanics should be a mandatory part of the care of every

[1] Shavelson, D, Steinberg, J, Bakotic B. The Diabetic Foot, Chapter 25, The Principles of

[2] Arad Y, Fonseca V, Peters A; Beyond the Monofilament for the Insensate Diabetic

[3] Southern Arizona Limb Salvage Alliance patient information. Available at: http://diabetic-foot.net/CLEAR/Patients.html. Accessed August 31, 2010

Diabes Mellitus, 2010, 6, 381-399 2nd Printing, DOI: 10.1007/978-0-387-09841-8\_25,

Foot: A systematic review of randomized trials to prevent the occurrence of plantar foot ulcers in patients with diabetes; Diabetes Care, April 2011. vol.34 no

diabetic and capable of being delivered by all members of the health care team.

**Excessive closed chain factors** 

chance to develop a Charcot Foot.

diabetics can be better cared for.

**4. References** 

4, 1041-46

biomechanically, injury, deformity and wound free.

Springer International Publishing

**3. Discussion** 


http://www.podiatry.com/ezines/?pub\_year=2009&section\_id=51#ezine483


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**8** 

*USA* 

**A Protocol for Primary Podogeriatric** 

**Assessment for Older Patients** 

*Department of Community Health, Aging and Health Policy 2Temple University Hospital, Thomas Jefferson University Hospital* 

The Pennsylvania Department of Health's Diabetes Prevention and Control Program provided a contract to develop a Comprehensive Podogeriatric and Chronic Diseases Podogeriatric Assessment Protocol (Helfand Index – Appendix A). The goal was to provide a methodology to assess foot, ankle, and related structural problems in older patients; stratify those patients most at risk to develop complications; develop a surveillance instrument for patient care: and to serve as a public health data collection outcome measurement. The information obtained would also provide a protocol to develop prevention (primary, secondary and tertiary) and management programs for individual patients, institutions, and their communities, augment geriatric and chronic disease assessment, as well as stressing the need for appropriate patient management, professional,

Foot problems identified in older diabetic patients are the result of the aging process, disease, disability, deformity, and complications associated with other chronic diseases. They are related to societal, environmental, and life style issues. Foot discomfort and pain or podalgia represent some of the most distressing, disabling, and known quality of life limiting conditions. Diabetic foot problems in the older patient are a major cause of morbidity, disability, and hospitalization and contribute to a lessening of the quality and independence of life, thus contributing to an earlier and higher mortality. The high prevalence of chronic diseases in the older population, such as, diabetes mellitus, arthritis, peripheral arterial disease as well as those conditions that produce sensory, peripheral vascular, musculo-skeletal, dermatologic, onychial, and neurologic deficits, lead to serious

complications that increase morbidity, mortality, and health care costs. (1, 2, 3, 4, 5, 6)

Other life altering issues in the older patient include constipation, weakened muscle and bone structure, social isolation, mobility deficits, reduced Activities of Daily Living and

**1. Introduction** 

and patient education.

*1Temple University, School of Podiatric Medicine,* 

**with Diabetes Mellitus** 

*3Temple University Institute on Aging 4Philadelphia Corporation for Aging* 

Arthur E. Helfand1,2,3,4

