Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update).

Aims: Offloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes-related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on offloading interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline.

Should weight-bearing activity be reduced during healing of plantar diabetic foot ulcers, even when using appropriate offloading devices?

Physical activity is an essential part of general health and diabetes management. However, recommending weight-bearing physical activity for people with plantar diabetic foot ulcers is controversial, even when gold standard offloading devices are used, as it is commonly thought to delay healing. We aimed to narratively review relevant studies investigating the relationship between plantar diabetic foot ulcer healing and weight-bearing activity, plantar pressure and device adherence.

Diabetes and Reactive Balance: Quantifying Stepping Thresholds With a Simple Spring Scale to Measure Fall-Risk in Ambulatory Older Adults.

Background: Fall-risk assessments for patients with diabetes fail to consider reactive responses to balance loss. The purpose of this study was to assess the feasibility of using a simple clinical tool to evaluate the impact of diabetes and fall history on reactive balance in older adults.

Methods: We recruited 72 older adults with and without diabetes.

Changing Perspectives: Offloading a Patient With a Diabetic Foot Ulcer as Opposed to Offloading a Diabetic Foot Ulcer.

Diabetic foot ulcers (DFUs) represent a tremendous burden to health care systems. Offloading is one of the key tenants to healing DFU and knee-high irremovable offloading devices are considered the gold standard for offloading DFU. However, the gold standard is rarely utilized in clinical practice.

Offloading for the Diabetic Foot: Considerations and Implications.

Offloading the diabetic foot remains the major consideration for ulceration prevention and healing. This narrative literature review presents a brief overview of current guidelines for offloading the diabetic foot and discusses the implications that come with offloading treatment modalities and their effects on the kinetic chain of the lower extremity. We also present the latest innovative studies from the Dr.

The Role of the Podiatrist in Assessing and Reducing Fall Risk: An Updated Review.

Falls present a tremendous challenge to health care systems. This article reviews the literature from the previous 5 years (2014-2019) in terms of methods to assess fall risk and potential steps that can be taken to reduce fall risk for patients visiting podiatric clinics. With regard to assessing fall risk, we discuss the role of a thorough medical history and podiatric assessments of foot problems and deformities that can be performed in the clinic.

Choosing a Vibratory Test to Pair With Semmes Weinstein Monofilament Testing for Evaluating Lower Extremity Sensation in Patients With Diabetes: A Comparison of Three Vibratory Methodologies.

Background: Numerous guidelines recommend pairing Semmes-Weinstein monofilament (SWM) testing with a secondary clinical test when screening for diabetic peripheral neuropathy, yet time is very limited in clinical practice. This study compared the time to complete and the diagnostic agreement of three vibratory sensation tests.

Methods: Sixty-five individuals (42% male; aged: 61 ± 12 years) were recruited.

Measuring Plantar Tissue Stress in People With Diabetic Peripheral Neuropathy: A Critical Concept in Diabetic Foot Management.

Excessive stress on plantar tissue over time is one of the leading causes of diabetic foot ulcers among people with diabetic peripheral neuropathy. Plantar tissue stress (PTS) is a concept that attempts to integrate several well-known mechanical factors into one measure, including plantar pressure, shear stress, daily weight-bearing activity, and time spent in prescribed offloading interventions (adherence). Despite international diabetic foot guidelines recommending the measure of each of these individual mechanical factors in people with neuropathy, only recently has technology enabled their combined measurement to determine PTS.

Decreasing an Offloading Device's Size and Offsetting Its Imposed Limb-Length Discrepancy Lead to Improved Comfort and Gait.

Objective: Patient adherence is a challenge in offloading diabetic foot ulcers (DFUs) with removable cast walkers (RCWs). The size and weight of an RCW, changes to gait, and imposed limb-length discrepancies may all discourage adherence. This study sought to determine whether RCW size and provision of a contralateral limb lift affected users' comfort and gait.

Recent Advances and Future Opportunities to Address Challenges in Offloading Diabetic Feet: A Mini-Review.

Diabetic foot ulcers (DFU) are a substantial dilemma for geriatric individuals with diabetes. The breakdown in tissue associated with DFU is typically a result of repetitive cycles of physical stress placed on the feet during weight-bearing activity. Accordingly, a key tenet in healing as well as preventing DFU is the use of offloading footwear to redistribute physical stress away from high stress locations such as bony prominences.

Association Between Second Metatarsal Length and Forefoot Loading Under the Second Metatarsophalangeal Joint.

Background: Metatarsal length is believed to play a role in plantar plate dysfunction, although the mechanism through which progressive injury occurs is still uncertain. We aimed to clarify whether length of the second metatarsal was associated with increased plantar pressure measurements in the forefoot while walking.

Methods: Weightbearing radiographs and corresponding pedobarographic data from 100 patients in our practice walking without a limp were retrospectively reviewed.

Psychological and Biomechanical Aspects of Patient Adaptation to Diabetic Neuropathy and Foot Ulceration.

Purpose Of Review: The purpose of this review was to elucidate how psychological and biomechanical factors interrelate in shaping patients' experience with diabetic symmetric polyneuropathy (DSPN) and its sequela-diabetic foot ulceration (DFU).

Recent Findings: Recent findings emphasize the importance not only of neuropathic pain but also of other DSPN symptoms, such as unsteadiness. We highlight the negative spiral between unsteadiness, falls, and psychological distress.

Control of lower extremity edema in patients with diabetes: Double blind randomized controlled trial assessing the efficacy of mild compression diabetic socks.

Aims: Persons with diabetes frequently present with lower extremity (LE) edema; however, compression therapy is generally avoided for fear of compromising arterial circulation in a population with a high prevalence of peripheral arterial disease. This double blind randomized controlled trial (RCT) assessed whether diabetic socks with mild compression could reduce LE edema in patients with diabetes without negatively impacting vascularity.

Methods: Eighty subjects with LE edema and diabetes were randomized to receive either mild-compression knee high diabetic socks (18-25mmHg) or non-compression knee high diabetic socks.

Preliminary Evaluation of a Cycling Cleat Designed for Diabetic Foot Ulcers.

Background: Offloading devices for diabetic foot ulcers (DFU) generally restrict exercise. In addition to traditional health benefits, exercise could benefit DFU by increasing blood flow and acting as thermotherapy. This study functionally evaluated a cycling cleat designed for forefoot DFU.

Physiological and psychological challenges of increasing physical activity and exercise in patients at risk of diabetic foot ulcers: a critical review.

Obesity and a sedentary lifestyle are common challenges among individuals at risk of diabetic foot ulcers. While substantial research exists on physical activity interventions in adults with diabetes, those at greatest risk for foot ulceration were often excluded or not well represented. Both at-risk patients and their clinicians may be hesitant to increase physical activity because of their perception of diabetic foot ulcer risks.

Role and Determinants of Adherence to Off-loading in Diabetic Foot Ulcer Healing: A Prospective Investigation.

Objective: Studies indicate that off-loading adherence is low in patients with diabetic foot ulcers (DFUs), which may subsequently delay healing. However, there is little empirical evidence for this relationship or the factors that influence adherence.

Research Design And Methods: This prospective, multicenter, international study of 79 (46 from the U.

Monitoring Location-Specific Physical Activity via Integration of Accelerometry and Geotechnology Within Patients With or At Risk of Diabetic Foot Ulcers: A Technological Report.

Objective: Physical activity variability is a risk factor for diabetic foot ulcers (DFU). Geographic context may influence variability. This study developed initial methods for monitoring location-specific physical activity in this population.

Physical Examination Variables Predict Response to Conservative Treatment of Nonchronic Plantar Fasciitis: Secondary Analysis of a Randomized, Placebo-Controlled Footwear Study.

Background: Plantar fasciitis is a common, disabling condition, and the prognosis of conservative treatment is difficult to predict.

Objective: To determine whether initial clinical findings could help predict patient response to conservative treatment that primarily consisted of supportive footwear and stretching.

Setting: Patients were recruited and seen at 2 outpatient podiatric clinics in the Chicago, Illinois, metropolitan area.

Prognostic Value of Diagnostic Sonography in Patients With Plantar Fasciitis.

Objectives: The primary objective of this study was to determine whether the sonographic appearance of the plantar fascia is predictive of the treatment (ie, pain) response in patients receiving supportive therapy for proximal plantar fasciitis. This study was a secondary analysis of data obtained from a randomized controlled trial of ambulatory adults, which examined the efficacy of 3 different foot supports for plantar fasciitis.

Methods: Participants underwent diagnostic sonographic examinations of their heel at baseline and again at 3 months by a single experienced foot and ankle surgeon.

A randomized controlled trial of custom foot orthoses for the treatment of plantar heel pain.

Background: Up to 10% of people will experience heel pain. The purpose of this prospective, double-blind, randomized clinical trial was to compare custom foot orthoses (CFO), prefabricated foot orthoses (PFO), and sham insole treatment for plantar fasciitis.

Methods: Seventy-seven patients with plantar fasciitis for less than 1 year were included.

An immediate effect of custom-made ankle foot orthoses on postural stability in older adults.

Background: Foot and ankle problems are highly prevalent fall risks in the elderly. Ankle foot orthoses designed to stabilize the foot and ankles have been studied within specific patient groups, but their efficacy with a less restrictive elderly population is unknown. This study investigated if custom-made ankle foot orthoses improve postural stability in older adults.

Association of footprint measurements with plantar kinetics: a linear regression model.

Background: The use of foot measurements to classify morphology and interpret foot function remains one of the focal concepts of lower-extremity biomechanics. However, only 27% to 55% of midfoot variance in foot pressures has been determined in the most comprehensive models. We investigated whether dynamic walking footprint measurements are associated with inter-individual foot loading variability.