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Objective: Peak plantar pressures (PPPs) have been studied extensively as a contributing factor to skin breakdown, especially in the forefoot where most plantar neuropathic ulcers occur. The purposes of this article were to 1) describe an additional pressure variable, the peak pressure gradient (PPG), 2) determine whether the PPG is higher in the forefoot than in the rearfoot (even when compared with PPP), and 3) determine the correlation between the PPG and PPP at the forefoot and rearfoot in subjects with diabetes, peripheral neuropathy, and a history of plantar ulcer., Research Design and Methods: Twenty subjects (12 male and 8 female) with diabetes, peripheral neuropathy, and a mean +/- SD age of 57 +/- 9 years participated. Plantar pressures were collected during walking in footwear. The PPP and the PPG (defined as the spatial change in plantar pressure across adjacent sites of the foot surface around the PPP) were determined for the forefoot and rearfoot, and the forefoot-to-rearfoot ratios for each variable were calculated., Results: The mean PPG was 143% higher in the forefoot than in the rearfoot, whereas the mean PPP was only 36% higher in the forefoot than in the rearfoot (P < 0.0001). The PPG forefoot-to-rearfoot ratio (2.84 +/- 1.36) was nearly two times greater than the PPP forefoot-to-rearfoot ratio (1.48 +/- 0.58) (P < 0.0001). The correlation between PPP and PPG was r = 0.59 at the forefoot and r = 0.75 at the rearfoot., Conclusions: The PPG was substantially higher in the forefoot than in the rearfoot even when compared with the PPP. The PPG appears to be providing additional information about the stresses experienced by the soft tissues of the foot, especially in the forefoot. The PPG may be a useful indicator of skin trauma because spatial changes in high plantar pressures may identify high stress concentrations within the soft tissue.

Objective: An Achilles tendon-lengthening (ATL) procedure is effective at reducing ulcer recurrence in patients with diabetes, peripheral neuropathy, and a plantar ulcer, but its effects on functional limitations and perceived disability are unknown. The purpose of this study is to report the effects of an ATL and total contact casting (TCC) on the functional limitations and perceived disability of patients with neuropathic plantar ulcers., Research Design and Methods: Twenty-eight subjects with a mean age of 55 +/- 10 years and a BMI of 33 +/- 6 kg/m(2) participated. All subjects had a history of diabetes, loss of protective sensation, limited ankle motion, and a recurrent forefoot ulcer. Subjects were randomized into two groups: an ATL group (n = 14), who received treatment of ATL, and TCC and a TCC group (n = 14), who received TCC only. Subjects completed a modified physical performance test (PPT) and the SF-36 Health Survey before treatment, after primary treatment and healing of the plantar forefoot ulcer, and 8 months after initial ulcer healing., Results: There were no significant changes in functional limitations as measured by the PPT between groups or over time. The physical summary score of the SF-36 decreased slightly from before treatment to 8 months after initial ulcer healing in the ATL group (35 +/- 7 to 31 +/- 6), whereas the TCC group score increased during this time (34 +/- 8 to 39 +/- 11; P < 0.05)., Conclusions: The ATL resulted in no measurable change in functional limitations, but patients receiving an ATL and TCC reported lower physical functioning at 8 months after initial ulcer healing than subjects receiving TCC alone and may require additional physical therapy to address this perceived disability.

Objective: To compare how footwear (full-length shoe or short shoe), a total contact insert, a rigid rocker-bottom (RRB) sole, and an ankle-foot orthosis (AFO) affect peak plantar pressure (PPP) on the distal residuum and contralateral extremity of patients with diabetes and transmetatarsal amputation (TMA)., Research Design and Methods: Thirty patients with diabetes and TMA participated (mean age 62 +/- 4 years). In-shoe plantar pressures during walking were measured in six types of footwear. Each measurement occurred after a 1-month adjustment period. Repeated measure analysis of variance (ANOVA) was used to compare treatments., Results: All five types of therapeutic footwear reduced plantar pressures compared with regular shoes with a toe-filler (P < 0.05). A full-length shoe, total contact insert, and RRB sole resulted in lower pressures on the distal residuum (222 vs. 284 kPa) and forefoot of the contralateral extremity (197 vs. 239 kPa), compared with a regular shoe and toe-filler. Footwear with an AFO showed reduced PPP on the residuum, but most patients complained of reduced ankle motion during walking. A short shoe reduced pressures on the residuum, but not on the contralateral extremity, and many patients had complaints regarding cosmesis of the shoe., Conclusions: The full-length shoe, total contact insert, and an RRB sole provided the best pressure reduction for the residuum and contralateral foot, with the optimal compromise for cosmetic acceptance and function.

This study compared the treatment of total contact casting (TCC) with traditional dressing treatment (TDT) in the management of diabetic plantar ulcers. Forty patients with diabetes mellitus and a plantar ulcer but with no gross infection, osteomyelitis, or gangrene were randomly assigned to the TCC group (n = 21) or TDT group (n = 19). Age, sex, ratio of insulin-dependent diabetes mellitus to non-insulin-dependent diabetes mellitus, duration of diabetes mellitus, vascular status, size and duration of ulcer, and sensation were not significantly different between groups (P greater than .05). In the experimental group, TCC was applied on the initial visit, and subjects were instructed to limit ambulation to approximately 33% of their usual activity. Subjects in the control group were prescribed dressing changes and accommodative footwear and were instructed to avoid bearing weight on the involved extremity. Ulcers were considered healed if they showed complete skin closure with no drainage. Ulcers were considered not healed if they showed no decrease in size by 6 wk or if infection developed that required hospitalization. In the TCC group, 19 of 21 ulcers healed in 42 +/- 29 days; in the TDT group, 6 of 19 ulcers healed in 65 +/- 29 days. Significantly more ulcers healed (chi 2 = 12.4, P less than .05) and fewer infections developed (chi 2 = 4.1, P less than .05) in the TCC group. We conclude TCC is a successful method of treating diabetic plantar ulcers but requires careful application, close follow-up, and patient compliance with scheduled appointments to minimize complications.