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Background: Midfoot and ankle movement dysfunction in people with diabetes mellitus and peripheral neuropathy (DMPN) is associated with midfoot deformity and increased plantar pressures during gait. If midfoot and ankle motion during heel rise and push-off of gait have similar mechanics, heel rise performance could be a clinically feasible way to identify abnormal midfoot and ankle function during gait., Research Question: Is midfoot and ankle joint motion during a heel rise associated with midfoot and ankle motion at push-off during gait in people with DMPN?, Methods: Sixty adults with DMPN completed double-limb heel rise, single-limb heel rise, and walking. A modified Oxford multi-segment foot model (forefoot, hindfoot, shank) was used to analyze midfoot (forefoot on hindfoot) and ankle (hindfoot on shank) sagittal angle during heel rise and gait. Pearson correlation was used to test the relationship between heel rise and gait kinematic variables (n = 60). Additionally, we classified 60 participants into two subgroups based on midfoot and ankle position at peak heel rise: midfoot and ankle dorsiflexed (dorsiflexed; n = 23) and midfoot and ankle plantarflexed (plantarflexed; n = 20). Movement trajectories of midfoot and ankle motion during single-limb heel rise and gait of the subgroups were examined., Results: Peak double-limb heel rise and gait midfoot and ankle angles were significantly correlated (r = 0.49 and r = 0.40, respectively). Peak single-limb heel rise and gait midfoot and ankle angles were significantly correlated (r = 0.63 and r = 0.54, respectively). The dorsiflexed subgroup, identified by heel rise performance showed greater midfoot and ankle dorsiflexion during gait compared to the plantarflexed subgroup (mean difference between subgroups: midfoot 3°, ankle 3°)., Significance: People with DMPN who fail to plantarflex the midfoot and ankle during heel rise have difficulty plantarflexing the midfoot and ankle during gait. Utilizing a heel rise task may help identify midfoot and ankle dysfunction associated with gait in people with DMPN., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: The purpose of this study is to develop a non-contrast magnetic resonance imaging (MRI) approach to evaluate skeletal muscle perfusion in the diabetic foot based on the concept of angiosomes of the foot., Methods: Five healthy volunteers and five participants with diabetes (HbA1c = 7.2 ± 1.8%) without a history of peripheral artery disease were examined. The non-contrast perfusion measurements were performed during a toe flexion challenge. Absolute perfusion maps were created and two regions (medial and lateral) on the maps were segmented based on angiosomes., Result: Regional difference in the perfusion of foot muscle was readily visualized in the MRI perfusion angiosomes during the challenge. In the participants with diabetes, the perfusion during toe flexion challenge was significantly lower than in healthy volunteers (P < 0.01). The average perfusion for the medial plantar region of the right foot was lower in subjects with diabetes (38 ± 9 ml/min/100 g) than in healthy subjects (93 ± 33 ml/min/100 g)., Conclusions: Non-contrast MRI perfusion angiosome maps demonstrate the feasibility of determining regional perfusion in foot muscles during toe challenge and may facilitate evaluation of muscle perfusion in diabetic feet., Key Points: • Non-contrast MRI perfusion angiosome maps measure regional perfusion in foot muscles non-invasively. • Foot perfusion response to challenge is reduced in persons with diabetes. • MRI perfusion angiosome maps may help evaluation of regional foot muscle perfusion.

Background: In people with diabetes and peripheral neuropathy (DM+PN), injury risk is not clearly known for weight bearing (WB) vs. non-weight bearing (NWB) exercise. In-shoe peak plantar pressures (PPP) often are used as a surrogate indicator of injury to the insensitive foot., Objective: Compare PPPs in people with DM+PN during selected WB and NWB exercises., Methods: Fifteen subjects with DM+PN participated. PPPs were recorded for the forefoot, midfoot, and heel during level walking and compared to; WB exercises--treadmill walking, heel and toe raises, sit to stands, stair climbing, single leg standing; and NWB exercises--stationary bicycling, balance ball exercise and plantar flexion exercise., Results: Compared to level walking; mean forefoot PPP during treadmill walking was 13% higher, but this difference was eliminated when walking speed was used as a covariate. Mean PPPs were similar or substantially lower for other exercises, except for higher forefoot PPP with heel raise exercises., Conclusions: Slow progression and regular monitoring of insensitive feet are recommended for all exercises, but especially for heel raises, and increases in walking speed. The remaining WB and NWB exercises pose no greater risk to the insensitive foot due to increases in PPP compared to level walking., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Plantar soft tissue stiffness and thickness are important biomechanical variables to understand stress concentrations that may contribute to tissue injury., Objective: The purpose of this study was to determine the effects of passive metatarsal phalangeal joint (MPJ) extension on plantar soft tissue stiffness and thickness., Methods: Seventeen healthy participants (7 male, 10 female, mean age 25.3 years, S.D. 4.4 years, mean BMI 24.7 kg/m(2), S.D. 3.2 kg/m(2)) were tested. Plantar soft tissue stiffness and thickness were measured at the metatarsal heads, midfoot and heel using a custom-built indentor device and an ultrasound machine., Results: Indicators of soft tissue stiffness (K1 values) at the metatarsal heads and midfoot showed increases in stiffness of 81-88% (S.D.20-33%) in the MPJ extension position compared with the MPJ neutral position. Soft tissue thickness measures at the metatarsal heads with the MPJ in neutral ranged from a mean of 8.9 to 13.5mm and decreased, on average, by 8.8% (S.D. 2.9%) with MPJ extension., Conclusions: MPJ extension has a profound effect on increasing forefoot plantar soft tissue stiffness and a consistent but minimal effect on reducing soft tissue thickness. These changes may help transform the foot into a rigid lever at push-off consistent with the theory of the windlass mechanism.

Background: Stresses within the neuropathic foot's tissues can be estimated by pressure distributions and may provide information regarding the potential for skin breakdown. The purposes of this study were to: (1) determine the magnitude of peak plantar pressure, pressure time integral, peak pressure gradient, and peak maximum shear stress; and (2) determine the association of these variables with one another., Methods: Forefoot peak plantar pressure, pressure time integral, peak pressure gradient, peak maximal shear stress, and depth of peak maximal shear stress were calculated for 16 controls, 16 people with diabetic neuropathy, and 22 people with diabetic neuropathy and a history of ulceration from pressure assessments., Findings: Peak plantar pressure, pressure gradient, and maximal shear stress were greater in subjects with a history of ulceration relative to control subjects (P<0.03), pressure gradient was greater in subjects with diabetic neuropathy and a history of ulceration compared to subjects with diabetic neuropathy and no history of ulceration (P<0.02), and depth of maximal shear stress was less in both groups of subjects with diabetic neuropathy compared to controls (P<0.03). Strong relationships existed between the variables., Interpretation: Although these variables are associated with one another, peak pressure gradient and peak maximal shear stress provide information concerning plantar pressure distribution and the potentially injurious internal stresses within the foot's soft tissues. Peak pressure gradient and peak maximal shear stress may perhaps be more discriminating than peak plantar pressure alone in distinguishing between groups of individuals who are at risk for developing a foot ulcer.

The pressure distribution on the plantar surface of the foot may provide insights into the stresses within the subsurface tissues of patients with diabetes mellitus and peripheral neuropathy (PN) who are at risk for skin breakdown. The purposes of this study were to (1) estimate the stress distribution in the subsurface soft tissue from a measured surface pressure distribution and determine any differences between values in the forefoot and rearfoot, and (2) determine the relationship between maximum shear stress (MSS) (magnitude and depth) and characteristics of the pressure distribution. The measured in-shoe pressure distributions during walking characterized by the peak plantar pressure and maximum pressure gradient on the plantar surface of the feet for 20 subjects with diabetes, PN and history of a mid foot or forefoot plantar ulcer were analyzed. The effects of peak pressure and maximum pressure gradient at the peak pressure location on the stress components in the subsurface soft tissue were studied using a potential function method to estimate the subsurface tissue stress. The calculated MSSs are larger in magnitude and located closer to the surface in the forefoot, where most skin breakdown occurs, compared to the rearfoot. In addition, the MSS (magnitude and depth) is highly correlated with the pressure gradient (r=-0.77 & 0.61) and the peak pressure (r=-0.61 & 0.91). The peak pressure and the maximum pressure gradient obtained from the surface pressure distribution appear to be important variables to identify where MSSs are located in the subsurface tissues on the plantar foot that may lead to skin break down.

Background: Standard prevention and treatment strategies to decrease peak plantar pressure include a total contact insert with a metatarsal pad, but no clear guidelines exist to determine optimal placement of the pad with respect to the metatarsal head. The purpose of this study was to determine the effect of metatarsal pad location on peak plantar pressure in subjects with diabetes mellitus and peripheral neuropathy., Methods: Twenty subjects with diabetes mellitus, peripheral neuropathy, and a history of forefoot plantar ulcers were studied (12 men and eight women, mean age=57+/-9 years). CT determined the position of the metatarsal pad relative to metatarsal head and peak plantar pressures were measured on subjects in three footwear conditions: extra-depth shoes and a 1) total contact insert, 2) total contact insert and a proximal metatarsal pad, and 3) total contact insert and a distal metatarsal pad. The change in peak plantar pressure between shoe conditions was plotted and compared to metatarsal pad position relative to the second metatarsal head., Results: Compared to the total contact insert, all metatarsal pad placements between 6.1 mm to 10.6 mm proximal to the metatarsal head line resulted in a pressure reduction (average reduction=32+/-16%). Metatarsal pad placements between 1.8 mm distal and 6.1 mm proximal and between 10.6 mm proximal and 16.8 mm proximal to the metatarsal head line resulted in variable peak plantar pressure reduction (average reduction=16+/-21%). Peak plantar pressure increased when the metatarsal pad was located more than 1.8 mm distal to the metatarsal head line., Conclusions: Consistent peak plantar pressure reduction occurred when the metatarsal pad in this study was located between 6 to 11 mm proximal to the metatarsal head line. Pressure reduction lessened as the metatarsal pad moved outside of this range and actually increased if the pad was located too distal of this range. Computational models are needed to help predict optimal location of metatarsal pad with a variety of sizes, shapes, and material properties.

The primary objective of conservative care for the diabetic foot is to protect the foot from excessive pressures. Pressure reduction and redistribution may be achieved by designing and fabricating orthotic devices based on foot structure, tissue mechanics, and external loads on the diabetic foot. The purpose of this paper is to describe the process used for the development of patient-specific mathematical models of the second and third rays of the foot, their solution by the finite element method, and their sensitivity to model parameters and assumptions. We hypothesized that the least complex model to capture the pressure distribution in the region of the metatarsal heads would include the bony structure segmented as toe, metatarsal and support, with cartilage between the bones, plantar fascia and soft tissue. To check the hypothesis, several models were constructed with different levels of details. The process of numerical simulation is comprised of three constituent parts: model definition, numerical solution and prediction. In this paper the main considerations relating model selection and computation of approximate solutions by the finite element method are considered. The fit of forefoot plantar pressures estimated using the FEA models and those explicitly tested were good as evidenced by high Pearson correlations (r=0.70-0.98) and small bias and dispersion. We concluded that incorporating bone support, metatarsal and toes with linear material properties, tendon and fascia with linear material properties, soft tissue with nonlinear material properties, is sufficient for the determination of the pressure distribution in the metatarsal head region in the push-off position, both barefoot and with shoe and total contact insert. Patient-specific examples are presented.

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: To determine the reliability of identifying the location of each metatarsal head from spiral X-ray computed tomography on a matrix type pressure sensor recording., Design: Experimental; test-retest and within subject two-condition comparison., Background: Plantar pressure data quantify the amount of pressure and the general location of pressure. Specific anatomical structures associated with the site of pressure can only be determined by registering radiological data to the pressure sensor., Methods: Eighteen subjects, nine individuals without diabetes mellitus and nine individuals with diabetes mellitus, peripheral neuropathy, and a history of plantar foot ulcers, participated in plantar pressure testing and spiral X-ray computed tomography scanning of their foot. A registration technique was developed to align spiral X-ray computed tomography data with pressure sensor data., Results: When mapping the metatarsal head locations to the pressure sensor 48 of 90 metatarsal head locations were identical between repeated test occasions (53.3%), 40 of 90 metatarsal head locations were one pixel (5.08 mm) different between repeated test occasions (44.4%), and 2 of 90 were two pixels different (2.2%). Ninety-eight percent of repeated measures replicated exactly or varied by one pixel., Conclusion: Anatomical data from spiral X-ray computed tomography scanning can be reliably co-registered with pressure data., Relevance: The ability to match bony anatomy to pressure data allows better understanding of structural factors contributing to peak pressure, provides precise information for three-dimensional modeling of the foot, and can improve orthotic fabrication and modification aimed at reducing pressure on the bottom of the foot.

Objectives: To compare the amount of weight-bearing activity and estimates of cumulative plantar tissue stress between subjects with and without diabetes mellitus and a history of recurrent plantar ulcers., Design: Cross-sectional study with matched groups., Background: Weight-bearing activity among individuals with diabetes is likely to influence the amount of mechanical trauma accumulated by plantar tissues, yet activity levels have not been accounted for in previous measurements of plantar tissue stress or predictions of plantar tissue injury., Methods: Study groups included subjects with diabetes mellitus and peripheral neuropathy, either with or without a history of recurrent plantar ulcers, and non-diabetic control subjects (n=10 per group). Pressure on the plantar foot was assessed as subjects walked at their preferred speed in the shoes they reported wearing most often each day. Physical activity was monitored over seven consecutive days using an accelerometer. The product of mean daily strides and forefoot pressure-time integral was used to estimate daily cumulative stress on the plantar forefoot., Results: Subjects with diabetes and a history of recurrent plantar ulcers were 46% less active than subjects without diabetes (mean (SD)=2727 (1345) versus 5037 (2624) strides/day, P=0.04), and accumulated 41% less daily stress on the forefoot than non-diabetic and diabetic control subjects without a history of plantar ulcers (mean (SD)= 210 (134) versus 354 (118) and 354 (148) MPas/day respectively, P=0.03)., Conclusions: Subjects with diabetes and a history a previous ulcers may be susceptible to plantar tissue injury even at relatively low levels of cumulative tissue stress., Relevance: Changes in weight-bearing activity following plantar tissue injury in patients with diabetes may influence plantar tissue adaptation and the risk of ulcer recurrence.

Objective: To test the accuracy and precision of computed tomography (CT) imaging for describing the 3-dimensional structure of the foot in patients with diabetes mellitus and peripheral neuropathy., Design: Experimental, test-retest., Setting: Clinical CT scanner at a local hospital., Specimens: Two tissue-equivalent phantoms and 6 cadaver feet., Main Outcome Measures: Measurements taken from CT data of phantoms and cadaver feet were compared with physical (caliper) measurements. The feasibility of creating a computer-aided design/rapid prototyping 3-dimensional model from CT data was assessed by using 1 cadaver foot., Results: No bias was found for phantom or cadaver CT measurements compared with caliper measurements. The mean difference between repeat scans of cadaver feet (1 observer) was 0.1 +/- 0.8 mm and between observers, 0.4 +/- 0.8 mm. Comparing caliper measurements of the rapid prototype model and actual foot measurements revealed an error of 0.3 +/- 0.4 mm., Conclusion: CT-based 3-dimensional imaging produced accurate and precise foot measurements, enabling description of internal and external structures. This capability will be coupled with plantar pressure measurements to improve our understanding and treatment of foot ulcers in people with diabetes., (Copyright 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)

We have designed, built, and tested a portable indentor device that allows us to determine force/displacement (F/D) measurements on soft tissue in a clinical or research setting. The indentor system consists of a load cell mounted on a three-dimensional measurement device (Metrecom). The output of the load cell and the Metrecom are recorded and analyzed by software running on a notebook computer. The displacement calibration of the Metrecom gave an average error = 0.005 mm [standard deviation (SD) = 0.062)]. The force calibration of the load cell resulted in an average error = 0.022 N (SD = 0.049) and a linearity of 1.0062 (R2 = 0.9998). The indentor device was tested on six different human soft tissues by two different investigators. The interreliabilities and intrareliabilities were 0.99 [interclass correlation (ICC)] indicating that the results were repeatable by more than one investigator. F/D measurements from indentor testing on two materials were comparable to values measured using an Instron device (5.34 versus. 5.52 N/mm, and 0.98 versus 1.04 N/mm). The device was used to measure the soft tissue characteristics on the plantar surface of the foot of one subject. These data were used to calculate the effective Young's modulus for the tissue using equations derived by Zheng et al. [1] and indicated a wide range of values dependent upon the portion of the F/D curve used. All results indicate data from this portable indentor device are reliable, accurate, and sensitive enough to identify mechanical properties of human tissues.

High plantar pressures contribute to skin breakdown in patients with diabetes mellitus and peripheral neuropathy. The primary purpose of this study was to determine the point during the stance phase of walking that corresponds with forefoot peak plantar pressures. Results indicate that peak plantar pressures occurred at 80% +/- 5% of the stance phase of gait in subjects with diabetes and transmetatarsal amputation, as well as in control subjects. Improved methods of footwear design or walking strategies proposed to patients should focus on the demands of the foot during the late stance phase of walking in order to increase available weightbearing area or to decrease forces, which will minimize plantar pressures and reduce trauma to the neuropathic foot.

Physical therapists use various gait training strategies to reduce stress on the lower extremities, but we could find no description or evaluation of the step-to gait using a cane. The purpose of this study was to evaluate the effect of a step-to gait pattern and a cane on peak plantar pressures on the forefoot and the heel. Ten healthy subjects were evaluated (five females, five males, mean age = 24.6 +/- 4.9 years). In addition, one subject with peripheral neuropathy was tested to determine if a patient could be trained to use the step-to walking pattern and show similar results. All subjects were instructed in four walking conditions; step-to with and without a cane and step-through with and without a cane. Walking speed during the step-through pattern (normal walking) was matched to the speed of the step-to pattern. For the 10 healthy subjects, peak plantar pressures and walking speed of each of the four conditions were compared using a 2 x 2 repeated measures analysis of variance. One factor was gait pattern and one factor was use of a cane. Peak plantar pressures decreased an average of 53% on the forefoot but increased an average of 14% on the heel when subjects walked using step-to gait compared with a step-through gait. There was no effect due to use of a cane or walking speed between the conditions. The patient with peripheral neuropathy demonstrated a similar pattern but greater magnitude of changes compared with the healthy subjects. The foot initiating the step-to pattern showed a reduction in peak plantar pressures on the forefoot, probably because the foot remained flat during stance phase and a large push-off was not required. The step-to pattern, however, results in a slower and less symmetrical gait. The use of a step-to gait may be beneficial for patient populations that need to reduce plantar pressures on the forefoot.

The purpose of this study of patients with transmetatarsal amputation (TMA) is to describe multiple patient characteristics, including the incidence of subsequent skin breakdown and higher amputation, that may influence rehabilitation treatment and outcomes. Data were gathered on all patients having a TMA at this facility between April 1989 and September 1993. One hundred twenty TMAs were performed on 107 patients with a mean age of 62.4 +/- 13.8 years. There were 55 men and 52 women. Thirteen patients (12%) had a bilateral TMA. Twenty-nine patients (27%) developed skin breakdown. Of these, 48% occurred within the first 3 months after surgery. Thirty patients (28%) required a higher amputation. Of these, 60% occurred in the first month after TMA. In addition, this group of patients had a high incidence of diabetes mellitus (77%), hypertension (54%), electrocardiogram (EKG) abnormalities (60%), congestive heart failure (22%), and prior ipsilateral vascular surgery (51%). These results indicate that patients with TMA often present with a complicated medical condition and that they are at high risk of skin breakdown or higher amputation, especially in the first 3 months after surgery. The investigators conclude that patients with TMA may benefit from a rehabilitation program emphasizing protection of the residuum during their return to functional activities. Additional research is needed to determine optimal acute and long-term rehabilitation of patients with TMA.

Treatment of neuropathic plantar ulcers often is directed at reducing excessive, repeated peak plantar pressures (PPP). The purposes of this study were to determine whether instructing a subject to walk using a hip strategy would reduce forefoot PPP and change the kinematics of walking during a single session of testing. Thirteen subjects, 7 with peripheral neuropathy and a history of a recent plantar ulcer, and 6 controls participated. PPPs were measured with an in-shoe pressure monitoring system. Kinematics were measured with a computer-assisted motion analysis system. After data were collected as subjects walked using their normal walking pattern, subjects were instructed to walk using the hip strategy by decreasing their push-off, pulling their leg forward from their hips, decreasing step length, and maintaining their normal walking velocity. Compared with using the normal (ankle) strategy, using the hip strategy showed a significant 27% decrease in forefoot PPP and a 24% increase in heel PPP. Kinematic changes were decreased plantar flexion angular velocity, hip extension range-of motion (ROM), and step length, increased dorsiflexion ROM, and hip flexion ROM, but no change in walking velocity. These findings indicate that a change in walking pattern can result in lower forefoot PPP during a single session. Assuming patients can maintain the alterations in their walking pattern, these adaptations may help to heal plantar ulcers in some patients with peripheral neuropathy.

The measure of navicular drop has been used as an indicator of pronation at the foot. It is defined as the distance the navicular tuberosity moves in standing, as the subtalar joint is allowed to move from its neutral position to a relaxed position. The purposes of this study were to test the reliability of a method to measure navicular drop and to assess the relationships among measures of forefoot to rearfoot position, subtalar joint neutral position, and navicular drop. The results support traditional biomechanical theory but indicate that other factors contribute significantly to navicular drop.

The purpose of this study was to examine the ability of a video-based, computer-interfaced motion analysis system to provide reliable data. Ten subjects with no significant orthopedic or neurological dysfunction and ranging in age from 22 to 45 years (mean = 29.6, SD = 7.8) were tested. Retroreflective markers were placed on the posterior shank and foot of each subject. Footswitches were attached to the plantar forefoot and rear foot. A video camera was placed behind the subject, and video data were collected while the subject walked on a treadmill. One representative gait cycle for each subject was selected and processed 10 times with a video processor and analysis software. Three intraclass correlation coefficients (ICCs) were calculated for variables generated by the analysis software, one for two individual measures and one each for the mean of three and five repeated measures. Except for temporal variables, processing data introduced additional variability into the measurement process, particularly for angular velocity data. Measurement of all variables was highly reliable (ICC values greater than or equal to .95) when based on the mean of at least three repeated measures. Although a single measure of temporal and angular position variables may be considered reliable, we recommend using a mean of three trials for angular velocity variables. Additional research is needed to determine tester and subject variability and validity of the measures.

The purpose of this study was to establish the interrater and intrarater reliability of various ankle and foot measures common to a diabetic evaluation. Bilateral biomechanical, sensory, and wound-size measurements were obtained in 31 subjects with diabetes mellitus. Twenty-five subjects were retested by the initial examiner to determine intratester reliability, and all subjects were retested by another examiner to determine intertester reliability. Both examiners participated in an extensive training period prior to the initiation of this study to minimize variability between and within measurers. Intraclass correlation coefficients for interrater and intrarater measurements ranged from .58 to .89 and from .74 to .99, respectively. The results of this study indicate that ankle and foot measurements common to a diabetic evaluation can be taken reliably between testers. We believe extensive examiner training in these clinically relevant measures can improve reliability between testers.