Amazing podiatric medical schools
Increasing need for Doctors of Podiatric Medicine
Expert in the lower extremity
Option to perform surgeries
Type 1 (juvenile diabetes)
- Approximately 10% are affected – not common
- Immune system attacks β cells that produce insulin
- Daily administration of insulin required
Type 2 (adult-onset diabetes)
- Approximately 90% are affected
- Characterized by insulin resistance and/or relative insulin
deficiency ~ due to receptor
- Being overweight/obese may play a role
Facts About Diabetes
Age, family history, and ethnicity play a role in
According to the International Diabetes Federation,
there are 382 million people in the world with diabetes;
37 million in North America
By 2035 an estimated 592 million may be affected
North America spends an estimated 263 billion on
Global killer – every 7 seconds someone dies
Is there any good news..?
Many inexpensive and cost-effective
Proven strategies for improving the living environment, changing
diet and increasing physical activity can reverse the pandemic.
Walking is an unconscious effort, but requires symmetry
and reproducible timing
Deviations from normal gait can hint at multiple disease
Diabetes affects feet through its impact on circulation and
sensation a lack thereof leads to complications
Gait analysis studies for patients with diabetes vary
Results can be confusing and contradictory, BUT clear
Gait Analysis Diagram
comprised of 2 phases
A series of “controlled” falls
*point of reference is the
Gait: Stance Phase
foot is in contact with the ground
1 Heel Contact – R.heel contact,
ends with tow off of L.foot
2 Midstance – toe off of L.foot and
ends with heel lift of R.foot
3 Active Propulsion – heel lift of
R.foot and ends with heel contact of
4 Passive Propulsion – heel contact
of L.foot and ends with toe off of
Gait: Swing Phase
foot is NOT grounded
During 2/3 of the stance phase,
the opposite leg is in swing phase
1 Acceleration – provides foot
clearance away from ground
2 Midswing – swing leg advances
through and in front of the stance
3 Deceleration – leg in the swing
phase must be slowed before heel
Other Points of Analysis
1 Pelvic Tilt
2 Pelvic Rotation
3 Lateral Shift
4 Width of Base
5 Stride Length
6 Step Length
Plantar Pressure & Gait
Repetitive mechanical stress & loss of protective
sensation on the plantar surface of the foot are
considered relevant factors in skin breakdown resulting
in foot ulcerations…so let’s reduce the peak plantar
Traditional view is that high PPP is bad and low PPP
is good…is it this cut and dry ?
How a Diabetic’s Gait Differs
Decreased walking speed
Decreased step length
Decreased single limb support
Decreased step variability
Decreased knee and ankle
Decreased ground reactive
Decreased joint angles
Increased width of base
Increased double stance support
Increased time needed to
complete gait cycle
Overall increase in energy
Why does it differ?
Research has not confirmed casual relationships between
gait and diabetes, but there are suspects – Neuropathy #1
Possible that proprioceptive deficits cause diabetics to walk
Studies comparing patients with and without diabetes aren’t
clear regarding which gait alterations are specific to
neuropathy and which affect those without neuropathy
The presence of other factors also impinge on normal gait
How DPM’s help…
Comprehensive foot care programs reduce amputation
rates by 45 – 85%
Use innovative treatments (i.e. HBOT)
Dedicated in executing treatments that are multi-faceted
- guidelines must be followed
Podiatry assessments/treatments can be all-inclusive
Amount of research completed and in-progress is
Case 1: PLANTAR PRESSURE DISTRIBUTION
IN DIABETIC NEUROPATHY PATIENTS WITH
A HISTORY OF FOOT ULCERS
Hypothesis: Even with healed ulcers, diabetic neuropathy patients with a
history of ulceration would still show an altered distribution of plantar
Method: PP distribution recorded during barefoot gait to avoid influence
of compounding factors (i.e. shoes)
CG: n=20 DN: n=17 DNU: n=10
Result: Velocities amongst the 3 groups were NOT significantly different.
Peak pressure, especially the pressure-time integral, was different in all
groups – highest in DNU sample
Case 2: EFFECTIVENESS OF INSOLES ON
PLANTAR PRESSURE REDISTRIBUTION
Figure. Definitions of foot
regions. MTH=metatarsal head
Methods: Analyze gait in non-diabetic control
group (n=8) and in a diabetic group (n=7)
using various insoles
- Types of Insoles: shoe-only, flat insole, and
three contoured insoles (non-weight, semi-
weight, and full-weight-bearing)
Result: Insoles are affective! Peak pressure
and pressure-time integral were highest in
diabetic group. Semi-weight bearing insole
was immediately effective.
Improvements To Be Made
Make gait analysis more accessible and
Try “ideal approach” when identifying the
relationship between plantar pressure and
Increased patient education
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DeBrule, Michael. "A Closer Look at Gait Analysis in Patients with Diabetes." Podiatry Today 27.3 (2014): 44-50. Web. 1 Apr. 2014.
Goldman, Sari, Devin Poonai, Oendrila Kamal, and Khurram H. Khan. "Emphasizing Proactive Gait Assessment in Patients with Diabetes." Podiatry Today 24.4
(2011): 20-26. Web. 1 Apr. 2014. <http://www.podiatrytoday.com/emphasizing-proactive-gait-assessment-patients-diabetes?page=1>.
Huang, Enoch T., and Javier La Fontaine. "HBOT: Is it worth it for DFU's?" Podiatry Today 27.3 (2014): 78-83. Web. 1 Apr. 2014.
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Khan, Tahir, and Ron Guberman. "Gait alterations associated with diabetic neuropathy." Lower Extremity Review Aug. 2012. Web. 6 Apr. 2014.
Ko, Mansoo. "Plantar pressure and gait in patients with diabetes." Lower Extremity Review Oct. 2010. Web. 2 Apr. 2014.
Liu, Rui, Ling Li, Mengliu Yang, Guenther Boden, and Gangyi Yang. "Systemic Review of the Effectiveness of Hyperbaric Oxygenation Therapy in the
Management of Chronic Diabetic Foot Ulcers." Mayo Clinic 88.2 (2013): 166-75. Web. 6 Apr. 2014.
Normal and Abnormal Gait Series. YouTube, 2013. Web. 1 Apr. 2014. <http://www.youtube.com/watch?v=VYVyoFdJHdU>.
Tsung, Bonne, Ming Zhang, Arthur Mak, and Margaret Wong. "Effectiveness of insoles on plantar pressure redistribution." Journal of Rehabilitation Research &
Development 41.6A (2004): 767-73. Web. 1 Apr. 2014.
Wu, Stephanie C., Vickie R. Driver, James S. Wrobel, and David G. Armstrong. "Foot ulcers in the diabetic patient, prevention and treatment." Vascular Health
and Risk Management 3.1 (2007): 65-76. Web. 20 Apr. 2014. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1994045/>.