This document discusses orthotic management for diabetes mellitus patients. It describes the types and causes of diabetes, common foot deformities and complications like diabetic foot ulcers. It explains that diabetic foot ulcers are wounds on the feet that occur in 15% of diabetics and increase the risk of lower extremity amputation. The document outlines various orthotic options for managing diabetic feet, including prescription footwear, total contact casts, removable cast walkers, half shoes, scotchcast boots, compressive wraps, shoe inserts, socks, and surgery in severe cases of infection or non-healing ulcers.

1. RANI KUMARI
AIIPMR,MUMBAI
Orthotic Management for Diabetes Mellitus patients

2. What is diabetes mellitus
Sign and symptoms of diabetic mellitus
Types of diabetic mellitus
Grade of diabetic mellitus
Cause of diabetic mellitus
Orthotic management of diabetic mellitus
How to control the diabetes
Complication of diabetic foot

3.  Diabetes mellitus is a group of metabolic diseases
characterized by hyperglycemia resulting from defects in
insulin secretion, insulin action, or both.
 The chronic hyperglycemia of diabetes is associated with
long-term damage, dysfunction, and failure of various
organs, especially the eyes, kidneys, nerves, heart, and
blood vessels.
 Diabetic foot is defined as any foot pathology that results
directly from diabetes or its long term complications
 Two types of diabetes: type I and type II diabetes

5.  Diabetes Ratio in India
 India is home to 50 million people with diabetes, Projections
show that this will increase to 70 million in 2025.
 With the largest number of diabetic patients, India leads the
“Diabetes Capital of the World”.
 Between 5% and 10% of the nation's health budget is spent
on the prevention and treatment of diabetes.
 In India, diabetes is no longer a disease of the affluent
or a rich man's disease.

12. 3.Types of diabetes…

13. 1. Type 1 diabetes mellitus: Results from the body's failure to
produce sufficient insulin.
2. Type 2 diabetes mellitus: Results from resistance to the
insulin, often initially with normal or increased levels of
circulating insulin.
3. Gestational diabetes: Pregnant women who have never had
diabetes before but who have high blood glucose levels during
pregnancy are said to have gestational diabetes. Gestational
diabetes affects about 4% of all pregnant women.
4. Maturity-onset diabetes of the young (MODY) includes several
forms of diabetes with monogenetic defects of beta-cell
function, usually manifesting as mild hyperglycemia at a young
age, and usually inherited in an autosomal-dominant manner.
Types of diabetes-

16. 5.Causes of diabetes

17. •Eat three meals a day.
•Reduce the fat in the diet,
especially saturated fats. Use
unsaturated fats or oils, especially
monounsaturated fats, eg- olive oil
and rapeseed oil.
•Eat more fruit and vegetables.
Aim for at least five portions a day.
•Limit sugar and sugary foods.
•Reduce salt in the diet to 6 g or
less per day.
Diabetes Diet and Exercise

18.  Preventative foot care
 Diabetic foot ulcer (DFU) care
 Ischemia management
 Neuropathy management

 Surgery
After surgery (amputation ) prosthetic management can be use…
6. Management

19. Fore-foot deformity -
1 .Claw toes
2. Hammer toe
3. Crowding of toes.
4. Cock-up deformity in
great toe
5. Varus deformity of toes
6.Hallux Valgus
Mid-foot deformity-
1. Midsole Ulcer
2.Charcot foot
Hind-foot deformity-
1. Ulcer
2.Gangrene
Common foot deformities in diabetic
mellitus

20. Crowding of
toe
Hammer
toe
Claw toe
Hallux
valgus

21.  Diabetic foot ulcers are sores on the feet that
occur in 15% of diabetic patients some time during
their lifetime. The risk of lower-extremity
amputation is increased 8-fold in these patients
once an ulcer develops.
 Foot ulcers are a common complication of diabetes. They
are most prevalent under your big toes as well as the balls
of your feet. Ulcers form as a result of skin tissue breaking
down and exposing underlying layers. These sores can
affect your feet down to the bones.
 All diabetes patients are at risk for developing foot ulcers
and foot pain. If neglected, infected ulcers may result in
amputation. Treatment for diabetic foot ulcers and foot pain
varies depending on their causes.
Diabetic foot ulcer

22.  What causes diabetic foot ulcers?
The most common causes of diabetic ulcers include:
•poor circulation
•high blood sugar (hyperglycemia)
•nerve damage
•irritated or wounded feet
Poor blood circulation is a form of vascular disease in which
blood doesn’t flow to your feet effectively. It’s just one cause
of foot ulcers. Poor circulation can also make it more difficult
for ulcers to heal.
High glucose levels can slow down the healing process of an
infected foot ulcer. This makes blood sugar management
critical. People with type 2 diabetes tend to have a harder
time fighting off infections from ulcers..

23. Wagner classification-
 Grade 1 - Skin intact, no foot deformity
 Grade 2- Superficial ulcer
 Grade 3 - Deep ulcer with infection
 Grade 4 - Limited necrosis
 Grade 5 - Necrosis of the entire foot
4.Classification of ulcer-

24. Grade -1
Grade-2
Grade-3

25. Grade -4
Grade -5

26. Treatment according to Ulcer Grade-
 Wagner 1-2
 Total contact cast
 Distributes
pressure and
allows patients to
continue
ambulation
 Principles of
application
 Changes, Padding,
removal
 Antibiotics if
infected
 Wagner 3
 Excision of
infected bone
 Wound allowed
to granulate
 Grafting (skin or
bone) not
generally
effective
 Wagner 4-5
 Amputation
 ? level

28. This is referred to as off-loading. It’s helpful for all forms of
diabetic foot ulcers. Pressure from walking can worsen an
infection and make an ulcer expand.
Doctor may recommend wearing certain items to protect your
feet:
1. Diabetic shoes
2. Total contact casts
3. Foot braces
4. Compression wraps
5. Shoe inserts
6. Toe socks
7. Diabetics socks
Treating Diabetic Foot Ulcers
Othoti
c
Manag
ement

30.  If you are in the early stages of diabetes, and have no
history of foot problems or any loss of sensation, a
properly fitting shoe made of soft materials with a shock
absorbing sole may be all that you need.
 It is also important for patients to learn how to select the
right type of shoe in the right size, so that future problems
can be prevented.
 The excessive pressure and friction from the wrong kind
of shoes or from poorly fitting shoes can lead to blisters,
calluses and ulcers, not only in the insensitive foot but
also in feet with no evidence of neuropathy.


31. Many patients with diabetes need special footwear
prescribed by a physician. Prescription footwear for
patients with diabetes includes---
Healing shoes-
Immediately following surgery or ulcer treatment, some
type of shoe may be necessary before a regular shoe
can be worn. These include custom sandals (open toe),
heat-moldable healing shoes (closed toe), and post-
operative shoes.
Prescription footwear

32. •In-depth shoes.
The in-depth shoe is the basis for
most footwear prescriptions. It is
generally an oxford-type or
athletic shoe with an additional
1/4- to 1/2-inch of depth
throughout the shoe, allowing
extra volume to accommodate
any needed inserts or orthosis, as
well as deformities commonly
associated with a Diabetic foot.
In-depth shoes also tend to be
light in weight, have shock-
absorbing soles, and come in a
wide range of shapes and sizes to
accommodate virtually any foot

33. •External shoe modifications-
This involves modifying the outside of the shoe in some
way, such as modifying the shape of the sole or adding
shock-absorbing or stabilizing materials relief.

34. •Custom-made shoes-
When extremely severe deformities are present, a
custom-made shoe can be constructed from a cast or
model of the patient's foot. These cases are rare. With
extensive modifications of in-depth shoes, even the
most severe deformities can usually be accommodated

36. The "total contact cast" is a casting
technique that is used to heal diabetic foot
ulcers and to protect the foot during the
early phases of Charcot fracture
dislocations.
The cast is used to heal diabetic foot ulcers
by distributing weight along the entire
plantar aspect (sole) of the foot. It is
applied in such a way to intimately contact
the exact contour of the foot; hence, the
designation "total contact cast."
By relieving the pressure on the prominent
areas of the foot, the ulcers are permitted
to heal if the cast is applied in such a way
that the patient can remain ambulatory
during the treatment of the ulcer.
2.Total contact cast

37. Charcot foot is a condition
causing weakening of the bones in
the foot that can occur in people who
have significant nerve damage
(neuropathy). The bones are weakened
enough to fracture, and with continued
walking the foot eventually changes
shape.
For the Charcot foot, the total contact
cast is used in two ways.
In the initial treatment of the Charcot foot
when the breakdown is occurring.
The foot is quite swollen and reactive,
the cast is applied to control the
movement of the foot and support its
contours.

39. 3. Diabetic foot brace
Diabetic brace

40. Removable cast walkers and the “instant” total contact cast. The
removable cast walker (RCW) offers several potential advantages
over traditional TCC.
Removable walkers are, easily removed for self-inspection of the
wound and application of topical therapies that require frequent
administration. Patients can bath and sleep more comfortably when
wearing these devices, and, because they are removable, RCWs
can be used with infected wounds.
1. Removable cast walkers

41. 2.Scotchcast boot.
The Scotchcast boot is an alternative plaster of
Paris cast, developed when fiberglass materials
were introduced. As a substitute for plaster of
Paris, Scotchcast is much lighter with high integral
strength .
The basic functions of the cast are to reduce the
pressure on the lesion, maintain patient mobility,
and protect the remaining foot.
The Scotchcast boot is a well-padded cast cut
away by the ankle and made either removable or
non removable by cutting away the cast over the
dorsum of the foot. A closure is made, consisting
of padding and tape with fabric hook–and-loop
fastener straps. Windows are cut over the ulcers
as needed, and a removable heel cap of fiberglass
is added for large heel ulcers.
The boot is worn with a cast sandal to increase
patient mobility, keeping the patient ambulatory
while protecting the ulcer from any pressure.

42. 3. Half shoes.
Originally designed to
decrease pressure on the
forefoot postoperatively, the
half shoe has become quite
popular for treating foot
wounds in people with
diabetes.
These devices are
inexpensive and easy to
apply.

43. 4.CROW
The Charcot Restraint Orthotic Walker or
CROW for short is a type of custom made
brace that is designed to reduce pressure
on the foot and the ankle for people who
have a neuropathic ulcer and/or
a Charcot Joint.
The CROW is made from a cast or
impression of the foot and lower leg and
is designed with a soft foot bed and
cushioned liner. The brace is made of
rigid plastic with a rockered bottom to
allow for normal heel to toe walking.
The brace works to reduce destructive
forces in the foot and ankle, protecting
the bone at the same time as reducing
pressure on the bottom of the foot to help
heel and prevent ulcers.

44. Layered compression therapy for
venous leg ulcers and ulcers
associated with chronic leg edema
has been shown to be an effective
treatment in patients with
adequate arterial circulation .
 Layered compression therapy
was an effective and safe
treatment in this diabetic
population with adequate arterial
circulation. Reduced compression
also can be helpful in some
patients with arterial compromise.
4.Compressive wrap

45. .
They are always applying
pressure to your arm or legs,
whether you’re sitting, standing
or laying down. Alternative
compression garments provide a
different type of compression
which is dynamic.
This means they only provide
compression when your muscles
push against them.
Dynamic compression is more
comfortable to wear when you are
resting, and can be worn for
longer periods of time, up to 24
hours a day if necessary.

46. 5.Shoe insert
• An orthosis is a
removable insole which
provides pressure relief
and shock absorption.
Both pre-made and
custom-made orthosis
or inserts are
commonly prescribed
for patients with
diabetes, including a
special "total contact
orthosis," which is
made from a model of
your foot and offers a
high level of comfort
and pressure.

47. People with diabetes have to be
especially careful with their feet,
as decreased circulation and
other diabetes-related conditions
could affect overall foot health.
People with diabetes are less
likely to notice foot damage,
such as a blister or cut. Patients
with diabetes can also get
common foot problems that
others do but, when left
untreated, it can possibly lead to
infection and serious
complications.

48. 6.Socks for diabetics

49. Management of ischemic diabetic foot.

51. Management for Neuropathic diabetes

55. Indications for amputation
 Uncontrollable infection
 Inability to obtain a plantar grade, dry foot that can tolerate
weight bearing
 Non ambulatory patient
Surgery