Plantar pressures are elevated in people with longstanding diabetes-related foot ulcers during follow-up

Malindu E Fernando, Robert G Crowther, Peter A Lazzarini, Saiumaeswar Yogakanthi, Kunwarjit S Sangla, Petra Buttner, Rhondda Jones, Jonathan Golledge, Malindu E Fernando, Robert G Crowther, Peter A Lazzarini, Saiumaeswar Yogakanthi, Kunwarjit S Sangla, Petra Buttner, Rhondda Jones, Jonathan Golledge

Abstract

Objective: High plantar pressures are implicated in the development of diabetes-related foot ulcers. Whether plantar pressures remain high in patients with chronic diabetes-related foot ulcers over time is uncertain. The primary aim of this study was to compare plantar pressures at baseline and three and six months later in participants with chronic diabetes-related foot ulcers (cases) to participants without foot ulcers (controls).

Methods: Standardised protocols were used to measure mean peak plantar pressure and pressure-time integral at 10 plantar foot sites (the hallux, toes, metatarsals 1 to 5, mid-foot, medial heel and lateral heel) during barefoot walking. Measurements were performed at three study visits: baseline, three and six months. Linear mixed effects random-intercept models were utilised to assess whether plantar pressures differed between cases and controls after adjusting for age, sex, body mass index, neuropathy status and follow-up time. Standardised mean differences (Cohen's d) were used to measure effect size.

Results: Twenty-one cases and 69 controls started the study and 16 cases and 63 controls completed the study. Cases had a higher mean peak plantar pressure at several foot sites including the toes (p = 0.005, Cohen's d = 0.36) and mid-foot (p = 0.01, d = 0.36) and a higher pressure-time integral at the hallux (p<0.001, d = 0.42), metatarsal 1 (p = 0.02, d = 0.33) and mid-foot (p = 0.04, d = 0.64) compared to controls throughout follow-up. A reduction in pressure-time integral at multiple plantar sites over time was detected in all participants (p<0.05, respectively).

Conclusions: Plantar pressures assessed during gait are higher in diabetes patients with chronic foot ulcers than controls at several plantar sites throughout prolonged follow-up. Long term offloading is needed in diabetes patients with diabetes-related foot ulcers to facilitate ulcer healing.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. Site-specific mean peak pressures over…
Fig 1. Site-specific mean peak pressures over time in participants with DFUs and participants without DFUs.
Figure indicates the mean peak pressure at ten plantar sites in cases (red) and diabetes controls (DM controls) (green) at each visit. The x-axis has been scaled to allow for better data visualisation. All values are in N/Cm2 and are reported for 10 plantar foot sites. T1 = hallux (big-toe), T2-5 = toes two to five, M1 = metatarsal one, M2 = metatarsal two, M3 = metatarsal three, M4 = metatarsal four, M5 = metatarsal five, Mid = mid-foot, HM = medial heel and HL = lateral heel.
Fig 2. Site-specific pressure-time integrals over time…
Fig 2. Site-specific pressure-time integrals over time in participants with DFUs and participants without DFUs.
Figure indicates the pressure-time integral at ten plantar sites in cases (red) and diabetes controls (DM controls) (green) at each visit. The x-axis has been scaled to allow for better data visualisation. All values are in Ns/Cm2 and are reported for 10 plantar foot sites. T1 = hallux (big-toe), T2-5 = toes two to five, M1 = metatarsal one, M2 = metatarsal two, M3 = metatarsal three, M4 = metatarsal four, M5 = metatarsal five, Mid = mid-foot, HM = medial heel and HL = lateral heel.

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