Distribution of the Highest Plantar Pressure Regions in Patients with Diabetes and Its Association with Peripheral Neuropathy, Gender, Age, and BMI: One Centre Study

Edyta Sutkowska, Krzysztof Sutkowski, Michał Sokołowski, Edward Franek, Szymon Dragan Sr, Edyta Sutkowska, Krzysztof Sutkowski, Michał Sokołowski, Edward Franek, Szymon Dragan Sr

Abstract

The abnormal plantar pressure distribution and value play a key role in the formation of plantar calluses and diabetic foot ulcer. The prevalence of the highest pressure different distribution and its association with various factors among patients with diabetes is not well known. The study purpose was to evaluate the prevalence of different regions for the highest pressure on the sole and its association with selected factors among patients with diabetes. Medical records of nonulcer patients were retrospectively analysed. The relationship between pressure patterns on the sole obtained during a pedobarographic test as a semiquantitative assessment with colourful print analysis and neuropathy, gender, age, and BMI was searched. The most common location of the highest pressure was the central part of the forefoot. No association was found between the different highest pressure regions and age, sensory neuropathy, calluses, and foot deformities. The highest pressure on the lateral part of the foot and midfoot was observed more often in females and in patients with a BMI ≥ 35. The prevalence of the highest pressure on the forefoot was more common in patients with a BMI < 35. Conclusions. The most frequent regions of the highest pressure on the sole in patients with diabetes were the central part of the forefoot (2-3 metatarsal heads) with no simple relationship to the assessed variables other than BMI < 35. Female gender and higher BMI seem to be responsible for shifting the place of the highest pressure to other places of the foot.

Figures

Figure 1
Figure 1
Examples of abnormal plantar pressure distribution (APD) for P1, P2, and P3.

References

    1. Cavanagh P. R., Rodgers M. M., liboshi A. Pressure distribution under symptom-free feet during barefoot standing. Foot & Ankle. 1987;7(5):262–278. doi: 10.1177/107110078700700502.
    1. Taha Z., Norman M. S., Omar S. F. S., Suwarganda E. A finite element analysis of a human foot model to simulate neutral standing on ground. Procedia Engineering. 2016;147:240–245. doi: 10.1016/j.proeng.2016.06.240.
    1. Hotfiel T., Carl H. D., Wendler F., Jendrissek A., Heiß R., Swoboda B. Plantar pressures increase with raising body weight: a standardised approach with paired sample using neutral shoes. Journal of Back and Musculoskeletal Rehabilitation. 2017;30(3):583–589. doi: 10.3233/BMR-150442.
    1. Martinez-Nova A., Huerta J. P., Sánchez-Rodriguez R. Cadence, age, and weight as determinants of forefoot plantar pressures using the biofoot in-shoe system. Journal of the American Podiatric Medical Association. 2008;98(4):302–310. doi: 10.7547/0980302.
    1. Rao S., Saltzman C., Yack H. J. Ankle ROM and stiffness measured at rest and during gait in individuals with and without diabetic sensory neuropathy. Gait & Posture. 2006;24(3):295–301. doi: 10.1016/j.gaitpost.2005.10.004.
    1. Orendurff M. S., Rohr E. S., Sangeorzan B. J., Weaver K., Czerniecki J. M. An equinus deformity of the ankle accounts for only a small amount of the increased forefoot plantar pressure in patients with diabetes. The Journal of Bone & Joint Surgery. 2006;88-B(1):65–68. doi: 10.1302/0301-620X.88B1.16807.
    1. Couppé C., Svensson R. B., Kongsgaard M., et al. Human Achilles tendon glycation and function in diabetes. Journal of Applied Physiology. 2016;120(2):130–137. doi: 10.1152/japplphysiol.00547.2015.
    1. Barn R., Waaijman R., Nollet F., Woodburn J., Bus S. A. Predictors of barefoot plantar pressure during walking in patients with diabetes, peripheral neuropathy and a history of ulceration. PLoS One. 2015;10(2, article e0117443) doi: 10.1371/journal.pone.0117443.
    1. Boulton A. J. M., Hardisty C. A., Betts R. P., et al. Dynamic foot pressure and other studies as diagnostic and management aids in diabetic neuropathy. Diabetes Care. 1983;6(1):26–33. doi: 10.2337/diacare.6.1.26.
    1. Boulton A. J. M., Betts R. P., Franks C. I., Newrick P. G., Ward J. D., Duckworth T. Abnormalities of foot pressure in early diabetic neuropathy. Diabetic Medicine. 1987;4(3):225–228. doi: 10.1111/j.1464-5491.1987.tb00867.x.
    1. Duckworth T., Boulton A. J., Betts R. P., Franks C. I., Ward J. D. Plantar pressure measurements and the prevention of ulceration in the diabetic foot. The Journal of Bone & Joint Surgery. 1985;67-B(1):79–85. doi: 10.1302/0301-620X.67B1.3968150.
    1. Stokes I. A. F., Faris I. B., Hutton W. C. The neuropathic ulcer and loads on the foot in diabetic patients. Acta Orthopaedica Scandinavica. 1975;46(5):839–847. doi: 10.3109/17453677508989271.
    1. Bacarin T. A., Sacco I. C. N., Hennig E. M. Plantar pressure distribution patterns during gait in diabetic neuropathy patients with a history of foot ulcers. Clinics. 2009;64(2):113–120. doi: 10.1590/S1807-59322009000200008.
    1. Boulton A. J. The importance of abnormal foot pressures in early diabetic neuropathy. Diabetic Medicine. 1987;4(3):225–228.
    1. Rich J., Veves A. Foorfoot and rearfoot plantar pressures in diabetic patients: correlation to foot ulceration. Wounds. 2000;12:82–87.
    1. Cavanagh P. R., Morag E., Boulton A. J. M., Young M. J., Deffner K. T., Pammer S. E. The relationship of static foot structure to dynamic foot function. Journal of Biomechanics. 1997;30(3):243–250. doi: 10.1016/S0021-9290(96)00136-4.
    1. Lavery L. A., Armstrong D. G., Wunderlich R. P., Tredwell J., Boulton A. J. M. Predictive value of foot pressure assessment as part of a population-based diabetes disease management program. Diabetes Care. 2003;26(4):1069–1073. doi: 10.2337/diacare.26.4.1069.
    1. Bus S. A., Maas M., de Lange A., Michels R. P. J., Levi M. Elevated plantar pressures in neuropathic diabetic patients with claw/hammer toe deformity. Journal of Biomechanics. 2005;38(9):1918–1925. doi: 10.1016/j.jbiomech.2004.07.034.
    1. Pham H., Armstrong D. G., Harvey C., Harkless L. B., Giurini J. M., Veves A. Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial. Diabetes Care. 2000;23(5):606–611. doi: 10.2337/diacare.23.5.606.
    1. Boulton A. J., Betts R. P., Franks C. I., Ward J. D., Duckworth T. The natural history of foot pressure abnormalities in neuropathic diabetic subjects. Diabetes Res. 1987;5(2):73–77.
    1. Frykberg R. G., Lavery L. A., Pham H., Harvey C., Harkless L., Veves A. Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care. 1998;21(10):1714–1719. doi: 10.2337/diacare.21.10.1714.
    1. Fernando M. E., Crowther R. G., Pappas E., et al. Plantar pressure in diabetic peripheral neuropathy patients with active foot ulceration, previous ulceration and no history of ulceration: a meta-analysis of observational studies. PLoS One. 2014;9(6, article e99050) doi: 10.1371/journal.pone.0099050.
    1. Masson E. A., Hay E. M., Stockley I., Veves A., Betts R. P., Boulton A. J. M. Abnormal foot pressures alone may not cause ulceration. Diabetic Medicine. 1989;6(5):426–428. doi: 10.1111/j.1464-5491.1989.tb01198.x.
    1. van Schie C. H. M. A review of the biomechanics of the diabetic foot. The International Journal of Lower Extremity Wounds. 2005;4(3):160–170. doi: 10.1177/1534734605280587.
    1. van Schie C. H. M., Boulton A. J. M. Biomechanics of the diabetic foot: the road to foot ulceration. In: Veves A., Giurini J. M., LoGerfo F. W., editors. The Diabetic Foot. Totowa: Humana Press; 2002.
    1. Veves A., Murray H. J., Young M. J., Boulton A. J. M. The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study. Diabetologia. 1992;35(7):660–663. doi: 10.1007/BF00400259.
    1. Wrobel J. S., Najafi B. Diabetic foot biomechanics and gait dysfunction. Journal of Diabetes Science and Technology. 2010;4(4):833–845. doi: 10.1177/193229681000400411.
    1. Weijers R. E., Walenkamp G. H. I. M., van Mameren H., Kessels A. G. H. The relationship of the position of the metatarsal heads and peak plantar pressure. Foot & Ankle International. 2003;24(4):349–353. doi: 10.1177/107110070302400408.
    1. Duckworth T., Betts R. P., Franks C. I., Burke J. The measurement of pressures under the foot. Foot and Ankle International. 1982;3(3):130–141. doi: 10.1177/107110078200300303.
    1. Fernando M. E., Crowther R. G., Wearing S. The importance of foot pressure in diabetes. In: Müller B., Wolf S. I., editors. Handbook of Human Motion. Springer International Publishing AG, part of Springer Nature; 2018. pp. 759–787.
    1. Jeffcoate W. J., Bus S. A., Game F. L., Hinchliffe R. J., Price P. E., Schaper N. C. Reporting standards of studies and papers on the prevention and management of foot ulcers in diabetes: required details and markers of good quality. The Lancet Diabetes & Endocrinology. 2016;4(9):781–788. doi: 10.1016/S2213-8587(16)30012-2.
    1. Arts M. L. J., Bus S. A. Twelve steps per foot are recommended for valid and reliable in-shoe plantar pressure data in neuropathic diabetic patients wearing custom made footwear. Clinical Biomechanics. 2011;26(8):880–884. doi: 10.1016/j.clinbiomech.2011.05.001.
    1. Segal A., Rohr E., Orendurff M., Shofer J., O'Brien M., Sangeorzan B. The effect of walking speed on peak plantar pressure. Foot & Ankle International. 2004;25(12):926–933. doi: 10.1177/107110070402501215.
    1. Burnfield J. M., Few C. D., Mohamed O. S., Perry J. The influence of walking speed and footwear on plantar pressures in older adults. Clinical biomechanics. 2004;19(1):78–84. doi: 10.1016/j.clinbiomech.2003.09.007.
    1. Chung M. J., Wang M. J. Gender and walking speed effects on plantar pressure distribution for adults aged 20–60 years. Ergonomics. 2012;55(2):194–200. doi: 10.1080/00140139.2011.583359.
    1. Choi Y. R., Lee H. S., Kim D. E., Lee D. H., Kim J. M., Ahn J. Y. The diagnostic value of pedobarography. Orthopedics. 2014;37(12):e1063–e1067. doi: 10.3928/01477447-20141124-52.
    1. Bus S. A., Waaijman R. The value of reporting pressure-time integral data in addition to peak pressure data in studies on the diabetic foot: a systematic review. Clinical Biomechanics. 2013;28(2):117–121. doi: 10.1016/j.clinbiomech.2012.12.002.
    1. Bennetts C. J., Owings T. M., Erdemir A., Botek G., Cavanagh P. R. Clustering and classification of regional peak plantar pressures of diabetic feet. Journal of Biomechanics. 2013;46(1):19–25. doi: 10.1016/j.jbiomech.2012.09.007.
    1. Deschamps K., Matricali G. A., Desmet D., et al. Efficacy measures associated to a plantar pressure based classification system in diabetic foot medicine. Gait & Posture. 2016;49:168–175. doi: 10.1016/j.gaitpost.2016.07.009.
    1. Cavanagh P. R., Rodgers M. M. The arch index: a useful measure from footprints. Journal of Biomechanics. 1987;20(5):547–551. doi: 10.1016/0021-9290(87)90255-7.
    1. Zulkifli S. S., Loh W. P. A state-of-the-art review of foot pressure. Foot and Ankle Surgery. 2018 doi: 10.1016/j.fas.2018.12.005.
    1. Lalande X., Vie B., Weber J. P., Jammes Y. Normal values of pressures and foot areas measured in the static condition. Journal of the American Podiatric Medical Association. 2016;106(4):265–272. doi: 10.7547/14-008.
    1. Dalal S., Widgerow A. D., Evans G. R. D. The plantar fat pad and the diabetic foot - a review. International Wound Journal. 2015;12(6):636–640. doi: 10.1111/iwj.12173.
    1. van Schie C. H., Whalley A., Vileikyte L., Wignall T., Hollis S., Boulton A. J. Efficacy of injected liquid silicone in the diabetic foot to reduce risk factors for ulceration: a randomized double-blind placebo-controlled trial. Diabetes Care. 2000;23(5):634–638. doi: 10.2337/diacare.23.5.634.
    1. van Schie C. H., Whalley A., Vileikyte L., Boulton A. J. Efficacy of injected liquid silicone is related to peak plantar pressures in the neuropathic diabetic foot. Wounds. 2002;14:26–30.
    1. Keijsers N. L. W., Stolwijk N. M., Louwerens J. W. K., Duysens J. Classification of forefoot pain based on plantar pressure measurements. Clinical Biomechanics. 2013;28(3):350–356. doi: 10.1016/j.clinbiomech.2013.01.012.
    1. Bus S. A. Innovations in plantar pressure and foot temperature measurements in diabetes. Diabetes/Metabolism Research and Reviews. 2016;32:221–226. doi: 10.1002/dmrr.2760.
    1. Scott G., Menz H. B., Newcombe L. Age-related differences in foot structure and function. Gait & Posture. 2007;26(1):68–75. doi: 10.1016/j.gaitpost.2006.07.009.
    1. Zimny S., Schatz H., Pfohl M. The role of limited joint mobility in diabetic patients with an at-risk foot. Diabetes Care. 2004;27(4):942–946. doi: 10.2337/diacare.27.4.942.
    1. Perkins B. A., Olaleye D., Zinman B., Bril V. Simple screening tests for peripheral neuropathy in the diabetes clinic. Diabetes Care. 2001;24(2):250–256. doi: 10.2337/diacare.24.2.250.
    1. Bakker K., Apelqvist J., Lipsky B. A., van Netten J. J., Schaper N. C., on behalf of the International Working Group on the Diabetic Foot (IWGDF) The 2015 IWGDF guidance documents on prevention and management of foot problems in diabetes: development of an evidence-based global consensus. Diabetes/Metabolism Research and Reviews. 2016;32(Supplement 1):2–6. doi: 10.1002/dmrr.2694.
    1. Crawford F., Cezard G., Chappell F. M., et al. A systematic review and individual patient data meta-analysis of prognostic factors for foot ulceration in people with diabetes: the international research collaboration for the prediction of diabetic foot ulcerations (PODUS) Health Technology Assessment. 2015;19(57):1–210. doi: 10.3310/hta19570.
    1. Inlow S. The 60-second foot exam for people with diabetes. Wound Care Canada. 2004;2:10–11.
    1. Carreau L., Niezgoda H., LeBlond S., Trainor A., Orsted H., Woodbury M. G. A prospective, descriptive study to assess the reliability and usability of a rapid foot screen for patients with diabetes mellitus in a complex continuing care setting. Ostomy/Wound Management. 2013;59:28–34.
    1. Gurney J. K., Kersting U. G., Rosenbaum D. Between-day reliability of repeated plantar pressure distribution measurements in a normal population. Gait & Posture. 2008;27(4):706–709. doi: 10.1016/j.gaitpost.2007.07.002.
    1. Gurney J. K., Kersting U. G., Rosenbaum D., et al. Pedobarography as a clinical tool in the management of diabetic feet in New Zealand: a feasibility study. Journal of Foot and Ankle Research. 2017;10(1):p. 24. doi: 10.1186/s13047-017-0205-6.
    1. Prompers L., Huijberts M., Apelqvist J., et al. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia. 2007;50(1):18–25. doi: 10.1007/s00125-006-0491-1.
    1. Bowling F. L., Reeves N. D., Boulton A. J. Gait-related strategies for the prevention of plantar ulcer development in the high risk foot. Current Diabetes Reviews. 2011;7(3):159–163. doi: 10.2174/157339911795843159.
    1. Perell K. L., Merrill V., Nouvong A. Location of plantar ulcerations in diabetic patients referred to a Department of Veterans Affairs podiatry clinic. Journal of Rehabilitation Research and Development. 2006;43(4):421–426. doi: 10.1682/JRRD.2005.10.0157.
    1. Ledoux W. R., Shofer J. B., Cowley M. S., Ahroni J. H., Cohen V., Boyko E. J. Diabetic foot ulcer incidence in relation to plantar pressure magnitude and measurement location. Journal of Diabetes and its Complications. 2013;27(6):621–626. doi: 10.1016/j.jdiacomp.2013.07.004.
    1. Dinh T. L., Veves A. A review of the mechanisms implicated in the pathogenesis of the diabetic foot. The International Journal of Lower Extremity Wounds. 2005;4(3):154–159. doi: 10.1177/1534734605280130.
    1. York R. M., Perell-Gerson K. L., Barr M., Durham J., Roper J. M. Motor learning of a gait pattern to reduce forefoot plantar pressures in individuals with diabetic peripheral neuropathy. PM&R. 2009;1(5):434–441. doi: 10.1016/j.pmrj.2009.03.001.
    1. Bakker K., Schaper N. C., on behalf of the International Working Group on the Diabetic Foot Editorial Board The development of global consensus guidelines on the management and prevention of the diabetic foot 2011. Diabetes/Metabolism Research and Reviews. 2012;28(Supplement 1):116–118. doi: 10.1002/dmrr.2254.
    1. Armstrong D. G. Detection of diabetic peripheral neuropathy: strategies for screening and diagnosis. Advanced Studies in Medicine. 2005;5:S1033–S1037.
    1. Wood W. A., Wood M. A., Werter S. A., et al. Testing for loss of protective sensation in patients with foot ulceration: a cross-sectional study. Journal of the American Podiatric Medical Association. 2005;95(5):469–474. doi: 10.7547/0950469.
    1. Mueller M. J., Minor S. D., Sahrmann S. A., Schaaf J. A., Strube M. J. Differences in the gait characteristics of patients with diabetes and peripheral neuropathy compared with age-matched controls. Physical Therapy. 1994;74(4):299–308. doi: 10.1093/ptj/74.4.299.
    1. Fernando M. E., Crowther R. G., Lazzarini P. A., Sangla K. S., Buttner P., Golledge J. Gait parameters of people with diabetes-related neuropathic plantar foot ulcers. Clinical Biomechanics. 2016;37:98–107. doi: 10.1016/j.clinbiomech.2016.06.006.
    1. Ishpekova B., Daslov M., Muradyan N., Alexandrov A. Clinical and electrophysiologi-cal studies in diabetic polyneuropathy. Acta Medica Bulgarica. 2007;34:18–22.
    1. Farndon L. J. The incidence of claw toes in diabetic and non-diabetic patients in a podiatry department. Practical Diabetes International. 2000;17(1):9–12. doi: 10.1002/(SICI)1528-252X(200001)17:1<9::AID-PDI12>;2-8.
    1. Lázaro-Martínez J. L., Aragón-Sánchez F. J., Beneit-Montesinos J. V., González-Jurado M. A., Morales E. G., Hernández D. M. Foot biomechanics in patients with diabetes mellitus: doubts regarding the relationship between neuropathy, foot motion, and deformities. Journal of the American Podiatric Medical Association. 2011;101(3):208–214. doi: 10.7547/1010208.
    1. Skopljak A., Muftic M., Sukalo A., Masic I., Zunic L. Pedobarography in diagnosis and clinical application. Acta Informatica Medica. 2014;22(6):374–378. doi: 10.5455/aim.2014.22.374-378.
    1. Hills A. P., Hennig E. M., McDonald M., Bar-Or O. Plantar pressure differences between obese and non-obese adults: a biomechanical analysis. International Journal of Obesity and Related Metabolic Disorders. 2001;25(11):1674–1679. doi: 10.1038/sj.ijo.0801785.
    1. Tuna H., Birtane M., Guldiken S., et al. The effect of disease duration on foot plantar pressure values in patients with type 2 diabetes mellitus. Türkiye Fiziksel Tip ve Rehabilitasyon Dergisi. 2014;60(3):231–235. doi: 10.5152/tftrd.2014.98470.
    1. Mayfield J. A., Reiber G. E., Sanders L. J., Janisse D., Pogach L. M. Preventive foot care in people with diabetes. Diabetes Care. 1998;21(12):2161–2177. doi: 10.2337/diacare.21.12.2161.
    1. Bus S. A., van Deursen R. W., Armstrong D. G., et al. Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review. Diabetes/Metabolism Research and Reviews. 2016;32:99–118. doi: 10.1002/dmrr.2702.
    1. Cavanagh P. R., Bus S. A. Off-loading the diabetic foot for ulcer prevention and healing. Journal of Vascular Surgery. 2010;52(3):37S–43S. doi: 10.1016/j.jvs.2010.06.007.

Source: PubMed

3
Sottoscrivi