Practical Orthotic Management of the Diabetic Lower Extremity

Let's looks at the numbers.....

• Diabetics in the US: 18.2 million

• New cases annually: 1.0 million

• Fatality ranking: 5th deadliest disease

• Non-traumatic amputations: 57,000 / year (156 / day)

• Cause of adult blindness: 20,000 / year (55 / day)

• End stage renal disease: 28,000 / year (77 / day)

• Related medical expenses: $100 billion / year ($274 million / day)

The Wall Street Journal Reports: “Lower Leg Amputations are Increasing…Diabetes Epidemic is Major Factor Though Doctors Say Many Aren’t Necessary” [*Michael J. McCarthy, Staff Reporter for The Wall Street Journal, February 23rd, 2005; Page D1]

What can we do as practitioners to slow the amputation numbers nationally?

Orthotic Management Objectives

• Accommodate deformities

• Prevent progression of deformities

• Relieve high pressure ares

• Reduce shear

• Provide prosthetic filler if necessary

• Recognize equinus and treat

• Always evaluate both lower extremities

• Educate, educate, educate...

Diabetic Toe Deformities

• Objectives

• Protect not correct

• Reduce toe tip pressures

• Footwear considerations

• Deep, seamless toe box

• Expandable uppers

• Heat moldable uppers

• Silver lined

• Athletic options

• Footwear modifications

• Metatarsal bar

• Drill and fill

• Stretch uppers

• Balloon patch

• Orthotic considerations

• Digital products

• Crest Pads

Plantar Ulcers or Callosities

• Objectives

• Reduce peak pressure areas

• Reduce shear

• Axially unload foot as needed

• Footwear considerations

• Depth inlay footware

• Temporary healing footware

• Footware modifications

• Rocker sole

• Metatarsal bar

• Drill and fill

• Orthotic considerations

• Total contact design

• Appropriate relief

• Material selection appropriate for activity level and size of patient with multiple densities

• Use of removable walking boot with incorporated custom foot orthosis with aperture relief to facilitate healing

• Use of patellar tendon bearing ankle foot orthosis in case of recurrent ulcerations

Charcot Deformities

• Objectives

• Accommodate existing deformity

• Prevent further progression of deformity

• Reduce bending stresses

• Axially unload foot as needed

• Footwear considerations

• Shoes with wide midfoot last

• Custom made shoes

• Footwear modifications

• Split and widen

• Rocker sole

• Extended shank or carbon footplate

• Orthotic considerations

• Multi-density design

• Visco-elastic polymers incorporated

• Interim management with pneumatic walker and custom orthosis

• Use of new prefabricated CORONA™ orthosis

• CROW

• Double upright calf lacer

• May need axial unloading

• Arizona® brace

Partial Foot Amputations

• Objectives

• Protect remaining residuum

• Facilitate propulsion

• Recognize equine

• Footwear considerations

• The shorter the limb the taller the shoe

• Custom boot

• Footwear modifications

• Extended shank

• Rocker sole

• Prosthetic considerations

• Multi-density partial foot prosthesis with dynamic footplate

• Imler or Chicago boot

• "Prosthosis"

Conclusions

• Prosthetic, orthotic, and pedorthic management a critical component is the care of diabetic patients

• Coverage for pedorthic services from Medicare

• Reimbursement the least for the hardest to manage