Effect of six types of footwear on peak plantar pressures in patients with diabetes and transmetatarsal amputation.

INTRODUCTION:: Patients with diabetes (DM) and transmetatarsal amputation (TMA) are at high risk for skin breakdown from excessive peak plantar pressures (PPP). The primary purpose of this study was to determine how footwear (full length shoe or short shoe), a total contact insert, a rigid-rocker bottom (RRB) sole, and an ankle-foot-orthosis (AFO) affect PPP on the distal residuum and contralateral extremity of patients with DM and TMA. A secondary purpose was to monitor various functional measures during use of the footwear. METHODS:: Thirty patients with DM and TMA participated (mean age 62+/-4 years). The mean duration of DM was 19.9+/-10.1 years, and the mean time since TMA was 27.4+/-28.1 months. The following footwear was provided after a check-out from an orthotist and physical therapist (PT); 1) Full length shoe (ie shoe length prior to surgery), with a toe filler, 2) full length shoe, total contact insert, and an AFO, 2) full length shoe, total contact insert, and an AFO, 3) full length shoe, total contact insert, and a RRB sole, 4) full length shoe, total contact insert, RRB sole, and an AFO, 5) short shoe (ie length of residuum), total contact insert, and RRB, 6) short shoe, total contact insert, AFO, and RRB sole. In-shoe PPP during walking at the distal residuum and forefoot of the contralateral extremity were measured using the F-Scan System with established reliability under similar conditions (Generilizability coefficient =.75). Each measurement occurred after a one month adjustment period. Data were analyzed using a univariate repeated measuresANOVA. Individual contrasts were used for post-hoc analysis on those variables showing a significant overall F value (p<.05). RESULTS:: Compared to a regular shoe with a toe-filler, all conditions except the short shoe (#5), resulted in lower PPP on the distal residuum (p<.05). Condition 3, the full length shoe, total contact insert, and RRB resulted in lower pressures on the distal residuum and forefoot of the contralateral extremity compared to a regular shoe and toe-filler, and had few functional complaints as identified by the patient, orthotist or PT (3/27). Footwear using an AFO (Conditions 2,4,6) showed reduced PPP on the residuum, but most patients (16/29) had functional complaints. The short shoe (condition 5) had the fewest[Table: see text] functional complaints (2/26), but did not significantly reduce PPP and had the highest cosmetic refusal rate (5/26). DISCUSSION AND CONCLUSIONS:: Although there are individual patient characteristics which warrant other prescriptions, based on the results of this study, we recommend the full length shoe, total contact insert, and RRB sole for most patients with DM and TMA to reduce PPP. A reduction in PPP should help to lower the high risk of skin breakdown in this patient population.