A common dilemma faced by the biomechanics practitioner involves how to treat the diabetic patient with orthotic devices. People with diabetes are similar to the general population in so much as no two cases are alike. Extra care must be taken in examining this patient population, and determining their circulatory, neurological and dermatological status in addition to our normal biomechanical exam findings is critical in achieving consistent outcomes.
I will preface this article by stating that I am referring to mostly “healthy” diabetics, those under good management of their disease with limited complications. Those patients with histories of deep ulcerations with or without osteomyelitis, amputation, concurrent peripheral vascular disease or total lack of protective sensation in their feet require a level of care that may be best served by a multi-speciality diabetic foot clinic, and I would urge referral out if you do not feel comfortable in treating this type of patient.
A thorough multi-system examination of the lower extremities may be the first opportunity to uncover the existence of diabetes in any given patient. Once diagnosed, diabetic patients should be counseled regarding how the disease may affect their feet and legs. Provide recommendations on frequent self-examination, hygiene, selection of the proper shoes and socks, and when to contact their healthcare practitioner regarding any change in their condition. A little problem can transform into a big problem very quickly in this population.
Once you have established how diabetes is affecting your patient's lower extremities you can tailor your biomechanical plans accordingly. If there is little or no impairment, then treating this patient as you would a non-diabetic, except for more closely monitoring them over time, looking for change in structure due to possible muscle wasting, or diminution of fat padding in the feet. If some minimal or mild diabetic complications are present, you may want to use a less controlling device than you normally would, such as using a more flexible polypropylene or substituting subortholene, or adding more cushioning to the device than usual. An all EVA device with a neoprene or plastazote cover can be an excellent choice when some biomechanical control is desired in the presence of diabetic neuropathy. If a relatively sedentary patient with diabetic complications KevinRoot Medical offers the T3 Premium Diabetic Orthosis, as well as T7 Diabetic insert to be paired with a therapeutic extra depth shoe. If significant circulatory and/or neurological impairment is present and accommodative device is most appropriate in most cases.
In this set of patients, you should also be mindful of the often overlooked signs of autonomic neuropathy. Dry skin, which scales and fissures easily thick distorted toenails, diminished hair growth are common early findings. Lack of perspiration, peripheral edema and numbness can all contribute to the tendency to form hotspots, calluses and potential diabetic foot ulcers, even in otherwise healthy individuals. As always, monitor your patient's progress with their orthotic devices and be willing to adapt and adjust as conditions warrant.
