Diabetic foot biomechanics

NewsBot · Dec 3, 2020

Midfoot and ankle motion during heel rise and gait are related in people with diabetes and peripheral neuropathy
Hyo-Jung Jeong et al
Gait Posture. 2020 Nov 16

Background: Midfoot and ankle movement dysfunction in people with diabetes mellitus and peripheral neuropathy (DMPN) is associated with midfoot deformity and increased plantar pressures during gait. If midfoot and ankle motion during heel rise and push-off of gait have similar mechanics, heel rise performance could be a clinically feasible way to identify abnormal midfoot and ankle function during gait.

Research question: Is midfoot and ankle joint motion during a heel rise associated with midfoot and ankle motion at push-off during gait in people with DMPN?

Methods: Sixty adults with DMPN completed double-limb heel rise, single-limb heel rise, and walking. A modified Oxford multi-segment foot model (forefoot, hindfoot, shank) was used to analyze midfoot (forefoot on hindfoot) and ankle (hindfoot on shank) sagittal angle during heel rise and gait. Pearson correlation was used to test the relationship between heel rise and gait kinematic variables (n = 60). Additionally, we classified 60 participants into two subgroups based on midfoot and ankle position at peak heel rise: midfoot and ankle dorsiflexed (dorsiflexed; n = 23) and midfoot and ankle plantarflexed (plantarflexed; n = 20). Movement trajectories of midfoot and ankle motion during single-limb heel rise and gait of the subgroups were examined.

Results: Peak double-limb heel rise and gait midfoot and ankle angles were significantly correlated (r = 0.49 and r = 0.40, respectively). Peak single-limb heel rise and gait midfoot and ankle angles were significantly correlated (r = 0.63 and r = 0.54, respectively). The dorsiflexed subgroup, identified by heel rise performance showed greater midfoot and ankle dorsiflexion during gait compared to the plantarflexed subgroup (mean difference between subgroups: midfoot 3°, ankle 3°).

Significance: People with DMPN who fail to plantarflex the midfoot and ankle during heel rise have difficulty plantarflexing the midfoot and ankle during gait. Utilizing a heel rise task may help identify midfoot and ankle dysfunction associated with gait in people with DMPN.
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NewsBot · Mar 25, 2021

The dysmorphic metatarsal parabola in diabetes—clinical examination and
management: a narrative review
AT Thompson et al
Journal of Endocrinology, Metabolism and Diabetes of South Africa 2021: 1–6

Foot posture and function is important in diabetes, particularly as neuropathy in diabetes may present with motor in addition
to sensory neural deficits. Examination of the anatomical architecture of the foot can inform on its load-bearing and balancing
function. An examination that does not feature in guidelines on assessment of the diabetic foot is that of assessing whether a
metatarsal parabola is present or malformed. The metatarsal ‘parabola’ (in the transverse plane) is so called because the
cascade of the differing lengths of the metatarsals form a parabola, defined as the intersection of an arc with a flat (plantar)
surface. The parabola serves a function in the rollover motion or forefoot rocker of the foot before heel rise to provide
stability and balance in static stance. A further function ensures that the lever-action at the first metatarsophalangeal joint
takes place with dorsiflexion of the hallux. This narrative review summarises the literature regarding methods of measuring
the metatarsal parabola, dysfunction of the foot due to a dysmorphic metatarsal parabola, clinical relevance, examination
and management in diabetes care. It documents the short first metatarsal (SFM) as a risk factor for diabetic foot ulceration.
Examination for identification and management of dysmorphic metatarsal parabolae is recommended for foot examinations
in diabetes care.
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NewsBot · Apr 24, 2021

Foot deformities in patients with diabetic mellitus (with and without peripheral neuropathy)
Chicharro-LunaEsther et al
Journal of Tissue Viability; 16 April 2021

Highlights
•Sensorimotor polyneuropathy is the disorder that most commonly affects the feet of persons with diabetes.
•The deformities in the foot, together with diabetic peripheral neuropathy are risks factors for ulceration.
•Our findings showed the importance of determining the relationship between DPN and the presence of deformities in the foot.
•DPN presents significant relationships for the left foot with the deformity of the second-third toe and the hallux extensus.
•DPN presents significant relationships for the right foot with the deformity of the second toe (claw, hammer or mallet).
•DPN and hyperkeratosis present significant relationships in the left foot with the distal area of the toes.
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Background
Diabetic peripheral neuropathy (DPN) is one of the most common complications in diabetes mellitus. It is the disorder that most commonly affects the feet of people with diabetes. The aim of the present study is to determine the relationship between DPN and the presence of deformities in the foot.

Material and methods
A descriptive observational study was conducted of 111 patients diagnosed with Diabetes Mellitus (DM) type 1 or 2. All participants were aged at least 18 years and were previously informed in detail about the aims and procedures of the study.

Results
Regarding the presence of DPN, the only significant relationships were found for the right foot with the deformity of the second toe (claw, hammer or mallet) (p = 0.017, OR 0.29 [0.10–0.83]) and for the left foot with the deformity of the second toe (p = 0.048; OR: 0.37 [0.14–1.01]), third toe (p = 0.012; OR: 0.29 [0.11–0.79]) and the presence of hallux extensus (p = 0.05; OR: 8.27 [1.05–64.98]).

Conclusions
A significant number of foot deformities were observed among these patients with DM, regardless of the presence of DPN. These deformities should be carefully evaluated in order to determine the most appropriate treatment at an early stage, which will reduce the risk of ulceration. Although it should be use with caution to be transferrable to the general population with peripheral neuropathy.
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NewsBot · May 23, 2021

Association of toe-extension movement pattern magnitude and variability during three functional tasks with diabetic foot complications
Jennifer A Zellers et al
Clin Biomech (Bristol, Avon). 2021 May;85:105371

Background: A toe-extension movement pattern may contribute to metatarsophalangeal joint deformity and ulceration in people with diabetes. We sought to quantify the relationship between toe extension magnitude and variability during three functional tasks (ankle range of motion, sit to stand, walking) with metatarsophalangeal joint deformity, and identify potential mechanisms associated with a toe-extension movement pattern.

Methods: Individuals with diabetes and peripheral neuropathy were included (n = 60). Metatarsophalangeal joint deformity was assessed using computed tomography (CT). Toe-extension movement was quantified using 3-dimensional motion capture. Linear regression was used to investigate the role of toe-extension movement pattern on metatarsophalangeal joint deformity. Regression analysis was used to identify mechanisms (neuropathy severity, foot intrinsic muscle deterioration ratio, ankle dorsiflexion range of motion) contributing to toe-extension movement pattern.

Findings: Toe extension with each functional task as well as the mean and coefficient of variation across all tasks were significantly related to metatarsophalangeal joint deformity (range of correlation coefficients = (-0.386, 0.692), p ≤ 0.001). Ankle dorsiflexion range of motion was associated with mean toe extension across all tasks (rsp = -0.282, p = 0.029). Neuropathy severity and foot intrinsic muscle deterioration ratio were associated with toe extension variability (rsp = -0.373, p = 0.003 and rsp = -0.266, p = 0.043; respectively).

Interpretation: Greater magnitude and lower variability of a toe-extension movement pattern was found to be associated with metatarsophalangeal joint deformity. These findings may support clinical assessment and treatment of movement across more than one task.
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NewsBot · Feb 23, 2022

Existing predictive methods applied to gait analysis of patients with diabetes: study protocol for a systematic review
Patrícia Mayara Moura da Silva et al
BMJ Open. 2022 Feb 21;12(2):e051981

Introduction: Type 2 diabetes can lead to gait abnormalities, including a longer stance phase, shorter steps and improper foot pressure distribution. Quantitative data from objective methods for evaluating gait patterns are accurate and cost-effective. In addition, it can also help predictive methods to forecast complications and develop early strategies to guide treatments. To date, no research has systematically summarised the predictive methods used to assess type 2 diabetic gait. Therefore, this protocol aims to identify which predictive methods have been employed to assess the diabetic gait.

Methods and analysis: This protocol will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P) statement. Electronic searches of articles from inception to January 2022 will be performed, from May 2021 to 31 January 2022, in the Web of Science, MEDLINE, Embase, IEEE Xplore Digital Library, Scopus, CINAHL, Google Scholar, APA PsycInfo, the Cochrane Library and in references of key articles and grey literature without language restrictions. We will include studies that examined the development and/or validation of predictive methods to assess type 2 diabetic gait in adults aged >18 years without amputations, use of assistive devices, ulcers or neuropathic pain. Two independent reviewers will screen the included studies and extract the data using a customised charting form. A third reviewer will resolve any disagreements. A narrative synthesis will be performed for the included studies. Risk of bias and quality of evidence will be assessed using the Prediction Model Risk of Bias Assessment Tool and the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis.

Ethics and dissemination: Ethical approval is not required because only available secondary published data will be analysed. The findings will be disseminated through peer-reviewed journals and/or presentations at relevant conferences and other media platforms.
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NewsBot · Mar 8, 2022

Body mass index and maximum available midfoot motion are associated with midfoot angle at peak heel rise in people with type 2 diabetes mellitus and peripheral neuropathy
Hyo-Jung Jeong et al
Foot (Edinb). 2022 Feb 11

Purpose: Midfoot movement dysfunction, as measured by heel rise performance, is associated with midfoot deformity in people with diabetes and peripheral neuropathy. Understanding contributors of midfoot movement dysfunction may help clinicians understand deformity progression. The purpose of this study was to determine the factors associated with midfoot angle at peak heel rise.

Methods: The outcomes of fifty-eight participants with type 2 diabetes mellitus and peripheral neuropathy were analyzed. Midfoot (forefoot on hindfoot) sagittal kinematics during unilateral heel rise task were measured using 3-dimensional motion analysis. A multivariate linear regression model was used to predict midfoot sagittal movements at peak heel rise. Independent variables that were entered in the model were (in order of entry): age, body mass index, intrinsic foot muscle volume, and maximum available midfoot plantarflexion range of motion. Intrinsic foot muscle volume was obtained from magnetic resonance imaging and maximum available midfoot motion was measured during non-weightbearing plantarflexion using 3-dimensional motion analysis.

Results: Body mass index (R2 = 30.5%, p < 0.001) and maximum available midfoot plantarflexion range of motion (R2 = 10.9%, p = 0.001) were significant factors that accounted for 41.4% of variance of midfoot angle at peak heel rise, while age and intrinsic foot muscle volume were not significant predictors.

Conclusions: Greater body mass index and less available midfoot plantarflexion range of motion were associated with greater midfoot movement dysfunction. These two significant predictors are potentially modifiable, suggesting possible improvements in midfoot movements with reduction in body weight and increasing midfoot plantarflexion range of motion. Health care professionals should consider patient's weight and joint motion when prescribing foot exercise(s) to prevent excessive midfoot collapse during weightbearing tasks.
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NewsBot · May 4, 2022

Correlation between the range of motion of the tibiotarsal joint and blood circulation in the lower limbs in diabetic individuals
Catarina Clapis Zordão et al
Rev. Assoc. Med. Bras. vol.68 no.3 São Paulo Mar. 2022

OBJECTIVE:

The aim of this study was to evaluate the relationship between the range of motion and lower-limb hemodynamic indices in the tibiotarsal joint of individuals with diabetic neuropathy.

METHODS:

Twenty volunteers of both sexes, with a mean age of 61.45±7.05 years, were diagnosed with type 2 diabetes mellitus and diabetic peripheral neuropathy. Arterial blood flow was assessed using Doppler ultrasound, and the variables such as average velocity, pulsatility index, and resistivity index were also evaluated. A range of dorsiflexion and plantar flexion joint movements were assessed using digital goniometry before and after exercise. Data distribution was assessed using the Shapiro-Wilk test, followed by Pearson's correlation for normal data and Spearman's correlation for non-normal data, in order to verify the association between variables.

RESULTS:

A moderate correlation was found between dorsiflexion and pulse rate on two occasions before (rs=0.497) and after initial evaluation (rs=0.511). A low correlation was found between plantar flexion and mean velocity (rs=-0.357), pulsatility index (rs=0.439), and resistivity index (rs=0.328); dorsiflexion and mean velocity (rs=0.374), pulse rate (rs=0.332), and resistance index (rs=0.327) before evaluation, and peak (rs=0.346) was observed after the evaluation of blood circulation.

CONCLUSION:

There is a correlation between the range of motion of the tibiotarsal joint and the blood circulation of diabetics, ranging from moderate to poor for the different variables evaluated.
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NewsBot · May 8, 2022

Midfoot and ankle movement coordination during heel rise is disrupted in people with diabetes and peripheral neuropathy
Hyo-Jung Jeong et al
May 07, 2022

Highlights
•People with diabetes showed less movement coordination compared to older controls.
•The movement coordination was not different between older and younger controls.
•Greater coordination was observed across low and high joint excursions.
•Heel rise analysis should consider both coordination and joint excursion.
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Background
A heel rise task can be used to evaluate midfoot and ankle movement dysfunction in people with diabetes mellitus and peripheral neuropathy. Quantifying movement coordination during heel rise is important to better understand potentially detrimental movement strategies in people with foot pathologies; however, coordination and the impact of limited excursion on coordination is not well-understood in people with diabetes.
Methods
Sixty patients with diabetes mellitus and peripheral neuropathy, and 22 older and 25 younger controls performed unilateral heel rise task. Midfoot (forefoot relative to hindfoot) sagittal and ankle (hindfoot relative to shank) sagittal and frontal kinematics were measured and normalized to time (0 to 100%). Cross-correlation coefficients were calculated across individuals in each group. A graphical illustration was used to interpret the relationship of midfoot and ankle excursion and cross-correlation coefficient during heel rise.
Findings
People with diabetes mellitus and peripheral neuropathy showed significantly lower midfoot and ankle cross-correlation coefficients during heel rise compared to older controls (p = 0.003–0.007). There was no difference in the midfoot and ankle cross-correlation coefficients during heel rise for the older and younger controls (p = 0.059–0.425). The graphic data illustrated a trend of greater excursion of two joints and a higher cross-correlation coefficient. Some individuals with lower excursion showed a high cross-correlation coefficient.
Interpretation
Foot pathologies, but not aging, impairs midfoot and ankle movement coordination during heel rise task. Investigating both movement coordination as well as joint excursion would better inform and characterize the dynamic movements of midfoot and ankle during heel rise task.
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NewsBot · Aug 25, 2022

Alterations to Plantar Loading and Ankle Range of Motion of the Contralateral Foot during Assisted Walking in Patients with Type 2 Diabetes Mellitus
Jose GAnguiano-Hernandeza et al
Gait & Posture 24 August 2022

Aims
Patients with diabetic foot ulcers are instructed to be non-weight bearing on the affected limb to promote healing. Therefore, the aim of this study was to investigate the effect of different assistive devices on whole foot plantar loading, peak forefoot force, ankle range of motion, and locomotion speed during gait in patients with Type 2 Diabetes Mellitus.

Methods
Participants walked normally, with crutches, a walker, and a wheeled knee walker in randomized order. Force sensitive insoles and 3D motion capture were used to record plantar normal force and ankle kinematics. Force sensitive pads were wrapped around handles of the crutches and walker to measure bodyweight offloaded onto the assistive device. An instrumented WKW was used to measure bodyweight offloaded onto the handlebars and knee cushion.

Results
Locomotion with the WKW produced the lowest whole foot plantar loading and peak forefoot force, while also producing the greatest ankle range of motion and locomotion speed amongst assistive devices.

Conclusions
This pre-clinical study found that the WKW could be the preferred assistive device for total unilateral offloading of diabetic foot ulcers as it reduced propulsive limb whole foot and forefoot plantar loading while retaining ankle range of motion and locomotion speed.
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NewsBot · Oct 21, 2022

Decoding foot deformity and joint-destruction pathways in diabetes: Emerging insights from in-vivo foot joint kinetic measures
Kevin Deschamps
October 19, 2022
Highlights
•Persons with diabetes mellitus had decreased sagittal angular velocity throughout foot segments.
•Decreased angular velocity contributed to reduced midtarsal power generation.
•Persons with diabetic neuropathy tend to acquire an ‘energy neutral foot’.

Background
A comprehensive insight into the effect of longstanding diabetes mellitus and neuropathy on foot joint kinetics during walking is lacking. Our goal was to assess the in-vivo kinetics of major foot joints in persons with diabetes.
Methods
Three groups, matched for age, sex and walking speed were recruited in this study: 1) people with diabetic peripheral neuropathy, 2) people with diabetes without peripheral neuropathy, and 3) control subjects without diabetes. Participants were instrumented with retroreflective markers on both feet and lower limbs and underwent a barefoot gait analysis using a state-of-the-art multi-segment kinetic foot modelling approach in order to provide accurate joint loading measures at the ankle, midtarsal, tarso-metatarsal and hallux joints.
Findings
The group with neuropathy showed reduced ankle peak plantarflexion angular velocity compared to the control group (P = 0.002). Both groups with diabetes showed a significantly reduced midtarsal peak plantarflexion angular velocity, peak power generation and positive work compared to the control group (p < 0.01). Groups showed significant differences with respect to the tarsometatarsal peak dorsiflexion (p = 0.006) and plantarflexion angular velocity (P < 0.05).
Interpretation
This study shows that both diabetes groups have similar joint loading and power absorption capacity but seem to lose their power generation capacity especially at the midtarsal joint. This loss of power generation capacity and the resulting decreased net mechanical work of the foot potentially embodies a foot that poorly supplements the body's mechanical energy during push-off. This phenomenon may cause excessive tissue stresses that contribute to foot deformity and joint-destruction mechanisms
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NewsBot · Jul 17, 2023

Compromised neuromuscular function of walking in people with diabetes: A narrative review
Roya Hoveizavi et al
Diabetes Research and Clinical Practice
Volume 202, August 2023, 110802

Aim
This review summarizes recent studies that have investigated the neuromuscular dysfunction of walking in people with diabetes and its relationship to ulcer formation.

Methods
A comprehensive electronic search in the database (Scopus, Web of Science, PsycINFO, ProQuest, and PubMed) was performed for articles pertaining to diabetes and gait biomechanics.

Results
The Achilles tendon is thicker and stiffer in those with diabetes. People with diabetes demonstrate changes in walking kinematics and kinetics, including slower self-selected gait speed, shorter stride length, longer stance phase duration, and decreased ankle, knee, and metatarsophalangeal (MTP) joint range of motion. EMG is altered during walking and may reflect diabetes-induced changes in muscle synergies. Synergies are notable because they provide a more holistic pattern of muscle activations and can help develop better tools for characterizing disease progression.

Conclusion
Diabetes compromises neuromuscular coordination and function. The mechanisms contributing to ulcer formation are incompletely understood. Diabetes-related gait impairments may be a significant independent risk factor for the development of foot ulcers.
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NewsBot · Jul 18, 2023

Limited Joint Mobility in Type 1 Diabetes: Diabetic Cheiroarthropathy, a Neglected Entity
Jayshree Swain, Brij Teli, Abhay Sahoo, Lavanya Kasukurti
JCEM Case Reports, Volume 1, Issue 4, July 2023, luad068, https://doi.org/10.1210/jcemcr/luad068

Musculoskeletal disorders are common in type 1 and type 2 diabetes mellitus. Among them, diabetic cheiroarthropathy (DCA), more commonly seen in type 1 diabetes, is a late complication that often causes physical and emotional disturbance. DCA, characterized by movement restrictions in the small joints of hands, is usually a clinical diagnosis and bears significance owing to the functional hand disabilities that it causes and its association with various microvascular complications, most importantly retinopathy. A 24-year-old male patient, with type 1 diabetes of 20 years duration, presented to us with difficulties in performing fine motor tasks such as buttoning his shirt and with positive “Namaste” sign and “Table Top” sign. He had reduced sensation on monofilament testing, decreased vibration perception threshold, and a nerve conduction study suggested distal sensory demyelinating and axonal polyneuropathy. He had a restrictive pattern on pulmonary function tests, normal lung parenchyma on high-resolution computed tomography of his thorax, proliferative diabetic retinopathy, proteinuria, vitamin D deficiency, and subclinical hypothyroidism. He was followed closely with tight glycemic control and physiotherapy. In rural setups, DCA can act as a mirror to screen for macrovascular and microvascular complications if not already done routinely or previously. Management includes physiotherapy, glycemic control, patient education, and regular follow-up, with surgical procedures being only the last option.
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NewsBot · Aug 12, 2023

Effects of foot-ankle exercises on foot-ankle kinematics, plantar pressure, and gait kinetics in people with diabetic neuropathy: Secondary outcomes from a randomized controlled trial
Renan L Monteiro et a
Braz J Phys Ther. 2023 May-Jun;27(3):100517

Background: Follow-up report of secondary outcomes of a randomized, single-blinded, parallel controlled trial that investigated the benefits of a foot-ankle therapeutic exercise program on foot-ankle kinematics, plantar pressure, and lower limb kinetics during gait in individuals with diabetic neuropathy (DPN).

Methods: Sixty-six participants with DPN were randomly allocated into a control group (CG; n = 31), which received usual care, and an intervention group (IG; n = 35), which received usual care plus a 12-week group-based foot-ankle exercise program. Outcomes were assessed at baseline and 12 weeks by an assessor blinded to group allocation.

Results: The generalized linear mixed model and intention-to-treat analysis revealed a greater hip extensor moment at push-off and greater hallux contact area in the IG than CG after 12 weeks. A within-group analysis revealed a larger arch height during stance and higher peak pressure and pressure-time integral at the central forefoot region in the IG after 12 weeks compared to baseline. There were no other significant group difference or changes over time in foot-ankle kinematics or in any other joint moment related to overall lower limb biomechanics.

Conclusion: The increases in hip moment at push-off and hallux surface contact area suggest an improvement in the propulsion phase with greater participation of the toes in foot rollover after 12 weeks of a group-based foot-ankle exercises program for people with DPN. Individual face-to-face, longer-term, and more intensive interventions may be needed to positively influence foot-ankle biomechanics and pressure parameters in other plantar areas.
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NewsBot · Nov 13, 2023

Addressing Biomechanics Matters in Treating Diabetic Foot Ulcers

NewsBot · Jan 12, 2024

A Biomechanical Investigation of Children with Type 1 Diabetes Mellitus: Are Children's Feet a Precursor to Adulthood Foot Complications?
Roxanne Agius et al
J Am Podiatr Med Assoc. 2023 Nov-Dec;113(6):21-134

Background: There is limited evidence on the biomechanical effects of type 1 diabetes mellitus (T1DM) on children's feet. This study aimed to determine whether children living with T1DM aged 10 to 16 years have altered foot structure and gait parameters compared with same-aged children without medical conditions.

Methods: A nonexperimental, case-control study was conducted. Thirty-four healthy children and children living with T1DM were recruited. Participants underwent a clinical biomechanical examination followed by instrumented gait analysis using the Oxford Foot Model to investigate foot segment motion.

Results: Children with T1DM demonstrated more dermatologic lesions and structural foot abnormalities, including claw toes (33.3%), hammertoes (22.2%), and hallux abducto valgus (11.1%), than their healthy counterparts. Gait analysis results indicate a significant difference between the two groups at the hindfoot-to-tibia angle at heel strike and toe-off, suggesting limited ankle joint motion.

Conclusions: Children with T1DM demonstrated a higher frequency of structural foot pathologies than did healthy children possibly associated with limited ankle sagittal plane movement. Screening is warranted to identify and manage these conditions early to reduce their risk of more significant foot problems associated with DM in adulthood.
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Diabetic foot biomechanics

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11th STAFFORDSHIRE CONFERENCE ON CLINICAL BIOMECHANICS - “Understanding Diabetic Foot”

Diabetic Foot biomechanics

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Homeopathy for Diabetic Foot Ulcers

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Diabetic foot biomechanics

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11th STAFFORDSHIRE CONFERENCE ON CLINICAL BIOMECHANICS - “Understanding Diabetic Foot”

Diabetic Foot biomechanics

Pravibismane for diabetic foot infections

Homeopathy for Diabetic Foot Ulcers

Diabetic Foot Influencers on Twitter

Low Plasma Arginine among Patients with Diabetic Foot Ulcer

Epalrestat is effective in treating diabetic foot infection

Share This Page

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