Post diabetic foot ulcer footwear

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If TCC is the gold standard for healing of ulcers,is it possible to use the same technology to produce a shoe/boot with an rthotic that will keep the ulcer healed ? Would something like the ski boot system that heat moulds an insole to the foot work?
Does anyone know of footwear that works miracles?
I would love to hear about it
thanks

 

Re: post ulcer footwear

Hi the Scottish Intercollegiate Guidelines Network has some info with references in the SIGN 116 diabetes guideline http://www.sign.ac.uk/guidelines/fulltext/116/index.html

No miracles, nothing new but the work of the Biomechanics unit in Dundee and of VanSchie et al in Manchester continues to point to using trainer style shoes or bespoke shoes with enough room for a total contact insole. Hope this helps.

 

I agree once you you healed the foot ulcer using a TCC or a RCW, what then?
often the problems are only begining.
We try to stage our progression from TCC to footwear. That is we will custom make a total contacty insole to off-load as best as possible the problem area.
We also review the clients footwear as to suitablility to the clients needs obvously or make foot wear recomendations to the client and refer to a suitable footwear supplier.
Or or Orthotist will refer to a shoe maker for custom footwear often these maty be extra depth, width or wider than what is available comercially and may include a rocker sole.

The important thing to over come is to get the client to use the inserts and appropiate footwear recomended. this is partially education but despite eyeryones best efforts it often goes wrong and breaks down.

the key thing i have learnt is that its good to work as part of a team in the management of these clients. comming from a problem from a diffrent point of view can give insight on what prehaps to try next.

 

We work with a lot of these clients, making a custom shoe and Total Contact Orthosis (TCO), also benefits are found with in the sole design.

Because we do so much of this work we put in the Fscan in-shoe pressure system to help us understand what we have done better and what we can be done further to ensure the best outcome, sometimes adding pressure somewhere else to decrease the pressure over the critical area, its all about the on going management, and the on going management is critical.

But the best results come from feed back from the client and podiatrist, before and after the product is delivered, a real team effort has to be made.

l forgot, we also make our clients sign a wearing agreement, stating the footwear must be shown to the pod and wound care specialist and care instructions, we keep a copy and they take a copy home, it put some responsibility on them and the fact that they sign it seems to have a very positive outcome

 

One thing I would point out is that it is generally accepted(I think) that shear forces play an enormous part in ulcerations. TCCs eliminate much of the shear as the foot/ankle is immobile within the cast.

With that in mind, think about the total contact insole and the incorporation of materials such as shearban or covers which have lower cofficients of friction(I am assuming you are referring to plantar lesion)

Further to that, the design of the footwear becomes critical. If the TCC heals the ulcer, perhaps considering footwear which has similar features may be an option - ie rigid keeled shoes(or perhaps better, boots) with minimum 12 degree toe spring rocker soles to speed the transition between foot flat and toe off(notwithstanding current discussions about reduced hallux dorsiflexion usage leading to less Windlass leading to other pathologies).

At the extreme end of the treatment plan is to use something like a CROW boot which essentially acts as a removable TCC. Cosmetically not great but the lesser of the 2 evils if recurrent ulceration is a problem.

Not really specifically what you were asking but hope it give some more food for thought

Robin

 

yes i agree a moon boot a walker is very way to go or a crow if required.
we generally progress patients form a tcc to a DH walker with a custom TCO and then into a boot or shoe if all is ok.

education of the client is an important thing because unless you have the client working with you it wont work and it all end in tears.