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What Causes Foot Creep

Discussion in 'Diabetic Foot & Wound Management' started by Bruce Williams, Dec 28, 2007.

  1. Bruce Williams

    Bruce Williams Well-Known Member

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    I consider foot creep to be when a patient's foot has a tendency to migrate distally within a shoe with or without a foot orthosis or brace.

    Does anyone have any ideas on how to stop foot creep?

    Does anyone have any idea why this occurs?

    Just curious.

    Bruce Williams:wacko:
  2. Not come across this terminology before. Obviously in biomechanics "creep" has a somewhat different definition.

    Try a tongue pad?

    Shoes inadequately fastened? Shoes too big?
  3. Bruce Williams

    Bruce Williams Well-Known Member

    Thanks for the reply Simon!
    Tougue pads are good at times and I definitely agree on shoe sizing.

    I'm just curious why I see this in many patients with diabetes so much. I imagine there is a neuropathic component often as well.
    Oh well, just one of the delights of practice!
    Cheers! :drinks
  4. Phil Wells

    Phil Wells Active Member


    My own observations about the mechanics of the diabetic foot have led me in the following direction -
    Glycosilation of tendons and ligaments leads to them becoming stiffer leading to a reduction in hysteresis by these structures. The lack of energy return leads to the muscles needing to work harder to keep things 'dynamic'. As fatigues occurs, then 'creep' may occur due to a lack of muscles effectiveness.
    Also rupture of ligaments due to them no longer being able to 'stretch' - possible Youngs Modulus changes - will have a similar effect.
    Add to this the tightness in the TA due to glycosilation and weak tib ant due to early de-innervation of the muscle unit, then GRF will also increase = midtarsal joint compensation.

    These are purely theories based on some research and I would welcome any comments.


  5. Bruce Williams

    Bruce Williams Well-Known Member

    I would say your theories are very good. The AJE is well documented in the literature and Craig P. has done some good work on the rupture of the plantar ligaments as well.

    It's still a pain in the ass to deal with! Any other thoughts than what Simon suggested?
    Always willing to learn someting new.

    thanks again.
  6. Phil Wells

    Phil Wells Active Member


    A few thoughts that may help
    1. A SACH heel to reduce platarflexory forces from initial contact
    2. A rocker sole designed to re-instate a more 'normal' CoP progression
    3. Extrinsic flexor support - a simple insole with MD EVA under the toes to apply a dorsiflexion moment to the toes - possibly will help with the flexors plantarflexory action.

    Any good?

  7. Bruce Williams

    Bruce Williams Well-Known Member


    all excellent ideas! I don't remember what SACH stands for anymore, so can you clarify for me?
    I have used all the rest with good success, though sometimes I get so problem focused I forget to utilize them all the time.
  8. pgcarter

    pgcarter Well-Known Member

    Having spent many years fitting footwear for a variety of purposes I can tell you that what you are talking about happens when the footwear is not a suitable shape for the foot. This is compounded by mobility and flattening of the foot during motion. Footwear is often sold by people who have no idea...even medical grade stuff is often very poorly fitted. Clearly footwear is about static and dynamic fit....rarely considered in a fitting situation. If the footwear is the right length, width, shape, proportions and stiffness for the foot and the activity, it will work. If one or more of these things is wrong success is less likely. The degree to which a foot changes shape under load is crucial in the dynamic fit of footwear. With the rigid "intrinsic minus" foot of diabetic neuropathy the dynamic change in shape during gait tends to be less. The amount which the foot will move forward in the shoe will depend largely on the suitable matching of the angle of descent of the mid foot and metatarsal shafts with the angle built into the shoe or boot when its laces are done up....if these two things match well not much creep will occur. It is the shaping of the 'vamp" region that will be the most important here. I also see many Australian feet that are broad in the forefoot, fairly high in the instep but fairly low volume in the calcaneus/achillies region. Not much foot wear is made in these proportions, and so the chances of a good static anatomical fit are low in the first place.
    regards Phill Carter
  9. Phil Wells

    Phil Wells Active Member


    SOLID ANKLE CUSHION HEEL - a bit of soft material inserted into the unit/sole counter to reduce PF moments.

    Last edited: Jan 3, 2008
  10. Bruce Williams

    Bruce Williams Well-Known Member

    Ahhhhh, thanks Phil. What thickness do you generally use?

    Howard and I will often utilize 3-6mm of poron or ppt as a heel lift to slow accelerations of one foot to the other. This also acts as a dampener to the immediate heel off that would accompany PFion moments as you stated above.

  11. Bruce Williams

    Bruce Williams Well-Known Member

    Dealing with two Phil's and getting confused! ;)

    I very much appreciate the insite of everyone here.

    I agree that matching the foot shape is paramount.
    I think that beyond that, function does take over.

    In those instances it seems to be important to utilize a rocker bottom sole, modifications of the Vamp (toungue pads, etc) and to potentially slow PFion with soft heel cushions.

    Wow, this was very educational for me. Much of this I do on patients with adequate to excellent function. As usuall I forget to transpose that to less functional feet in patients with diabetes and other dysfunctions.

    I am still learning - thanks Michelangelo!

    Thanks everyone!
    Happy New Year!
  12. Boots n all

    Boots n all Well-Known Member

    "I'm just curious why I see this in many patients with diabetes so much"

    So maybe you should be looking for another common factor that your diabetic clients all share other than the diabeties, it cant be the material you cover the orthotics with as you stated

    "....within a shoe with or without a foot orthosis or brace."

    Maybe they are all sharing the same type/brand of diabetic socks which is not giving enough traction in shoe ?

    Other than that l going with poorly fitted shoe, but that cant be happening to so many.........l hope

    Just a thought
  13. T - C.Ped

    T - C.Ped Welcome New Poster

    First, I'm new here so hi.

    Part of my job as a C.Ped is to see that patients understand not only the importance of wearing therapeutic foot gear, but also the correct way of donning that gear.

    I'm going to assume the shoe has been fit correctly for length, width, and depth.

    Migration or shear in a diabetic shoe can have tragic consequences. So as the patient dons the shoe for the first time I watch closely. Almost always I have to suggest tapping the back of the heel gently against the floor. In doing so you seat the heel firmly. Only then should the patient secure the lace bar or velcro shoe.

    Consider how we all put our shoes on. We slide them on, put them on the floor and lean forward. If you watch closely, in that leaning forward motion we also migrate forward, leaving a gap behind the heel. Then we tie the shoe snug and wonder why it's slipping.

    Tapping the heel before securing the shoe prevents a good bit of that migration. And a neuropathic patient likely doesn't even feel that forward migration.

    If the heel continues to slip (which isn't always a dangerous circumstance) or the foot continues to migrate, I also recommend a tapered felt tongue pad. This also helps to seat the heel.

    Please don't go crazy with the tongue pads. If it takes 1/4" or more, likely the shoe isn't too wide, it's too deep. Many of these PTTD patients have very shallow feet, as do a few diabetics. (Drew shoes makes a few shallower shoes that are SADMERC approved.)

    Oh, and the simplest way to ease migration is to first make sure the patient isn't just tugging hard on the laces and only snugging the top two, leaving the lower lace bar primed to loosen.

    Mine is just another opinion. Hope it helps.
  14. Jeremy Long

    Jeremy Long Active Member

    I'm in agreement with pgcarter. All too often therapeutic shoe fitters rely on one or two brands to fit all their patients. The disappointing reality is that it is impossible to adequately fit a full patient population with the shoe last shapes afforded by so few brands.

    Couple that with the prevalence of ankle equines in many individuals requiring therapeutic footwear, and the often resultant clawing of the lesser digits from reduced hallux function. In a shoe last poorly matched to the wearer, the foot can easily "creep" distally.

    One of my top priorities is always to identify the brand that best matches the physical contours of the patient's feet. Then identifying the dynamic changes that occur in the individual when weight bearing can better isolate what size is most relevant. As T C-Ped stated, counseling the patient on proper closure of the shoe is important, just as selecting a closure system that better matches the foot shape and patient's physical abilities. These, in combination, offer excellent reduction/elimination in creeping of the foot within the shoe ... and work best in the initial evaluation and fitting, rather than in attempts to modify the shoe for fit, later.

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