The Insensate Foot

Foot Orthotics Course 2012

Philippine School of Prosthetics and Orthotics College of Allied Rehabilitation Sciences University of East Ramon Magsaysay

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Introduction

Absent or impaired sensation. Reduced or lack of protective sensation in the foot. Ulcer can develop over time.

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Ulceration

is not typically caused by a single injury or ischemic episode, but rather evolves as a slow change in the tissues resulting from succession of moderate mechanical stresses.

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Mechanisms for Tissue Damage

High localized pressure Prolong and sustained low pressure Application of constant repetitions of moderate pressure

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Stages of Tissue Damage

1. Callus 2. Inflammation 3. Ulcer 4. Infection 5. Abscess 6. Gangrene
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Callus

Ulcer

Abscess

Gangrene

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PREVENT THE FIRST ULCER IS VERY IMPORTANT!

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Wagner Classification of Diabetic Foot Ulcers

Grade
Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

Description
Skin intact but bony deformities produce a foot at risk Localized, superficial ulcer Deep ulcer to tendon, bone, ligament or joint Deep abscess, osteomyelitis Gangrene of toes or forefoot Gangrene of entire foot

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Complications of Insensate Foot

Risk of foot injury Ulceration of the plantar surface of the foot Destruction of mid-foot leading to Charcot foot

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Plantar Ulcer

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Objectives

Reduce Pressure Reduce Shear Unload

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Orthotic Consideration
Total Contact Design Relief Removable walking boot with a custom foot orthosis Use of patella tendon bearing

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Total Contact Casting

Plaster (or fiberglass) is molded to relieve pressure on the ulcer.

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Charcots Foot

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Charcot Foot

Also known as Charcot Joint Charcot Arthropathy Rocker Bottom Foot

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Charcot Foot

A common complication of diabetes with neuropathy Very disabling. Early diagnosis and treatment vitally important

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What causes a Charcots Foot?

Usually occurs in people whose sense of pain is lost or impaired. Muscles lose their ability to support the foot correctly. Minor trauma (e.g., sprains, stress fracture) goes undetected and not treated This leads to laxity of ligament, joint dislocation, bone and cartilage being damaged and deformity of the foot
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Pathophysiology Anatomical Classification

Images: Johnsen, 2007

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Charcots Foot

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Resulting deformities
Pes planus with rear foot being valgus or varus External rotation Valgus forefoot Thick calluses with underlying ulcers

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Charcots Foot

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Objectives
Accommodate existing deformity Prevent further progression of deformity Reduce bending stresses Unload foot as needed

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Treatment
Total Contact Cast or non-weight bearing Assisted weightbearing Accommodative footwear and insole

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