When treating Diabetic Gait with orthotics, there are a few modifications that can have impactful benefits to the patient. Depending on their circumstances, consider the following when prescribing diabetic orthotics:
Recommended Orthotic Modifications for Diabetic Gait
Top Cover: Diabetic orthotics usually use a Plastazote / Poron bilaminate top cover. Changing the material to an EVA / Poron bilaminate is a good choice for a longer lasting device.
Heel Lift: For limb length discrepancies, adding a poron heel lift equal to 1⁄2 the amount of the short limb distance is usually recommended.
Arch Height: Add a higher arch height for pronation and lower the arches for supination. For extra cushioning without too much increased height, consider combing lowering the arch height with adding a poron arch pad.
Shell Rigidity: Change the shell rigidity to semi-rigid when the patient is heavier and/or has a bigger shoe size. Changing the arch reinforcement to EVA will also increase the rigidity.
There is an adage to be considered: the more flexible the foot, the more control it needs. Where length is concerned, the longer the foot, the longer the device, which makes the shell less rigid.
Metatarsal pads: Adding a 1/16” metatarsal pad can help distribute weight in the forefoot by taking weight off of the 1st meta head. Add a poron Morton’s extension for off-loading the 2nd.
Cuboid Pad: Adding a 1⁄8” poron cuboid pad will help pronate the midfoot and relieve pressure from the meta base. Keep all pads as thin and soft as possible.
Metatarsal Accommodations: Add metatarsal head accommodations as needed for offloading ulcers. Once the ulcers have healed, you can remove the accommodations when it is no longer needed.
Amputee Cast Fill
If the patient has already undergone amputation due to diabetic complications, it is even more important to ensure that they have a proper orthotic device to accommodate their new gait.
An Amputee cast fill is a specialized modification that can be incorporated into orthotics to address the unique gait patterns and pressure distributions associated with toe amputations. This modification involves filling the voids in the orthotic shell with a moldable material, such as polyurethane foam, to create a custom fit that accommodates the residual limb.
This customized fit provides enhanced support and stability, helping to distribute weight more evenly and reduce pressure points to compensate for the reduced sensation in the residual limb. Additionally, amputee cast fills can help to improve balance and proprioception, enhancing overall mobility and confidence in individuals with diabetic toe amputations.
In addition to orthotics, there are a number of other things that podiatrists can do to help manage diabetic gait and prevent foot problems. These include:
Diabetic Shoes: At risk patients should find Diabetic shoes that fit well and have enough extra depth and width to prevent rubbing. These shoes should also have enough room for their orthotics.
Less Going Barefoot: Encourage neuropathic patients to avoid going barefoot as much as possible. Macro traumatic events can lead to serious complications.
The majority of diabetic ulcers develop as a result of everyday stresses, or repetitive micro-trauma at the foot’s plantar surface. These can occur during routine ambulation as patients go about their normal routine, or occurrence can be heightened with specialized activities.
Gait Training: Many patients can benefit from gait training to teach them proper heel strike and lengthening their stride length. The more time the patient spends on their heel the better.
Multi-disciplined approach: Involving other physicians and specialists (such as physician assistants, certified prosthetists, physical therapists, occupational therapists) will help high risk diabetic patients have better outcomes.
By taking a comprehensive approach to managing diabetic gait, you will be able to help your patients avoid the serious complications that can result from this condition.
This article is part 2 of a series, read our Diabetic Gait Part 1 here