This is our presentation for the British Association for Prosthetists and Orthotists meeting to be held in Telford, March 22/23rd 2013. We cover foot screening, assessment and footwear prescription in diabetic foot disease. Footwear in diabetes is much misunderstood. It is important that footwear is prescribed with an understanding of the individual patient's risk level. We describe a rational process for doing this. All footwear for persons with diabetic foot disease may have some consistent features - but there is no such thing as "diabetic footwear" in the sense of one design being good for everyone.

1. Screening, Assessment
and Prescription
Diabetic Foot Disease
William A Munro, Derek Jones

2. Screening
What is it?
Why do it?

3. Screening Is..
The Starting Point
for Effectiveness
Quick & Simple
Assess Patient’s Risk
Level
Not the Same as
Assessment

4. What Do We
Screen For?
Previous Amputation
Significant deformity
Significant callus
Active ulceration
Previous ulceration
Vascular insufficiency
Neurological insufficiency
Able to self care?

5. Risk Stratification
5 % Active Ulcers or Infection -
revascularisation or amputation
Multidisciplinary management
15 % High Risk
Intensive foot protection Ulcerated
High Risk 20 % Moderate Risk
60% Low Risk Regular foot protection
Routine annual screening
Moderate Risk
Low Risk

6. Patient Information
Leaflets
Foot Screening in Scotland

8. Screening
• Detects early • Requires healthcare
disease worker trained for
competence in
• Involves tests that screening
have a predictive
value and an agreed • Does not involve a
cut-off point for treatment plan
referral
• Patient does not
influence outcome

9. Assessment
• Establishes a diagnosis • Patient may influence
outcome
• Involves clinical decision
making skills and clinical • Reassessment is patient-led
autonomy for onward depending on symptoms or
referral response to therapy
• Requires a healthcare
professional with the
appropriate training/
competence in assessment
• Decides on a future
management plan
Adapted from Article in DFJ,Vol. 9, No. 4. Mousley, M

10. se of
po s
ur oe
P h
S
• Protection
• Prophylaxis
• Ambulant pressure
relief

11. Preventing Trauma Means
Controlling the Mechanical
“Environment”
su re
P res
n anics
. nsatio ech y
s . Se
ha d
ot ere e M natom
Fo lt ssu l A
Ti ra
Friction
A ered ctu
✓ Alt tru
✓ and S She
ar F
✓ orce

12. Mechanical Challenge
External Series of Skeletal
Force Interfaces Force
Ground - Shoe Sole - Insole - Soft Tissue - Bone

13. Mechanical Challenge

14. Orthotic Prescription
• Deformity • Pain
• Significant • Previous
• Non-significant Ulceration
• Ambulation • Environment
• Biomechanical
• Neuropathy
• Vascular

15. Biomechanical Assessment
• Range of motion
• Deformity
• Flexibility
• Rigidity
• Sensory
Reduced joint mobility leads to elevated plantar pressure
Sauseng & Kastenbauer

16. hoes
bet ic” S Roomy
“Dia Soft and s
Upper
Pressure Relief? ck?
r Sto
ke o
spo R
Be ocker
We Must S Sole?
ave Money
.. But Who Has the Skills?
Relieve Pressure?
How
Complicated
Can Shoes Be..?

17. Basic Shoe Function
• Prescription Matrix – Defines function
• Function – Defines Style/Design
Possibilities

18. Footwear Design Criteria
Spectrum of Activity
• Newly screened • Deformed neuro-
neuropathic foot ischaemic foot
• Moderate Risk • High Risk
• Previous Ulceration
• Non-ulcerated

19. • Shoe and Contact Surface
(footbed) Must Work Together
• Materials & Structures Chosen
& Positioned for BOTH Control
and Tissue Matching
• Shoes Need to act like the
“Skeleton” as well as the “Soft
Tissues” - Support as well as
protect
• “Soft” Uppers not Necessarily
Best - Match to the Ambulatory
Status and Load Expectations

20. Fashion Options

21. Foot Orthoses
• Integral Part of Shoe Design
• Total Contact Orthoses
• Functional Foot Orthoses
• Simple Insoles
• The Foot Orthoses Type Will Impact On The
Volume of the Shoe

22. NO
Due to Complexity of the
Situation

23. You Have to Have Faith - and then
build rational processes for
management

24. Conclusion
• Base on individual patient
needs
• Materials to suit the interfaces
• Don’t design the foot orthosis
without thinking of the shoe
• Multi-disciplinary education
and mutual understanding of
orthotic interventions