What orthotic management is suitable for a patient with IDDM type 1, diabetic neuropathy, and dropped foot, who has experienced discomfort with standard orthotic shoes?

From the Guidelines

I strongly recommend proceeding with the Rosendahl orthotics consultation for this 38-year-old male patient with Type 1 diabetes mellitus and diabetic neuropathy. The patient has demonstrated specific needs that standard Apex diabetic footwear cannot address, including a documented dropped foot with limited range of motion in the left foot. The current foot blisters on his 4th left toe and 3rd right toe indicate ongoing pressure points that require custom orthotic intervention. According to the guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update) 1, custom orthotics are particularly important in this case because the combination of diabetic neuropathy and foot deformity (dropped foot) significantly increases ulceration risk.

Key Considerations

• The patient's previous negative experience with standard diabetic footwear highlights the need for personalized intervention to prevent serious complications like ulcers and potential amputation, which are common in diabetic patients with neuropathy and foot deformities.
• The guidelines recommend considering prescribing extra-depth shoes, custom-made footwear, custom-made insoles, and/or toe orthoses for patients with a foot deformity that significantly increases pressure or a pre-ulcerative lesion (IWGDF risk 2 or 3) 1.
• While awaiting the Rosendahl consultation, the patient should be advised to:
  • Inspect his feet daily
  • Keep the blisters clean and covered with sterile dressings
  • Avoid walking barefoot
  • Wear well-fitting temporary footwear that doesn't exacerbate the existing lesions

Rationale

The IWGDF guidelines emphasize the importance of proper footwear and orthotics in preventing foot ulcers in patients with diabetes 1. The patient's specific needs, including dropped foot and limited range of motion, require custom orthotic intervention to reduce the risk of ulceration. The guidelines also recommend educating patients on proper foot care, including daily inspection, proper cleaning and dressing of wounds, and avoiding walking barefoot 1.

Next Steps

The patient should be referred for a Rosendahl orthotics consultation to determine the best course of treatment for his specific needs. In the meantime, the patient should be advised to follow the recommended foot care guidelines to prevent further complications. According to the guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus (IWGDF 2023) 1, footwear and/or orthoses that best accommodate and support the shape of the foot/feet and ankle are recommended to help prevent re-activation of Charcot neuro-osteoarthropathy (CNO).

From the Research

Patient Assessment and History

• The patient is a 38-year-old male with IDDM I and documented diabetic neuropathy.
• He has tried Apex shoes, which were too heavy and caused foot lesions.
• The patient presents with limited ROM in his left foot, previously documented as dropped foot.
• He also has two blisters, one on his left foot 4th toe and one on his right third toe.

Relevant Studies and Findings

• Diabetic neuropathy can lead to the loss of sensation, making patients more susceptible to foot lesions and ulceration 2.
• Offloading of areas with increased pressure is crucial for preventing and healing foot ulcers in diabetic patients 3.
• Patients with diabetes and peripheral neuropathy are at risk for foot deformities and mechanical imbalance, emphasizing the need for proper foot care and education 4.
• Diabetic foot lesions often result from a combination of neuropathy and vascular disease, and high-risk patients require frequent follow-up and education to reduce the risk of lesions developing 5.
• Foot ulceration in diabetic patients can be prevented with comprehensive screening programs, education, and proper management, including offloading and aggressive treatment of infection 6.

Management and Recommendations

• The patient's limited ROM and dropped foot require careful assessment and management to prevent further complications.
• Offloading and proper footwear are essential to prevent foot ulcers and promote healing.
• Regular follow-up and education on proper foot care are crucial to reduce the risk of foot lesions and ulceration.
• A Rosendahl consult has been requested to further assess and manage the patient's condition.