title: Plantar pressure relief in the diabetic foot using forefoot offloading shoes.
abstract: OBJECTIVE
  Forefoot offloading shoes (FOS) are commonly used in clinical practice for treatment of plantar forefoot ulcers in the diabetic foot. The aim of this study was to assess the offloading efficacy of four different FOS models in comparison with a cast shoe and control shoe.
  
  
  METHODS
  In-shoe plantar pressures were measured during walking in each of the six footwear conditions in 24 neuropathic diabetic patients at high risk for plantar foot ulceration. For each of six foot regions, peak pressure, pressure-time integral, and force-time integral were calculated. Load transfer diagrams were developed to assess the footwear mechanisms of action. Perceived walking comfort was measured using a visual analogue scale (VAS). All comparisons between conditions were tested at P<0.05.
  
  
  RESULTS
  Peak pressures and pressure-time integrals at the metatarsal heads and hallux regions were significantly reduced (by 38-58%) in all FOS models when compared with the control shoe. The FOS also relieved metatarsal head peak pressure to a significantly larger extent than the cast shoe (approximately 20%). The load transfer diagrams showed a major transfer of approximately 40% of forefoot load to the midfoot explaining the offloading efficacy of the FOS. Perceived walking comfort was significantly lower in the FOS (VAS score 2.7-5.9) when compared with the control shoe (VAS 8.2) and cast shoe (VAS 6.8).
  
  
  CONCLUSIONS
  The data showed that all FOS models were effective in their primary goal, relieving forefoot pressure in at-risk neuropathic diabetic patients. Therefore, these shoes may be effective in offloading and healing plantar forefoot ulcers, although the low comfort scores should be considered as this may potentially affect adherence to treatment.
authors.affiliation: Diabetic Foot Unit, Department of Surgery, Twenteborg Hospital, Almelo, The Netherlands. s.a.bus@amc.uva.nl
authors.forename: Sicco A
authors.initials: SA
authors.lastname: Bus
authors.forename: Robert W M
authors.initials: RW
authors.lastname: van Deursen
authors.forename: Rajani V
authors.initials: RV
authors.lastname: Kanade
authors.forename: Marieke
authors.initials: M
authors.lastname: Wissink
authors.forename: Erik A
authors.initials: EA
authors.lastname: Manning
authors.forename: Jeff G
authors.initials: JG
authors.lastname: van Baal
authors.forename: Keith G
authors.initials: KG
authors.lastname: Harding
mesh_terms: D000704:Analysis of Variance; D001696:Biomechanical Phenomena; D017719:Diabetic Foot / Q000534:rehabilitation*; D004867:Equipment Design; D005260:Female; D005545:Forefoot, Human / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011312:Pressure; D012775:Shoes; D018709:Statistics, Nonparametric; D016138:Walking / Q000502:physiology*