title: What has finite element analysis taught us about diabetic foot disease and its management? A systematic review.
abstract: BACKGROUND
  Over the past two decades finite element (FE) analysis has become a popular tool for researchers seeking to simulate the biomechanics of the healthy and diabetic foot. The primary aims of these simulations have been to improve our understanding of the foot's complicated mechanical loading in health and disease and to inform interventions designed to prevent plantar ulceration, a major complication of diabetes. This article provides a systematic review and summary of the findings from FE analysis-based computational simulations of the diabetic foot.
  
  
  METHODS
  A systematic literature search was carried out and 31 relevant articles were identified covering three primary themes: methodological aspects relevant to modelling the diabetic foot; investigations of the pathomechanics of the diabetic foot; and simulation-based design of interventions to reduce ulceration risk.
  
  
  RESULTS
  Methodological studies illustrated appropriate use of FE analysis for simulation of foot mechanics, incorporating nonlinear tissue mechanics, contact and rigid body movements. FE studies of pathomechanics have provided estimates of internal soft tissue stresses, and suggest that such stresses may often be considerably larger than those measured at the plantar surface and are proportionally greater in the diabetic foot compared to controls. FE analysis allowed evaluation of insole performance and development of new insole designs, footwear and corrective surgery to effectively provide intervention strategies. The technique also presents the opportunity to simulate the effect of changes associated with the diabetic foot on non-mechanical factors such as blood supply to local tissues.
  
  
  CONCLUSIONS
  While significant advancement in diabetic foot research has been made possible by the use of FE analysis, translational utility of this powerful tool for routine clinical care at the patient level requires adoption of cost-effective (both in terms of labour and computation) and reliable approaches with clear clinical validity for decision making.
authors.affiliation: Institute for Applied Health Research, Glasgow Caledonian University, Glasgow, United Kingdom; Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, United States of America.
authors.forename: Scott
authors.initials: S
authors.lastname: Telfer
authors.affiliation: Computational Biomodeling (CoBi) Core, Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, United States of America.
authors.forename: Ahmet
authors.initials: A
authors.lastname: Erdemir
authors.affiliation: Institute for Applied Health Research, Glasgow Caledonian University, Glasgow, United Kingdom.
authors.forename: James
authors.initials: J
authors.lastname: Woodburn
authors.affiliation: Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, United States of America.
authors.forename: Peter R
authors.initials: PR
authors.lastname: Cavanagh
mesh_terms: D001696:Biomechanical Phenomena; D003198:Computer Simulation; D017719:Diabetic Foot / Q000150:complications / Q000473:pathology*; D019468:Disease Management; D020342:Finite Element Analysis; D016523:Foot Ulcer / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D008953:Models, Anatomic; D011312:Pressure; D012775:Shoes; D013314:Stress, Mechanical