September 2013

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How-To Insights On Orthotic Modifications For Patients With Diabetes

For a plantar ulcer on the second metatarsal head, Dr. Kirby suggests modifying the orthosis to accommodate the second metatarsal head in the forefoot extension area of the orthosis, which will place greater pressures on the first, third, fourth and fifth metatarsal heads. In addition, he says one may also modify the orthosis to have a metatarsal pad proximal to the second metatarsal head to increase the plantar pressure on the distal second metatarsal shaft and off the second metatarsal head.

Dr. Kirby says another possible modification would be adding a bar forefoot post or "dropoff" across all the metatarsal necks to increase the plantar pressures across all the distal metatarsal shafts. This should reduce the plantar pressures across all the metatarsal heads, according to Dr. Kirby.

Dr. Kirby says the sum total of ground reaction force acting on the plantar foot does not decrease with foot orthoses. However, he notes foot orthoses do have the potential to effectively redistribute ground reaction force to different areas of the plantar foot and hopefully away from the high pressure at-risk areas of the plantar skin.

“Once the biomechanics of plantar pressure reduction is understood, then the only limitation to foot orthosis therapy for patients with diabetes is the imagination and skills of the prescribing podiatrist,” says Dr. Kirby.

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   Max Weisfeld, DPM, feels tavaborole has several specific advantages over ciclopirox, saying the smaller molecular weight of tavaborole allows a greater penetration of the nail plate to get to the site of the infection. In contrast, he says ciclopirox tends to accumulate on top of the nail plate. Another advantage of tavaborole, states Dr. Weisfeld, is that it is water soluble, allowing for penetration of the nail, and is active in the presence of keratin, a main component of the nail plate.

   Dr. Weisfeld, a principal investigator on the phase 3 trials, also speculates that even though debridement is optional for patients using tavaborole, debridement might improve the efficacy of the antifungal. In addition, Dr. Weisfeld has found tavaborole to have little or no detectable systemic exposure.

   “I think that the ‘holy grail’ of onychomycosis was always to find a safe, effective, easy to apply topical since so many people, to this day, do not want to take oral agents and risk even the minimal chance of a toxicity,” says Dr. Joseph. “I will say that with the upcoming potential approvals of both tavaborole and efinaconazole (Valeant Pharmaceuticals), there is certainly more ‘excitement’ about the topic than there has been.”

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Dr. Steven Kingsays: August 26, 2013 at 6:09 pm

Aloha,

Plantar redistribution of force and shear is paramount for healing and protection.

Use of an external sole rocker or the newer technology of using a levered internal midsole shoe rocker can achieve this.

Use of compressible foams to donut hole a lesion is helpful or the newer technology of using a composite spring plate with lesion cuttouts is very helpful to not only reduce pressure but shear as well by transferring the force distally and plantar through the spring plate. Modified carbon fiber dynamic AFOs work very well for this but have only been really used for stroke support. We should start using the AFOs if we want to maximize our orthotic therapies.

Mahalo,

Dr. King

Co-Principal Investigator SBIR A11-109 "Advanced Composite Insoles for the Reduction of Stress Fractures." US Department of Defense and Army Medical Research and Materials Command,

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