Pressure relief and load redistribution by custom-made insoles in diabetic patients with neuropathy and foot deformity

OBJECTIVE: To study the effects of custom-made insoles on plantar pressures and load redistribution in neuropathic diabetic patients with foot deformity. DESIGN: Cross-sectional. BACKGROUND: Although custom-made insoles are commonly prescribed to diabetic patients, little quantitative data on their mechanical action exists. METHODS: Regional in-shoe peak pressures and force-time integrals were measured during walking in the feet of 20 neuropathic diabetic subjects with foot deformity who wore flat or custom-made insoles. Twenty-one feet with elevated risk for ulceration at the first metatarsal head were analysed. Load redistribution resulting from custom-made insoles was assessed using a new load-transfer algorithm. RESULTS: Custom-made insoles significantly reduced peak pressures and force-time integrals in the heel and first metatarsal head regions; pressures and integrals were significantly increased in the medial midfoot region compared with flat insoles. Custom-made insoles successfully reduced pressures in and integrals at the first metatarsal head in 7/21 feet, were moderately successful in another seven, but failed in the remaining seven. Load transfer was greatest from the lateral heel to the medial midfoot regions. CONCLUSIONS: Custom-made insoles were more effective than flat insoles in off-loading the first metatarsal head region, but with considerable variability between individuals. Most off-loading occurred in the heel (not a region typically at risk). The load transfer algorithm effectively analyses custom-made-insole action. RELEVANCE: Because similar insole modifications apparently exert different effects in different patients, a comprehensive evaluation of custom designs using in-shoe pressure measurement should ideally be conducted before dispensing insoles to diabetic patients with neuropathy and foot deformity.     

Biomechanical treatment approach to diabetic plantar ulcers. A case report

The purpose of this case report is to describe a physical therapy approach designed to reduce the mechanical pressure at the site of a diabetic plantar ulcer. The patient was a 69-year-old man with diabetes mellitus for 24 years, insensitive feet, and a right plantar ulcer at the first metatarsal head for 21 months. He had a fixed equinus and rear-foot varus deformity, which seemed to place increased pressure on his forefoot. The patient was treated with total contact casting and showed progressive healing until he refused additional casting. One week later, the ulcer was considerably larger. He consented to resume casting, and the ulcer was completely healed in 85 days from the initial treatment. We provided the patient with extra-depth shoes with rigid rocker-bottom soles and a polyethylene-lined ankle-foot orthosis. The ulcer remained healed at one-week and six-month follow-up visits. The primary cause of diabetic plantar ulcers is often excessive pressure on an insensitive foot, and physical therapists should utilize biomechanical principles to reduce these excessive plantar pressures.     

The characteristics and clinical significance of plantar pressure distribution in patients with diabetic toe deformity: a dynamic plantar pressure analysis

This study evaluated plantar pressure distribution and its clinical significance in patients with diabetic foot toe deformities. Patients with diabetic claw or hammer toe deformities (patient group; n = 30) and healthy subjects without toe deformities (control group; n = 30) were recruited into the study. Plantar pressures in different regions of the foot were measured using the F-scan(?) in-shoe plantar pressure dynamic analysis system. Peak pressures in the hallux and first to fifth metatarsal heads were significantly higher in the patient group compared with the control group. In the midfoot there was no significant difference between the two groups. Hindfoot peak plantar pressures were significantly lower in the patient group compared with the control group. The results indicated that toe deformities in patients with diabetes increased forefoot plantar pressures to abnormally high levels. If plantar pressure is regularly monitored in patients with diabetic foot, toe deformities might be detected earlier and ulceration prevented.     

Use of liquid crystal thermography in the evaluation of the diabetic foot

Liquid crystal thermography (LCT) was used to determine temperature variations on the plantar surface of feet. The purpose was to identify thermal emission patterns associated with diabetic foot ulcers. Three population groups were screened: group I, 16 nondiabetic controls; group II, 21 diabetic patients with no history of pedal ulcers; and group III, 28 diabetic patients with active pedal ulceration or history of foot ulcerations. The results demonstrate a generalized increase in plantar foot temperature in group III compared with groups I and II. Temperature readings under metatarsal heads 1-5, great toe, heel, and lateral band were significantly increased (P less than .01) in group III. Additionally, the warm lateral surface displayed by group III patients was not significantly different in temperature from the medial arch of the foot. In groups I and II, the lateral band was significantly cooler (P less than .01) than the medial arch. In group III patients with active ulceration on only one foot, no significant difference in temperature was found between the foot with active ulceration compared with the contralateral nonulcerated foot. When patients with active pedal ulceration were compared with patients with a history of foot ulcers, no significant difference in temperature was seen at five of seven sites tested. A warm concentric color band surrounding active plantar ulcers was identified in group III. This pattern extended from the center of the ulcer to a distance of 8 mm. A significant change in temperature (P less than .01) was noted at 6- and 8-mm distances from the center of the ulcer. In addition, a mottled thermographic pattern was observed more frequently in group III patients than in groups I and II.(ABSTRACT TRUNCATED AT 250 WORDS)     

Plantar pressures in individuals with normal and pronated feet according to static squat depths

[Purpose] The purpose of the present study was to investigate differences in plantar pressure between individuals with normal and pronated feet according to 3 static squat depths. [Subjects and Methods] Study subjects were 10 young adults with normal and pronated feet. Plantar pressures were measured in the standing position and static squat positions at 45° (semi-squat) and 90° (half-squat) knee flexion using the F-Mat. Subjects’ plantar pressures were analyzed by dividing the foot into 4 areas: forefoot medial, forefoot lateral, midfoot, and heel. [Results] In the half-squat position, the pronated foot group showed a higher foot pressure in the forefoot medial than was seen in the normal group, whereas the normal group exhibited a higher foot pressure in the heel than was seen in the pronated foot group. [Conclusion] An increase in squat depth led to the transfer of plantar pressure to the heel in normal feet and to the forefoot medial in pronated feet.Key words: Plantar pressure, Pronated feet, Squat     

A study of in-shoe plantar shear in patients with diabetic neuropathy

OBJECTIVE: To quantify in-shoe plantar shear in diabetic neuropathic feet. DESIGN: Plantar shear stresses are measured in a group of six patients with a history of diabetic neuropathic ulceration. BACKGROUND: Although elevated pressure between foot and shoe frequently found in diabetic neuropathic patients has been linked to a raised incidence of plantar ulceration, the shear component of stress at this interface is as yet unquantified. It is suggested that its effects may be equally damaging. METHODS: Measurements of shear were made locally beneath the medial four metatarsal heads and heel during unpaced gait in orthopaedic footwear, using a bi-axial magneto-resistive shear transducer. Similar methodology was previously employed on a group of asymptomatic adults, thereby allowing comparisons to be made. RESULTS: Overall the maximum shear stress for this patient group (73 kPa) was not significantly different to that in the asymptomatic group (87 kPa). However the patient group exhibited lower magnitudes of shear stress under the third/fourth metatarsal heads (average 51/39 vs. 86.5/71 kPa, respectively) and higher magnitudes under the first/second heads (73/64 vs. 35/31 kPa, respectively), indicating a medial shift. Step-to-step variability of maximum shear measured under the third metatarsal head showed an increase in the transverse component (coefficient of reliability 67% vs. 98%). CONCLUSIONS: Although the overall patterns of shear are broadly similar to the asymptomatic group, these pilot trials indicate a medial shift in shear loading under the forefoot coupled to increased step-to-step variability in the diabetic group.RelevanceMechanical stress at the plantar interface between foot and shoe is of particular clinical relevance to the formation and management of ulcers in diabetic neuropathy. Whereas the pressure component of stress is widely studied, the shear component is poorly described although it may be of equal importance.     

Effect of the application of a metatarsal bar on pressure in the metatarsal bones of the foot

[Purpose] The aim of this study was to determine the effect of application of a metatarsal bar on the pressure in the metatarsal bones of the foot using a foot analysis system (pressure on the forefoot, midfoot, and rearfoot). [Subjects and Methods] Forty female university students in their twenties were selected for this study, and an experiment was conducted with them as the subjects, before and after application of a metatarsal bar. The static foot regions were divided into the forefoot, midfoot, and rearfoot, and then the maximum, average, and low pressures exerted at each region were measured, along with the static foot pressure distribution ratio. 1) Static foot pressure: The tips of both feet were aligned to match the vertical and horizontal lines of the foot pressure measuring plate. The subjects were told to look toward the front and not to wear shoes. 2) Distribution ratio: The distribution ratio was measured in four regions (front, back, left, and right) using the same method as used for static foot pressure measurement. [Results] The results of this study showed that the maximum, average, and minimum static pressures in the forefoot were significantly decreased. The minimum static pressure in the midfoot was significantly increased, and the pressure in the other parts was significantly decreased. The maximum and average static pressures in the rearfoot were also significantly decreased. [Conclusion] As reduction of foot pressure with a metatarsal bar results in lowering of the arch and an increased contact surface, the foot pressure was dispersed. These results suggest that wearing shoes with a bar that can decrease the foot pressure is therapeutically helpful for patients with a diabetic foot lesion or rheumatoid arthritis.Key words: Foot pressure, Distribution ratio, Metatarsal bar     

Total contact casting and chronic diabetic neuropathic foot ulcerations: healing rates by wound location

This study investigated healing rates of chronic diabetic neuropathic foot ulcerations located on the plantar surface of the forefoot (n = 30) versus those located on other parts of the foot (n = 25). Each type of ulceration was treated with total contact casting. Ulcerations in the first group were located on the metatarsal heads and toes, while ulcerations in the second group were located on the dorsum of the foot, heel, plantar arch, ankle, medial aspect of foot, and toe or transmetatarsal amputation sites. Successfully healed diabetic neuropathic foot ulcerations treated with total contact casting were rated according to patient age, ethnic origin, sex, patient weight, ulcer size, ulcer location, duration of ulcer prior to casting, and ulcer grade. Analysis of variance and posthoc analyses demonstrated that (1) total contact casting was a highly effective method of treatment regardless of ulcer location (forefoot ulcer healing time mean = 30.6 days; nonforefoot ulcer healing time mean = 42.1 days) and (2) forefoot ulcerations healed significantly faster than ulcerations located on other parts of the foot. Complex correlational relationships were explored in this study, and multiple regression equations were developed for each location grouping.     

Removable cast walker boots yield greater forefoot off-loading than total contact casts

Background

Elevated plantar loading has been implicated in the etiology of plantar ulceration in individuals with diabetes mellitus and peripheral neuropathy. Total contact casts and cast walker boots are common off-loading strategies to facilitate ulcer healing and prevent re-ulceration. The purpose of this study was to compare off-loading capabilities of these strategies with respect to plantar loading during barefoot walking.

Methods

Twenty-three individuals with diabetes, peripheral neuropathy, and plantar ulceration were randomly assigned to total contact cast (n = 11) or removable cast walker boot (n = 12). Each subject underwent plantar loading assessment walking barefoot and wearing the off-loading device. Analysis of covariance was used to compare loading patterns in the off-loading devices for the whole foot, hindfoot, midfoot, and forefoot while accounting for walking speed and barefoot loading.

Findings

For the foot as a whole, there were no differences in off-loading between the two techniques. Subjects wearing cast walker boots had greater reductions in forefoot peak pressure, pressure-time integral, maximum force, and force-time integral with respect to barefoot walking. Healing times were similar between groups, but a greater proportion of ulcers healed in total contact casting compared to cast walker boots.

Interpretation

In subjects with diabetes, peripheral neuropathy, and plantar ulceration, cast walker boots provided greater load reduction in the forefoot, the most frequent site of diabetic ulceration, though a greater proportion of subjects wearing total contact casts experienced ulcer healing. Taken together, the less effective ulcer healing in cast walker boots despite superior forefoot off-loading suggests an important role for patient compliance in ulcer healing.     

The efficacy of a removable vacuum-cushioned cast replacement system in reducing plantar forefoot pressures in diabetic patients

Background

The purpose of this study was to determine the plantar forefoot offloading efficacy of a new prefabricated vacuum-cushioned cast replacement system designed for foot ulcer treatment in neuropathic diabetic patients.

Methods

Fifteen diabetic subjects with peripheral neuropathy underwent in-shoe plantar pressure assessment while walking in five different footwear types: a standard vacuum-cushioned system with instantly moldable vacuum cushion and roller outsole, two modified vacuum-cushioned systems, one with flat surface vacuum cushion and one with flat outsole, a forefoot offloading shoe, and a control shoe. Regional peak pressures, pressure–time integrals, and inter-regional load transfers were calculated to determine the mechanical action of the footwear. Perceived walking comfort was tested using a 10-point visual analogue scale.

Findings

Forefoot peak pressures and pressure–time integrals were significantly lower (by 41–56%) in the vacuum-cushioned system compared to control. Compared to the forefoot offloading shoe, the vacuum-cushioned system showed significantly higher metatarsal head peak pressures, similar metatarsal head pressure–time integrals, and significantly lower hallux peak pressures and pressure–time integrals. A major transfer of forefoot load to the midfoot explained the offloading efficacy of the vacuum-cushioned system. Few significant differences were present between the modified and standard vacuum-cushioned systems. Perceived walking comfort was significantly higher in the vacuum-cushioned system (score 6.6) than in the forefoot offloading shoe (score 3.4).

Interpretation

The results showed that the vacuum-cushioned cast replacement system was effective in offloading the plantar forefoot of diabetic patients at risk for ulceration, although the contribution of the instantly moldable vacuum cushion and roller outsole were relatively small. The combined peak pressure, pressure–time integral and walking comfort results indicate that the vacuum-cushioned system may be a useful alternative for the forefoot offloading shoe in offloading the plantar diabetic forefoot.     

Distal ligamentous restraints of the first metatarsal. An in vitro biomechanical study

BACKGROUND: Hypermobility or instability of the first metatarsal is associated with increased hallux valgus deformity and greater risk of recurrence after surgery. The objective of this in vitro study was to determine the ranges of movement, under directional loading, of the normal first metatarsal and the effect of the longitudinal plantar aponeurosis and the transverse tie-bar ligamentous system. METHODS: A model has been developed to quantify the influence of the first intermetatarsal ligament and plantar aponeurosis on movements of the first metatarsal. All muscular structures controlling movements of the first ray in cadaver feet were detached and static ligament structures retained for study. Using a specially designed test system, a static load was applied to the metatarsal to produce flexion, extension, abduction or adduction moments. The first intermetatarsal ligament and the plantar aponeurosis were detached sequentially and a movement map of the first metatarsal in the frontal plane was obtained using the Isotrak II magnetic measuring system. RESULTS: The first intermetatarsal ligament was shown to be an important stabiliser of the first metatarsal in all directions. The plantar aponeurosis was shown to be a secondary stabiliser resisting medial and dorsal rotation of the metatarsal after division of the first intermetatarsal ligament. INTERPRETATION: Recognition of the importance of the plantar aponeurosis and the first intermetatarsal ligament in the normal foot has implications for our understanding of hallux valgus.     

Plantar tissue thickness is related to peak plantar pressure in the high-risk diabetic foot.

OBJECTIVE: To investigate the relationship among plantar foot pressure, plantar subcutaneous tissue thickness, severity of neuropathy (vibration perception threshold [VPT]), callus, and BMI in a large group of neuropathic diabetic patients at risk of foot ulceration. RESEARCH DESIGN AND METHODS: A total of 157 diabetic neuropathic patients (VPT >25 V) without either peripheral vascular or ulcer history were studied. Plantar foot pressure and plantar tissue thickness were measured at each metatarsal head (MTH) using an optical pedobarograph and an ultrasound scanning platform, respectively. RESULTS: A significant association was observed between peak plantar pressure and plantar tissue thickness at all MTHs (-0.26 < r < -0.61, P < 0.0001), with the least pronounced association at the first MTH. In addition, the pressure time integral was significantly associated with plantar tissue thickness (-0.24 < r < -0.57, P < 0.0001). BMI was significantly related to plantar tissue thickness (0.18 < r < 0.45, P < 0.05), but not to peak forefoot pressures. Subjects with callus had significantly reduced plantar tissue thickness at all MTHs except the first MTH and increased peak pressures at all MTHs (P < 0.001). CONCLUSIONS: This study confirms a strong inverse relationship between plantar tissue thickness and dynamic foot pressure measurements. Long-term follow-up of this patient population will confirm whether reduced plantar tissue thickness predicts the development of diabetic foot ulcers.     

Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings.

OBJECTIVE: To determine the frequency and constellations of anatomic, pathophysiologic, and environmental factors involved in the development of incident diabetic foot ulcers in patients with diabetes and no history of foot ulcers from Manchester, U.K., and Seattle, Washington, research settings. RESEARCH DESIGN AND METHODS: The Rothman model of causation was applied to the diabetic foot ulcer condition. The presence of structural deformities, peripheral neuropathy, ischemia, infection, edema, and callus formation was determined for diabetic individuals with incident foot ulcers in Manchester and Seattle. Demographic, health, diabetes, and ulcer data were ascertained for each patient. A multidisciplinary group of foot specialists blinded to patient identity independently reviewed detailed abstracts to determine component and sufficient causes present and contributing to the development of each patient's foot ulcer. A modified Delphi process assisted the group in reaching consensus on component causes for each patient. Estimates of the proportion of ulcers that could be ascribed to each component cause were computed. RESULTS: From among 92 study patients from Manchester and 56 from Seattle, 32 unique causal pathways were identified. A critical triad (neuropathy, minor foot trauma, foot deformity) was present in > 63% of patient's causal pathways to foot ulcers. The components edema and ischemia contributed to the development of 37 and 35% of foot ulcers, respectively. Callus formation was associated with ulcer development in 30% of the pathways. Two unitary causes of ulcer were identified, with trauma and edema accounting for 6 and < 1% of ulcers, respectively. The majority of the lesions were on the plantar toes, forefoot, and midfoot. CONCLUSIONS: The most frequent component causes for lower-extremity ulcers were trauma, neuropathy, and deformity, which were present in a majority of patients. Clinicians are encouraged to use proven strategies to prevent and decrease the impact of modifiable conditions leading to foot ulcers in patients with diabetes.     

Efficacy of multilayered hosiery in reducing in-shoe plantar foot pressure in high-risk patients with diabetes

OBJECTIVE: High plantar pressure is an acknowledged risk factor in the development of plantar ulcers in the diabetic neuropathic foot. This study examines the ability of preventive foot care (PFC) socks to reduce plantar foot pressures in a sample of high-risk patients with diabetes. RESEARCH DESIGN AND METHODS: Nineteen patients with established peripheral neuropathy attending a complications clinic of the Manchester Diabetes Centre were recruited to the study. Fifteen (78%) of the patients were male, 40-80 years of age, and ulcer-free at the time of recruitment. In-shoe plantar pressure measurements were recorded using the F-Scan and compared PFC socks with ordinary supermarket socks. The analysis measured differences in maximum foot contact area and plantar pressure for the whole foot, forefoot, and peak plantar pressure areas. RESULTS: The results showed a significant increase in maximum foot contact area of 11 cm2 (95% CI 7-11) when subjects wore the PFC socks (P < 0.01). This was accompanied by 5.4 kPa (3.5-7.3) or 9% reduction in total foot pressure (P < 0.01). Similar results were observed at the forefoot, which showed a 14.2% increase in contact area and a 10.2% reduction in peak forefoot pressure. CONCLUSIONS: These results suggest that the wearing of PFC socks increases the underfoot contact area and hence decreases plantar foot pressures. Further studies are required to determine whether the pressure and friction reductions achieved by this simple intervention would be effective in reducing the incidence of foot ulcers in high-risk patients.     

The correlation between selected measurements from footprint and radiograph of flatfoot

OBJECTIVES: To assess the subarch angle obtained from electronic footprints using a capacitive mat transducer system in children with flatfeet, to evaluate other foot arch indexes, and to compare the results with radiographic measurements. DESIGN: A cross-sectional study. SETTING: Rehabilitation clinic in a municipal hospital. PARTICIPANTS: Thirty-two children (age range, 7-13y) diagnosed with flatfeet. INTERVENTIONS: Radiographic measurements and foot shape measurements obtained from feet. MAIN OUTCOME MEASURES: Talo-first metatarsal angle, talocalcaneal angle, talo-horizontal angle, and calcaneal angle were obtained from radiographs. Subarch angle, arch indexes, and long plantar angle were all captured and calculated via a capacitive transducer plate. RESULTS: Correlations between the subarch angle and the talo-first metatarsal angle, talo-horizontal angle, and arch height were significant, as was the correlation between midfoot arch index and talo-horizontal angle. The forefoot arch index had no significant relationship with radiographic parameters. The talo-horizontal angle and arch height had significant relationships with the long plantar angle. CONCLUSIONS: Measurement of the subarch angle had significant correlation with the radiographic parameters in children with flatfeet and it was accurately and easily obtained from a capacitive forceplate. Measurement of the subarch angle can be a useful tool in the assessment and diagnosis of flatfoot.     

Use of experimental padded hosiery to reduce abnormal foot pressures in diabetic neuropathy

High pressures under the feet of diabetic patients with neuropathy are associated with the development of plantar ulceration. The aim of management is the reduction of such stresses with orthoses and insoles. An American hosiery manufacturer has developed socks designed to reduce stress on athletes' feet, and we report a preliminary evaluation of this technique in the reduction of elevated plantar pressure in 27 neuropathic diabetic patients. With a computerized optical pedobarograph, three footsteps on each side were recorded under three conditions: 1) barefoot, 2) wearing the patients' own hosiery, and 3) wearing experimental patented padded hosiery. The patients' own hosiery did not have a significant effect on plantar pressure, but the experimental hosiery reduced both peak forefoot pressure and the area under the time-pressure curve (P less than .001) by a mean of 26 and 29%, respectively. We conclude that the experimental hosiery is effective in reducing vertical pressures under the diabetic foot and, in conjunction with established orthotic techniques, may be a useful addition to the treatment of the diabetic patient at risk for foot ulceration.     

Segmental foot mobility in individuals with and without diabetes and neuropathy

BACKGROUND: Impairment in intrinsic foot mobility has been identified as an important potential contributor to altered foot function in individuals with diabetes mellitus and neuropathy, however the role of limited foot mobility in gait remains poorly understood. The purpose of our study was to examine segmental foot mobility during gait in subjects with and without diabetes and neuropathy. METHODS: Segmental foot mobility during gait was examined using a multi-segment kinematic foot model in subjects with diabetes (n=15) and non-diabetic control subjects (n=15). FINDINGS: Subjects with diabetes showed reduced frontal as well as sagittal plane excursion of the calcaneus relative to the tibia. Decreased excursion of the first metatarsal relative to the calcaneus in the frontal as well as transverse plane was noted in subjects with diabetes. INTERPRETATION: Our findings agree with traditional understanding of foot mechanics and shed new light on patterns and magnitude of motion during gait. Calcaneal pronation, noted in early stance in both groups, was reduced in subjects with diabetes and may have important consequences on joints proximal as well as distal to it. Subjects with diabetes showed reduced foot 'splay' in early stance, indicated by first metatarsal and forefoot eversion. At terminal stance, decreases in calcaneal plantarflexion, first metatarsal and forefoot supination were noted in subjects with diabetes, suggesting that less supination is required in subjects with diabetes to create a rigid lever. In subjects with diabetes, a greater proportion of midfoot stability may be derived from modified/stiffer soft tissue such as the plantar fascia.     

The forefoot-to-rearfoot plantar pressure ratio is increased in severe diabetic neuropathy and can predict foot ulceration

OBJECTIVE: We have previously demonstrated that high plantar pressures can predict foot ulceration in diabetic patients. The aim of the present study was to evaluate both the relationship between forefoot and rearfoot plantar pressure in diabetic patients with different degrees of peripheral neuropathy and their role in ulcer development. RESEARCH DESIGN AND METHODS: Diabetic patients of a 30-month prospective study were classified according to the neuropathy disability score: scores of 0, 1-5, 6-16, and 17-28 are defined as absent (n = 20), mild (n = 66), moderate (n = 95), and severe (n = 57) neuropathy, respectively. The F-Scan mat system was used to measure dynamic plantar pressures. The peak pressures under the forefoot and the rearfoot were selectively measured for each foot, and the forefoot-to-rearfoot ratio (F/R ratio) was calculated. RESULTS: Foot ulcers developed in 73 (19%) feet. The peak pressures were increased in the forefoot of the severe and moderate neuropathic groups compared with the mild neuropathic and non-neuropathic groups (6.2 +/- 4.5 and 3.8 +/- 2.7 vs. 3.0 +/- 2.1 and 3.3 +/- 2.1 kg/cm(2) [mean +/- SD], respectively; P < 0.0001). The rearfoot pressures were also higher in the severe and moderate neuropathic groups compared with the mild neuropathic and non-neuropathic groups (3.2 +/- 2.0 and 3.2 +/- 1.9 vs. 2.5 +/- 1.3 and 2.3 +/- 1.0, respectively; P < 0.0001). The F/R ratio was increased only in the severe group compared with the moderate and mild neuropathic and non-neuropathic groups (2.3 +/- 2.4 vs. 1.5 +/- 1.2, 1.3 +/- 0.9, and 1.6 +/- 1.0, respectively; P < 0.0001). In a logistic regression analysis, both forefoot pressure (odds ratio 1.19 [95% CI 1.11-1.28], P < 0.0001) and the F/R ratio (1.37 [1.16-1.61], P < 0.0001) were related to risk of foot ulceration, whereas rearfoot pressure was not. CONCLUSIONS: Both the rearfoot and forefoot pressures are increased in the diabetic neuropathic foot, whereas the F/R ratio is increased only in severe diabetic neuropathy, indicating an imbalance in pressure distribution with increasing degrees of neuropathy. This may lend further evidence toward the concept that equinus develops in the latest stages of peripheral neuropathy and may play an important role in the etiology of diabetic foot ulceration.