From DARCO India Innovation E-News,

Issue 18, December 2017

Currently there are several classification systems known to specify a Diabetic Foot Ulcer (DFU). Some of them are very complex, some of them are too superficial, and some of them are simply not efficient.

Jeffcoate stated in 2003⁽⁵⁾ that "...there is no widely accepted method for classification or even describing foot ulcers. Non-specialists commonly refer to all ulcers as diabetic foot. Two international working parties are trying to define a system of describing individual ulcers to improve communication and develop a classification for audit and research. Without classification, selection of comparable populations for urgently needed multicenter trials will be impossible ..."⁽⁵⁾. Such comments like "not widely accepted" or "not commonly used" appear all the way through the literature, even in the latest cited reference of 2012⁽²⁴⁾.

In 2006 the Editors comment in Podiatry Today, Vol. 19 Issue 6 May⁽⁶⁾, asked "Can a Diabetic Foot Surgery Classification System Help Predict Complications?" Researchers concluded that a non-vascular surgical classification system - including variables such as neuropathy, open wound and acute infection - may help predict peri- and postoperative complications.

From DARCO India Innovation E-News,

Issue 17, September 2017

Gait Training - essential to use an off-loading shoe correctly

Hindfoot relief can remove the entire load from the heel while providing targeted relief to specific areas through cushioning and/or additional customizable insoles. Great caution must be taken when treating patients with neuropathies!*

As long as the upper and lower ankle joints are properly aligned, plantar ulcers of the heel / calcaneus are often forced by foreign bodies (i.e. little stones in the shoe) and shear force, especially in Hawaiin style sandals. Also, deformities with intrinsic bone spurs might create high peak pressure point.

Usually in human gait after the swing phase, the first ground contact is done with the heel. In case of injuries, ulcers, pain, etc. this first heel strike needs to be avoided. An off-loading shoe can do this, but the patient also needs to get advised and perhaps trained to change his normal gait during the healing process. Patient must be taught to walk correctly in this device as gait pattern must be altered to reduce trauma to heels. Like in some running styles patients need to have first initial contact with the forefoot.

This changed gait will also shift some load further to the forefoot. Therefore additional injuries or ulcers on the forefoot are a contraindication for such an off-loader.

Also be careful in the use of these rear foot off-loaders in the case of achilles tendon injuries. So "forefoot-gait" might also put some additional tension on this area.

Additional helping aids might be required such as height adjustment shoes on the contralateral side or crutches.

As a conclusion: especially with off-loading shoes the patient education / gait training must be regarded as an important aspect of the whole healing process.

© DARCO (Europe) GmbH

From DARCO India Innovation E-News,

Issue 16, June 2017

Although Orthotics and stretching are effective, some young patients may require a surgical correction ...

A pediatric flatfoot can be caused by a variety of reasons and surgical therapy may be indicated. The catch is to correct the hindfoot without impacting the structures and alignment of the forefoot.

Soft Tissue Procedure
The majority of the young patients already benefit from an Achilles tendon and/or gastrocnemius muscle lengthening to increase ankle joint range of motion.

Subtalar Implants
A subtalar implant is indicated in the event of a hyper-pronated foot and where stabilization of the subtalar joint is required. It blocks forward, downward and the medial displacement of the talus, thus allowing normal subtalar joint motion. Excessive pronation and the resulting sequela will be blocked with this minimally invasive technique.

Evans procedure
One of the most commonly used lateral column procedures in both the pediatric and the adult population is the Evans Osteotomy. According to Dr. Baravarian, this is the single strongest hindfoot alignment procedure.

From DARCO India Innovation E-News,

Issue 15, March 2017

How useful can a hybrid between a Wound Care Shoe and a Diabetic Shoe be?

In newsletter No. 6 we discussed the advantages of the toe/heel rocker bottom coupled with a flat midstance area for the neuropathic patient. In newsletter No. 8 we pointed out the advantages of a light weight diabetic shoe; the GentleStep™. By combining the features of both models we've created a very effective hybrid.

Patients at risk of developing diabetic foot ulcers need to avoid getting foreign objects in their shoes, such as sand or little stones. Such objects may irritate or even harm the skin and this increases the chance of getting a foot ulcer. A closed-toe shoe is therefore recommended. The shoe should have a wide toe box and made with a breathable fabric. The upper material needs to be strong enough to protect, yet flexible in order to reduce dorsal pressure; especially in the case of hammer toes.

Once an ulcer exists, it is crucial that the footwear allows for selective off-loading. Customizable, multilayered, insoles with different foam densities can be carefully altered to off-load the wounded area and redistribute the weight. WAGNER grade 3 or 4 ulcers are severe and therefore also require a shoe with a wide opening to accommodate the thick dressings. For example our sandal style of shoes; the WCS™. Regardless whether an ulcer has manifested, individuals at risk would still benefit from a multilayered, customizable insole system.

Combining the advantages of the WCS™'s outer and insoles systems, together with the friendly upper material found in the GentleStep creates a superior, versatile therapeutic shoe treating WAGNER 1 or 2 ulcerations.

WCS™ Closed Toe shoe has a closure system that cannot expose the entire interior of the shoe, as found with the WCS™ Open-Toe model. Therefore in the case of very bulky dressings, the WCS™ Open-Toe model should be the first choice. Keep in mind that the off-loading capabilities of both models are identical.

In addition, there's a small marking located on the medial aspect of the outer sole; the DARCO "D". This insignia indicates the correct position of the first metatarsal and facilitates proper fitting of the shoe. An ill-fitting shoe may actually do more harm than good.

© DARCO (Europe) GmbH

From DARCO India Innovation E-News,

Issue 14, December 2016

Testing for Diabetic
Neuropathy easy and
affordable: The Monofilament

Diabetic neuropathy is the most common complication for individuals with diabetes mellitus (DM) type 1 or type 2. Diabetic peripheral neuropathy (DPN) is peripheral nerve dysfunction affecting 50 % of the patients with diabetes

Diabetic Neuropathy may be categorized as follows:

• Sensory neuropathy occurs when nerves which detect touch and temperature are damaged. This form of neuropathy commonly affects the feet or hands.

• Motor neuropathy results from damage to the nerves affecting muscle movement.

• Autonomic neuropathy is the term if the nerves which control involuntary actions are affected; such as digestion or heart rate and also includes sweating and remoistening.

Monofilament can be used to help detect sensory neuropathy in otherwise normal feet. The thin plastic filament is applied perpendicularly to the area being tested. Pressure is then exerted and patient's feedback is noted when the sensation is first perceived. This can help identify a reduced or lost sense of sensation.

J. Mayfield ⁽¹⁾ stated "The Monofilament is currently the best choice for screening for clinically significant neuropathy ..." This method is frequently found in several best practice guidelines (i.e. American Diabetes Association, Dutch Association of Neurology, NHS and the National Institute for Clinical Excellence).

A systemic review by J. Dros ⁽²⁾ found 54 potentially eligible studies on the subject and 3 were selected for data synthesis. Dros stated that "... little can be said about the test's accuracy for detecting neuropathy in feet without visible ulcers." With regard to the diagnostic value of the Monofilament, the findings vary widely. Monofilament screening I vital in identifying DPN early, enabling earlier intervention and management, to reduce the risk of ulcerations in the lower extremities.

Groner ⁽³⁾ again summarized the necessity of the monofilament test as a tool for assessing diabetic foot ulcer risk. He quotes David Armstrong, DPM, MD, PhD, of Tucson AZ USA, "The tool itself may not be very accurate, but after study, it does seem useful in identifying clinically significant loss of sensation".

© DARCO (Europe) GmbH

From DARCO India Innovation E-News,

Issue 13, September 2016

Conservative Treatment of a Bunion (Hallux Valgus) -
is this possible?

The short answer is: YO (yes and no!). The problem is not an isolated Great Toe deformity. Almost always there is a underlying complex pathology like a splayfoot, Metatarsalgia, rear foot problems, etc. which leads to a bunion.

Conservative treatment often only addresses one, sometime two, seldom more of the potential pathologies. Foot gymnastics may be helpful in a very early stage, with a moderate deformity. But once an obvious visible bunion is developed, the tendon forces of the HV are already too strong to be compensated with gymnastics.

A very first and effective conservative way of treatment is the usage of comfort shoes with soft upper material, adequate width and deep toe box. This would also allow the usage of soft padding, cushioning and/or corrective insoles, which effectively off-load under prominent areas, i.e. head of MT1 or toe tips (in case of hammer toes). But the effects are purely static and do not show any improvement of the muscular situation. If the footwear is not wide and deep enough, the usage of therapeutic insoles can even be contra-indicated as this may cause additional pressure areas through volume increase (foot & insole).

Orthotics, like HV-Splints - mostly worn by night, can reduce the deformity in moderate cases, but they do not offer a permanent correction. Symptoms along with a bunion like bursitis, Shoe pressure pain, capsula expansion pain, lesser toe pressure pain do benefit from conservative treatments. The muscular misbalance resulting in non-physiologic tendon forces and bony deformities cannot be treated with a conservative therapy.

Conclusion: Preventive foot gymnastics and a proper fitting, foot form adapted footwear may reduce the occurrence of Hallux Valgus deformities. But once manifested, a painful Hallux Valgus deformity should - if there are no contra-indications - undergo a surgical therapy as only the symptoms can be treated conservatively whereas the causes require surgical intervention. Post-operative the operated area needs off-loading in a stabilizing off-loading or woundcare shoe, in an ideal manner with a rocker bottom outer sole.

© DARCO (Europe) GmbH

From DARCO India Innovation E-News,

Issue 12, June 2016

Is there a biomechanical need for the use of a counter side height adjustment while wearing a Wedge Shoe?

By wearing a wedged post-surgical or off-loading shoe, the patient will experience a bilateral asymmetry in leg length which leads to a limping gait. Patients might claim knee, hip and/or lower back pain after wearing a wedged shoe for a while due to a changed biomechanical function chain.

It looks like the human body can tolerate a leg length difference up to 2 cm (1). Differences of more than 2 cm can lead to difficulties in walking. Even patients without diabetic ulcers and/or neuropathy often claim pain in the Sacroiliac Joint. In Berlin Germany, Dr. Edelmann observed 100 patients in a period of 8 months who underwent a Hallux Valgus correction surgery and had to wear a forefoot off-loading shoe.

In 1991 McCaw et al (2) described the biomechanical implications of mild leg length inequality and pointed to

In 2013 O'Leary et al (3) did a systemic literature review and came to the conclusion that foot & ankle deviations can be considered a potential cause of lower back pain.

A height adjustment, i.e. in the form of a height difference shoe, can therefore be considered an important part of the complex treatment of foot & ankle disorders.

© DARCO (Europe) GmbH

From DARCO India Innovation E-News,

Issue 11, March 2016

When a TCC treatment is needed, protection of the cast and gait support is important

An earlier Newsletter (No. 7/2015) offered a literature overview on CAM Walkers as an alternative to the TCC. Physicians seek to achieve the best results based upon indications and within the confines of available resources. Therefore, a natural or synthetic cast may be the best solution at hand.

Orthopedic casts were first developed in the 1850s and their aesthetics haven't changed much over the past 160 years. A cast can be used to brace, immobilize, protect as well as off-load at and around the foot and ankle, hence providing effective treatment for many indications. Fiberglass replaced plaster in the 1970s and waterproofing arrived in the '90s.

Walking on a cast without protection can lead to cast damage and other complications. Foreign bodies can find their way through the sole of the cast (pic1 & 2), and the toes are exposed and unprotected. In the 1950s, rubber heels were invented and are still often used today (pic3). The rubber walking heel prevents direct contact of the cast with the ground and is designed to make the gait more comfortable. But the height difference can lead to biomechanical stress and may interfere with a normal gait cycle. This can be avoided with a height compensation shoe (pic4). The abnormal walking pattern often leads to lateral rotation affecting the ankle joint. This is especially true after several days as the cast loosens around the calf due to muscle atrophy. Self-Repair strategies are often seen, including "shoe-like" improvements (pic4 & 6).

These improvements can easily be achieved with an off-the-shelf cast shoe, which not only provides protection, but can also allow the patient to experience a normal gait cycle as much as possible while wearing a cast.

From DARCO India Innovation E-News,

Issue 10, December 2015

The importance of treating edema in Plantar Fasciitis conditions

In newsletter No. 5 we explained briefly the condition of a plantar fasciitis. Night splints are a treatment option with high healing potential. But what about wearing an additional device to support healing during the day?

According to A. Jacobs(1), 21 % of patients with plantar fasciitis are also subject to swelling and edema. And of these patients he identified a small group as having plantar fascial fibromatosis (Morbus Ledderhose). Although a true Morbus Ledderhose is less common, it usually occurs in the middle and medial part of the plantar aponeurosis(2). In the Jacobs findings, 25 % of all plantar fasciitis cases experience some kind of fibromatosis. The final 54 % of those suffering from plantar fasciitis were related to degenerative conditions cause by age and/or overuse. In this group, there was an occurrence of microscopic and tiny tears in the plantar aponeurosis, which can eventually lead to partial rupturing.

A compression sleeve can address the edema issue and due to the different compression areas in the sleeve, an increased support of the medial arch can also be achieved. One can also support of the medial arch with orthotics and/or by adding a soft padding to the heel area. For an effective compression sleeve, different compression zones are needed to facilitate the proper flow of fluids without constricting circulation. In order to support the medial arch, a higher compression is needed around the base of the metatarsal bones. Using the same manufacturing process for medical compression stockings, six different zones with varying levels of compression were designed into this Foot Sleeve to strengthen and support the natural foot structures. The end zones on most tight compression garments prove to be troublesome due to the sudden and abrupt increase of pressure, causing an "edge" effect that can lead to an increase in edema where the garment itself stops, which is not the case with the DCS.

From DARCO India Innovation E-News,

Issue 9, September 2015

R.I.C.E. vs. M.E.A.T.
The treatment of ankle sprains

Ankle sprains are one of the most common sports injuries, but can happen during daily work or leisure activities as well. General knowledge often leads patients to cool the ankle with ice.

Recent Studies have shown that a pure R.I.C.E.* treatment for ankle sprains can actually delay the healing of the injured area. Whereas M.E.A.T.**, can encourage and promote the healing process. An acute ankle sprain could still be treated with R.I.C.E. immediately, but only for a maximum of 48 hours.

Uninterrupted icing is not recommended. Cooling can help reduce the initial, massive swelling of an injury at first and act as a pain reliever. This is especially affective in combination with compression. But a permanent icing can also have a negative effect - in worst case - frostbite.

After 48 hours, careful movements are found to promote the body's own mechanism to heal the injured area. Coupled with physiotherapeutic treatment may actually lead to faster recovery. Naturally, it is important not to overuse the injured ankle and to keep it protected from re-injury. The several braces and orthotics available are designed to prevent unintentional supination/pronation or the reoccurrence of trauma. The different braces are designed to fit the requirements of the patient, i.e. severity of the ankle sprain, patient's activity level and the patient's determination to return sporting activities, etc.

Caringmedical.com once published a comparison table with the healing rate and grade of ligament injury relative to R.I.C.E. and M.E.A.T. treatment:

From DARCO India Innovation E-News,

Issue 8, June 2015

One fits all?
The difficulty of selecting an adequate shoe size.

A good fitting shoe is always important. But for patients with foot problems and especially those with a Diabetic Foot Syndrome, it is essential to use properly fitting, therapeutic shoes to avoid additional pressure.

For such a patient, initially there are only two options to determine correct shoe size. The first and most unreliable option is the declared size in the shoe he or she is wearing. 2nd best method is to measure the length of the foot itself. These measurements still the needs to be converted in to an actual shoe size. Conversion tables are then used.

One problem is, that there are several different shoe-size systems used worldwide. Even within one country different systems might be in place. And the problem is not only the different versions of available converters, but also the different units of length (i.e. inches vs. cm), and the way of collecting measurement (i.e. weight bearing vs. sitting).

The Paris Point System: Equates one incremental unit of size to 2/3 centimeters (6.6 mm or ~ 0.26 inch). Resulting in an increment of 2/3 of a centimeter (1/4 of an inch) in whole sizes, and 1/3 of a centimeter (1/8 of an inch) between half sizes. This system is commonly used throughout Continental Europe.

The barleycorn: An old English unit of measurement that equates to 1/3 inch or ~ 8.46 mm. Half sizes are commonly used, resulting in an increment of 1/6 inch (4.23 mm). This measure is the basis for current UK and U.S. shoe sizes, with the largest shoe size taken as twelve inches (a size 12) and then counting backwards in barleycorn units.

Zero point: The sizing systems also place size 0 (or 1) at different locations: Only if size 0 is placed at a foot's length of 0, the shoe size is directly proportional to the length of the foot in the chosen unit of measurement. Otherwise conversion tables create overlapping sizes.

Due to the different units of measurements, converting between different sizing systems, the conversion tables create overlapping sizes and the result can be rounding-off errors as well as un-usual sizes such as 10 2/3. Furthermore, metric measurements in centimeters (cm) or millimeters (mm) are used. The increment of 0.5 cm (5 mm or ~ 0.20 in) is common. This is between the step size of the Parisian and the English system. It is used with the international Mondopoint system and with many Asian systems.

© DARCO (Europe) GmbH

Literature: Raphael Böhm, 2015
"The Foot & The Shoe" (PDF), DARCO Presentation

From DARCO India Innovation E-News,

Issue 7, March 2015

Total Contact Cast (TCC)
The Golden Standard - Or is it?

TCC is still regarded as the golden standard in the treatment of the severe diabetic foot, but also frequently common in trauma care. According to the literature CAM Walker can be an alternative.

In conservative treatments and after surgical suture of Achilles tendon ruptures a cast is still widely used. In general there is a trend to prefer a conservative treatment. Carter et al (1) observed no higher complication rate in 21 patients with surgically repaired Achilles tendon and treated with a functional orthosis rather than routine cast (in reliable patients). For Buchgraber et al (2) cast immobilization after Achilles tendon suture repair is no longer justified as there was no higher re-rupture rate when a functional orthotic was used. Speck et al (3) also had no higher re-rupture rate by using a plantigrade splint for 24hors, followed by 6 weeks in a removable walker. Petersen et al (4) recommend CAM walker as a useful alternative to a cast after observing 21 patients having no re-ruptures, but 5 re-ruptures in 29 patients treated with a routine cast. In 2003 Weber et el (5) stated that in their study, comparing operative with non-operative treatments of Achilles tendon ruptures, the overall out-comes were equal.

All these studies had a small number of patients (n=20 - 50). Therefore Suchak et al (6) conducted a Meta-Analysis on an extensive literature research for randomized studies. They identified six trials involving 315 patients. Their conclusion was that early functional treatment protocols, when compared with postoperative (cast) immobilization, led to more excellent rated subjective responses (by the patients) and no difference in re-rupture rate.These studies contribute to Mueller's et al findings for the treatment of plantar ulcers. If Achilles tendons rupture could be well treated conservatively with a CAM Walker, so could be a Achilles tendon tenotomy. Mueller et al (7) published already in 2003 the positive effect of such an Achilles Tendon Lengthening procedure. All ulcers healed, in both groups, with or without tenotomy. But the group with tenotomy had significant lower rate of recurrence of the ulceration.

Should the Achilles Tendon Lengthening incl. an early functional postoperative treatment with partial weight bearing in a CAM Walker be considered as an effective strategy to reduce recurrence of neuropathic ulceration of the plantar aspect of the forefoot? Especially in patients with diabetes mellitus and limited ankle dorsiflexion?

© DARCO (Europe) GmbH