Shear-Reducing Insoles to Prevent Foot Ulceration in High-Risk Diabetic PatientsAdvances in Skin & Wound Care: November 2012 - Volume 25 - Issue 11 - p 525–526 doi: 10.1097/01.ASW.0000422624.17407.da Features: Clinical Management Extra In Brief This continuing education activity evaluates the effectiveness of a shear-reducing insole compared with a standard insole design to prevent foot ulceration in high-risk patients with diabetes. Figure Vibratory perception threshold testing can be used as evidence of loss of protective sensation. The clinician notes high risk at levels greater than 10 volts. greater than 25 volts. less than 10 volts. less than 25 volts. The patient is diagnosed with Hallux rigidus. For this study, requirements included dorsiflexion of the first metatarsophalangeal joint of less than or equal to 10 degrees. 25 degrees. 50 degrees. 75 degrees. Compared with the standard therapy group (STG), the patients in the shear-reducing insole (SRI) group had a mean older age. shorter duration of diabetes. greater history of amputation. reduced number of left ankle equinus. Footwear compliance of 8 to 12 hours per day in the SRI group was greater than that if the STG group. less than that of the STG group. equal to the STG group. non-existent. One variable that was not included in the Cox regression analysis is the ankle-brachial index. vibration perception threshold. history of foot ulceration. metatarso-phalangeal joint range of motion. Study sample data comparing patient characteristics of the SRI and STG groups showed no differences. no significant differences. statistically significant differences. significant differences only in self-reported footwear usage. The results of this study found that compared with the STG group, the SRI group had a trend of fewer amputations. an equal number of foot ulcers. statistically significant fewer foot ulcers. a slightly higher number of foot ulcers and amputations. A search for randomized clinical trials evaluating foot ulcer prevention using therapeutic shoes and traditional custom-molded insoles revealed 2 studies. 7 studies. 13 studies. 28 studies. Uccioli investigated patients with a history of diabetic foot ulcers being treated with custom shoes and insoles versus self-selected shoes. The study found that the insole group had no advantage in foot ulcer incidence. minimally increased foot ulcer incidence. minimally reduced foot ulcer incidence. significant reduction in foot ulcer incidence. A study by Rieber compared 3 patient groups who self-selected their shoes, used therapeutic shoes with cork insoles, or used therapeutic shoes with prefabricated insoles. Findings of the study showed no difference in foot ulcers. fewer foot ulcers with the cork insoles. fewer foot ulcers with prefabricated insoles. more foot ulcers in self-selected shoes. Ms D. has sensory neuropathy and a structural foot deformity. The clinician explains that the incidence of foot ulceration for patients with these risk factors is 3% to 6% per year. 10% to 15% per year. 19% to 40% per year. 50% to 83% per year. Mr F. had a foot ulcer 2 years ago that is now well healed. The clinician explains that for patients with his history, the incidence of ulceration is 3% to 6% per year. 10% to 15% per year. 19% to 40% per year. 50% to 83% per year. Mrs K. has diabetes but does not use preventative foot care. The clinician explains that for her, the incidence of ulceration is 3% to 6% per year. 10% to 15% per year. 19% to 40% per year. 50% to 83% per year. Mr T. has limited joint mobility in his left foot. The clinician knows that this places this patient at higher risk of ulceration due to all of the following except abnormal weight bearing. peripheral neuropathy. areas of concentrated pressure. abnormal shear forces. The patient asks about the effectiveness of shoe insoles. The clinician explains that in laboratory studies, the insole used in this study showed no difference in shear. a significant reduction in shear. a significant increase in shear. conflicting results regarding shear. Shear is a force that patients experience when walking. In vivo testing of shear in the gait laboratory or clinic setting is not readily available. shows significant ulcer reduction with use of insoles. shows a non-significant relationship to ulcer development. shows a clear relationship to development of foot ulcerations in the neuropathic foot. Mrs M. has diabetes and uses insoles for her shoes. In keeping with Medicare guidelines, the clinician recommends insole replacement every 4 months. 6 months. 12 months. 18 months. Ms P. asks about use of insoles with conventional shoes. Based on this study, the clinician explains that using shear-reducing insoles with conventional shoes is not advisable. requires expensive modifications to the shoe. works well and does not require any modifications. is usually not well tolerated. © 2012 Lippincott Williams & Wilkins, Inc.