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Board Review Orthotics & Prosthetics

Footwear Therapy for the High Risk Diabetic Patient

Dennis Janisse, C.Ped

Dennis Janisse, C.Ped discusses the definition of pedorthic management and reviews patient cases and the shoes he created for the specific problems.

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Goals and Objectives
  1. Identify appropriate shoe modifications for diabetic foot deformities
  2. Explain why and how pedorthic management can be effective for the diabetic foot
  3. Develop a pedorthic prescription for the diabetic patient/foot complications
  4. Identify when a pedorthic prescription is fulfilling its purpose and objectives
  • Accreditation and Designation of Credits
  • CPME (Credits: 0.5)

    PRESENT eLearning Systems, LLC is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine.

    PRESENT eLearning Systems, LLC has approved this activity for a maximum of 0.5 continuing education contact hours.

    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Dennis Janisse, C.Ped

    Assistant Professor, Dept. PM&R Medical College of Wisconsin

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    ---

    Dennis Janisse Dennis Janisse has disclosed that he has a financial relationship with Orthofeet, Inc

  • Lecture Transcript
  • Male Speaker: Our next speaker, Dennis Janisse, has been on the wound care stages for many, many years. I think I met Dennis when I was still back in Boston many, many years ago. He has written chapters on footwear therapy and several diabetic foot textbooks. He’s been a pedorthist for many, many years and has made great contributions to the conservative management of diabetic foot. Fresh from the land of cheese, Wisconsin, let's welcome Dennis Janisse.

    [Applause]

    Okay, all right, just to let you know, right?

    Dennis Janisse: Yeah. Those lights are bright. Good afternoon or good morning. I guess it's still a little bit morning. I do want to thank all of you for being here. Thank Desert Foot and everyone involved for including me on the program. We're going to talk about foot therapy for the high risk diabetic patient. It was sort of hard for me to figure out how to approach that in 20 minutes. Some of you that might know me know that I really have an issue, that it’d be very had to fill just 20 minutes. I'm going to talk a little bit about what is a pedorthist? I'm assuming most of everybody here understands what a pedorthist is. But I want to spend a few minutes talking about that. Then, actually go through and talk about pedorthic management by using case studies. We can look at some fairly complicated feet and how we can approach them pedorthically. I think that's probably as good a way and explore the use of pedorthics. Oh with financial relationship I have, I am director of Scientific Affairs for Orthofeet. Here are my learning objectives. I just want to start to help you understand pedorthic management better. How to write a prescription, a pedorthic prescription? Because that can be a challenge for us and I think sometimes for some of you folks too. You're not really sure what to write for a prescription. I’ll help you with that if that's okay, and just how to evaluate a pedorthic prescription, some references here. What is a pedorthist? Really, a pedorthist is like a pharmacist for the foot, or another way, orthotist or prosthetist but limited to the foot. Our training is basically similar to an orthotist or prosthetist, but of course, we just have one part of the body that we can work with. Maybe wouldn’t appreciate that, but another way to talk about it would be comparing an orthopedic surgeon to a pedorthist. I mean, we all have the same interest in a particular part of the body. We don't diagnose or prescribe and we are like a pharmacist. We don't have the advantage of being able to diagnose or prescribe, but because of our education, we certainly understand the foot and we’ll certainly understand any information you give us when referring. Pedorthics is a design, manufacture, fit and/or modification of shoes and foot orthoses to alleviate foot problems caused by disease, overuse or injuries. Pretty much anything we need for the foot, we'll be able to take care for you. Certification is actually a moving target at the stage of the game. We’re really involved in racing the bar. I am on our National Certifying Board, ABC. ABC working with NCOPE, NCOPE accredits the schools. We are changing the education pretty significantly. There is a required education level, obviously, pre-certification education. There is a work experience component of a thousand hours, then an exam by either ABC or BOC. There are two certifying organizations for pedorthist. Then, of course, continuing education. We have a very involved and credible facility accreditation, and actually very well recognized because a lot of the things that we do, particularly the therapeutic shoe benefit, a pedorthist has to be an accredited facility, so ABC plays a pretty big role in that. There, similar things to you, obviously staffing requirements, facility requirements, inventory and documentation. We all know about the need for documentation. Basic pedorthic objectives, and start out with reducing shear. I mean, these are things that we have available to us through actually most of the modalities that we use are reducing shear. I'm going to show you a couple of different ways of being able to accomplish that. I think it's something we don't always think about it.

    [04:58]

    I've been probably doing lectures for 25, 35 years, I don't know, and I always have reduced shear and then I never get back to that, because it really wasn't a good way to reduce shear. In fact, some of the things that we thought and things we were doing to reduce shear, we’re actually increasing shear on the foot. Now, we do have ways to accomplish that and it's pretty exciting. We certainly always think about pressure, but if you throw that shear component into it as well, the management is much more successful actually. Reduce shock, obviously, on heel strike or through the entire gait cycle, transfer forces, obviously, from one place to another, correct or support flexible deformities, and then accommodate fix deformities. We’ve had some good lectures obviously over the last few days. With the diabetic foot, I mean, we can look at that foot sometimes. In nonweightbearing, it can look very similar. But if it's flexible and/or rigid, that really can change our management practice or techniques in control or limit motion of joint. How do we that? It used to be just four. We added another one to this. One of the most important ways of managing the foot and applying pedorthic practices is the shoe. Actually, for me as a pedorthist, that’s probably one of the hardest things and that's probably the thing I like least of my job. I have fun showing you foot orthoses and different things that I can do with foot orthoses and shoe modifications. I think a lot of podiatrists now are actually involved in that shoe process as well, I think, especially since the therapeutic shoe benefit came about, but the shoe part of it is a big challenge. It has to be the right size, the right width. It has to be the right shape, style, color. It has to fit the foot as well as the head, and that's where we get into some real challenges with the shoe. The shoe is the most important part of the process because it's the foundation of the body and really we need that container, if nothing else, to do everything else we do. The shoe is so terribly important. I think in many respects, it's overlooked by some other practitioners out there that just say, “It’s a shoe.” I mean, it’s more than just a shoe. Custom shoes, we do use. In our facilities, we use custom shoes only when it's an absolute necessity because, actually I had one of my practitioners just called me yesterday frustrated because they had made some custom shoes and they didn't live up to the expectations of the patient, and then very often, that happens with the way it looks. Of course, we make a custom shoe, it's going to take on the look of the foot itself and people don't necessarily like that. We do a lot of customizing of shoes rather than making custom shoes. Actually, the compliance is better if you can do that, and the timeframe of delivery is significantly decreased as well if you can use a shoe modification. Orthoses, inserts, whatever we want to call them, obviously that's the most intimate control that we have. We can accomplish the most by being right next to the foot. There’s a variety of different types of materials that we use. With the more complex diabetic foot, we've got to be real creative with some of the materials that we are using. Then, we throw in there that last one, hosiery and footage aids, because there really are a lot of other things. When I became a pedorthist, actually down at Ball State, we talked about the foot, the foot orthoses and the shoe, and we totally ignored that other barrier in there. As I talk about shear, I mean, we’ve got hosiery now that reduces shear. We’ve got sock within a sock. Teflon fibers in the socks, mohair. I mean, there's a lot. You get cushioning out of the hosiery. You’ve got antibacterial/antifungal materials in the hosiery. That’s really a barrier that is being explored now and there’s a lot of fun in it. It really is helping our management techniques as well. I'm going to talk real quickly about the pedorthic prescription and then I think you'll see it as I go through my case studies. We have a brochure and it’s been redone umpteen times at National Pedorthic Services, telling physicians how to write prescriptions. Now, I don't think the podiatry world is as big a problem as [indecipherable] [09:45] as a lot of other people. But here, you’re receiving prescriptions from other practitioners as well and other physicians. We tend to get bad prescriptions with no information because people are afraid to write a prescription because they don't know what to write it for.

    [10:01]

    I mean, if you’ve got an internist then I go there with bronchitis, he/she knows if I write a prescription for amoxicillin, I’ll go get that filled at the pharmacist. Then, in 10 days, I’ll feel better. That isn’t the way it works with pedorthics obviously. Most of the physicians don’t really know what to order as far as that actual pedorthic modality. But you and everybody else that’s prescribing understand the information that we need. Remember, I said we’ve got the knowledge to be able to treat those patients. We break it down into why, what and how. What’s the diagnosis? Give us the diagnosis. What do you want us to accomplish, the desired effect? If we have a diagnosis and what the physician is looking for, we can fill in the how. That’s the part that I think a lot of people are intimated by writing. Give us that other information, we can do an adequate job of caring for your patients. Let’s start out here. We’ve got 50-year old male, type 2 diabetes, peripheral neuropathy, previous amputations as well as ulcerations. You can see, he tends to be fairly somewhat hyperkeratotic. I’m not sure exactly why, but he had a partial metatarsal amputation or removal. He’s got that superficial ulcer on his first metatarsal. The physician is a good friend of mine. He called me one day, a podiatrist, and he called me and read me to write [indecipherable] [11:36]. But he said, “I’m sick and tired of debriding that callus off of that guy’s foot. You’ve got to come up with something.” He was in a shoe with rocker soles and I had offloaded that area. This was early on when we started using that white material and that’s called ShearBan. That’s a low-friction interface similar to Teflon. Some of you I’m sure have seen that. I don’t know if anybody is using it. I had his foot orthosis. I had posted it, done a lot of different things to try and unload it, but I was still getting that continual build up of callus on there. I put that ShearBan underneath there, didn’t do anything at all. In three months later, that ulcer was totally closed. I just sort of started out with that talking about the friction component because it really is a major component. I don’t know that I would have really made that kind of progress had I not addressed the friction. The material is fairly durable. Although, this is this fellow that we just looked at, he does not have any skills that he can get a sit down job, so he is working. He manages a pretzel shop in a mall, and as well works in a convenience store at night. He’s on his feet a lot. You can see, it will delaminate. Sometimes, it will actually wear out. Very easy to replace it. You can actually cut a piece and put it right back into that same indentation that we had put it on originally. You’re all used to this, but this screw ball, I’ve known him for a long time. He came in to have that replaced. I saw that red spot on his foot orthosis and I said, “What is that?” He’s, “Well, I had spaghetti the other night.” He said, “I must’ve dropped some spaghetti sauce.” That, of course, was nonsense. You can see that little piece of wood that he actually had in the orthosis, and see the callus on his heel. We all have those stories. Okay. Here’s LP, a 51-year old male, diabetes neuropathy, post ulcer, amputations and a skin graft. This is a fellow, he was actually a case study for me when I used to do a lot of pre-certification education at our facility. He didn’t know that he had some Charcot involvement till I started talking about it. You can see, very, very wide, in the midfoot there, very prominent base of the fifth. He had his first fully amputated. He’s got a skin graft on there, but the nice thing is skin graft is really not on the plantar surface. It’s all on that medial aspect on his right foot. He lost his third toe. The crazy thing with this guy is, again, as with you, I’ve had this patient for a number of years, probably 20, 25 years. When he came to me and we finally found out the combination that that worked, he insisted on steel toes, because he wanted to protect his toes. He didn’t want any of his toes amputated. Well, something falling on his toes had absolutely nothing to do with the fact that he lost those toes. That was a real challenge, trying to come up with a steel toed shoe that was not going to apply more pressure or possibly friction or breakdown to those toes. We actually, there, had an extra-depth steel toe and it’s actually somewhat of an oblique toe.

    [15:00]

    Extended steel shanks, foot orthoses obviously with a toe filler on the one end and rocker soles. With the rocker soles, he’s lost his great toe, all those metatarsal heads are at risk. You bring the apex of that rocker sole proximal to all the metatarsal heads and we can relief pressure on the metatarsal. I’d say, rocker soles are the only thing that we really have any research on. Peter Cavanagh started that whole process and it’s very significant at managing those forefoot post ulcers. Here, we got JM, 60-year-old male, insulin dependent, peripheral neuropathy, rheumatoid arthritis as well, and he had a transmetatarsal amputation. You can see here, we’ve got actually a very nice transmit amp. He had lengthening, so he’s got good range of motion there. On the other side, you can see the result of the arthritis. I mean, very significant hallux valgus, hammer toes. We talked about the diabetic foot, and I do a lot of education on the diabetic foot for shoe fitters, for pedorthists and everything else, and thank goodness, a lot of those folks have that benefit through Medicare. But we’re not just treating diabetes. When we get to people 60, 70, 80 years old, there are so many other things going on, and thank goodness, they’re getting shoes but we have to recognize that the complication with a foot like this is his arthritis. Yes, he’s totally insensate but we’ve got so much deformity that we have to manage as well. High top work boot, extended steel shanks, heel to rocker soles so that we can replace some of that motion. I mean, if we replace the motion or the push off from the front of his foot, partial foot prosthesis on the one side and then custom or metatarsal relief on the other foot orthosis. This guy is a farmer. He is back driving tractor and milking cows. I mean, it looks like a fairly significant problem but he is doing very well. A 63-year-old female, now, this is an interesting one. This is a modification that we call it re-lasting. You can see, significant Charcot deformity there. She does wear in-depth shoes that have been modified and everything, but she wanted something nice so that she can get dressed up. That’s an issue for, say, if you don’t try and accommodate some of these folks, if we can’t accommodate them, they’ll cheat and start wearing what they want to wear and then they’re back in trouble. You can see the deformity we’ve got here. Down in the lower left hand corner is a modification we call re-lasting. Basically what we do, we cut the shoe and widen the shoe to fit the plantar aspect of the foot. This sandal, this particular sandal had a removable footbed, so we’re able to put a custom foot orthosis into that shoe that was re-last. Basically, there was no pressure at all. Had we not done that, she would have been rolling out over the edge of the shoe and would have been certainly an ulceration, and probably a very serious problem. KR, 63-year-old male, and diabetes, chronic heel ulceration. You can see here, he’s very lucky that he didn’t have osteo looking at that x-ray. It was ultimately closed at the clinic with total contact casting. That was a challenge to keep close. There, we went with in-depth shoes, steel shanks, but we put a SACH heel on there, so we’ve got a heel to toe rocker. Research had shown that we can decrease a lot of pressure and shock on heel strike with the rocker, but we added SACH heel to that as well, and the concept obviously, to move the pressure and the weightbearing more distally on the foot. Then, with our orthosis, we actually used a viscoelastic polymer. It’s a polymer that we can mix and make it actually just as soft as our own fatty tissue. You can see, the cast there with a divot in it. We make the foot orthosis with something like a plastazote top cover, but then filling that void with that real soft viscoelastic polymer. Actually, that’s been very successful for him. Okay. Here’s an interesting one, SC, 32-year-old female, draw a line to that rheumatoid arthritis so I can get back to that arthritis thing. I don’t mean to beat that up, but cascade as fixed hammertoes, plantar nodules, I mean the whole kit and caboodle. Then most recently, type 2 diabetes. This is what she looked like, and those feet are basically rigid. I mean, what you see is what you get. That’s severe varus heel and the nodules. I actually managed her a long time very effectively with just in-depth shoes, a real mild rocker sole.

    [20:04]

    Actually, the way I got that mild rocker sole was just by lowering the heel, lateral flares obviously for that cavus foot, that supinated foot. She did well with that modification. Then, she had some knee surgery and they straightened her leg out. Then, you can see what happened to the foot. You can see how much pressure she’s got on that lateral border after the surgery, and of course, breakdown on her foot. We actually did there, started out with an insole excavation in the shoe and the ShearBan. It still didn’t quite do it, so then we also did that re-lasting. In the slide on the right side, we did a re-last with that excavation and we got that whole thing to heal up. I think I’m just about out of time. Just my parting slide, that we’ve got one more case study, I’m not going to go there, that pedorthic management works. We enjoy working with all of you folks. Make use of us whenever you can. Thank you.