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Year : 2019  |  Volume : 32  |  Issue : 4  |  Page : 1214-1216

Plantar pressure changes in diabetic peripheral neuropathy

Pyongyang Medical College, Kim Il Sung University, Pyongyang, Democratic Peoples Republic of Korea

Date of Submission23-Aug-2018
Date of Decision04-Dec-2018
Date of Acceptance19-Dec-2018
Date of Web Publication31-Dec-2019

Correspondence Address:
Hak-Chol Ri
Pyongyang Medical College, Kim Il Sung University, Pyongyang, Taesong District
Democratic Peoples Republic of Korea
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_256_18

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To assess the plantar pressure changes in diabetic peripheral neuropathy compared to healthy condition.
Patients and methods
The study was performed with 150 participants containing 42 nondiabetic, 66 diabetic without peripheral neuropathy and 42 patients with diabetes mellitus with peripheral neuropathy. Using the plantar pressure platform, dynamic pressure variables such as peak plantar pressures and pressure–time integral (PTI) were measured in each foot.
We have divided the participants into three groups: group A, healthy individuals (n = 42); group B, those with diabetes mellitus without peripheral neuropathy and plantar foot ulceration (n = 66); and group C, diabetic peripheral neuropathy with plantar foot ulceration (n = 42). There is no significant difference in peak plantar pressures between groups A and B, and between groups A and C (P < 0.05). No pressure on the medial midfoot region was recorded in both groups A and B, but a little in group C. There is also no significant difference in plantar PTIs between groups A and B, but there is significant difference of plantar PTI between groups A and C (P < 0.05). No significant difference was found on the medial midfoot region in both groups A and B, but a little in group C.
There were significant correlations between plantar pressures in diabetic peripheral neuropathy. Furthermore, plantar pressure can be helpful in detecting the possible sites for plantar foot ulcerations.

Keywords: diabetes, diabetic peripheral neuropathy, medial midfoot, plantar foot ulceration, plantar pressure

How to cite this article:
Ri HC, Hwang SH, Ho CJ, Paek RH. Plantar pressure changes in diabetic peripheral neuropathy. Menoufia Med J 2019;32:1214-6

How to cite this URL:
Ri HC, Hwang SH, Ho CJ, Paek RH. Plantar pressure changes in diabetic peripheral neuropathy. Menoufia Med J [serial online] 2019 [cited 2020 Jul 7];32:1214-6. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1214/274249

  Introduction Top

Foot is one of the most ergonomically efficient structures of the body that not only sustains enormous pressures generated by dynamic activities, but also provides sensory information regarding contact with the ground. The normal foot in bipedal stance exhibits contact across the heel, forefoot, and usually the lateral border of the foot.

Diabetic neuropathy and peripheral vascular diseases are the main etiological factors in foot ulceration and weight-bearing foot is one of the risk factors for it [1],[2].

There is general agreement that once sensation has been lost, the presence of high plantar pressures represents a strong risk factor for the development of plantar ulcers. Although most of the supporting evidence is retrospective rather than prospective, the argument that high pressure causes damage to tissues is logical. It has also been shown that, for reasons as yet unknown, diabetic patients with neuropathy tend to have higher plantar pressures than either nondiabetic controls or diabetic patients without neuropathy [3].

The first study on plantar pressures in diabetic patients was conducted in 1975 by Stokes and colleagues. Investigators noted that the maximum loading was present at the site of ulceration in 20 diabetic patients. Compared with the nondiabetic patients, the greater vertical loading force was recorded in the lateral border of the foot like the fourth and fifth metatarsal heads [4].

Moreover, some investigators have measured the plantar pressures in diabetic neuropathy and found these patients might have a greater risk of developing plantar foot lesions [5],[6],[7].

Although these studies established the basis for understanding the pathogenesis of plantar ulceration, they were conducted on a limited number of patients and with an instrument that was not widely utilized. We have measured the peak plantar pressure (PPP) and pressure–time integral (PTI) in comparison between the diabetic peripheral neuropathy and the nondiabetic patients, using a newly developed plantar pressure platform.

The aim of the present study was to compare plantar pressures in patients with type 2 diabetes mellitus but without and with peripheral neuropathy, and to investigate any associations between plantar pressures and plantar foot ulceration in Koreans.

  Patients and methods Top

All participants were volunteers who contracted the researchers and signed an informed consent form. All procedures were approved by the ethnics committee on human research of the local institution. Our study patients were recruited at the hospital of the Pyongyang Medical College, Kim Il Sung University. All of the 150 volunteers consisted of nondiabetic patients (n = 42), diabetics without peripheral neuropathy (n = 66) and diabetics with peripheral neuropathy (n = 42). We made the equal variance of the weight of the groups. That is because weight is an important factor that influence the pressure distribution [8].

Patients with diabetes mellitus were diagnosed by American Diabetes Association criteria in 2010 [9]. Diabetic peripheral neuropathy was considered by the Michigan Diabetic Neuropathy Score.

Each patient was evaluated on the customized plantar pressure platform. We have used the ' first step approach' as described by Bus and Lange [10]. At least 10 trials were performed with acceptable separate walking barefoot across the customized platform [11],[12],[13] for each foot. Using the 'Plantar Pressure Analysis' software, the foot was subdivided into eight regions such as medial heel (No. 1), lateral heel (No. 2), medial midfoot (No. 3), lateral midfoot (No. 4), first metatarsal head (No. 5), second and third metatarsal head (No. 6), fourth and fifth metatarsal head (No. 7), and hallux (No. 8) [Figure 1]. Normalized peak pressure of PPP and PTI on each foot were analyzed. PPP represents the maximum pressure detected by each sensor during the gait. The resolution of pressure is 1 kPa and the time resolution of measuring pressure is 10 ms. PTI represents the integral amount of the area under the pressure–time curve each time. Parameters were normalized by body weight to allow for statistical comparison among the patients. All statistical analyses were performed using SPSS, Version 16.0 for Windows SPSS 16.0 (IBM, Chicago, USA).
Figure 1: Regions for measuring plantar pressures.

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No. 1: medial heel.

No. 2: lateral heel.

No. 3: medial midfoot.

No. 4: lateral midfoot.

No. 5: lateral forefoot.

No. 6: central forefoot.

No. 7: medial forefoot.

No. 8: hallux.

  Results Top

[Table 1] shows the common physical data for all.
Table 1: Common physical data

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[Table 2] shows that there is no significant difference in PPPs between groups A and B, and between groups A and C (P < 0.05). No pressure was recorded in the region No. 3 in both groups A and B, but a little in group C.
Table 2: Comparison of peak plantar pressure (kPa) (mean±SE)

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There is also no significant difference in plantar PTIs between groups A and B, and between groups A and B, as demonstrated in [Table 3] (P < 0.05).
Table 3: Comparison of pressure-time integral (kPa) (mean±SE)

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  Conclusion Top

Plantar pressure distribution measurements are useful not only for the analysis and understanding of the biomechanics of the human foot in bipedal standing, but also for the evaluation of the potential risk factors for diabetic plantar ulceration [3] and for the identification of loading patterns of the feet in people with various postural deformities [14].

In this study, we were able to show that there is significant increase in plantar pressure variables in both PPP and PTI in group C using the customized platform [Table 2] and [Table 3]. When analyzing the PPPs in each certain region for the three groups, group C had the highest PPP levels of all groups. A significant increase in PPP was seen in No. 5 regions and 6 in group C, when compared with group A. This correlates well with the presence of potential plantar ulcerations seen under the first metatarsal head in group C.

One study group researches the contribution of plantar fascia to the increased forefoot pressures in diabetic patients [15]. This may be one of the mechanisms why plantar pressures on the forefoot becomes higher.

Some studies have analyzed the plantar pressures between healthy people and diabetic peripheral neuropathy patients [4],[5]. Of these studies, it has been shown that higher pressures for diabetic neuropathic patients, indicate that higher pressures are related to the risk of the diabetic foot ulcer. In this present study, we obtained similar results. The increased pressure in the border of the foot recorded in group C means increased midfoot index, and also the increased PPP was recorded in this group. When the plantar midfoot is achieved, the load of the weight is dispersed. However, if the plantar midfoot is broken, the loading of the weight is also concentrated into certain areas. By the way, the plantar ulceration also takes place in certain areas where the high plantar pressure is concentrated and the disorder of blood circulation occurs.

Although there are several studies about the plantar pressures in patients with diabetic peripheral neuropathy, there is no accurate threshold of plantar pressure at risk of plantar foot ulceration. Therefore, we need further studies to find out the plantar pressure threshold at the risk of plantar foot ulceration.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sinwar PD. The diabetic foot management – recent advance. Int J Surg 2015; 15:27–30.  Back to cited text no. 1
Abd El Fatah Al Kafrawy N, Abd El-Atty Mustafa EA, El-Din Abd El-Salam Dawood A, Ebaid OM, Ahmed Zidane OM., Study of risk factors of diabetic foot ulcers. Menouf Med J 2014; 27:28–34.  Back to cited text no. 2
Sims DS Jr, Cavanagh PR, Ulbrecht JS. Risk factors in the diabetic foot: recognition and management. Phy Ther 1988; 68:1887–1902.  Back to cited text no. 3
Stokes IA, Faris IB, Hutton WC. The neuropathic ulcer and loads on the foot in diabetic patients. Acta orthop Scand 1975; 46:839–847.  Back to cited text no. 4
Frykberg RG, Lavery LA, Pham H, Harvey C, Harkless L, Veves A. Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care 1998; 21:1714–1719.  Back to cited text no. 5
Shaw JE, van Schie CH, Carrington AL, Abbott CA, Boulton AJ. An analysis of dynamic forces transmitted through the foot in diabetic neuropathy. Diabetes Care 1998; 21:1955–1959.  Back to cited text no. 6
Bus SA, Ulbrecht JS, Cavanagh PR. Pressure relief and load redistribution by custom-made insoles in diabetic patients with neuropathy and foot deformity. Clin Biomech 2004; 19:629–638.  Back to cited text no. 7
Birtane M, Tuna H. The evaluation of plantar pressure distribution in obese and non-obese adults. Cli Biomech 2004; 19:1055–1059.  Back to cited text no. 8
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2010; 33 (Suppl 1):S62.  Back to cited text no. 9
Bus SA, Lange AD. A comparison of the 1-step, 2-step, and 3-step protocol for obtaining barefoot plantar pressure data in the diabetic neuropathic foot. Clin Biomech 2005; 20:892–899.  Back to cited text no. 10
Orlin MN, McPoil TG. Plantar pressure assessment. Phy Ther 2000; 80:399–409.  Back to cited text no. 11
Karkokli R, McConville V. Design and development of a cost effective plantar pressure distribution analysis system for the dynamically moving feet. Proceedings of the 28th IEEE EMBS Annual International Conference, New York City, USA. August 30–September 3, 2006; 6008–6011.  Back to cited text no. 12
Chedevergene F, Faivre A, Dahan M Development of a mechatronical device to measure plantar pressure for medical prevention of gait issues. Poceedings of the 2006 IEEE International Conference on Mechatronics and Automation, Luoyang, China. June 25–28, 2006; 928-932.  Back to cited text no. 13
Giacomozzi C, Caselli A, Macellari V, Giurato L, Lardieri L, Uccioli L. Walking strategy in diabetic patients with peripheral neuropathy. Diabetes Care 2002; 25:1451–1457.  Back to cited text no. 14
D'ambrogi E, Giurato L, D'Agostino MA, Giacomozzi C, Macellari V, Caselli A, Uccioli L. Contribution of plantar fascia to the increased forefoot pressures in diabetic patients. Diabetes Care 2003; 26:1525–1529.  Back to cited text no. 15


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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