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Pronation and Diabetic Ulcers

Limiting Excessive Pronation to Reduce Ulceration Risk in Diabetic Patients

The two primary goals for the at-risk diabetic patient is to reduce pressure and to reduce friction. Controlling abnormal pronation also plays a role in reducing abnormal pressures.

The diabetic patient with an excessively pronated foot may see increased plantar metatarsal head pressures compared to the non-diabetic patient.  This is likely due to glycosylation of the midfoot ligaments causing limited joint mobility at the midtarsal joint (MTJ).11 In a situation where there is normal mobility of the MTJ, heel eversion will result in inversion of the forefoot against the rearfoot.  In the presence of limited joint mobility at the MTJ, the ability of the forefoot to invert is limited. In this situation more pressure must be applied against the medial forefoot in order to invert the forefoot on the rearfoot.  Several studies have confirmed this increase in submetatarsal pressure in the diabetic patient with limited joint mobility.11-14

Orthotic Prescription Recommendation: Diabetic patients are often prescribed softer, accommodative  orthoses with the idea that softer devices offer greater protection.  While topcover materials to supplement soft tissue should be included, functional orthoses that control excessive pronation should be considered for the diabetic patient with excessive STJ pronation in order to reduce medial forefoot pressure.

  • Material: Use an orthotic  shell material that is not prone to excessive deformation under body weight, for example a semirigid polypropylene
  • Pronation Control Features: Deep heel cup, medial heel skive, wide orthoses and minimum cast fill will help control excessive STJ pronation. 

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