Diabetic foot biomechanics and gait dysfunction

Abstract

Background: Diabetic foot complications represent significant morbidity and precede most of the lower extremity amputations performed. Peripheral neuropathy is a frequent complication of diabetes shown to affect gait. Glycosylation of soft tissues can also affect gait. The purpose of this review article is to highlight the changes in gait for persons with diabetes and highlight the effects of glycosylation on soft tissues at the foot-ground interface.

Methods: PubMed, the Cochrane Library, and EBSCOhost on-line databases were searched for articles pertaining to diabetes and gait. Bibliographies from relevant manuscripts were also searched.

Findings: Patients with diabetes frequently exhibit a conservative gait strategy where there is slower walking speed, wider base of gait, and prolonged double support time. Glycosylation affects are observed in the lower extremities. Initially, skin thickness decreases and skin hardness increases; tendons thicken; muscles atrophy and exhibit activation delays; bones become less dense; joints have limited mobility; and fat pads are less thick, demonstrate fibrotic atrophy, migrate distally, and may be stiffer.

Interpretation: In conclusion, there do appear to be gait changes in patients with diabetes. These changes, coupled with local soft tissue changes from advanced glycosylated end products, also alter a patient's gait, putting them at risk of foot ulceration. Better elucidation of these changes throughout the entire spectrum of diabetes disease can help design better treatments and potentially reduce the unnecessarily high prevalence of foot ulcers and amputation.

Figure 1.

Gait characteristic changes in persons with diabetes.

Figure 2.

Spatial distribution of plantar loading for (A) a typical healthy foot case, (B) a Charcot foot case, and (C) the same Charcot case postfoot reconstruction, respectively, during first foot contact, foot flat, and terminal foot contact phases.

Figure 3.

Magnitude of plantar pressure during walking for a typical Charcot foot case (blue color) and the same case postfoot reconstruction (red case). Postfoot reconstruction, subject walked faster (stance duration was reduced approximately 15%). However, the peak of plantar pressure was increased by 14% postfoot reconstruction, which is viewed historically as a negative outcome.