Association between ankle equinus and plantar pressures in people with diabetes. A systematic review and meta-analysis

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BackgroundDiabetes is one of the most common chronic diseases in the world and is associated with a life-time risk of foot ulcer of 12–25%. Diabetes related restriction in ankle joint range of dorsiflexion is proposed to contribute to elevated plantar pressures implicated in the development of foot ulcers. MethodsA systematic search of EBSCO Megafile Premier (containing MEDLINE, CINAHL, SPORTSdiscus and Academic Search Complete) and The Cochrane Library was conducted to 23rd November 2016. Two authors independently reviewed and selected relevant studies. Meta-analysis of study data were conducted where possible. FindingsFifteen studies met the inclusion criteria. Three studies were eligible to be included in the meta-analysis which found that equinus has a significant, but small, effect on increased plantar pressures (ES=0.26, CI 95% 0.11 to 0.41, p=0.001). Of the remaining studies, eight found evidence of an association between limited ankle dorsiflexion and increased plantar pressures while four studies found no relationship. InterpretationLimited ankle joint dorsiflexion may be an important factor in elevating plantar pressures, independent of neuropathy. Limited ankle dorsiflexion and increased plantar pressures were found in all the studies where the sample population had a history of neuropathic foot ulceration. In contrast, the same association was not found in those studies where the population had neuropathy and no history of foot ulcer. Routine screening for limited ankle dorsiflexion range of motion in the diabetic population would allow for early provision of conservative treatment options to reduce plantar pressures and lessen ulcer risk.