Pressure Distribution In Patients Research Articles

The effect of personalized orthopedic insoles on plantar pressure during running in subtle cavus foot.

Objective: This study aims to investigate the patterns of plantar pressure distribution during running for patients with subtle cavus foot (SCF) and determine the impact of personalized orthopedic insoles with forefoot wedge on plantar pressure distribution in patients with SCF. Methods: Sixteen undergraduate participants (8 with SCF and 8 with normal arches) were recruited based on arch height index measurements. Two full-length insoles were personalized for each SCF based on plantar pressures during running, an arch support insole (ASI) and an arch support with forefoot wedge insole (AFI). Foot pressure data collected during different insole conditions in running, analyzing ten regions of footprints for peak pressure and pressure-time integral. Results: Higher peak pressures were observed in patients with SCF at the medial forefoot (p = 0.021), medial heel (p = 0.013), and lateral heel (p = 0.025), with a higher pressure-time integral also noted at the medial forefoot (p = 0.025), medial heel (p = 0.015), and lateral heel (p = 0.047) when compared to normal arches. Compared with without-insole, both the AFI and the ASI reduced peak pressure at the medial (AFI p = 0.011; ASI p = 0.024) and lateral heel (AFI p = 0.028; ASI p = 0.032). The AFI reduced peak pressure at the medial heel (p = 0.013) compared with the ASI. Both the AFI and the ASI reduced pressure-time integral at the medial forefoot (AFI p = 0.003; ASI p = 0.026), central forefoot (AFI p = 0.005; ASI p = 0.011), medial heel (AFI p = 0.017; ASI p = 0.005), and lateral heel (AFI p = 0.017; ASI p = 0.019). Additionally, the ASI reduced pressure-time integral at the big toe (p = 0.015) compared with the without-insole. Conclusion: These findings demonstrate that during running in patients with SCF, plantar pressures are concentrated in the forefoot and heel compared to the normal arch. The personalized orthotic insoles can be used to effectively redistribute plantar pressure in patients with SCF running. Incorporating a forefoot wedge to specifically address the biomechanical abnormalities associated with SCF may enhance the effectiveness of orthopedic insoles.

Discrepancies in plantar pressure distribution between affected and unaffected sides in patients with plantar fasciitis.

A fundamental understanding of plantar pressure distribution is important for prescribing an appropriate orthosis and applying nonoperative methods, such as stretching exercises, for the treatment of plantar fasciitis. Despite existing research on plantar pressure distribution, discrepancies between affected and unaffected sides in unilateral plantar fasciitis patients warrant further investigation. This study aimed to evaluate the plantar pressure distribution in patients with unilateral plantar fasciitis by comparing it with that on the contralateral unaffected side. We retrospectively reviewed records from 20 consecutive patients diagnosed with unilateral plantar fasciitis, using the unaffected side as the control. The emed® pedobarographic system was used to measure the plantar pressure distribution during gait. The analysis was performed using a 4-mask configuration (toes, forefoot, midfoot, and hindfoot). Both sides showed no significant differences in radiographic parameters. The affected side showed a significantly higher contact area, maximum force, and force-time integrals in the midfoot. However, the unaffected side demonstrated significantly higher maximum force and force-time integrals in the hindfoot. There was no difference in the distribution of the peak pressure and pressure-time integrals between the two sides in all mask regions. The increased contact area and maximum force in the midfoot on the side with plantar fasciitis may result from heel pain-induced weight transfer from the hindfoot. The findings of this study provide a basic understanding of plantar pressure distribution in the treatment of plantar fasciitis and highlight the importance of considering inter-side differences when designing treatment interventions or orthotic devices.

PATIENT-SPECIFIC CONTACT MECHANICS IN SYNDESMOTIC ANKLE LESIONS

Syndesmotic ankle lesions involve disruption of the osseous tibiofibular mortise configuration as well as ligamentous structures stabilizing the ankle joint. Incomplete diagnosis and maltreatment of these injuries is frequent, resulting in chronic pain and progressive instability thus promoting development of ankle osteoarthritis in the long term. Although the pathogenesis is not fully understood, abnormal mechanics has been implicated as a principal determinant of ankle joint degeneration after syndesmotic ankle lesions. Therefore, the focus of this presentation will be on our recent development of a computationally efficient algorithm to calculate the contact pressure distribution in patients with a syndesmotic ankle lesion, enabling us to stratify the risk of OA development in the long term and thereby guiding patient treatment.

The effect of Progressive Core Stability Exercises with and without Respiratory Exercises on Plantar Pressure Distribution in Patients with Lumbar Segmental Instability: a Semi-Experimental Study

The effect of Progressive Core Stability Exercises with and without Respiratory Exercises on Plantar Pressure Distribution in Patients with Lumbar Segmental Instability: a Semi-Experimental Study

Study Protocol titled as "Effectiveness of neural mobilization in improving the ankle ROM and plantar pressure distribution in patients with diabetic peripheral neuropathy: A single group, pre post, quasi experimental study protocol".

Diabetic Peripheral Neuropathy (DPN) is the commonest complication in individuals with type 2 diabetes mellitus affecting 50% of total diabetic population. The ankle mobility is seen to be significantly reduced along with alteration in plantar pressure distribution. Neural mobilization is a neoteric technique that is being used to treat various conditions of neural involvement. It is hypothesized that the application of neural mobilization will improve ankle mobility and plantar pressure distribution in individuals with DPN by restoring the mechanical and neurophysiological functions of the tibial and common peroneal nerves. A single group pre-post, quasi experimental, same subject design will be used. Participants with prior diagnosis of DPN will be selected according to eligibility criteria. The ankle ranges of motion (Both Active & Passive) and plantar pressure distribution at six foot regions will be taken as the outcome measures. All the participants will receive neural mobilization of tibial & common peroneal nerves (3 sets of 30 repetitions in 2min with 1min break in between) for 3 times/ week for 4weeks. Outcome measurements will be taken at the baseline and after completion of the intervention. This study will be investigating the possible advantageous effects of neural mobilization in improving ankle joint ranges of motion and plantar pressure distribution in patients with DPN and will help the clinicians and researchers develop preventive measures to reduce the burden of diabetic ulcers.CTRI/2022/04/042187 [Registered on: 27/04/2022].

Foot Loading Analysis of Intra-articular Tibia Pilon Fracture.

Although pilon fractures are rare, they are important for orthopedic surgeons because of the difficulty of their treatment and their adverse effects on gait function. The aim of this was study to evaluate the relationship between the reduction quality of the fracture, functional results, ankle arthrosis, and plantar pressure distribution in patients with tibia pilon fractures. In this study, a total of 62 patients treated for an intraarticular pilon fracture in our clinic between January of 2015 and January of 2019 were evaluated retrospectively. Postoperative reduction qualities of the patients were evaluated with the Ovadia-Beals criteria; ankle functional scores were evaluated with the Teeny-Wiss score; and ankle arthrosis was evaluated with the Takakura classification. At the last patient follow-up, foot loading analysis was performed, and the results were evaluated for their relation with postoperative reduction quality, ankle function, and ankle arthrosis. There were 62 patients (50 men and 12 women). The average age was 43.3 years (range, 19-78 years). The mean follow-up was 34.3 months (range, 24-58 months). The mean Ovadia-Beals score was 12.35 ± 4.6 on the postoperative plain radiographs of the patients; the mean Teeny-Wiss score at the last follow-up was 76.82 ± 17.69; and the mean Takakura score was 1.47 ± 1.35. Based on the pedobarographic measurements, 47.58% of the patients put weight on the anterior portion and 52.42% on the posterior portion of the foot in the anteroposterior plane. In the mediolateral plane, 42.15% loaded on the medial portion of the ankle and 57.85% loaded on the lateral portion of the foot. Intra-articular tibia pilon fractures can be demonstrated by lateralization of the walking axis and changes in gait patterns and can be associated with clinical outcome.

The effect of pre-fabricated insole on plantar pressure distribution in patients with rheumatoid arthritis

BackgroundFoot deformities result in pain and changes in plantar pressure distribution in rheumatoid arthritis (RA) patients. Medical insoles are commonly prescribed for declining pain and modifying foot pressure distribution in these patients. The purpose of this study was to evaluate the effect of a pre-fabricated insole with metatarsal pad and medial longitudinal arch support on plantar pressure distribution in rheumatoid arthritis patients. MethodsFifteen females with RA participated in this study. All patients received a pair of pre-fabricated insoles that were individually modified using metatarsal pads and medial longitudinal arch supports. Mean peak pressure (kPa), maximum force (N), and contact area (cm2) were calculated for the heel, midfoot, metatarsophalangeal joint, and toe regions using the Pedar-X system immediately and after a month follow-up. FindingsIn the heel and metatarsophalangeal joint regions, maximum pressure and force showed a significant reduction in the follow-up assessment (p < 0.05). The comparison showed a significant increase in maximum pressure and force in the midfoot when participants walked with insole compared to without insole condition (p < 0.001). InterpretationUsing a pre-fabricated insole with an individually modified metatarsal pad and medial longitudinal arch support could alter rheumatoid arthritis patients’ plantar pressures after one month of follow-up. This type of insole is simple and inexpensive and showed a significant effect on decreasing pressures under the metatarsal heads.

Detection of ataxia in low disability MS patients by hybrid convolutional neural networks based on images of plantar pressure distribution

BackgroundThis study aimed to detect ataxia in patients with multiple sclerosis (PwMS) with a deep learning-based approach based on images showing plantar pressure distribution of the patients. The secondary aim of the study was to investigate an alternative and objective method in the early diagnosis of ataxia in these patients. MethodsA total of 105 images showing plantar pressure distribution of 43 ataxic PwMS and 62 healthy individuals were analyzed. The images were resized for the models including VGG16, VGG19, ResNet, DenseNet, MobileNet, NasNetMobile, and NasNetLarge. Feature vectors were extracted from the resized images and then classified using Support Vector Machines (SVM), K-Nearest Neighbors (K-NN), and Artificial Neural Network (ANN). A 10-fold cross-validation was applied to increase the validity of the classifiers. ResultsThe VGG19-SVM hybrid model showed the highest accuracy, sensitivity, and specificity values (89.23%, 89.65%, and 88.88%, respectively). ConclusionThe proposed method provided an automatic decision support system for detecting ataxia based on images showing plantar pressure distribution in patients with PwMS. The performance of the proposed method indicated that this method can be applied in clinical practice to establish a rapid diagnosis of ataxia that is asymptomatic or difficult to detect clinically and that it can be recommended as a useful aid for the physician in clinical practice.

Plantar Pressure Distribution during Standing in Female Patients with Hip Osteoarthritis Who Underwent Total Hip Arthroplasty

Introduction: Assessment of plantar pressure indicates the manner in which the plantar region contacts the ground as the first point in a leg-linked kinetic chain, and receives force from the ground. However, few studies have examined the changes in plantar pressure distribution in patients who underwent Total Hip Arthroplasty (THA) before and after THA, or compared plantar pressure distribution between THA patients and healthy adults. Objective: Plantar pressure distribution in patients with end-stage hip osteoarthritis who undergo THA may be adjusted to that in healthy adults by correcting leg length discrepancy. Herein, our objective was to find out if the plantar pressure distribution during standing differs before and after THA, and between healthy adults and THA patients. Design: Case control study. Setting: Single orthopedic clinic in Japan. Participants: THA patients (n=58; THA group) and healthy adults (n=53; control group). Interventions: Not applicable. Main outcome measure(s): The maximum plantar pressure under each foot measured during standing for 20 s was assessed for location, symmetry, and leg length discrepancy. Results: The distribution plantar pressure in the THA group differed preand postoperatively. The maximum plantar pressure region was the heel in approximately 80% of the patients three months after THA; it was not different in THA patients three months postoperatively and in healthy adults. Patients with asymmetrical maximum plantar pressure regions were those whose postoperative maximum plantar pressure region in the affected leg was the forefoot and those whose maximum plantar pressure region in the affected leg shifted to the heel. The leg length discrepancies decreased significantly after THA. Conclusions: The plantar pressure distribution during standing in female patients adjusted to that in healthy adults after THA. Patients with asymmetrical distribution of maximum plantar pressure may benefit from balance assessment and physical therapy.

Comparison between the plantar pressure effects of toe separators and insoles in patients with hallux valgus at a one-month follow-up

BackgroundVarious designs of foot orthoses for hallux valgus have been developed to reduce foot pain. The plantar pressure assessment can determine the better intervention. This study aimed to compare the effectiveness of plantar pressure distribution in patients with hallux valgus during walking with toe separator and insole. MethodPatients with hallux valgus were randomized into one of two interventions: prefabricated toe separator or customized insole. The plantar pressure distribution of the participants was measured during walking with the devices after use for one month with an in-shoe measurement system. ResultsTwenty-three participants were analyzed. After 1-month, significant peak pressures and pressure-time integral reductions were observed during walking in the middle forefoot (64.28 kPa and 28.97 kPa s, respectively) and lateral forefoot regions (54.03 kPa and 22.30 kPa s, respectively) after insole use compared with a toe separator. ConclusionsAfter one month of use, the customized insole was more effective in plantar pressure reduction than the toe separator for a hallux deformity.

Vitamin D Supplementation Improves the Effects of the Rehabilitation Program on Balance and Pressure Distribution in Patients after Anterior Cervical Interbody Fusion-Randomized Control Trial.

Study Design: A double-blinded, randomized controlled trial. Background: Surgery is effective in reducing pain intensity in patients with cervical disc disease. However, functional measurements demonstrated that the results have been not satisfactory enough. Thus, rehabilitation programs combined with the supplementation of vitamin D could play an essential role. Methods. The study recruited 30 patients, aged 20 to 70 years, selected for anterior cervical interbody fusion (ACIF). The patients were randomly divided into the placebo (Pl) and vitamin D (3200 IU D3/day) supplemented groups. The functional tests limits of stability (LOS), risk of falls (RFT), postural stability (PST), Romberg test, and foot pressure distribution were performed before supplementation (BS—week 0), five weeks after supplementation (AS—week 5), four weeks after surgery (BSVR—week 9), and 10 weeks after supervising rehabilitation (ASVR—week 19). Results. The concentration of 25(OH)D3 in the serum, after five weeks of supplementation, was significantly increased, while the Pl group maintained the same. The RFT was significantly reduced after five weeks of vitamin D supplementation. Moreover, a further significant decrease was observed following rehabilitation. In the Pl group, no changes in the RFT were observed. The overall postural stability index (OSI), LOS, and the outcomes of the Romberg test significantly improved in both groups; however, the effects on the OSI were more pronounced in the D3 group at the end of the rehabilitation program. Conclusions. Our data suggest that vitamin D supplementation positively affected the rehabilitation program in patients implemented four weeks after ACIF by reducing the risk of falls and improving postural stability.

Plantar pressure distribution during standing in women with end-stage hip osteoarthritis

BackgroundPatients with hip osteoarthritis (OA) experience abnormal movement patterns and reduced loading of the affected leg. The plantar contacts the ground and receives force from the ground. Plantar pressure distribution may differ in patients with hip OA compared to healthy adults and may influence physical functioning in these patients. Research questionWe investigated whether plantar pressure distribution during standing differed between patients with hip OA and healthy adults. We also analyzed the relationship between plantar pressure distribution and walking ability and the factors affecting plantar pressure distribution. MethodsMaximum plantar pressure distribution during standing for 20 seconds was investigated in patients with hip OA (n = 62; OA group) and in healthy adults (n = 53; Control group). Statistical comparisons between these groups were made using Fisher’s exact test and residual analysis. In the OA group, leg length discrepancy, range of hip extension, leg loading, knee extensor strength, and 10 m walking time were assessed; multiple linear regression and logistic regression analyses were used to examine the relationships between these factors and maximum plantar pressure distribution. ResultsMaximum plantar pressure distribution was different between the OA and control groups. In the OA group, maximum plantar pressure distribution was one of the significant predictors of 10 m walking time. Additionally, leg length discrepancy was a significant predictor of maximum plantar pressure distribution in this group. SignificanceDuring standing, the proportion of patients for whom the maximum plantar pressure region was the heel tended to be lower in the group with hip OA compared to the healthy adults. Plantar pressure distribution may have an importance for evaluating walking ability in patients with hip OA. Correcting leg length discrepancy and loading under the heel could adjust plantar pressure distribution in patients with hip OA.

Forefoot pathology in relation to plantar pressure distribution in patients with rheumatoid arthritis: A cross-sectional study in the Amsterdam Foot cohort

BackgroundIn patients with rheumatoid arthritis (RA), both high and low forefoot plantar pressures have been reported. Better understanding of pathology in the forefoot associated with altered pressure distribution in patients with RA could help to better formulate and specify goals for treatment with foot orthoses or therapeutic footwear. ObjectivesTo investigate the association of plantar pressure with disease activity and deformity in the forefoot in patients with rheumatoid arthritis and forefoot symptoms. MethodsA cross sectional study, using data of 172 patients with rheumatoid arthritis and forefoot symptoms, was conducted. Peak pressure (PP) and pressure time integral (PTI) in the forefoot were measured with a pressure platform. Forefoot deformity was assessed using the Platto score. Forefoot disease activity was defined as swelling and/or pain assessed by palpation of the metatarsophalangeal joints. The forefoot was divided in a medial, central and lateral region, in which the following conditions could be present: 1) no pathology, 2) disease activity, 3) deformity or 4) disease activity and deformity. A multilevel analysis was performed using condition per forefoot region as independent variable and PP or PTI in the corresponding region as dependent variable. ResultsStatistically significant higher plantar pressures were found in forefoot regions with deformities (RR 1.2, CI 1.1-1.3, P<0.0001), compared to forefoot regions without forefoot pathology. No significant differences in plantar pressures were found when solely forefoot disease activity was present in forefoot regions. SignificanceForefoot deformities are related to higher plantar pressures measured in the corresponding forefoot regions. The absence of an association between local disease activity and plantar pressure might be explained by the low prevalence of metatarsophalangeal joint pain or swelling. Future research with sensitive imaging measures to detect disease activity is recommended to reveal the effect of forefoot disease activity on plantar pressure.

Plantar Pressure Distribution in Patients with Diabetic Peripheral Neuropathy and a First-Ray Amputation.

Elevated dynamic plantar pressures are a consistent finding in diabetic patients with peripheral neuropathy, with implications for plantar foot ulceration. This study aimed to investigate whether a first-ray amputation affects plantar pressures and plantar pressure distribution patterns in individuals living with diabetes and peripheral neuropathy. A nonexperimental matched-subject design was conducted. Twenty patients living with diabetes and peripheral neuropathy were recruited. Group 1 (n = 10) had a first-ray amputation and group 2 (n = 10) had an intact foot with no history of ulceration. Plantar foot pressures and pressure-time integrals were measured under the second to fourth metatarsophalangeal joints, fifth metatarsophalangeal joint, and heel using a pressure platform. Peak plantar pressures under the second to fourth metatarsophalangeal joints were significantly higher in participants with a first-ray amputation ( P = .008). However, differences under the fifth metatarsophalangeal joint ( P = .734) and heel ( P = .273) were nonsignificant. Pressure-time integrals were significantly higher under the second to fourth metatarsophalangeal joints in participants with a first-ray amputation ( P = .016) and in the heel in the control group ( P = .046). Plantar pressures and pressure-time integrals seem to be significantly higher in patients with diabetic peripheral neuropathy and a first-ray amputation compared with those with diabetic neuropathy and an intact foot. Routine plantar pressure screening, orthotic prescription, and education should be recommended in patients with a first-ray amputation.

Effects of extracorporeal shock wave therapy on plantar pressure distribution of patients with epin calcanei

Effects of extracorporeal shock wave therapy on plantar pressure distribution of patients with epin calcanei

The effect of eliminating leg length difference on plantar foot pressure distribution in patients wearing forefoot offloading shoe

Background and purposeElevated heel construction offloads the forefoot after surgery. However, side-to-side height difference alters limb kinetics, whereas leg-length equalizing-sole at non-operated side may have beneficial effects on foot loading. The purpose of this study was to characterize leg-length equalizing sole effect on bilateral plantar pressures when using heel-lift forefoot-offloading shoe. Materials and methodsTwenty men were tested walking. Plantar peak pressures (PP) and pressure-time integrals (PTI) in the forefoot-offloading shoe and in contralateral running shoe were compared between two conditions: one with- and the other without leg-length equalizing sole elevation at the running shoe. ResultsAdding leg-length equalizing sole to the running shoe resulted in the following changes in the forefoot-offloading shoe: increased lateral midfoot PP (8.7%, p=0.03), increased lateral midfoot (11.3%, p=0.05) and lateral metatarsals PTI (10.3%, p=0.04), and decreased medial and lateral heel PTI (>5%, p=0.02). These changes were non-significant when applying a Bonferroni correction. Changes in the running shoe were: increased medial midfoot (20.5%, p=0.03) and decreased 2nd and lateral metatarsals PP (23%, p<0.01). PTI increased in medial and lateral heel (>25%, p<0.01), medial midfoot (63.2%, p<0.01) and lateral midfoot (9.2%, p=0.04) and decreased in 2nd and lateral metatarsals (>24.5%, p<0.01). ConclusionLeg-length equalizing sole at contralateral running shoe in subjects wearing forefoot-offloading shoe results in lateral load shift alongside heel pressure attenuation within the forefoot-offloading shoe, which is beneficial during first month after medial forefoot surgery. Reciprocal medial load-shift in the elevated running shoe itself should yet be considered when bilateral medial forefoot pathology is present.

Changes of gait parameters following constrained-weight shift training in patients with stroke.

[Purpose] This study aimed to investigate the effects of training involving compelled weight shift on the paretic lower limb on gait parameters and plantar pressure distribution in patients with stroke. [Subjects and Methods] Forty-five stroke patients participated in the study and were randomly divided into: group with a 5-mm lift on the non-paretic side for constrained weight shift training (5: constrained weight shift training) (n=15); group with a 10-mm lift on the non-paretic side for constrained weight shift training (10: constrained weight shift training) (n=15); or the control group (n=15). Both, the 5 constrained weight shift training and 10 constrained weight shift training groups underwent constrained weight shift training 5 times per week for 4 weeks, whereas the control group performed ergometer exercises for lower limb muscle strengthening. [Results] The 10 constrained weight shift training group showed a significant increase in the contact surface and impulse of the hindfoot compared to the control group, and the step length and walking speed were significantly longer and faster. [Conclusion] We found that constrained weight shift training on the paretic lower limb is an effective treatment method for improving normal gait pattern in stroke patients.

Plantar pressure distribution in patients with ankylosing spondylitis

BackgroundAnkylosing spondylitis is one of the most common inflammatory rheumatic diseases and is associated with alterations in posture. The aim of this study was to investigate the pedobarographic changes among ankylosing spondylitis patients, in an attempt to understand whether the alterations in the posture affect the plantar pressure distribution. MethodsThe study population consisted of 38 patients with ankylosing spondylitis and 33 healthy volunteers. The static and dynamic pedobarographic measurements were performed to determine the plantar pressure distribution. Moreover, the Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, Ankylosing Spondylitis Quality of Life Questionnaire and Bath Ankylosing Spondylitis Metrology Index were used to assess the clinical state of the patients. ResultsThe static pedobarographic measurements did not reveal any intergroup difference. There were differences between the groups in the results of dynamic peak pressure measurements under the metatarsal areas and under the midfoot region. The percentage of the midfoot in the dynamic plantar contact area was higher in ankylosing spondylitis patients in comparison to the controls. No clinically significant correlation was found between the clinical scores and static pedobarographic measurements. The plantar pressures under the metatarsal heads, medial and lateral heel regions declined with increasing disease activity according to the Bath Ankylosing Spondylitis Disease Activity Index scores. The lower peak pressures on the forefoot and rearfoot, were associated with the higher Bath Ankylosing Spondylitis Metrology Index scores of the patients. InterpretationThe alterations in the posture may have effects on the plantar pressures in patients with ankylosing spondylitis, especially during dynamic activities.

Role of Footwear Alteration along with Conventional Physiotherapy in Osteoarthritis Knee

Inspite of vast array of conservative treatment interventions for medial knee osteoarthritis, their effectiveness in its management is still contentious. Numerous researchers have suggested the role of footwear modification in reducing medial knee joint space load and hence reducing pain and improving functional status. However, most of the studies were cross-sectional in nature and have not seen the alteration in compendium of factors like radiographic changes, static alignment, kinesiological factors, gait parameters and most importantly plantar pressure distribution following 6 months of footwear modification along with conservative physiotherapy. The results of the present study suggested that footwear alteration along with conventional physiotherapy was effective not only in improving clinical outcomes but also increasing medial knee joint space width, changing static alignment, improving kinesiological factors, gait parameters and plantar pressure distribution in patients of osteoarthritis knee.

Classification of forefoot plantar pressure distribution in patients with diabetes: A novel perspective for the management of the diabetic foot

Classification of forefoot plantar pressure distribution in patients with diabetes: A novel perspective for the management of the diabetic foot