Figure 3. Primary modalities for the orthotic management of neuropathic foot patients.

1. Depth Inlay Shoes and Multi-Durometer Foot Orthoses: Depth inlay or diabetic shoes provide protection to the dorsal and plantar aspects of the foot and accommodate multi-durometer foot orthoses. They can be modified with the inclusion of a medial or lateral flare, sole lift, or rocker sole to widen the patient’s base of support, address atypical joint moments, accommodate a leg-length discrepancy, and increase the stance phase timing. These combinations reduce pressure on high-pressure areas and provide better support [27].

2. Offloading Footwear: Offloading shoes are designed to minimise sheer pressure at wound sites. Forefoot offloading shoes support the metatarsal heads and phalanges, keeping the ankle in a relatively dorsiflexed position. Conversely, hindfoot offloading shoes limit pressure on the calcaneus. Offloading footwear is modifiable with rocker-bottom soles or by removing pre-punched pads [27].

3. Customised Management: In cases of Charcot's arthropathy, active ulcerations, and severe deformities, custom-made orthotic tools are used. Examples include the Charcot restraint orthotic walker (CROW) orthosis, which provides full support to the plantar aspect of the foot, ankle and calf; the patellar tendon-bearing (PTB) orthosis, applied to the patellar tendon (ligament), popliteal fossa, and medial tibial flare, which provides plantar offloading; and the conventional ankle-foot orthosis (AFO) with moulded calf lacer, which provides unloading of the plantar aspect of the foot by circumferential loading of the calf musculature. These tools provide specific support and offloading tailored to the patient's condition [28].

Image created by the authors.