Biomechanics in Wound Care

Brian McCurdy:

Welcome back to Podiatry Today Podcasts, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. I'm Brian McCurdy, the managing editor of Podiatry Today. In today's episode, our wound care Q&A is with Jim McGuire, DPM and our clinical editor, Dr. Kazu Suzuki. Dr. McGuire is a professor in the Department of Podiatric Medicine and biomechanics, and the director of the Leonard Abrams Center at the Temple University School of Podiatric Medicine in Philadelphia. Dr. Suzuki is the medical director of the Apex Wound Care Clinic in Los Angeles. He's also a member of the attending staff at Cedar Sinai Medical Center in California. Welcome, and today, we're going to be talking about wound care and biomechanics. So my first question is, in general, how do you feel applications of biomechanics can improve wound care outcomes?

Dr. Jim McGuire:

Across the board? Well, I think probably one of the primary reasons why you develop a wound in the first place other than the neuropathy, which deadens your sensation and ability to feel the stresses, is the mechanical stress on the foot. We all do a great deal of walking. We all have numerous footwear choices that we make sometimes in a day, sometimes not. Sometimes we're in a really old shoe that's broken down, and sometimes we're in a brand new shoe and it puts a great deal of stress on the planter surface of the foot. There's tremendous amount of problems with sheer direct planter forces, job demands, surface demands, et cetera, on the foot. If you have a kind of deadened or a blunted neuropathic system, and on top of that, problems with glycosylation and tissue flexibility, the foot's ripe for problems, and they're all in the biomechanical arena. So addressing that with either shoes or orthotics or offloading devices is essential to healing the wound at all. If you don't address them, you're going to be spinning your wheels with expensive grafts and tissue applications and not getting anywhere.

Brian McCurdy:

Dr. Suzuki, did you want to add anything?

Dr. Kazu Suzuki:

I do spend a great deal of the time educating my patient or discussing with my patients about shoe gear, because so many times patients come in with the shoes that's too flimsy or maybe too filthy or broken down. So I absolutely look at the patient's foot, how they walk, and I look at their shoes, and oftentimes, it's fine. Many times I see mismatch in what they should be wearing and really they're not wearing what they're wearing, so what they should be wearing, I should say. So that is a big part of my practice in wound care or taking care of the foot wounds. The biggest challenge there is, let's say, it's to some extent, it's fashion choice. Like yesterday, I saw this new patient, a very well-dressed business person, a female who was wearing very stylish Gucci high heel kind of shoes.

She was coming to me for a toe wound, well almost like pressure ulcer. I was telling her, "Hey, you should wear something different, something like softer athletic shoes." She told me yeah, there's no way that she's going to wear those, so there's a disconnect there. Also, sometime patient have come in with broken down shoes that's clearly three-year-old, five-year-olds completely worn out with the holes. But they may tell me, "Hey, I don't have money to buy new shoes," and again, I'm stuck. So there's a disconnect between the feet and the biomechanics and the shoes, but I always try to educate them the best I can. That's really the best I can do in terms of shoe gear, but that's a big part of my practice, and I'm sure it's a challenge for many of us.

Brian McCurdy:

How do you incorporate biomechanics into your wound care practice?

Dr. Jim McGuire:

Well, from the beginning, it's a thorough biomechanical evaluation in patients that come in. You don't just concentrate on the wound, you take a look at the whole person, and that includes their entire medical history and all aspects of it. But their biomechanical history is extremely important to look at the tissue flexibility, the presence of hallux limitus, posterior tibial problems, bunions, hammertoes, all the malformations that the foot takes on over the course of a lifetime, and then take a look at whether they're appropriately balanced in the foot. Does the foot actually sit under the ankle or is it off to the side, and has the arch collapsed, and what are the stresses on the foot? Then take a look at where the ulcers showing itself and why biomechanically is that ulcer there? And then start to look at and prepare for either prevention of an ulceration, which is probably the more important use of biomechanics.

But then after the ulcer has been healed, and there are a number of techniques for that, and you can go into the whole total contact cast and removable walkers and all the biomechanics and healing the wound, but I think most of the focus of what we're talking about here is, what do you do before and after? We try to get the patients into depth shoes, but I'm really appalled by the molded inserts that are in diabetic shoes today. I think we're wasting a great deal of money on people that have low levels of risk and are getting shoes in these triple layer inserts that are barely molded and people that really, really need diabetic footwear and a good custom molded foot orthoses to offset the forces in the foot. So the inserts in the shoes are grossly inadequate. We're actually engaging in this study right now to start to look at that and see what types of interventions would be necessary.

But most people are walking around in diabetic shoes that they think protect them because they're, quote, "diabetic shoes" on a triple layer or insole with no arch, no biomechanical like rebalancing, no attempt at trying to realign the foot or even make significant protective interventions in the area of the ulceration. We're constantly pulling insoles out, modifying insoles, adding arch pads, adding metatarsal pads, putting in cutouts. I think pedorthists are under a great deal of pressure right now because of the reimbursement for shoes, but nobody on the pedorthic end is really diving into doing expert balancing work in the diabetic shoe. So if we got to where we had good footwear, much of the diabetic footwear is very cheap. I think we pushed pedorthists into that box, which is, cut the reimbursement, cut the reimbursement, cut the reimbursement, and what do you get for that? You get cheaper shoes, and you get no time put into making an insole. So we do our best to offset that gap by what we're doing in our clinic.

Brian McCurdy:

Okay. Dr. Suzuki, anything to add?

Dr. Kazu Suzuki:

I agree with Dr. McGuire. It is tough because of reimbursement, which we cannot do much about it, but again, still education. We have to educate our patients about their shoes and the socks and their feet and how their feet work. If they have budget for it, we guide them towards getting better insoles, better shoes, better socks, and that's part of the whole wound care diabetic foot care practice. That's what I believe.

Brian McCurdy:

What use of biomechanics has been the most impactful for your patients?

Dr. Kazu Suzuki:

Most what biomechanics has been, all about pressure relief. So I examine our patients. If they have equinus, and if they benefit from it, I'll do tendon Achilles releasing and rebalancing. I do that often. Another thing I do that most often is actually flexer tenotomy. I see lots of diabetic patients with a toe tip ulcers in any of the toes. I don't hesitate to recommend flexer tenotomy to release that pressure because often, so many times patients come up with that toe tip ulcers, distal toe ulcers, and oftentimes, that comes solely because they have contracted digit hammertoes. Even if it's not painful, I aggressively recommend flexer tenotomy just to rebalance the biomechanics in the toes. I think that's very important to prevent ulceration and the cascading into infection and foot loss, limb loss.

Dr. Jim McGuire:

We try to adhere to the international working group of the diabetic foot recommendations, and we follow them every time they come out and make adjustments to it. What the most impactful biomechanical intervention has been total contact cast or the knee-high, non-removable device. You can then go into other non-removables. A simple one is football dressings. Football dressings are a biomechanical bandage, a little costly to us on the front end, but very, very impactful. If you want to go to something really super practical, it's being very up on what's available on Amazon. A lot of patients can't afford orthotics or if they get in their diabetic shoes, they can't afford a custom foot orthosis to go into it. They're not often covered, so there are a tremendous number of over-the-counter devices that are available to patients today that we've been able to hop in and use as alternative insoles for patients that don't get what they need in the shoe that they got or who are wearing regular footwear and putting themselves at risk for ulceration.

The surgical procedure that Dr. Suzuki mentioned, the flexer tenotomy in the Achilles tendon, those are the two that are in the International Working Group guidelines that they recommend pretty wholeheartedly to help with offloading, that's surgical biomechanics. Other surgeries, if they're applied appropriately, bunionectomies and metatarsal head removals, et cetera, can be extremely helpful in getting wounds healed quickly. But I've been all over the board with different biomechanical devices, but using something that actually addresses the alignment, the malalignment of the foot in the shoe and during ambulation, rocker soles. There are so many shoes out there on the market now that have built in rockers. Rockers have been tremendous in reducing forefoot pressures, metatarsal head pressures, even digital pressures and contractures because they relax the toes. So a rocker sole is the prevalence of them on the market now for people in regular footwear has been very helpful in slowing down ulcer development for a lot of my patients.

Brian McCurdy:

What one thing can DPMs do in their practices today to enhance the use of biomechanics in wound care?

Dr. Jim McGuire:

Don't take no for an answer when it comes to the shoes that are dispensed to your patients many times. It's perfectly fine. All the patients that we write a script for for our shoes and inserts, we have them come back right away before they've worn them so they don't ... they'll start beating up a shoe and then find out it wasn't the right one. So we ask for them to come in, let us look at the shoe, make sure it fits appropriately. Most pedorthists do a great job in that area, make sure that the insert has been manufactured appropriately. Use the option of getting a custom foot orthoses manufacturer for a patient and try to get your pedorthic people to work with you carefully on that so you get the right device. Modify the inserts immediately if they need it, and don't wait to see if an ulcer developed and then modify it later.

Our patients are seen for, I consider most of these patients have had a previous ulcer. They should be seen six times a year, every two months almost if they have nail care and other issues. But they should be evaluated regularly and get the patients in the habit of doing that. We saw the degree of ulceration and the complications from ulcers drop precipitously when we started patients coming in regularly for follow up and emphasizing that and doing education like Dr. Suzuki said. So yeah, I think just apply good biomechanical principles, don't take no for an answer on orthotics and on insoles and do what you know is best practice and the patients will be a lot better.

Brian McCurdy:

Okay. Dr. Suzuki?

Dr. Kazu Suzuki:

Yeah, I think it comes down to, in my mind, it's all about education, especially the shoe education for our patients is the most impactful. I have shoes that I like on the wall, shoes that I recommend. On each exam room, I have four exam rooms. I have them on the wall right there so the patients can look at it, they can play with it, touch it. I do show-and-tell. I show them, "Hey, this is the one I like. This is what I recommend. Here's a flyer where you can buy them. Here's a website and this is the pricing. This is a local store that you can go to and buy them today." Maybe the first time around you may get not get through, but if I tell them a second, third, first time. I can usually get through to them that, "Hey, maybe this doctor already recommended these shoes and maybe this should actually be what I think. So I think it does go through. I hope Dr. McGuire agrees with me. So there's a local company called Hoka. They're a California shoe company.

They're a national brand, I think, international brand, maybe. So the Hoka has a brand of shoe called Bondi, which is a maximally cushioned shoes with a little bit of a rocker bottom. What I found that to be, it's a very high-quality shoe. It's the closest thing to diabetic shoes that we know, so I recommend them routinely to my patients. They also make Hoka recovery shoes, which is about $90, which is very similar maximally cushioned shoes with a rocker bottom, but it's to slip on so there's no ties. You can almost slip on into the shoe. They are the closest thing to a diabetic shoes that we can prescribe. This may be local thing in Los Angeles, but all my local pedorthists offices they don't accept Medicare anymore, in my local area anyway, so I've been having a hard time prescribing diabetic shoes. So I actually have these shoes on the wall. I recommend to my patient, "Hey, go get these maximally cushioned rocker bottom shoes 'cause they are good for you. They're the best thing for you." Oftentimes, they actually follow through with that.

Dr. Jim McGuire:

Yeah, that's an excellent shoe. The problem with Hoka is, and although my population does, Center City Philly, they love shoes, so they're willing to spend a little more money on shoes. But I think you need to have an armamentarium. I always tell my students that if you have something that you consider the ideal for a patient and they say no, and it's because of financial reasons, you have a medium level shoe that you can recommend and then an inexpensive shoe. I would say the majority of the patients that we see here end up running to Skechers and to discount shoe stores for things. So you need to know what's out there in a bigger area, or at least in your area, and then what your patient population can afford and always have available different options for them, different kinds of over-the-counter devices, different kinds of custom devices.

I can make you a custom foot orthoses that'll be the best, but it's not covered by your insurance, and it's expensive. It might be four or five, $600 depending on the doc. My students ask me, "What's the difference in orthotic prices?" I said, "You can take this to the bank. The cost of the orthotic is directly proportional to the ego of the physician prescribing it. However great you think you are in biomechanics, that's what you'll charge." We all get them for the same price, from the same place or similar places. They're either made from casts or they're made from scans, or they're printed or however they're made. We all get them from the same basic construction market. Then what we charge for them is dependent on the market you're in and then also your perceived level of expertise.

I have to try to keep ours down to the lowest price we can get, so it doesn't change the quality, it just changes what the patient ends up having to pay. But even those are expensive. So you have to have something that's maybe modifiable over the counter, or even an over the counter that's already set up to be like ... I use a lot of the Danenbergs orthotics by VASYLI, but they aren't even affordable by a lot of my patients. They're set up to be a good supportive over the counter. So we go all the way down to Spenco over-the-counters and then modify them ourselves. So there's a lot of great companies out there making things in every price range, you just have to work to make it work. You just can't slip it into their shoe and send them out the door. You got to see them, see them, see them, modify, adjust, and be available for them if they have a problem.

Brian McCurdy:

Thank you for sharing your years of experience-

Dr. Jim McGuire:

You're welcome.

Brian McCurdy:

... and I hope readers will learn a lot from this. I hope everyone will join us again for future episodes of the Podiatry Today podcast, which you can find at podiatrytoday.com and on your favorite podcast platforms.