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Structural Changes in the Forefoot of Individuals with Diabetes and a Prior Plantar Ulcer

Investigation performed at Washington University School of Medicine, St. Louis, Missouri

Douglas D. Robertson, MD, PhD
Departments of Radiology and Orthopaedic Surgery, University of Pittsburgh Medical Center Musculoskeletal Imaging and Biomechanics Laboratory, 200 Lothrop Street, Pittsburgh, PA 15213. E-mail address: robertson{at}computer.org

Michael J. Mueller
Kirk E. Smith
Paul K. Commean
Thomas Pilgram, PhD
Jeffrey E. Johnson, MD
Program in Physical Therapy (M.J.M.), Mallinckrodt Institute of Radiology (K.E.S., P.K.C., and T.P.), and The Foot and Ankle Service, Department of Orthopaedic Surgery (J.E.J.), Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from National Institutes of Health Grant RO1 HD 36895-03. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Plantar ulcers produced by diabetic foot disease are devastating and costly. Better understanding of the ulcer-producing process is important to improve detection of feet that are at risk and to improve intervention. We identified and quantified soft-tissue and osseous structural changes in the forefoot of diabetic patients with a prior plantar ulcer.

Methods: Thirty-two individuals with a mean age (and standard deviation) of 57 ± 11 years were studied; sixteen had diabetes (of a mean of 20 ± 11 years' duration), peripheral neuropathy, and a prior plantar ulcer, and sixteen were matched controls. Computed tomography was used to evaluate forefoot structure, including the plantar soft-tissue (muscle) density, soft-tissue thickness beneath the metatarsal heads, metatarsophalangeal joint angle, metatarsal bone density, and metatarsophalangeal joint arthropathy.

Results: Plantar soft-tissue (muscle) density was lower in the individuals with diabetes (mean, 1 HU [Hounsfield unit]) than it was in the controls (mean, 18 HU). There was no difference in the soft-tissue thickness beneath the metatarsal heads (mean, 10 mm) between the individuals with diabetes and the controls, but the soft-tissue thickness decreased with age. The individuals with diabetes had greater extension deformity of the first, second, and third metatarsophalangeal joints and greater arthropathy of the second, third, and fourth metatarsophalangeal joints. There were no significant differences in metatarsal bone density between the groups.

Conclusions: There were significant differences between the forefeet of individuals with diabetes and a previous plantar ulcer and those of controls: plantar muscle density was decreased, and metatarsophalangeal joint extension and arthropathy were increased. Interestingly, the soft-tissue thickness under the metatarsal heads in the controls was not greater than that in the diabetic patients.

Clinical Relevance: This study demonstrated structural differences between the forefeet of patients with diabetes and a previous ulcer and those of normal age-matched controls. The information can serve to guide new interventions to prevent or treat foot ulcerations in this patient population.

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