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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 58-62

Assessment of foot pressure in patients with diabetes by using mat scan in a tertiary care teaching hospital in North India

1 Department of Endocrinology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Internal Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
3 Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
4 Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission15-Jun-2022
Date of Acceptance28-Apr-2023
Date of Web Publication25-Aug-2023

Correspondence Address:
Manjunath Totaganti
Department of Endocrinology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JCDM.JCDM_6_22

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Introduction: Diabetic foot ulcers are a common diabetic complication that can be lethal. Abnormal plantar pressures are hypothesized to influence the pathogenesis of neuropathic ulcers in the diabetic foot. Aim: To analyze the maximum plantar pressures and average plantar pressures in diabetic patients. Materials and Methods: The study used 62 diabetes individuals as participants. Body mass index was calculated, as well as illness duration and hemoglobin A1c. Plantar pressure was measured in static (standing) and dynamic (walking/taking a step on the mat) settings for all patients using the BTS (BTS is a bioengineering company based in Italy) walk system. The plantar pressures (kPa) at the five metatarsal regions, the mid-foot region, and the medial and lateral heel regions were measured. Results: We found that the maximum dynamic pressures were higher in at metatarsal region, which were above 600 kPa, which were considered a risk for ulceration. Conclusion: Persons with diabetes have higher maximum plantar pressures. These people are at high risk for foot ulceration in the metatarsal and mid-foot regions. This can be used as an indicator of the development of ulcers.

Keywords: Diabetes mellitus, high-risk foot, mat system, plantar foot ulcers, plantar pressures

How to cite this article:
Totaganti M, Kant R, Yadav RK, Khapre M. Assessment of foot pressure in patients with diabetes by using mat scan in a tertiary care teaching hospital in North India. J Cardio Diabetes Metab Disord 2022;2:58-62

How to cite this URL:
Totaganti M, Kant R, Yadav RK, Khapre M. Assessment of foot pressure in patients with diabetes by using mat scan in a tertiary care teaching hospital in North India. J Cardio Diabetes Metab Disord [serial online] 2022 [cited 2023 Sep 22];2:58-62. Available from: http://www.cardiodiabetic.org/text.asp?2022/2/2/58/384340

  Introduction Top

Diabetes is a group of metabolic illnesses characterized by hyperglycemia without treatment. Diabetes mellitus is becoming a primary medical and social concern worldwide and one of contemporary medicine’s most significant problems. Diabetes has piqued the scientific community’s interest since its discovery, owing to its ubiquitous nature and harmful repercussions.

Diabetic patients’ pathological alterations on their feet are the most common cause of hospitalization in the Western world, and the condition consumes the most healthcare resources worldwide.[1] High blood sugar’s direct and indirect consequences cause macrovascular (coronary artery disease, stroke, peripheral vascular disease) and microvascular problems (neuropathy, nephropathy, and retinopathy).

Diabetes-related foot problems, such as ulcers, infections, and amputations, are complex and might involve multiple causative pathways. One of the most common conditions affecting the feet is the plantar ulcer. In the past, higher plantar pressure was connected to the development of ulcers in diabetics.[2] Unusual foot pressure appears to be caused by inadequate diabetes control in the diabetic population.[3] It is well-recognized that increased pressure in diabetic individuals with peripheral neuropathy may cause foot ulceration. Pathological foot morphology and gait impairments are responsible for excessive pressure on the sole, and it should be highlighted that both contribute to the risk of diabetic foot.[4] The first creates a problem in standing and walking mechanics, which can seriously influence inappropriate foot peak plantar pressure (PPP) value and position.[5] A pedobarographic examination can identify the pattern and value of plantar pressure.

  Materials and Methods Top

We conducted a 15-month cross-sectional study in partnership with the physical medicine and rehabilitation department at a tertiary care teaching hospital in the division of diabetes and metabolism (internal medicine). In total, 170 type 2 diabetes mellitus (T2DM) patients were screened after receiving written and informed permission from the institutional ethical committee. Diabetic individuals of both sexes over the age of 18 who can walk freely without any clear, evident gait abnormalities were included in the study. Patients with an abnormal gait, nonhealing chronic ulcers, acute ulcers, amputation of one or both limbs, foot deformity, spine deformity, severe cardiovascular disease (New York heart association class 3 and 4), nephropathy (chronic kidney disease, stage 4 and 5) and other illnesses that impair quality of life and movement were all excluded from the study. Pregnant women and individuals who were unable to follow instructions were also excluded.

All participants underwent the following tests: full medical history, including the duration of diabetes and any diabetic complications. A complete medical check-up, including height, weight, and body mass index (BMI) calculation, was evaluated for nephropathy (by 24-h urine proteins).

The BTS P-Walk system was used in the current study. It incorporates the resistive pressure mat platform of 40 cm × 70 cm × 5 mm. The resolution is 9216 sensors on each platform with an acquisition frequency of up to 100 Hz. The BTS P-Walk platform is mounted on a flat 10-m walkway. The long path allows measurements to be recorded during free movement. It ensures that the effect of acceleration and deceleration at the start and end of each walk is minimized. The maximum pressures were taken in standing (static) and walking across (dynamic) the mat system. Standardized instructions were given to participants. The pressures were documented in the first metatarsal area (M1), the second metatarsal area (M2), the third metatarsal region (M3), the fourth metatarsal area (M4), the fifth metatarsal area (M5), the mid-foot area (MF), and the medial and lateral heel (MH) areas. The following parameters were recorded by the BTS P-WALK system—maximum pressure and average pressure in kPa. The average pressure is the mean of all the sensor values. In contrast, maximum pressure is the highest individual sensor value that was achieved during the analysis.

Data were recorded on an MS office excel sheet, and various clinical and demographic parameters were analyzed with SPSS software 25. SPSS is a was a software house headquartered in Chicago and owned by International Business Machines Corporation (IBM).

Ethical consideration

The source data and documents were kept confidential by the principal investigator. Patients’ data had been used only for study purposes. The patient’s identity had been kept confidential. The Institutional Ethics Committee has access to the data for study-related inspection, if necessary. Individual data of this study will be kept anonymous. This study was initiated only after obtaining clearance from the Institutional Ethics Committee (IEC no: AIIMS/IEC/20/502), All India Institute of Medical Sciences, Rishikesh, Uttarakhand. The investigators have no conflicts of interest to declare. The study had no involvement with any organization or entity with financial interests.

  Results Top

The mean age of the study population was 48.93 ± 9.5 years. The study groups included 36 male patients (58%) and 26 female patients (41.9%). The mean BMI in the study group was 25.51 ± 3.85 [Table 1].
Table 1: Demographic data of the patients

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The mean HbA1C in the study participants was 8.51% ± 1.9%. The duration of diabetes was 5.55 ± 3.42 years. The other baseline investigations are tabulated in [Table 2].
Table 2: Baseline clinical parameters

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The static and dynamic foot pressures are tabulated in [Table 3] and [Table 4]. While standing, the maximum pressures on the hind foot were higher than the pressure on the forefoot. In the forefoot, the pressures were more under the metatarsal heads. In the heal region, the pressures were more in the medial part compared to the lateral part. The highest pressure was recorded at the medial heal (169 kPa) and lowest under the toes.
Table 3: Showing static maximum and average pressure in the left and right foot in kiloPascals

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Table 4: Showing dynamic maximum and average pressure in the left and right foot in kiloPascals

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In dynamic pressure mapping, the maximum pressures were recorded in a similar fashion to that of static pressures. The metatarsal heads had the highest pressures in the forefoot. The medial heal had the highest pressures in the hindfoot region. Correspondingly the maximum dynamic pressure of 662.25 kPa was located below the second metatarsal head of the left foot.

  Discussion Top

In both type 1 and type 2 diabetes, hyperglycemia’s direct and indirect effects on the vascular system constitute the primary cause of morbidity and mortality.[6] Diabetic foot problems, such as ulcers, infections, and amputations, are complex and might include several different causative pathways. Plantar ulcer is one of the most prevalent foot ailments. Diabetic foot ulcers are caused by high pressure being applied to the plantar area of the foot repeatedly during walking. The lifetime chance of a person with diabetes developing a foot ulcer is as high as 25%.[7] According to studies, patients with diabetes have a seven-fold greater chance of getting ulcers, contributing to more than 60% of lower limb amputations.[8]

Diabetic foot ulcers are caused by a complicated interaction between the internal structure and functionality of the foot and external forces and pressures experienced when walking.[9],[10],[11]

Diabetes patients have higher body weight, have limited joint mobility,[12] have a thicker plantar fat pad,[13] have changes to plantar soft tissue, muscle strength, motor neuropathy, and sensory neuropathy,[14] have foot structure changes, and have a foot deformity.

Pressure distribution and value beneath the plantar surface are affected by body weight,[15] age, and foot deformities caused by disease.[16],[17] Unusual foot pressure appears to be caused by inadequate diabetes control in the diabetic population.[3]

A pedobarographic examination can identify the pattern and value of plantar pressure. Much research has confirmed the importance of pedobarography as a diagnostic tool in plantar pressure patterns and value creation during stance and/or motion. Because of the problem’s intricacy and a lack of high-quality studies, there is no reliable data on quantifying plantar pressure in diabetic foot treatment and prevention recommendations.[18] As a result, most dynamic pressure measurement tools are only utilized for clinical studies and are not frequently employed as screening tools in clinical practices for people with diabetes.

Halawa et al.[19], who researched the association of plantar pressure in T2DM with and without neuropathy in 80 people, discovered that diabetic neuropathy patients have higher PPPs than patients without neuropathy and healthy subjects.

In a meta analysis which included about 16 studies conducted by Fernando et al.[20] showed people diabetic peripheral neuropathy had considerably higher plantar pressures. Biomechanical aspects of peripheral diabetic neuropathy: a comprehensive review and meta-analysis of data from the gait cycle, muscle activity, and dynamic barefoot plantar pressure found that diabetes individuals had considerably higher plantar pressures.

Our study found dynamic pressures around 600 kPa in metatarsal heads, which are the frequent sites for ulcer development. This study found that dynamic maximum and average pressure were higher under metatarsals and midfoot. Stess et al.[21] demonstrated higher dynamic pressures in medial and lateral metatarsals.

Frykberg et al.[22], studied the role of foot pressure in ulcer development. They found that even after controlling for age, sex, diabetes duration, and race, individuals with foot pressures more than 6 kg/cm2 (588.399 kPa) were twice as likely to develop ulcers as those with lower pressures. In 1992, Veves et al.[2] examined foot pressure in diabetic and nondiabetic amputees. They observed that diabetic amputees had high pressures beneath their remaining feet, which are linked to diabetic neuropathy. He further highlighted that among nondiabetic amputees, using a prosthetic does not raise the pressures beneath the residual foot.

On standing, the hindfoot pressures were higher than the forefoot pressures. The increased pressures in the rear foot were found near the heel, whereas the higher pressures in the forefoot were found under the metatarsal heads. These results are consistent with Grieve et al.[23] and Cavanagh et al.[24]

Attempts to establish a maximum pressure threshold for ulceration have been unsuccessful, and the apparent magnitude of pressure levels across studies is variable.[25] Different studies across the world have different thresholds. Veves et al.[2] discovered that ulceration requires a pressure of over 1000 kPa when walking barefoot. In a case–control study, Armstrong and Lavery[26] examined peak pressure in 219 diabetic individuals and indicated that 700 kPa is the ulceration threshold.

Identifying these pressures has screening value in determining the area of high risk. Casting, insoles, rocker shoes, and tailored shoes are among the clinically utilized ways to reduce pressure when walking for persons with diabetic neuropathies. These devices function by increasing the area of weight-bearing force and preventing localized pressure on the foot.

The limitations of this study were as follows:

  1. The lack of a control group of healthy individuals.

  2. It was a cross-sectional study. This study can be extended to a longitudinal study to assess the effectiveness of interventions in preventing diabetic foot complications over time.

The clinical utilization of foot pressure mapping could be as follows:

  1. For identifying the high-risk foot and as an indicator for ulcer development.

  2. For patients who have undergone amputations, plantar pressure mapping can be utilized to create specialized prosthetic devices that will optimize the distribution of foot pressure and guard against pressure sores.

  3. Plantar pressure mapping can be utilized in the creation of orthotics to make specialized orthotics that specifically address a range of elevated foot pressures.

  4. In rehabilitation, plantar pressure mapping can be used to assess how well various interventions, such as physical therapy, shoe inserts, and orthotics, reduce aberrant foot pressure.

  5. The study of the mechanics of the foot and ankle via plantar pressure mapping can help biomechanists create new therapies and interventions for conditions affecting the foot and ankle.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Economic consequences of diabetes mellitus in the U.S. in 1997. American Diabetes Association. Diabetes Care 1998;21:296-309.  Back to cited text no. 1
Veves A, Murray HJ, Young MJ, Boulton AJM The risk of foot ulceration in diabetic patients with high foot pressure: A prospective study. Diabetologia 1992;35:660-3.  Back to cited text no. 2
Barn R, Waaijman R, Nollet F, Woodburn J, Bus SA Predictors of barefoot plantar pressure during walking in patients with diabetes, peripheral neuropathy and a history of ulceration. PLoS ONE 2015;10:e0117443.  Back to cited text no. 3
Wrobel JS, Najafi B Diabetic foot biomechanics and gait dysfunction. J Diabetes Sci Technol 2010;4:833-45.  Back to cited text no. 4
Weijers RE, Walenkamp GHIM, van Mameren H, Kessels AGH The relationship of the position of the metatarsal heads and peak plantar pressure. Foot Ankle Int 2003;24:349-53.  Back to cited text no. 5
Standards of medical care in diabetes-2016: Summary of revisions. Diabetes Care2016;39:S4-5.  Back to cited text no. 6
Boulton AJM, Armstrong DG, Albert SF, Frykberg RG, Hellman R, Kirkman MS, et al. Comprehensive foot examination and risk assessment. Diabetes Care 2008;31:1679-85.  Back to cited text no. 7
Ramsey SD, Newton K, Blough D, McCulloch DK, Sandhu N, Reiber GE, et al. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care 1999;22:382-7.  Back to cited text no. 8
Yarnitzky G, Yizhar Z, Gefen A Real-time subject-specific monitoring of internal deformations and stresses in the soft tissues of the foot: A new approach in gait analysis. J Biomech 2006;39:2673-89.  Back to cited text no. 9
Atlas E, Yizhar Z, Khamis S, Slomka N, Hayek S, Gefen A Utilization of the foot load monitor for evaluating deep plantar tissue stresses in patients with diabetes: Proof-of-concept studies. Gait Posture. 2009;29:377-82.  Back to cited text no. 10
Jan YK, Lung CW, Cuaderes E, Rong D, Boyce K Effect of viscoelastic properties of plantar soft tissues on plantar pressures at the first metatarsal head in diabetics with peripheral neuropathy. Physiol Meas 2013;34:53-66.  Back to cited text no. 11
Fernando DJ, Masson EA, Veves A, Boulton AJ Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration. Diabetes Care 1991;14:8-11.  Back to cited text no. 12
Gooding GA, Stess RM, Graf PM, Moss KM, Louie KS, Grunfeld C Sonography of the sole of the foot. Evidence for loss of foot pad thickness in diabetes and its relationship to ulceration of the foot. Invest Radiol 1986;21:45-8.  Back to cited text no. 13
Payne C, Turner D, Miller K Determinants of plantar pressures in the diabetic foot. J Diabetes Complications 2002;16:277-83.  Back to cited text no. 14
Hotfiel T, Carl HD, Wendler F, Jendrissek A, Heiß R, Swoboda B Plantar pressures increase with raising body weight: A standardised approach with paired sample using neutral shoes. J Back Musculoskelet Rehabil 2017;30:583-9.  Back to cited text no. 15
Martínez-Nova A, Huerta JP, Sánchez-Rodríguez R Cadence, age, and weight as determinants of forefoot plantar pressures using the biofoot in-shoe system. J Am Podiatr Med Assoc 2008;98:302-10.  Back to cited text no. 16
Orendurff MS, Rohr ES, Sangeorzan BJ, Weaver K, Czerniecki JM An equinus deformity of the ankle accounts for only a small amount of the increased forefoot plantar pressure in patients with diabetes. J Bone Joint Surg Br 2006;88-B:65-8.  Back to cited text no. 17
Jeffcoate WJ, Bus SA, Game FL, Hinchliffe RJ, Price PE, Schaper NC Reporting standards of studies and papers on the prevention and management of foot ulcers in diabetes: Required details and markers of good quality. Lancet Diabetes Endocrinol 2016;4:781-8.  Back to cited text no. 18
Halawa MR, Eid YM, El-Hilaly RA, Abdelsalam MM, Amer AH Relationship of planter pressure and glycemic control in type 2 diabetic patients with and without neuropathy. Diabetes Metab Syndr Clin Res Rev 2018;12:99-104.  Back to cited text no. 19
Fernando M, Crowther R, Lazzarini P, Sangla K, Cunningham M, Buttner P, et al. Biomechanical characteristics of peripheral diabetic neuropathy: A systematic review and meta-analysis of findings from the gait cycle, muscle activity and dynamic barefoot plantar pressure. Clin Biomech Bristol Avon 2013;28: 831-45.  Back to cited text no. 20
Stess RM, Jensen SR, Mirmiran R The role of dynamic plantar pressures in diabetic foot ulcers. Diabetes Care 1997;20:855-8.  Back to cited text no. 21
Frykberg RG, Lavery LA, Pham H, Harvey C, Harkless L, Veves A Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care 1998;21:1714-9.  Back to cited text no. 22
Grieve DW, Rashdi T Pressures under normal feet in standing and walking as measured by foil pedobarography. Ann Rheum Dis 1984;43:816-8.  Back to cited text no. 23
Cavanagh PR, Rodgers MM, Liboshi A Pressure distribution under symptom-free feet during barefoot standing. Foot Ankle 1987;7:262-78.  Back to cited text no. 24
MacWilliams BA, Armstrong PF Clinical applications of plantar pressure measurement in pediatric orthopedics. Pediatric Gait: A New Millennium in Clinical Care and Motion Analysis Technology. Chicago, IL: IEEE; 2000.  Back to cited text no. 25
Armstrong DG, Lavery LA Diabetic foot ulcers: Prevention, diagnosis and classification. Am Fam Physician 1998;57:1325-32, 1337.  Back to cited text no. 26


  [Table 1], [Table 2], [Table 3], [Table 4]


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