Re: June, 2010 Article ■ I READ WITH INTEREST THE CASE STUDY PRESENTED BY Dr. DaNCHIK ON THE DIABETIC PATIENT WITH PERIPHERAL NEUROPATHY, FOOT PRONA-TION, AND CAI.CANEAI. EVERSION BILATERALLY. As A CHIROPRACTIC PHYSICIAN AND BOARD CERTIFIED PEDORTHIST, 1 MUST URGE EXTREME CAITION TO ALL OK MY FELLOW DOCTORS CONCERNING TREATING DIABETIC PATIENTS WITH ORTHOTICS. I have been the pedorthist for a local hospital wound clinic for over 5 years and I have seen many cases where improper foot care has led to ulceration down to the bone and foot amputations. When giving orthotics to better the gait of a diabetic person or correct a biomechanical abnormality, you joined the ranks of all the doctors treating the diabetic condition. I carry additional malpractice insurance as a pedorthist, and have had my clinic certified by the American Board of Certification to qualify for Medicare. In the case mentioned in the article, it appears to me that there is a torsional dysfunction between the hindfoot and the midfoot. If the person is in midfoot pronation and hindfoot eversion, there is a moment created at the navicular bone with every step. If the person is a typical diabetic and overweight, the condition is exacerbated by the additional weight. The patient probably has an ulcer developing at the plantar area of the navicular bone, even if it is not visible yet. It is critical that the area be off-loaded from the bottom of the orthotic and the orthotic must be made from a form with the patient in sub-talar neutral. It is good that proper shoe size was mentioned to the patient, but in addition, the doctor must be certain that the orthotic is sitting in a totally flat position in the shoe so the interface between the foot and the orthotic is maintained. Shoes which are the right size may not be the right size with an orthotic inside. The shoes that I offer in my clinic are "extradepth" to accommodate both the foot and orthotic. Also, some patients have feet which are of different sizes and shoe selection must be taken into consideration again. I have seen a foot which looks perfectly normal require a below-the-knee amputation in 6 weeks. Sincerely, Westeron Stephens 111. M.S.. D.C.. C. Ped Elgin, IL
