Chapter 1 Introduction

1. Background

Kinetics is the branch of classical mechanics, concerned with the relationship

between the motion of bodies and the forces acting upon them. Kinematics refers to the

branch of classical mechanics describing the motion of points, objects, and system of

bodies without consideration of the causes of motion (force). The study of Kinetics and

Kinematics in a biological system (body) refers to Biomechanics. Precisely, the term

Biomechanics is defined as the “study of the mechanics of the movement of the living

organism”(Collins English Dictionary). In the human body, the kinetic variables

comprise of the joint forces, muscular forces, ground reaction force, plantar pressure,

joint moment, the force of gravity, etc. On the other hand, Kinematic variables include a

joint range of motion, joint velocity, joint acceleration, spatiotemporal parameters of

gait, joint power, etc. The present study deals with lower limb kinematics and kinetics

mainly at the foot, ankle, and the knee joint.

1.1 Overview of Diabetes Mellitus and Diabetes Peripheral Neuropathy

“Diabetes mellitus (DM) is a metabolic disorder characterized by hyperglycemia,

which results from defects in insulin secretion, insulin action, or both- IDF Atlas 2015”

(Ogurtsova et al.2017). Deficiency in insulin leads to chronic hyperglycemia with

disturbances of protein, carbohydrate, and fat metabolism (ADA 2014). Type 2 Diabetes

Mellitus (T2DM) is the most common form of diabetes affecting 85-90% of the

population with diabetes Mellitus (Ogurtsova et al. 2017). It leads to multiple numbers of

microvascular and macrovascular complications. Among all the complications, Diabetes

Peripheral Neuropathy (DPN) is the most common and devitalizing microvascular

complication defined as the “presence of peripheral nerve dysfunction in people with

diabetes after exclusion of other causes” (Bansal et al. 2014).

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1.2 Epidemiology-Type 2 Diabetes Mellitus and Diabetes Peripheral Neuropathy

The prevalence of the disease is high both globally and nationally. According to

the data obtained from the International Diabetes Federation Atlas (2015), the estimated

global prevalence of Type 2 DM among men and women was 215.2 million and 199.5

million respectively in the year 2015. It is expected that the figures will incline to 328.4

million men and 313.3 million women suffering from the disease by the year 2040. The

data also reported a national prevalence of 78.3 million at present which is expected to

rise to 140.2 million by 2040. The present trend indicates that Asia will hold the 60% of

the world‟s diabetes mellitus population, and China to be the first country among the top

10 countries with India holding the second position. Adding to the increasing prevalence

rate in India, the data from IDF Atlas 2017 suggests that the number is expected to reach

151 million in 2045 from 82 million in 2017. India may correctly be known as the

“Diabetic Capital” with the potential epidemic and tremendous increase in the number of

sufferers (Kaveeshkar & Cornwall 2014).

Considering the prevalence of DPN, national and global prevalence report is

similar in the range of 26-32 % among Type 2 DM. The study done by Gill et al. (2014)

reported a national prevalence rate of 26.2% whereas D‟souza et al. (2015) reported a

rate of 32.2 %. The unpublished data from our center has reported a higher prevalence of

33-49% (n= 100000). The higher prevalence rate has lead to greater social and economic

burden. For instance, it has been proposed that diabetes could be the 7th leading cause of

mortality by 2030 (IDF Atlas 2015). Apart from health, the economic burden of the

disease is also significant regarding treatment cost, productivity loss, and disability (IDF

Atlas 2017).

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1.3 Foot Complications in Diabetes - Diabetic Foot Syndrome

Foot complications are the most ignored part of diabetes management in Indian

settings. Thus microvascular and musculoskeletal foot complications need to be

addressed well. It is well known that DPN is one the most common complications of

diabetes that account for significant morbidity in terms foot ulceration and amputation

(Sawacha et al. 2009). The number of diabetic foot amputations is huge with at least one

amputation per 30 seconds around the world (Papanas & Maltezos 2009). All

complications of the foot due to diabetes were previously described under the term

„Diabetic Foot.' In the recent past, the term Diabetic Foot has been replaced with

“Diabetic Foot Syndrome”. Diabetic Foot Syndrome (DFS) as defined by the World

Health Organization, is an “ulceration of the foot (distally from the ankle and including

the ankle) associated with neuropathy and different grades of ischemia and infection”.

(Tuttolomondo, Maida, & Pinto 2015). In better words, DFS could be considered as a

clinical triad of neurological, vascular and musculoskeletal changes in a foot of diabetes

mellitus individuals. Therefore, foot complications in diabetes are combined dysfunction

of the nervous system, musculoskeletal system, vascular changes, dermopathy and

autonomic changes; and we shall discuss these complications accordingly. The

neuropathic foot complication is the most common clinical presentation of diabetic foot

syndrome. It includes both sensory and motor neuropathy. The sensory deficit leads to

common foot complications like altered sensations (tingling, burning, pricking,

hypoesthesia, allodynia), etc. The sensory deficit could be manifested with the loss of

protective sensation initially (touch and temperature) and progression to damage to large

diameter sensory fibers (vibration loss) (Dyck et al. 2013). The motor neuropathy

presents as weakness and atrophy of intrinsic and extrinsic foot muscles as well as

proximal muscles of thigh like quadriceps. Studies have shown that one of the most

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common reasons for the loss of muscle strength among DPN was Diabetes Muscle

Infarction (DMI).A study has reported ischemic infarction of thigh muscles (vastus

lateralis, thigh adductors, and biceps femoris) (Chawla 2011).The musculoskeletal

changes lead to common foot deformities like claw toes, hammer toes, equines, changes

in foot arch, charcoat foot, tightness of plantar aponeurosis, tightness of foot and lower

limb muscles, etc. The primary changes in the musculoskeletal structures could be

attributed to secondary changes in joint structure and function like the decreased range of

motion (Kwon et al. 2009). The vascular changes are often seen as reduced blood supply

to peripheral microvasculature of foot. Vascular insufficiency may be clinically

manifested by the altered ankle-brachial index (ABI), blackish discoloration of the foot,

altered temperature of the foot. Autonomic neuropathy and dermatological changes are

the most common manifestation that accounts for 47.5-91.2 % of people with type 2

diabetes mellitus (Verotti et al. 2014). Dry skin is the first and most commonly seen

autonomic change. It could be seen as a result of uncontrolled blood glucose levels

which can alter the blood flow to the skin as well as damage blood vessels and nerves.

Decreased blood circulation can lead to changes in the skin collagen altering its texture,

appearance, and ability to heal. As a result, the skin‟s endothelial cells get damaged, and

this may even reduce its ability to sweat which leads to dry skin, fissure and callus

formation as well as a decrease in the ability to sense temperature and pressure

(Petrofsky et al. 2012).

In the presence of these combined changes, the increase in plantar pressure and

repetitive microtrauma could ultimately cause a diabetic foot ulcer. The ulcers may

progress to gangrene leading to amputation (Hazari et al. 2016). Loss of protective

sensation may impose the foot into very high load plantar pressure which is found to be

the most important factor for foot ulceration among diabetes population (Bacarin et al.

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2009). The result was supported by another study which concluded 57% higher risk for

ulceration at high-pressure points (Murray et al. 1996). The study also reported a high

association of callus and fissures points with foot ulceration (Murray et al. 1996). In the

context of the most prominent area of foot ulcers in diabetes, the previous studies have

reported that forefoot was the most vulnerable area for higher plantar pressure during late

stance phase and thus prone to the greater risk of ulcer in the presence of DPN. Also, the

individual areas of foot like hallux, metatarsal heads, midfoot and heel were positively

associated with the peak plantar pressure and incidence of foot ulcers (Ledoux et al.

2013). Also, it was found that the ratio of peak plantar pressure between the forefoot and

hindfoot is increased among DPN (Caselli et al. 2002).

1.4 Epidemiology of Foot Complications in Type 2 Diabetes Mellitus

The previous studies have suggested that 15 % of T2DM participants develop at

least a single or a combination of foot complication in their lifetime (Singh et al. 2005).

In developed countries like UK and US prevalence of 5-7 % diabetic foot ulcers has been

suggested (Sriyani et al. 2013). The prevalence of foot complication in North India was

found to be higher with 14 % having foot ulcers and 70.10 % and 29.9 % population

living in rural and urban areas respectively (Shahi et al. 2012). Another study concluded

that overall prevalence of diabetic foot complication was 3.3 % (Al-Rubeaan et al. 2015).

The study also reported a prevalence of 2.05%, 0.19% and 1.06% for foot ulcer,

gangrene, and amputation respectively (Al-Rubeaan et al. 2015). Studies have also

suggested that Diabetic Foot Syndrome and its complications are more predominately

seen in male patients. The study done by Al-Rubeaan et al. (2015) reported that the risk

factors like Charcot's joints, peripheral vascular disease, neuropathy, diabetes duration≥

10 years, insulin use, retinopathy, nephropathy, age≥45 years, cerebral vascular disease,

poor glycemic control, coronary artery disease, smoking, and hypertension was strongly

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Chapter 1 Introduction
associated with diabetic foot complications.However, there is a lack of research and data

on diabetic foot profile, its risk factors and biomechanical analysis (Foot Kinetics and

Kinematics) among the Indian population.

1.5 Elevated plantar pressure as risk factors for foot complications

It is well documented that plantar pressure in diabetes population is higher which

could increase the chances of tissue breakdown causing foot problems (Payney et al.

2002). High plantar pressure is the most important etiological factor for foot

complications in diabetes mellitus (Sawacha et al. 2012), (Yazdanpanah et al. 2015).

Higher plantar pressure may be applied with higher loading over a small bony area

during static and dynamic gait cycle (Young et al. 1993).Therefore, plantar pressure

should be considered as a strong predictor for determining the occurrence of diabetic foot

ulcers. Also, a strong correlation has been reported between the peak plantar pressure

and site of ulcer (Waaijman et al. 2012).A number of factors has also been identified

which interact to alter the plantar pressure in diabetes. The comparison of body weight

and plantar pressure has been an area of interest as seen in the previous studies.

Unfortunately, the results have shown variability. Few studies (Menz & Morris 2006),

(Hills et al. 2001) showed a strong relationship between plantar pressure and body

weight whereas studies like (Birtane & Tuna 2004) showed no significant correlation.

The other important factor for causing altered plantar pressure could be foot deformities

(Bus 2008a). Callus formation and prominent metatarsal heads followed by clawing and

hammer toe deformities should be considered as the most important risk factors (Bus

2008a).Hallux valgus and limited joint mobility could also be a significant contributing

risk factor (Bus 2008a). Foot deformities may result from motor neuropathy causing

intrinsic and extrinsic muscular force imbalance (Levin & O'Neal 1988). However, tissue

breakdown down in diabetes mellitus has been observed even in the absence of

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neuropathy (Veves et al. 1992).Therefore, it is evident that a biomechanical factor like

foot deformity interacting with other kinetic and kinematic variable could be a source of

ulcer prediction and prevention in people with type 2 diabetes mellitus.

1.6 Biomechanics of Foot and Ankle joint

The foot and ankle are a complex structure of 28 bones, 33 joints, 112 ligaments,

surrounded by 13 extrinsic and 21 intrinsic muscles.It is characterized as a triaxial joint

with talus as the center of rotation whereas the ankle joint, also known as the „Talocrural

joint‟ (hinge type) and the subtalar joint (Condyloid type) forms the main joints for

movement. The axis of rotation for ankle joint is oblique, placed 13°-18° laterally from

the frontal plane and 8°-10° from the transverse plane (Houglum & Bertoti 2011).

Therefore, the motion predominately occurs in the sagittal plane as dorsiflexion (0°-30°)

and plantarflexion (0°-55°). The other major movements at foot are supination,

pronation, inversion, and eversion taking place at the subtalar joint. For such a motion,

the axis of rotation is reported at 42° superior to the sagittal plane and 16°-23° medial to

the transverse plane. Therefore a normal pronation range of 0°-5° and supination range

of 0°-20° has been reported by previous researchers (Stagni et al. 2003). The normal

inversion range of 0°-30° and eversion range of 0°-18° have been suggested (Ball &

Johnson 1996). A normal range of 1-6° is observed at the 1st Tarso-metatarsal (TMT)

Joint. Similarly, a range of 0.6°,3.5°,9.6°, and 10.2° has normally been demonstrated at

2nd,3rd,4th, and 5th TMT joint respectively (Lundburg et al. 1989).

1.7 Biomechanics of Knee Joint

Knee joint biomechanics comprises of two major joints namely tibiofemoral and

patellofemoral joint. The tibiofemoral joint is a hinge type of joint with the predominant

sagittal plane of motion referred to as flexion and extension of the knee (0°-150°).The

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patellofemoral joint forms the extensor mechanism stabilized by the surrounding

capsular ligaments.

1.8 Foot Kinetics and Kinematics

The kinetics and kinematic of foot are an important part of biomechanical

assessment. The kinetic variables like average and maximum plantar pressure should be

assessed clinically to prevent future foot complications (Sawacha et al. 2012). The

kinematic variables like joint angle, velocity and acceleration have been shown to alter

significantly among participants with diabetes mellitus (Fernando et al. 2013).

1.9 Etiopathogenesis of Diabetic Foot Syndrome

The diabetic foot complications do not start spontaneously. Some physiological

changes and interactions take place before the Diabetic Foot Syndrome develops. As

mentioned in the previous studies, the ultimate threat to a diabetic foot syndrome is

ulceration and amputation. Their etiopathogenesis could be traced to the factors causing

the ulcers.In other words, a diabetic foot ulcer could be neuropathic and ischemic in

origin or their combination. In either case, the biomechanical factors play a very

important role in prevention, promote healing and proper management. Thus an

interaction of neuropathy, vascular insufficiency, and musculoskeletal changes may be

considered as the most suitable pathological process in the development of foot

complications and ulcers in type 2 diabetes mellitus. A flowchart has been presented

below to understand these factors and their association in determining the etiopathogenesis

for diabetic foot syndrome.

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Chapter 1 Introduction

Type 2 Diabetes Mellitus

Sensory Motor Altered Foot Autonomic Vascular

Neuropathy Neuropathy Biomechanics Neuropathy Changes

Reduced Reduction in Reduced Impaired

Altered Muscular Sweating, Blood
Touch, Pain Strength, Texture Flow
Temperature Mass and Change
Vibration and Flexibility
Proprioception
Sense

Altered Joint and

Muscular Forces Dryness of
Repititive Skin
Microtrauma Foot
Deformities

High Callus
Plantar Pressure and Fissures

Foot complication
Foot ulcer

Fig. 1.1. Etiopathological pathway for development of foot ulcers in Type 2 DM.

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Chapter 1 Introduction

The above flowchart demonstrates that neuropathy, vascular system,

biomechanical and musculoskeletal changes are the major etiological pathway for

causing a diabetic foot ulcer. In a neuropathy mechanism, the loss of protective

sensation may predispose the foot to a higher risk of complications and ulcers directly or

with an increased plantar pressure. Motor neuropathy could further add to muscular and

structural changes which ultimately leads to shedding of plantar tissues with excessive

and repetitive external stress. The plantar tissue and skin layers(epidermis, dermis and

subcutaneous tissues) act like a mechanical protective layer which may get disrupted by

the excessive plantar loading and abrupt ground reaction forces. Dryness of skin due to

autonomic changes could lead to the formation of callus on the higher pressure,

prominent bony areas followed by hardening of the plantar tissue and excessive

keratinization (Simandl & Porth 1990). Due to repetitive stress on walking, the

hypertrophy of the stratum corneum could increase the proliferation of epidermal cells

converting callus to corns (Murray et al. 1996). Due to increased hardness and density of

the skin, further plantar pressure may cause corns to open and cause a neuropathic foot

ulcer (Reiber et al. 1998), (Boulton 2000; 2013). Neuropathic ulcers have a rounded

shape, seen in the middle of the callus breakdown, more common in people with type 2

diabetes mellitus with a prevalence of 70% (Oyibo et al. 2001b).

Vascular changes lead to ischemic ulcers which are different from the

neuropathic ulcers. Ischemia is a complication of peripheral vascular disease and defined

as “insufficient supply of blood to an organ, usually due to a blocked artery” (Stadler et

al. 2006). Narrowing of blood vessels in the lower limb of type 2 diabetes mellitus

individuals may lead to ischemia and ischemic ulcers. Due to ischemia, the skin becomes

very delicate and susceptible to break open (Oyibo et al. 2001b). Ischemic ulcers can

occur at any part of the foot due to capillary closure and breakdown of the skin
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Chapter 1 Introduction
characterized by the irregular shape and color (Oyibo et al. 2001b). Biomechanical

parameters and musculoskeletal changes play an important role either of the above

mechanism of diabetic foot ulcers. A kinetic variable like high plantar pressure may be

not perceived adequetly due to neuropathy, or a higher plantar pressure may further

dampen the blood flow. Through this study, we would like to draw attention towards the

various musculoskeletal changes, biomechanical parameters, kinetics and kinematics of

foot as potential and standing etiological factor in determining the presence and

progression of diabetic foot syndrome.

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