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J Diabetes Sci Technol. 2019 Apr 29:1932296819849092. doi: 10.1177/1932296819849092. [Epub ahead of print]

Measuring Plantar Tissue Stress in People With Diabetic Peripheral Neuropathy: A Critical Concept in Diabetic Foot Management.

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1 School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia.
2 Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia.
3 Center for Lower Extremity Ambulatory Research (CLEAR), Dr William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA.
4 Amsterdam UMC, Department of Rehabilitation, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands.
5 Ziekenhuisgroep Twente, Department of Surgery, Almelo and Hengelo, the Netherlands.
6 School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia.
7 Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.
8 College of Podiatry, London, UK.
9 Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.


Excessive stress on plantar tissue over time is one of the leading causes of diabetic foot ulcers among people with diabetic peripheral neuropathy. Plantar tissue stress (PTS) is a concept that attempts to integrate several well-known mechanical factors into one measure, including plantar pressure, shear stress, daily weight-bearing activity, and time spent in prescribed offloading interventions (adherence). Despite international diabetic foot guidelines recommending the measure of each of these individual mechanical factors in people with neuropathy, only recently has technology enabled their combined measurement to determine PTS. In this article we review the concept of PTS, the mechanical factors involved, and the findings of pivotal articles reporting measures of PTS in people with neuropathy. We also discuss key existing gaps in this field, including the lack of standards to measure and report PTS, a lack of practical solutions to measure shear stress, and the lack of PTS thresholds that may indicate benefit or detriment to people with neuropathy. To address some of these gaps, we propose recommended clinical and research standards for measuring and reporting PTS in people with neuropathy. Last, we forecast future clinical, research, and technological advancements that may use PTS to highlight the importance of this critical concept in the prevention and management of diabetic foot ulcers.


activity; adherence; diabetic foot; plantar pressure; plantar tissue stress; shear stress


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