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VOLUME 7, ISSUE 1 

 2024 
 

RESEARCH ARTICLE 

 

Nouman M, Apiputhanayut R, Narungsri T, Tipchatyotin S, Dissaneewate T. Comparative analysis of three types of therapeutic offloading diabetic shoes with 

custom made insole on plantar pressure distribution in severe diabetic Charcot foot. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.3. 

https://doi.org/10.33137/cpoj.v7i1.41780 

 

https://jps.library.utoronto.ca/index.php/cpoj/index
mailto:cpoj@online-publication.com
https://publicationethics.org/about/our-organisation
https://publicationethics.org/members/canadian-prosthetics-orthotics-journal
https://doi.org/10.33137/cpoj.v7i1.41780


 

1 

Nouman M, Apiputhanayut R, Narungsri T, Tipchatyotin S, Dissaneewate T. Comparative analysis of three types of therapeutic offloading diabetic shoes with 
custom made insole on plantar pressure distribution in severe diabetic Charcot foot. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v7i1.41780 

 

 

RESEARCH ARTICLE 

 

COMPARATIVE ANALYSIS OF THREE TYPES OF THERAPEUTIC OFFLOADING 

DIABETIC SHOES WITH CUSTOM MADE INSOLE ON PLANTAR PRESSURE 

DISTRIBUTION IN SEVERE DIABETIC CHARCOT FOOT 

Nouman M1, Apiputhanayut R2, Narungsri T3, Tipchatyotin S2, Dissaneewate T2 

1  Sirindhorn School of Prosthetics and Orthotics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand. 
2  Department of Rehabilitation Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand. 
3  Prosthetics and Orthotics Unit, Department of Rehabilitation Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand. 

 

  

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

INTRODUCTION   

Charcot neuropathic osteoarthropathy, also known as 

Charcot foot, is a serious complication that can result from 

any disorder associated with sensory or autonomic 

neuropathy. This complication leads to bone destruction, 

deformities, and ulcerations  that can  lead to amputation if  

 

 

 

left untreated promptly and properly.1 Charcot foot is a 

major cause of morbidity and mortality in people with 

diabetes, with a 5-year mortality rate of 29% for those with 

Charcot foot alone and up to 56.6% for those who have 

undergone major amputations.2 Early diagnosis and 

treatment are crucial in preventing the progression of 

Charcot foot and minimizing the risk of complications. 

Charcot foot progresses through four stages: stage 0, 

characterized by asymptomatic or nonspecific symptoms 

and normal radiographs; stage 1, characterized by 

inflammation, swelling, and bone fragmentation visible on 

 
OPEN  ACCESS 

ABSTRACT 

BACKGROUND: Charcot foot deformity, a severe complication of diabetes, involves neuropathy and 

abnormal peak plantar pressure in the midfoot and forefoot. However, orthotic interventions and shoe 

modifications are used to address the sequelae of Charcot neuroarthropathy, offering different 

approaches to managing abnormal peak plantar pressure. 

OBJECTIVE: To compare the effects of three types of therapeutic offloading diabetic shoes; 

prefabricated, relasting, and double rocker-modified shoes on peak plantar pressure in the midfoot and 

forefoot of nonulcerated chronic Charcot foot during walking. 

METHODOLOGY: A repeated measure design involved 15 participants (40% males and 60% females) 

with a mean age of 60.73 years (SD=10.50), with Charcot neuropathy. Participants were provided with 

three types of shoes; prefabricated, relasting, and double rocker-modified shoes, each equipped with the 

same custom-made insole (CMI). Plantar pressure was recorded while walking on level ground, focusing 

on the forefoot, midfoot, and hindfoot. The study also investigated additional variables affecting plantar 

pressure distribution, including the pressure-time integral and contact area. 

FINDINGS: The type of shoe had distinct effects on the distribution of plantar pressure. The double 

rocker-modified shoe particularly impacted forefoot pressure during the terminal stance phase of the gait 

cycle. Peak plantar pressure at the forefoot increased by 5.37% with double rocker-modified shoes 

compared to relasting shoes. Both double rocker-modified and prefabricated shoes reduced midfoot 

peak plantar pressure by 8.73% and 11.97%, respectively. Similar trends were observed at the hindfoot, 

with reductions in peak plantar pressure. However, there were no significant differences in regional peak 

plantar pressure between the types of shoes except for the central forefoot (F (1.61, 22.5) = 5.69, 

p = 0.014). 

CONCLUSION: There were no significant differences in the effectiveness of prefabricated, relasting, and 

double rocker-modified shoes in reducing and redistributing peak plantar pressure in high-risk areas of 

chronic Charcot foot. 

ARTICLE INFO 

Received: September 25, 2023 

Accepted: July 30, 2024 

Published: August 17, 2024 
 

CITATION 

Nouman M, Apiputhanayut R, 

Narungsri T, Tipchatyotin S, 

Dissaneewate T. Comparative 

analysis of three types of 

therapeutic offloading diabetic 

shoes with custom made insole 

on plantar pressure distribution in 

severe diabetic Charcot foot. 

Canadian Prosthetics & Orthotics 

Journal. 2024; Volume 7, Issue 1, 

No.3. 

https://doi.org/10.33137/cpoj.v7i

1.41780 

KEYWORDS 

Neuroarthropathy, Therapeutic 

Shoe, Charcot Foot, Diabetic 

Foot, Plantar Pressure, Custom 

Made Insole, Orthotics, Orthosis, 

Gait 

 

 

* CORRESPONDING AUTHOR: 

Tulaya Dissaneewate, 

Department of Rehabilitation Medicine, Faculty of Medicine, Prince of 
Songkla University, Hatyai, Songkhla, Thailand. 

E-mail: tulaya.p@psu.ac.th 

ORCID ID: https://orcid.org/0000-0003-2947-0375 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

Volume 7, Issue 1, Article No.3. 2024 

 

 

https://doi.org/10.33137/cpoj.v7i1.41780
https://doi.org/10.33137/cpoj.v7i1.41780
https://doi.org/10.33137/cpoj.v7i1.41780
mailto:tulaya.p@psu.ac.th
https://jps.library.utoronto.ca/index.php/cpoj/index


 

2 

Nouman M, Apiputhanayut R, Narungsri T, Tipchatyotin S, Dissaneewate T. Comparative analysis of three types of therapeutic offloading diabetic shoes with 
custom made insole on plantar pressure distribution in severe diabetic Charcot foot. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v7i1.41780 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X COMPARATIVE ANALYSIS OF OFFLOADING DIABETIC SHOES FOR CHARCOT FOOT 

Nouman et.al, 2024 

radiographs; stage 2, features decreasing inflammation and 

evidence of healing on radiographs.; and stage 3, noted for 

reduced swelling, joint stabilization, and new bone 

formation on radiographs.  Each stage needs customized 

treatment approaches, emphasizing the importance of early 

recognition and appropriate management to prevent 

progression and complications.3,4 Treatment may involve 

immobilization, proper offloading devices, wound care, and 

surgery to repair or stabilize the affected foot.2,5  

According to the 2017 Global Burden of Disease Research, 

the cost of caring for diabetic foot diseases and their 

complications in the United States was estimated to be 

around $237 billion.2 At present, there is no offloading 

device guideline for chronic Charcot foot without plantar 

ulcer. Proper therapeutic footwear is recommended to 

remove high pressure sites and in severe cases it also 

promotes the healing process for Charcot foot with ulcer.6,7  

To prevent chronic Charcot foot ulceration, it is important to 

address gait dysfunction and biomechanical abnormalities 

that are common in people with diabetic neuropathic foot. 

These abnormalities often include an increase in the 

distribution of plantar pressure in sensitive areas. Notably, 

maintaining plantar pressure below the critical physiological 

skin tolerance level generally acknowledged to be less than 

200 kPa to reduce the risk of developing foot ulceration and 

re-ulceration.8 The peak plantar pressure in Charcot foot 

mainly occurs in the midfoot area and redistribution of 

plantar foot pressure is considered the main method to 

reduce it. The footwear designs for redistributing midfoot 

peak plantar pressure are offloading pads, double rocker 

profile, proper shoe fitness, ankle-high, and knee-high 

offloading devices.9,10  

Double rocker modification of diabetic shoes uses the 

rocker-shaped sole in the shoe to help redistribute plantar 

pressure. There was a suggestion that the double rocker 

modification may be effective in offloading the peak plantar 

pressure at the deformed midfoot area in people with 

chronic Charcot foot.8,11 Currently, there is very limited 

literature that focuses on evaluating the effect of double 

rocker modification on the midfoot and forefoot area of 

chronic Charcot foot without plantar ulcer.  

The extra width of the Charcot foot can also be a problem 

for shoe fitting, as it may cause improper foot pressure 

loading during gait. To address this issue, a relasting 

technique may be used to reduce and redistribute peak 

plantar pressure. Relasting shoes are recommended for 

people with foot deformities, arthritis, or other conditions 

that make it difficult to find proper shoes that fit 

comfortably.12 The relasting technique requires reshaping 

the insole, outsole and heel of the shoe to better match the 

shape and size of the wearer's foot, which involves 

expanding the width of the shoe in the midfoot area to 

provide wider total contact of the plantar surface of the foot 

with the shoe.13,14 However, to the author’s knowledge, there 

is currently no research evaluating the effect of the relasting 

technique on midfoot peak plantar pressure of chronic 

Charcot foot without plantar foot ulcer. It was hypothesized 

that the relasting shoe with a custom-made insole (CMI) 

improves the offloading of the plantar aspect of the midfoot. 

Therefore, the aim of this study was to compare the 

effectiveness of prefabricated, relasting, and double rocker 

modified shoes to reduce and redistribute peak plantar 

pressure in the midfoot and forefoot in chronic Charcot 

without plantar ulcer. The outcome of this study may 

enhance the selection of suitable modified shoes to achieve 

optimal plantar pressure distribution, helping to prevent 

ulceration and re-ulceration in diabetic Charcot 

neuroarthropathy. 

METHODOLOGY 

Study population  

Fifteen patients with Charcot neuroarthropathy were 

recruited from the Rehabilitation outpatient clinic, the 

Prosthetics and Orthotics clinic, the Diabetic clinic, and the 

Songklanagarind hospital inpatient department. 

Demographic characteristics including gender, body weight, 

height, shoe size, duration of diabetes, glycemic level, and 

foot-related problems were collected.  

The type of foot was determined with the Foot Posture Index 

(FPI-6) by a clinician.  FPI-6 is a clinical tool used to 

evaluate standing foot posture that provides a quantifiable 

measure, allowing clinicians to categorize foot types as 

supinated, neutral, or pronated. FPI-6 is widely recognized 

in clinical settings due to its reliability and ease of use, 

making it a valuable tool in both diagnostic and treatment 

planning processes for various foot-related conditions.15,16 

This project was approved by the Research Ethics 

Committee (REC.62-421-11-1), Faculty of Medicine, Prince 

of Songkla University. 

The inclusion criteria for all participants were an age range 

18 to 80 years old, unable to feel the 10-gram monofilament, 

and able to walk at least 10 meters without any aid at a self-

selected speed. Participants were excluded if they had an 

active infected plantar foot wound, severe peripheral 

vascular disease, angina, dyspnea, major or minor lower 

limb amputation, and unstable vital signs. All participants 

signed written informed consent forms after understanding 

the whole experimental protocol.    

Sample size determination  

The sample size of 15 was determined to provide 80% 

probability of a clinically meaningful difference detection of 

40 kPa in peak plantar pressure between footwear 

conditions. The standard deviation was set at 50 kPa and 

the alpha level was set at 0.05.17  

https://doi.org/10.33137/cpoj.v7i1.41780


 

3 

Nouman M, Apiputhanayut R, Narungsri T, Tipchatyotin S, Dissaneewate T. Comparative analysis of three types of therapeutic offloading diabetic shoes with 
custom made insole on plantar pressure distribution in severe diabetic Charcot foot. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v7i1.41780 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X COMPARATIVE ANALYSIS OF OFFLOADING DIABETIC SHOES FOR CHARCOT FOOT 

Nouman et.al, 2024 

 

Shoe and custom-made insole fabrication  

A certified orthotist fabricated custom-made insoles (CMI) 

from Nora® 5 mm top layer, Plastazote® 8 mm middle layer, 

and cork 10 mm base layer (Figure 1-A). All patients 

received CMI with three footwear conditions, prefabricated 

shoes, double rocker shoes, and relasting shoes. The 

design of the prefabricated shoes (CDM*: Cordoma 

International Co., Ltd.) are seamless lining with 

microcellular rubber outsole and a synthetic leather quarter. 

A certified orthotist modified the outsole of the prefabricated 

shoes with the addition of 10 mm ethylene vinyl acetate 

(EVA) 30 Shore A and reshaped it to make it a double rocker 

shoe with an angle of 10 degrees. Moreover, relasting 

shoes are fabricated by cutting the middle of the shoes and 

adding polyurethane foam to provide more room for the 

midfoot in the mediolateral direction as shown in Figure 1-B. 

A 5 mm thick layer of anti-slip microcellular rubber with 70 

Shore hardness was added to both double rocker and 

relasting shoes, resisting wearing out and provide high 

stability.   

* CDM is the brand of the prefabricated shoe used in this study. 

 

Evaluation of plantar pressure 

The peak plantar pressure was collected during gait with the 

Pedar-X® system (Novel Inc.; Munich, Germany), following 

the final fitting of the custom-made insole and three types of 

shoes. Data were collected from three gait cycles along a 

10-meter walkway with self-selected speed. Before data 

collection, subjects walked along a 10-meter walkway at 

their comfortable speed to determine their walking speed 

and familiarize themselves with their shoes (Figure 1-C). 

The sensors were placed under CMI and each sensor was 

calibrated according to the guidelines. Novel Multimask 

software (Novel GmbH, Munich, Germany) was used to 

divide the foot area into 3 main regions, namely hindfoot, 

midfoot, and forefoot. The main three regions of the foot 

were divided into the medial hindfoot, lateral hindfoot, 

medial midfoot, lateral midfoot, medial forefoot, central 

forefoot, lateral forefoot, and big toe. Peak plantar pressure, 

pressure-time integral, contact area, and pressure mapping 

during gait were evaluated with three types of shoes. To 

evaluate the impact of shoes on plantar pressure 

distribution, each participant wore three types of shoes with 

the same CMI. 

 

Figure 1: Charcot neuroarthropathic subjects are provided with a custom made insole (A), three types of shoes: prefabricated shoe; double 

rocker shoe, and relasting shoes (B), with the data collected during gait (C) from three main regions of foot as hindfoot, midfoot, forefoot. The 

forefoot is subdivided into four regions as follows: lateral forefoot (LFF), central forefoot (CFF), medial forefoot (MFF) and hallux using masking 

software. The medial and lateral division is performed for the midfoot and the hindfoot (D). 

https://doi.org/10.33137/cpoj.v7i1.41780


 

4 

Nouman M, Apiputhanayut R, Narungsri T, Tipchatyotin S, Dissaneewate T. Comparative analysis of three types of therapeutic offloading diabetic shoes with 
custom made insole on plantar pressure distribution in severe diabetic Charcot foot. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v7i1.41780 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X COMPARATIVE ANALYSIS OF OFFLOADING DIABETIC SHOES FOR CHARCOT FOOT 

Nouman et.al, 2024 

Data analysis 

The data's descriptive statistics were presented as mean 

and standard deviation. Statistical analysis was performed 

using Prism 5.0 (GraphPad Software, San Diego, CA, 

USA). Analyses were conducted on the affected foot. A 

repeated measures ANOVA was used to compare plantar 

pressure and derived parameters among prefabricated, 

double rocker, and relasting shoes to assess the impact of 

shoe modifications. Post hoc comparisons were conducted 

where significant differences were found. Statistical 

significance was set at p<0.05. 

RESULTS 

Participant characteristics  

The participant demographics are shown in Table 1. Fifteen 

Charcot neuroarthropathic patients (6 (40%) males and 9 

(60%) females) were included with a mean age of 60.73 

(SD=10.5) years were included. The mean body mass index 

was 25.13 kg/m2 (SD=2.52). Charcot foot cases 

represented a long duration of diabetes (16.33 years 

(SD=6.05)) related to poor glycemic control, and the serum 

HbA1c level was 7.88% (SD=0.85). The results also 

showed that 66.67% of patients with Charcot arthropathy 

had a history of previous foot problems, such as foot ulcers 

or surgery. Patients with stage 3 Charcot arthropathy in this 

study showed a mean foot posture index (FPI-6) of 6.71 

(SD=1.93). 

Table 1: Demographic data of Charcot neuroarthropathic subjects. 

Parameters  Mean SD 

 Age (y) 60.73 10.50 

Body weight (kg) 78.53 8.29 

Height (m) 1.56 0.04 

BMI (kg/m2) 25.13 2.52 

Shoe size (EU) 40.40 1.25 

Duration of diabetes (y) 16.33 6.05 

Serum HbA1C (% NGSP) 7.88 0.85 

FPI-6 6.71 1.93 

 

Regional peak plantar pressure   

The midfoot showed higher peak plantar pressure with three 

types of shoes compared to the forefoot and hindfoot 

regions of the foot. Moreover, the tendency for the peak 

plantar pressure was higher in the lateral midfoot compared 

to the medial midfoot, as shown in Figure 2. 

 

Figure 2: Peak plantar pressure during gait for three types of shoes—double rocker, prefabricated, and relasting—across different foot regions. 

The data is divided into: (A) Three main regions of the foot; (B) Four forefoot regions; (C) Two midfoot regions; (D) Two hindfoot regions. 

Significant differences are marked with an asterisk (*), indicating a p-value of less than 0.05. 

* 

Double Rocker 
Prefabricated 
Relasting 

Double Rocker 
Prefabricated 
Relasting 

Double Rocker 

Prefabricated 

Relasting 

Double Rocker 

Prefabricated 

Relasting 

https://doi.org/10.33137/cpoj.v7i1.41780


 

5 

Nouman M, Apiputhanayut R, Narungsri T, Tipchatyotin S, Dissaneewate T. Comparative analysis of three types of therapeutic offloading diabetic shoes with 
custom made insole on plantar pressure distribution in severe diabetic Charcot foot. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v7i1.41780 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X COMPARATIVE ANALYSIS OF OFFLOADING DIABETIC SHOES FOR CHARCOT FOOT 

Nouman et.al, 2024 

The peak plantar pressure at the forefoot increased with 

double rocker-modified shoes compared to relasting shoes. 

Furthermore, the maximum plantar pressure was highest in 

the lateral forefoot with double rocker-modified shoes 

compared to relasting and prefabricated shoes. However, 

the central forefoot and medial forefoot peak plantar 

pressure is reduced with double rocker-modified shoes and 

prefabricated shoes (Table 2). There was no significant 

difference in regional peak plantar pressure among the 

measured variables except for the central forefoot with 

prefabricated and relasting shoes. 

Regional pressure-time integral and contact area 

The pressure-time integral and contact area from three 

regions of the foot are shown in Table 3. The pressure-time 

integral was highest at the midfoot compared to the forefoot 

and hindfoot using three types of shoes. The type of shoe 

has a minimum effect on the regional pressure-time integral.  

The overall contact area among the foot regions increased 

in the forefoot with all types of shoes followed by the midfoot 

and the hindfoot.   

Pressure mapping during gait 

The pressure distribution across different phases of the gait 

cycle with various types of shoes reveals distinct patterns 

(Figure 3). Relasting shoes exhibit reduced pressure from 

initial contact to loading response. Moreover, during 

midstance, a similar trend can be observed with relasting 

and double rocker shoes, but the pressure increased in the 

lateral forefoot with prefabricated shoes. During terminal 

stance, double rocker shoes promote a more centralized 

pressure distribution. Conversely, prefabricated and 

relasting shoes resulted in higher lateral foot pressure. 

 

 

 

Table 2: Regional peak plantar pressure with three types of shoes PF: prefabricated; DR: double rocker and RL: relasting from different 

regions of the foot.  

Foot region 
Shoe type 

comparison  
Mean diff. p-value 

Geisser-
Greenhouse's 

epsilon 
r2 F (DFn, DFd) 

Forefoot 

PF vs. DR -6.60 0.609  

 0.047 

 

RL vs. DR -10.30 0.604 0.818 0.69 (1.64, 22.90)  

RL vs. PF -3.65 0.910   

Toes 
PF vs. DR 10.10 0.254  

0.097  
 

RL vs. DR 0.963 0.991 0.818 1.50 (1.64, 22.90) 

RL vs. PF -9.09 0.219   

Medial forefoot 

PF vs. DR -9.99 0.391  

0.100  

 

RL vs. DR 2.86 0.894 0.860 1.56 (1.72, 24.10)  
RL vs. PF 12.90 0.352   

Central forefoot 

PF vs. DR -5.01 0.745  

0.289  

 

RL vs. DR 25.00 0.077 0.803 5.69 (1.61, 22.50) 

RL vs. PF 30.00 0.036 *   

Lateral forefoot 

PF vs. DR -5.74 0.822  

0.187 

 

RL vs. DR -23.80 0.101 0.961 3.21 (1.92, 26.90)  

RL vs. PF -18.10 0.149   

Midfoot 
PF vs. DR -6.97 0.867  

0.158 
 

RL vs. DR 19.80 0.154 0.895 2.62 (1.79, 25.00) 

RL vs. PF 26.80 0.115   

Medial midfoot 

PF vs. DR -10.60 0.707  

0.197 

 

RL vs. DR 25.40 0.161 0.930 3.44 (1.86, 26.00) 
RL vs. PF 36.00 0.095   

Lateral midfoot 

PF vs. DR -1.09 0.995  

0.116 

 

RL vs. DR 17.60 0.296 0.945 1.83 (1.89, 26.50) 

RL vs. PF 18.70 0.162   

Hind foot 

PF vs. DR -16.50 0.666  

0.099 

 

RL vs. DR 11.10 0.564 0.748 1.55 (1.50, 21.00)  

RL vs. PF 27.60 0.253   

Medial hindfoot 

PF vs. DR -1.74 0.990  

0.014 

 

RL vs. DR 5.91 0.687 0.665 0.21 (1.33, 18.60) 

RL vs. PF 7.65 0.873   

Lateral hindfoot 
PF vs. DR -16.40 0.580  

0.133 
 

RL vs. DR 13.00 0.577 0.919 2.16 (1.84, 25.70)  

RL vs. PF 29.40 0.107   
 

https://doi.org/10.33137/cpoj.v7i1.41780


 

6 

Nouman M, Apiputhanayut R, Narungsri T, Tipchatyotin S, Dissaneewate T. Comparative analysis of three types of therapeutic offloading diabetic shoes with 
custom made insole on plantar pressure distribution in severe diabetic Charcot foot. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v7i1.41780 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X COMPARATIVE ANALYSIS OF OFFLOADING DIABETIC SHOES FOR CHARCOT FOOT 

Nouman et.al, 2024 

 

Table 3: Pressure-time integral and contact area with three types of shoes from three main regions of the foot during gait. 

Foot region 
Shoe type 

comparison  

Mean 

diff. 
p-value 

Geisser-Greenhouse's 

epsilon 
r2 F (DFn, DFd) 

Pressure-time integral     

Forefoot 

PF vs. DR -6.96 0.301    

RL vs. DR -10.80 0.210 0.866 0.140 2.28 (1.73, 24.30) 

RL vs. PF -3.86 0.698    

Midfoot 

PF vs. DR -2.94 0.919    

RL vs. DR 5.18 0.764 0.947 0.037 0.54 (1.89, 26.50)  

RL vs. PF 8.12 0.634    

Hind foot 

PF vs. DR -9.46 0.493    

RL vs. DR 2.87 0.767 0.678 0.101 1.58(1.36, 19.00) 

RL vs. PF 12.30 0.357    

Contact area      

Forefoot 

PF vs. DR 0.41 0.947     

RL vs. DR -1.43 0.513 0.851 0.089 1.37 (1.70, 23.80) 

RL vs. PF -1.84 0.135    

Midfoot 

PF vs. DR 2.29 0.275    

RL vs. DR -0.94 0.769 0.971 0.159 2.64 (1.94, 27.20) 

RL vs. PF -3.22 0.132    

Hind foot 

PF vs. DR 1.25 0.349    

RL vs. DR 0.62 0.676 0.748 0.099 1.55 (1.50, 21.00) 

RL vs. PF -0.63 0.675    
 

Note: PF: Prefabricated, DR: Double rocker, RL: Relasting 

 

Figure 3: Pressure mapping during gait using double rocker, prefabricated, and relasting shoes. The data is shown for a single 

representative subject and includes: IC – LR: Initial Contact to Loading Response; MST: Midstance; TST – PSW: Terminal Stance to Pre-

Swing. 

https://doi.org/10.33137/cpoj.v7i1.41780


 

7 

Nouman M, Apiputhanayut R, Narungsri T, Tipchatyotin S, Dissaneewate T. Comparative analysis of three types of therapeutic offloading diabetic shoes with 
custom made insole on plantar pressure distribution in severe diabetic Charcot foot. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v7i1.41780 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X COMPARATIVE ANALYSIS OF OFFLOADING DIABETIC SHOES FOR CHARCOT FOOT 

Nouman et.al, 2024 

DISCUSSION 

This study found that relasting shoes increased the peak 

plantar pressure compared to prefabricated shoes and 

double rocker shoes at the central forefoot. However, 

opposite results were found in the lateral forefoot, as 

metatarsal heads are at high risk of ulceration and 

reulceration during gait. The peak plantar pressure was 

consistently less than 200 kPa with the modified shoes with 

custom-made insole at the medial midfoot and lateral 

midfoot, suggesting a potentially lower risk of ulceration in 

the midfoot region. These observations highlight the impact 

of shoe modifications on peak plantar pressure at specific 

regions, offering valuable insights into differential effects of 

various shoe types on foot pressure distribution.  

Although the results did not reach statistical significance, 

they contribute to our understanding of how shoe 

modifications may affect plantar pressure distribution. The 

double rocker and prefabricated shoes demonstrated a 

reduction in peak plantar pressure in the midfoot and central 

forefoot areas compared to relasting shoes. This suggests 

a potential benefit in the offloading high-risk areas, which is 

critical to reduce the risk of ulceration.18  

Shoe modification considering pathological foot 

biomechanics is one of the most common practices in 

normal clinical practice for Charcot neuroarthropathy.19,20 

Shoe modifications, including rocker bottom outsoles, are 

effective in further reducing and redistribute peak plantar 

pressure in various foot complications.21 Rocker shoes 

provide a shorter contact time on heel strike and toe 

release, resulting in instability during gait in Charcot 

neuroarthropathy.22 However, relasting shoes that provide a 

wider mediolateral space for the foot to accommodate 

provide better stability during gait, but resulted in increased 

peak plantar pressure, especially at the forefoot and hallux 

compared to a double rocker shoe.23  

Researchers investigated double rocker shoes in reduction 

of hindfoot and forefoot peak plantar pressure, while 

preventing excessive overloading at the midfoot. During 

gait, shoes with rocker sole peak plantar pressure 

decreased especially in the forefoot regions but increased 

in the midfoot.24 In this study, a similar pattern was observed 

in which there was a decrease in peak plantar pressure in 

both the forefoot and midfoot areas for patients with Charcot 

neuroarthropathy. The findings align with previous research 

that indicates that these areas are particularly vulnerable in 

the Charcot foot due to structural deformities and altered 

gait mechanics.16,25 The elevated pressure in these regions 

highlights the need for targeted interventions to better 

redistribute pressure during walking, particularly in the 

lateral midfoot and central to the medial forefoot.  

 

Reducing peak plantar pressure while considering the 

importance of pressure-time integral to plantar ulceration, 

hence minimizing the combination of plantar pressure and 

the duration for which plantar pressure is applied to tissue, 

may be preferable than evaluating and reducing peak 

plantar pressure alone.26 In this study, shoe modification 

impacts both peak plantar pressure and pressure-time 

integral outcomes in the forefoot and midfoot regions. 

Furthermore, the contact area in different foot regions did 

not show statistically significant differences. This suggests 

that the choice of shoe type with CMI may not significantly 

affect the contact area in specific foot regions.27     

There were several limitations while investigating the 

plantar pressure distribution among three types of 

therapeutic designs with CMI. The barefoot data was not 

included in this study due to the severity and potential to 

harm the plantar soft tissue during gait. The width dimension 

of the sensor insole could affect the accuracy of plantar 

pressure, especially in the midfoot, in Charcot 

neuroarthropathy. Only one type of rocker shoe was 

compared; however, other designs might be effective for 

populations facing severe foot complications. Further 

studies are required to evaluate the effectiveness of CMI 

and various shoe designs with varying rocker bottom sole 

angle and height on plantar pressure distribution in Charcot 

neuroarthropathy. 

CONCLUSION 

There were nonsignificant trends of pressure distribution 

and offloading in the high-risk areas of the foot using 

different types of shoe with CMI. Prefabricated and double 

rocker shoes showed some effectiveness in reducing peak 

plantar pressure in the midfoot, and central forefoot, 

compared to relasting shoes. However, achieving 

significant offloading in areas of high risk, such as the lateral 

midfoot, remains a challenge, which requires further shoe 

modifications and consideration of the materials and design 

of CMI. These insights are crucial for improving footwear 

interventions for diabetic Charcot neuroarthropathy, with the 

aim of reducing the risk of ulceration while maintaining foot 

functionality.   

ACKNOWLEDGEMENTS 

The authors would like to thank the Faculty of Medicine, Prince of 

Songkla University, for their financial support. We also extend our 

gratitude to the participants for their involvement in this study. 

Special thanks to Miss Phakatip Cheunchoksan for her assistance 

and to the Prosthetic and Orthotic Unit for providing the facilities. 

DECLARATION OF CONFLICTING INTERESTS 

The authors declare no potential conflict of interest. 

 

 

 

https://doi.org/10.33137/cpoj.v7i1.41780


 

8 

Nouman M, Apiputhanayut R, Narungsri T, Tipchatyotin S, Dissaneewate T. Comparative analysis of three types of therapeutic offloading diabetic shoes with 
custom made insole on plantar pressure distribution in severe diabetic Charcot foot. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v7i1.41780 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X COMPARATIVE ANALYSIS OF OFFLOADING DIABETIC SHOES FOR CHARCOT FOOT 

Nouman et.al, 2024 

AUTHORS CONTRIBUTION 

Muhammad Nouman: Conceptualization, design, methodology, 

analysis, reviewing/revising manuscript, data interpretation. 

Ravissada Apiputhanayut: Conceptualization, design, 

methodology, analysis, investigation, writing   original   draft, data   

interpretation, ethic certification application. 

Tuanjit Narungsri: Conceptualization, methodology, 

reviewing/revising manuscript. 

Suttipong Tipchatyotin: Conceptualization, supervision, 

methodology, reviewing/revising manuscript. 

Tulaya Dissaneewate: Conceptualization, supervision, 

methodology, reviewing/revising manuscript, final manuscript 

approval. 

All authors have read and approved the final version of the 

manuscript. 

 

SOURCES OF SUPPORT 

Faculty of Medicine, Prince of Songkla University, Songkhla 

Thailand. 

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https://doi.org/10.33137/cpoj.v7i1.41780 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

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Nouman et.al, 2024 

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