CASE REPORT:
Forefoot Ulcer Treatment using Neuropathic Boot and ShearBan®
Charles Kuffel CPO, FAAOP, President/Clinical Director
Arise Orthotics and Prosthetics, Inc. Minneapolis, MN USA
Patient Demographics:
Name: Mr. X
Age/sex: 58 yrs / Male
Primary Diagnoses: Type II Diabetes with infection and recurrent ulceration
Secondary Diagnoses: Sensory, motor, and autonomic neuropathy
9‐18‐2009 11‐22‐2009
PRESENT Case Overview
The referenced patient is a 58-year old male who was seen in my office on 9-18-2009 for
evaluation of a left forefoot ulcer that had been present for the previous four years. Infection
and recurrent ulceration limited his ability to function in his activities of daily living and he was
relegated to limited ambulation and frequent hospital stays. This patient is a poorly controlled
type II diabetic who presents with sensory, motor and autonomic neuropathy. His left foot is in
a fixed eight degree plantarflexed position and he historically wore off-the-shelf shoes with no
arch supports or accommodative shoe modifications.
Treatment Protocol
Following the initial evaluation, this patient was
cast and fit with a left neuropathic walking boot
which addressed his fixed plantarflexed position
through a heel lift which placed his shank at 90
degrees during stationary standing. The sole was
further modified with a slight hindfoot rocker, a
midfoot rocker terminating just posterior to the
area of concern and a forcepoint forefoot rocker.
The neuropathic boot was fabricated to create a
relief beneath the area of ulceration to limit direct
contact while standing stationary.
Footwear Modifications
Additionally, ShearBan® (Tamarack Habilitation Technologies,
Minneapolis, MN USA) was applied beneath the area of
concern which followed the motion pathway of the ulceration
during ambulation. His contralateral depth inlay shoe was
modified to address his leg length discrepancy caused by the
sole build-up on the neuropathic walking boot and the sole
was modified with appropriate rockers.
The sole modifications allowed for near normal ambulation and
the patient began to increase the time he ambulated. He was
followed three times per week along with his vascular surgeon
for debridement and orthotic modifications. Significant healing
and regranulation of the damaged tissue was observable
within the first week and complete healing was observed five
months after initial evaluation.
Neuropathic boot incorporating ShearBan® Ongoing Management
He is now released from his neuropathic walking boot and
continues to be ulcer free. He is currently being managed in
modified depth inlay shoes and custom accommodative arch
supports. The shoes have been modified to address his left
fixed plantarflexed position with resulting right leg length
discrepancy. ShearBan use has been continued beneath the
area of forefoot concern to reduce shear.
About Charles Kuffel CPO, FAAOP
Charles graduated from the University of Arizona with a degree in Exercise Physiology, emphasis in
biomechanics and kinesiology. He attended Northwestern University in Chicago, Illinois where he
completed his orthotic and prosthetic education. During his orthotic residency in Chicago, he treated
both pediatric and diabetic patients. During his prosthetic residency in Phoenix, Arizona, he treated
both upper and lower extremity prosthetic patients. Charles is an expert faculty member of the
American Academy of Orthotists and Prosthetists (AAOP) where he has spent more than a decade
educating patients, healthcare professionals and fellow practitioners in the utilization of orthotics and
prosthetics. Also, for the past several years, Charles has lectured internationally on behalf of Tamarack
Habilitation Technologies and Becker Orthopedic regarding the management of the neuropathic foot
using thermoplastic technology. Charles currently serves as President-Elect of the Northern Plains
Chapter of AAOP and as Treasurer of the National Commission on Orthotic Prosthetic Education
(NCOPE).
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