Increased exposure to loading is associated with decreased plantar soft tissue hardness in people with diabetes and neuropathy

D. Allan, P.E. Chatzistergos, S. Mahadevan, A. Healy, L. Sundar, A. Ramachandran, S. Kumar, A. Punnoose, N. Chockalingam, R. Naemi

Research output: Contribution to journalArticlepeer-review

7 Citations (Scopus)
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Aims: Literature indicates that altered plantar loading in people with diabetes could trigger changes in plantar soft tissue biomechanics which, in turn, could affect the risk for ulceration. To stimulate more research in this area, this study uses in vivo testing to investigate the link between plantar loading and tissue hardness. Methods: Tissue hardness and plantar pressure distribution were measured for six plantar areas in 39 people with diabetes and peripheral neuropathy. Results: Spearman correlation analysis revealed that increased pressure time integral at the 1st metatarsal-head region (r = -0.354, n = 39, P = 0.027) or at the heel (r = -0.378, n = 39, P = 0.018) was associated with reduced hardness in the same regions. After accounting for confounding parameters, generalised estimating equations analysis also showed that 10% increase in pressure time integral at the heel was associated with ≈ 1 unit reduction in hardness in the same region. Conclusions: For the first time, this study reveals that people with diabetes and neuropathy who tend to load their feet more heavily also tend to have plantar soft tissues with lower hardness. The observed difference in tissue hardness is likely to affect the tissue's vulnerability to overload injury. More research will be needed to explore the implications of the observed association for the risk of ulceration.

Original languageEnglish
Article number109865
JournalDiabetes Research and Clinical Practice
Early online date6 Apr 2022
Publication statusPublished online - 6 Apr 2022

Bibliographical note

Funding Information:
Funding from the British Council through the Newton Bhabha PhD Placement Program is acknowledged ( Application ID: 228301826) . The authors would also like to thank Tekscan for the loan of the pressure mat used in this study.

Publisher Copyright:
© 2022 The Authors


  • Diabetic foot
  • Heel pad
  • Plantar pressure
  • Plantar soft tissue
  • Shore hardness
  • Stiffness


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