For decades, clinicians and researchers have sought a simple, reliable biomechanical predictor of diabetic foot ulceration. Peak plantar pressure has been the standard metric, but its predictive value has always been modest. A newer, more holistic measure—cumulative plantar tissue stress (CPTS)—was thought to offer better predictive power by integrating multiple factors: plantar pressure, time spent walking or standing, and footwear adherence.
A recent prospective study by our Dutch colleagues Hulshof and colleagues challenges this assumption, while opening new avenues for prevention .
What the Study Found
The investigators followed 60 people with diabetes at high risk of ulceration for 12 months. They carefully measured barefoot and in-shoe pressures, activity patterns, and footwear adherence, combining them into a CPTS score.
- 37% of participants developed a new plantar ulcer within one year, consistent with the sobering recurrence rates seen worldwide.
- CPTS did not predict ulceration. Some people with high cumulative stress remained ulcer-free, while others with lower CPTS developed ulcers.
- Instead, two baseline markers stood out:
- The presence of pre-ulcers (callus, hemorrhage, blister, fissure) increased the odds of ulceration almost tenfold.
- Slower walking speed emerged as a novel predictor, associated with dramatically higher risk.
Interestingly, while CPTS was not predictive of ulcers directly, it was significantly associated with pre-ulcers, reinforcing the mechanical pathway hypothesis—stress leads to tissue damage, which then progresses to ulceration .
Why This Matters
These findings highlight two important shifts:
- From models to markers. Complex biomechanical indices like CPTS may still provide mechanistic insights, but in practice, easily observed clinical markers—walking speed and pre-ulcers—may offer more immediate predictive power.
- From pressure to capacity. The absence of CPTS as a predictor raises the possibility that ulceration is not simply about the load applied, but about the capacity of tissue to tolerate stress. Frailty, physical deconditioning, and local tissue health may be decisive.
Clinical Implications
- Assess walking speed: A quick, inexpensive measure that may reflect both systemic frailty and local vulnerability.
- Identify and treat pre-ulcers early: This remains central to prevention, and this study underscores just how strongly they predict progression.
- Use CPTS with caution: While valuable for research, its current models may not be practical for clinical prediction, especially without accounting for shear forces or tissue resilience.
Looking Ahead
This study reminds us that simple measures can sometimes outperform complex models in clinical utility. Future work may refine CPTS with continuous monitoring and shear stress inclusion, but until then, slowing down—literally—may be the red flag we should not ignore.
As we continue to strive for a future without preventable amputations, the message is clear: watch the walkers, and watch their speed.
📖 Reference: Hulshof CM, van Netten JJ, Busch-Westbroek TE, et al. “The predictive value of cumulative plantar tissue stress on future plantar foot ulceration in people with diabetes—A 12-month prospective observational study.” Diabet Med. 2025;42:e70099. doi:10.1111/dme.70099
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