Pathophysiology of Charcot Foot Deformity
Charcot foot (Charcot neuroarthropathy) is a severe complication documented in patients with diabetes mellitus, characterized by the progressive destruction of pedal bones and joints. This leads to structural degeneration, midfoot collapse, and ultimate foot deformity. Furthermore, it induces peripheral nerve damage, resulting in a loss of protective sensation (LOPS). Consequently, patients continue to bear weight without pain perception, even when plantar pressures elevate to dangerous clinical levels. When excessive pressure is repetitively concentrated on a specific anatomical area over prolonged periods—particularly at the collapsed midfoot—it precipitates the development of plantar ulcers or recurrent ulcerations. If these ulcers become severe or infected, amputation may be required to prevent the proximal progression of infection and tissue necrosis.

Challenges in Charcot Foot Management
The prescription of therapeutic footwear and custom-made insoles plays a pivotal role in evenly distributing plantar pressure across the foot, thereby mitigating repetitive loading on high-risk areas to prevent ulceration. This biomechanical intervention enables patients to perform activities of daily living with enhanced safety. However, there is currently a lack of a definitive clinical consensus regarding which specific design of therapeutic shoes is most optimal for this patient cohort. Therefore, this study was conducted to compare the efficacy of three distinct types of therapeutic shoes in reducing and redistributing plantar pressure to safe thresholds, aiming to provide evidence-based data for optimal footwear selection in clinical care.

Evaluating the Efficacy of Footwear on Plantar Pressure Reduction
This experimental trial evaluated 15 participants diagnosed with chronic severe diabetic Charcot foot. All subjects were assessed while wearing three variations of therapeutic shoes: (1) off-the-shelf therapeutic shoes, (2) double rocker sole shoes, and (3) relasting shoes.

All footwear interventions were uniformly paired with identical custom-made insoles. Participants were instructed to perform a 10-meter walking trial, during which in-shoe plantar pressure distribution was quantified using the Pedar X^® system. Measurements were acquired across three specific anatomical regions: the forefoot, midfoot, and hindfoot.

The results demonstrated that all three shoe types successfully offloaded peak plantar pressures at the midfoot—an anatomical region highly susceptible to ulceration in this demographic—to below 200 kPa, which is fundamentally established as a safe ulceration threshold. Peak pressures exceeding this limit inherently carry a high risk of causing skin breakdown and subsequent ulcer formation. A comparative analysis revealed that the off-the-shelf therapeutic shoes and the double rocker sole shoes reduced midfoot pressure by 11.97% and 8.73%, respectively. Conversely, while the relasting shoes demonstrated slightly lower efficiency in midfoot pressure reduction relative to the first two designs, they still successfully maintained the overall plantar pressure within the clinically safe threshold.

Conclusion
All three therapeutic shoe designs demonstrated comparable efficacy in offloading and redistributing plantar pressure, yielding no statistically significant differences. Therefore, the optimal prescription of footwear must be clinically individualized, taking into account the specific anatomical characteristics of the patient’s resultant foot deformity. This intervention must invariably be utilized in conjunction with custom-made insoles to effectively offload plantar pressure and successfully prevent the onset of ulcerations.