In-shoe pressure thresholds for people with diabetes and neuropathy at risk of ulceration: A systematic review

Introduction
In-shoe pressure thresholds play an increasingly important role in the prevention of diabetes-related foot ulceration (DFU). The evidence of their effectiveness, methodological consistency and scope for refinement are the subject of this review.
Methods
1,107 records were identified (after duplicate removal) based on a search of five databases for studies which applied a specific in-shoe pressure threshold to reduce the risk of ulceration. 37 full text studies were assessed for eligibility of which 21 were included.
Results
Five in-shoe pressure thresholds were identified, which are employed to reduce the risk of diabetes-related foot ulceration: a mean peak pressure threshold of 200 kPa used in conjunction with a 25% baseline reduction target; a sustained pressure threshold of 35 mmHG, a threshold matrix based on risk, shoe size and foot region, and a 40-80% baseline pressure reduction target. The effectiveness of the latter two thresholds have not been assessed yet and the evidence for the effectiveness of the other in-shoe pressure thresholds is limited, based only on two RCTs and two cohort studies.
Conclusions
The heterogeneity of current measures precludes meta-analysis and further research and methodological standardisation is required to facilitate ready comparison and the further development of these pressure thresholds.