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01-12-2021 | Review | Uitgave 1/2021 Open Access

Journal of Foot and Ankle Research 1/2021

Plantar soft tissues and Achilles tendon thickness and stiffness in people with diabetes: a systematic review

Journal of Foot and Ankle Research > Uitgave 1/2021
Benedictine Yen Chen Khor, James Woodburn, Lisa Newcombe, Ruth Barn
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Supplementary Information

The online version contains supplementary material available at https://​doi.​org/​10.​1186/​s13047-021-00475-7.

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Diabetes mellitus is associated with changes in soft tissue structure and function. However, the directionality of this change and the extent to which either tissue thickness or stiffness contributes to the pathogenesis of diabetes-related foot ulcerations is unclear. Hence, this systematic review aims to summarise the existing evidence for soft tissue structural differences in the feet of people with and without diabetes.


In compliance with MOOSE and PRISMA guidelines, AMED, CINAHL, MEDLINE, ProQuest Health & Medical Collection, ProQuest Nursing & Allied Health Database, and Web of Science electronic databases were systematically searched for studies published from database inception until 1st October 2020 [Prospero CRD42020166614]. Reference lists of included studies were further screened. Methodological quality was appraised using a modified critical appraisal tool for quantitative studies developed by McMaster University.


A total of 35 non-randomised observational studies were suitable for inclusion. Within these, 20 studies evaluated plantar tissue thickness, 19 studies evaluated plantar tissue stiffness, 9 studies evaluated Achilles tendon thickness and 5 studies evaluated Achilles tendon stiffness outcomes. No significant differences in plantar tissue thickness were found between people with and without diabetes in 55% of studies (11/20), while significantly increased plantar tissue stiffness was found in people with diabetes in 47% of studies (9/19). Significantly increased Achilles tendon thickness was found in people with diabetes in 44% of studies (4/9), while no significant differences in Achilles tendon stiffness were found between people with and without diabetes in 60% of studies (3/5).


This systematic review found some evidence of soft tissue structural differences between people with and without diabetes. However, uncertainty remains whether these differences independently contribute to diabetes-related foot ulcerations. The heterogeneity of methodological approaches made it difficult to compare across studies and methodological quality was generally inadequate. High-quality studies using standardised and validated assessment techniques in well-defined populations are required to determine more fully the role of structural tissue properties in the pathogenesis of diabetes-related foot ulcerations.

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