About 415 million people around the world live with diabetes; chances are that every person knows someone whose life has been affected by this deadly disease. One of the challenges that people with diabetes face is painful ulcers, which develop on their feet due to poor blood circulation and a lack of feeling in their limbs. A significant portion of those who develop diabetes-related ulcers one or more limbs amputated. In fact, 68 percent of all amputations are attributable to diabetes.
With the direction of exercise science professor Dustin Bruening, public health student Andrew Hillier (‘22), and manufacturing engineering student Seth Huber (‘20) teamed up to research different off-loading braces that help people heal from diabetes-related ulcers and avoid amputation.
GETTING A FOOT IN THE DOOR
Hillier currently works with a foot and ankle surgeon in Utah County and helps many diabetic patients. “I thought it was fascinating that [the surgeons] could take someone who was suffering and help them get going again,” Hillier says. His goal is to become a podiatrist because he loves “seeing people be able to walk again. It really can make or break someone’s life.”
Foot ulcers can start with something as simple as a rock in a shoe. Due to limited blood flow, diabetics usually can’t feel the pressure of a pebble tumbling around, so they might not find an injury until the end of the day when taking off their shoes. Decreased circulation due to diabetes also means fewer nutrients can reach the sore on the foot, which slows or disrupts the healing process.
The current healing method for diabetics with foot ulcers is to immediately put them in a rigid controlled ankle motion (CAM) boot that reaches to the high calf in order to reduce pressure around the ulcer area. The boot allows individuals to walk around during the healing process. But when Hillier saw these boots in actions, he was skeptical of their effectiveness.
“Clinically, they showed success, but I didn’t understand how they were able to off-load the lower limbs as claimed. The physics just didn’t make sense because you cannot dissipate force or pressure into thin air,” Hillier explains. “I was really curious as to whether these boots actually do this, and how. Do they actually off-load onto the shank?”
Before Hillier initiated research on the boots, Seth Huber (‘20), a manufacturing engineering technology student, created a unique foot brace prototype that eventually developed into the SpringEase Boot. It is designed to off-load using a cushioned gap between the foot and sole of the brace. Springs at the ankle decrease foot strain and help soften the blow of each step. Huber originally got the idea when one of his friends was in a climbing accident and broke both of his feet.
“I was watching him go through the recovery process, and even after going through surgery, he still had a lot of pain in his feet and ankles,” Huber says. “It got me thinking, why don’t you just transfer the weight from your foot and ankle to your lower leg? It seemed like an obvious thing to do.”
After investigating, it turned out there weren’t many great options for a boot that would transfer the weight effectively. So Huber began designing an off-loading brace himself.
“As I showed [the boot] to podiatrists, one thing that continued to come up is that they thought it would be useful for patients with diabetic foot ulcers,” Huber says. “There is a niche of people that are pretty healthy otherwise, but that have diabetes and have developed foot ulcers. This [boot] would be a good fit for them.”
The prototype boot could enable the quicker healing of ulcers by decreasing the amount of stress on the foot throughout the day. Huber wanted to test his new invention to see if it worked better than the traditional boots.
RESEARCHING STEPS FORWARD
Hillier and Huber’s interest in footcare led them to Professor Bruening’s office. Huber provided the specialized brace, and Hillier provided the legwork to start the project. Hillier applied for a College Undergraduate Research Award (CURA) and received a grant to fund the research.
Along with Bruening’s mentorship, Hillier enlisted the aid of exercise science students Dylan Parry (‘22), Amy Hayward (‘22), and Jordan Grover (‘22) to help lead the research, write the paper, and gather and analyze the data, respectively. The team spent the 2021 school year testing the effectiveness of various braces.
“We wanted to figure out what the boots are doing to the foot and what they are doing to walking patterns,” Bruening says. “In order to do the study in a reasonable timeframe, we did it on healthy subjects . . . to try and understand just what the boot does to people in general.”
Hillier and Huber compared three different biomechanical off-loading braces: a traditional CAM boot, a hinged boot, and Huber’s SpringEase Boot. They tracked the ground reaction force (GRF) by inserting a special insole underneath the foot and using a plate on the ground, similar to a scale. Then they measured the force as the test subjects walked in the different boots.
Hillier and Hubert recorded and graphed the data to visualize the effectiveness of each kind of boot. According to their findings, the spring-loaded boot has the potential to decrease the amount of healing time, which leads to better patient outcomes.
“The spring-loaded boot helps spread that force over time,” Hillier says. “It has a hefty amount of off-loading as well.”
The spring-loaded boot works by taking pressure off the heel and slowing the impact of the foot as it hits the ground. This improved model could significantly impact individuals trying to get back on their feet by providing a shorter healing time for sores.
IMPACTING PUBLIC HEALTH
Innovations like the spring-loaded boot are essential in helping people stay healthy. Hillier chose to study public health because he loves seeing the bigger picture. With his future plans to become a podiatrist, he anticipates discovering new ways to help people get back on their feet—literally.
“Not only will [this brace] help avoid amputation, but it will also help speed up the healing process,” Hillier says. “It will save money on the medication and healthcare, making the overall public health healthier.”
Hillier believes that improvements in healthcare will have the greatest impact on the overall population.
“Not all of our projects have such a direct connection with something that people can grab onto and see the application of,” Bruening says. “Everybody knows someone who’s had something to do with diabetes and how devastating it is, so it’s really easy to catch the vision.”
GIVING A LEG UP
Hillier and Huber agree that even though the research was challenging, it was worth it at the end of the day. Of the students involved in mentored research, Bruening says, “When we get people in the right places, it really helps give them experience as they launch themselves into their own careers."
As Huber prepares to partner with a company in New York to produce the SpringEase Boot, he hopes to continue testing the boot so that he can measure the improvements on patients.
“The main value in [doing research] is validating its efficacy,” Huber says. “It’s irresponsible to put something out there and say it’s helpful without doing the testing and showing that it actually does what you say it does. This is the first step towards that.”
For Hillier, research is where the rubber meets the road. His passion for research provided a new perspective on his education at BYU, more confidence in his ability to face challenges, and an opportunity to see how learning is applied outside the classroom.
“The point of science is to better the lives of those around us,” Hillier says. "Even by just starting small, we are taking another step in helping those around us: our neighbors, our parents, and our grandparents.”