Keep the Legs You Stand On by Dr. Mark Hinkes
A foot ulcer in the foot that has no feeling is usually the result of painless or silent trauma of mechanical, thermal, or chemical origin—we're not talking about events like major car accidents. In the foot of a patient with diabetes, a trauma can be something as minor as too much pressure against the heel from the bed sheets that are tucked in too tight and do not permit the feet enough room to move under the covers.
Trauma can also occur when you bump your foot against the doorframe on your way to the bathroom at night, when you walk barefooted on the sizzling hot blacktop to get the mail, or when you use a medicated corn pad with salicylic acid that causes a chemical burn to your skin. These are all examples of silent, painless traumas, unfelt, unnoticed, yet dangerous to the diabetic patient.
A foot wound provides a point of entry for bacteria and causes the risk of a soft tissue infection, which can turn into an ulcer or the most-feared complication a diabetic patient can face—a bone infection (osteomyelitis). In either case, you will spend significant time and money to treat these infections, including possible time in the hospital. In fact, foot infections account for the largest number of diabetes-related hospital admissions and are the most common non-traumatic cause of amputations. If left untreated, these infections can threaten life and limb. Proper healing of a foot ulcer and intervention to reduce the rate of recurrence can reduce the risk of a second ulcer, infection and the risk of lower-extremity amputation.
Eighty-five percent of all lower extremity amputations are preceded by a foot infection or ulcer in patients with diabetes. Preventing these ulcers is one of the main goals in preventing lower limb amputations. Professor Andrew J.M. Boulton, MD, FRCP, is in the department of medicine at the University of Manchester, Manchester, UK, and the Division of Endocrinology, Metabolism and Diabetes, University of Miami. Professor Boulton says, "People at the greatest risk of ulceration can easily be identified by careful clinical examination of the feet, education, and frequent follow-up is indicated in these patients." Yet, most medical doctors do not ask to see a patient's feet during a routine examination.
X Marks the Spot Where Can Ulcers Be Found
Gait platforms and in-shoe measuring devices are used to analyze pressure against the foot during gait and show where the highest forces are on the bottom of the foot. The areas of the foot that receive the highest forces are the most likely to ulcerate, so this technology provides the key to building proper orthotics or placing padding to offload the site of highest pressure to protect your feet.
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