Diabetic foot wounds are among the most common complications of diabetes, and are some of the more difficult conditions to treat. In the USA, yearly, approximately 8% of diabetic Medicare beneficiaries have a foot ulcer. When these occur, 1.8% of these patients will have an amputation. These are further elevated for patients with lower extremity peripheral artery disease. The costs of diabetic foot ulcerations range from $12,211 for hospitalizations without amputation, to $34,671 for patients requiring an amputation.

It is fairly simple to understand why prevention of the first wound or amputation is so crucial. Somewhere between 50-79% of people hospitalized with a diabetic foot infection will be either unable to work, or unemployed after the episode.[iii] These events, while often not life threatening, (can become so if not treated) can have significant influences on entire households. This includes children and spouses.

In our practice, we have a comprehensive policy for diabetic foot prevention. The first and most important step is education. I often get asked during new diabetic evaluation questions related to when foot loss or lower extremity amputation will occur (as most of these patients have friends or family members who have had an amputation). My answer is always the same. While we can’t prevent every amputation, most are probably avoidable with simple steps. The American College of Foot and Ankle Surgeons has set specific guidelines for diabetic foot care. These include:

Inspect your feet daily
Bathe feet in lukewarm, never hot, water
Be gentle when bathing your feet.
Moisturize your feet but not between your toes.
Cut nails carefully.
Never treat corns or calluses yourself.
Wear clean, dry socks.
Consider socks made specifically for patients with diabetes. Wear socks to bed. Shake out your shoes and feel the inside before wearing.
Keep your feet warm and dry. Never walk barefoot.
Take care of your diabetes.
Don’t smoke.
Get periodic foot exams.

In our office, we make sure that all diabetics start out with a yearly diabetic foot examination. This assumes no known preexisting conditions for example vascular disease, neuropathy, or deformities. As risk factors increase, so do visit frequency. The range can be from twice yearly all the way up to weekly. Our doctors know how to evaluate and treat these problems, and have strategies to prevent wounds.

If you have a wound, all is not lost. First, make sure you get this checked by a qualified physician as soon as possible. Tomorrow is never advisable. Second, I always tell patients that this is a 2 step process; first is getting the wound healed, second is keeping the wound healed. The rate of re-ulceration is reported as high as 35–40% over 3 years, and that increasing to 70% over the 5years after the first wound. Five-year mortality rates after a diabetic foot ulceration have been reported to be between 43 and 55 percent, and can be as high as 74 percent in patients with lower-extremity amputation. Prevention is crucial to longevity of patients with diabetes.

Dr. Marc Fink

P.S. If you are diabetic, even if you have no complications, get your feet checked today. It may save your life.

In diabetics, neuropathy is defined as a loss of protective sensation. The condition occurs in what we call and stocking and glove distribution. It starts at the distal ends of the toes and fingers, and moves proximally up the foot/hand into the leg/arm. While there are many causes of peripheral neuropathy, diabetes is the most common.

Neuropathy can occur in several forms. The most common is sensory neuropathy. This is a change in the ability of the patient to feel their feet and hands. Starting in a stocking and glove distribution, a patient will not feel items touching their toes and feet. Over time, patient can step on objects such as glass shards, nails, or tacks, and will not feel it. This is a significant risk for infections and amputation.

Neuropathy can also occur as a motor neuropathy. This is a loss of function in the distal most muscles, and can be combined with sensory neuropathy to be called sensorimotor neuropathy. The most common examples of this include the development of hammertoes in a neuropathy foot, or ankle contractures causing ulcerations in the ball of the foot.

Lastly, neuropathy can cause an autonomic issue. This will be symptoms such as a loss of ability to sweat or release oils (also called sebum) from the skin. This is the type of neuropathy that also involves the cardiovascular system, gastrointestinal system, and genitourinary system.

With loss of sensation and function, patients become higher risk for infections, wounds and amputation. Daily foot examinations, proper shoe gear, and regular diabetic foot care can prevent many problems. So that begs the question, if I can’t feel it, why does it hurt?

60-70% of diabetics will eventually suffer from this condition. The best way to think about it, is to use the telephone as an analogy. If you are on the phone, and there is static, you can still hear, right? The more static, the louder you have to yell to have the person on the other end hear you, until eventually there is so much static that you can’t hear anything, and they you hang up. This is what happens with your nerves.

Each and every nerve in your body is connected directly to your brain. Millions and millions of individual wires, from every aspect of your body, connected directly to your brain. As neuropathy advances, the static to your brain increases. Patients perceive this as neuropathic symptoms, burning, tingling, fire, ices, etc. The louder the static, the more symptoms, until finally your brain hangs up, and then you have a complete loss of sensation. This basically means that you can remove portions of your foot without anesthesia and not know it.

Treatments for painful diabetic neuropathy include proper glucose control, diet, exercise, and many different medication options. You may have even seen a television commercial for Lyrica for example. There are also sensory feedback options, cold laser and other light treatments, and even surgical options for releasing the nerves.

Dr. Marc Fink

P.S. Best treatment for diabetic Neuropathy is prevention. Good glucose control, exercise, and preventive foot care are essential.

Here’s a quick primer on the situation. Corns and calluses are patches of thickened skin that develop over time, as your body’s way of protecting that skin from constant pressure and friction damage. Calluses tend to be wider and flatter and appear where you bear weight, whereas corns are cone-shaped and more likely to show up on top of, and between, your toes.
Both are highly likely to occur on a hammertoe because of how the digit’s arcing bend brings it into contact with the inside of your shoe. The top knuckle of the hammertoe may rub up against the “roof” of the shoe, while the tip of the toe pushes downward into the insole. The resulting friction brings the corns and calluses into being.
So how do you deal with it? Some solutions include:

1.Opt for roomier shoes. Deep, wide toe boxes enough space in the toe box for toes to wiggle up, down, and side to side are what you need.
2.Make sure your insole is well padded and cushioned.
3.Thicker socks are often a good choice since they can further absorb the pressure.
4.Pick up some non-medicated corn pads and use them. These may have a donut-shaped hole in the middle.
5.Soak your feet regularly in warm, soapy water to soften hard patches of skin. Once soft, use a pumice stone, nail file, or emery board to gently thin the corn or callus.
6. See a podiatrist for a surgical consultation to correct the hammartoes if the corns and callouses persist.

Dr. Marc Fink

P.S. Do not treat corns or calluses on your own if you are diabetic. Seek the treament of a podiatrist for this.

If you have diabetes, one of the most common issues and concerns are your feet. Your feet are complex structures consisting of 26 bones, 33 joints, and 120 muscles/ligaments/nerves. Each structure has a unique purpose, and diabetes can causes alternation in function for any of them.

The most common problem we see in diabetics is diabetic peripheral neuropathy. This is nerve damage that is a result of elevated glucose that is the root cause of all other diabetic foot problems. With neuropathy, there are 3 main types; Sensory, Autonomic, and Motor. While most people have an understanding of the loss of sensation associated with sensory neuropathy, the other two types can cause significant problems, and must be considered in any article about the diabetic foot.

Autonomic nervous system is part of your body responsible for involuntary action. These are things like your heart beat, dilation and constrictions of the blood vessels, and secretion of natural skin oils, called sebum. In the diabetic foot, these cause changes in the flow of blood to the foot, the amount of sweat your foot can produce, and how fast the blood flows. These symptoms develop over years of disease progression, and the progression is enhanced under poorly controlled glucose levels.

Motor neuropathy is a progressive loss of muscle tone and strength. This results in weakness and muscle atrophy. Most common in the upper and lower extremities, symptoms include cramping, twitching, and muscle wasting. As in sensory and autonomic neuropathy, diabetes is a common cause, but other factors can contribute to each of these problems. Motor neuropathy is the cause for problems associated with progressive hammertoe and bunion deformities.

When diabetes causes complications to your feet, it is related to each one of these types of neurologic conditions. Sensory loss creates a situation where you can’t feel your feet. Autonomic changes allow skin to become dry, atrophic, and easily damaged. Motor neuropathy causes changes in the foot shape and mechanics, increasing pressure points, leading to the development of musculoskeletal imbalance.

I always tell my patients that when it comes to diabetes, if you live long enough, you are subject to all of these problems. That being said, the better controlled your diabetes is, the longer and slower these symptoms progress, and the less likely to result in an infection, ulceration, or amputation. Diabetes numbers are more than half of what it was 20 years ago due to proper education and better understanding of these problems.

Dr. Marc Fink

P.S.Good quality foot care, proper shoes, glycemic control, and some education can go a long way in preventing loss of limb or life.

Heel pain has many causes. Heel pain is generally the result of faulty biomechanics (walking gait abnormalities) that place too much stress on the heel bone and the soft tissues that attach to it. The stress may also result from injury, or a bruise incurred while walking, running, or jumping on hard surfaces; wearing poorly constructed footwear (such as flimsy flip-flops); or being overweight.

Common causes of heel pain include:
Heel Spurs: A bony growth on the underside of the heel bone. The spur, visible by X-ray, appears as a protrusion that can extend forward as much as half an inch. When there is no indication of bone enlargement, the condition is sometimes referred to as “heel spur syndrome.” Heel spurs result from strain on the muscles and ligaments of the foot, by stretching of the long band of tissue that connects the heel and the ball of the foot, and by repeated tearing away of the lining or membrane that covers the heel bone. These conditions may result from biomechanical imbalance, running or jogging, improperly fitted or excessively worn shoes, or obesity.

Plantar Fasciitis: Both heel pain and heel spurs are frequently associated with plantar fasciitis, an inflammation of the band of fibrous connective tissue (fascia) running along the bottom (plantar surface) of the foot, from the heel to the ball of the foot. It is common among athletes who run and jump a lot, and it can be quite painful.

The condition occurs when the plantar fascia is strained over time beyond its normal extension, causing the soft tissue fibers of the fascia to tear or stretch at points along its length; this leads to inflammation, pain, and possibly the growth of a bone spur where the plantar fascia attaches to the heel bone. The inflammation may be aggravated by shoes that lack appropriate support, especially in the arch area, and by the chronic irritation that sometimes accompanies an athletic lifestyle.

Resting provides only temporary relief. When you resume walking, particularly after a night’s sleep, you may experience a sudden elongation of the fascia band, which stretches and pulls on the heel. As you walk, the heel pain may lessen or even disappear, but that may be just a false sense of relief. The pain often returns after prolonged rest or extensive walking.

Excessive Pronation: Heel pain sometimes results from excessive pronation. Pronation is the normal flexible motion and flattening of the arch of the foot that allows it to adapt to ground surfaces and absorb shock in the normal walking pattern.

As you walk, the heel contacts the ground first; the weight shifts first to the outside of the foot, then moves toward the big toe. The arch rises, the foot generally rolls upward and outward, becoming rigid and stable in order to lift the body and move it forward. Excessive pronation—excessive inward motion—can create an abnormal amount of stretching and pulling on the ligaments and tendons attaching to the bottom back of the heel bone. Excessive pronation may also contribute to injury to the hip, knee, and lower back.

Achilles Tendinitis: Pain at the back of the heel is associated with Achilles tendinitis, which is inflammation of the Achilles tendon as it runs behind the ankle and inserts on the back surface of the heel bone. It is common among people who run and walk a lot and have tight tendons. The condition occurs when the tendon is strained over time, causing the fibers to tear or stretch along its length, or at its insertion on to the heel bone. This leads to inflammation, pain, and the possible growth of a bone spur on the back of the heel bone. The inflammation is aggravated by the chronic irritation that sometimes accompanies an active lifestyle and certain activities that strain an already tight tendon.

Other possible causes of heel pain include:
Rheumatoid arthritis and other forms of arthritis, including gout, which usually manifests itself in the big toe joint; an inflamed bursa (bursitis), a small, irritated sac of fluid; a neuroma (a nerve growth); or other soft-tissue growth. Such heel pain may be associated with a heel spur or may mimic the pain of a heel spur;

Haglund’s deformity (“pump bump”), a bone enlargement at the back of the heel bone in the area where the Achilles tendon attaches to the bone. This sometimes painful deformity generally is the result of bursitis caused by pressure against the shoe and can be aggravated by the height or stitching of a heel counter of a particular shoe; a bone bruise or contusion, which is an inflammation of the tissues that cover the heel bone. A bone bruise is a sharply painful injury caused by the direct impact of a hard object or surface on the foot.

When to Visit a Podiatrist
If pain and other symptoms of inflammation—redness, swelling, heat—persist, limit normal daily activities and contact a doctor of podiatric medicine.

Diagnosis and Treatment
The podiatric physician will examine the area and may perform diagnostic X-rays to rule out problems of the bone.

Early treatment might involve oral or injectable anti-inflammatory medication, exercise and shoe recommendations, or use of shoe inserts or orthotic devices. Physical therapy may be used in conjunction with such treatments.

A functional orthotic device may be prescribed for correcting biomechanical imbalance, controlling excessive pronation, and supporting the ligaments and tendons attaching to the heel bone. It will effectively treat the majority of heel and arch pain without the need for surgery.

Prevention

A variety of steps can be taken to avoid heel pain and accompanying afflictions:
-Wear shoes that fit well—front, back, and sides—and have shock-absorbent soles, rigid shanks, and supportive heel counters
-Wear the proper shoes for each activity
-Do not wear shoes with excessive wear on heels or soles
-Prepare properly before exercising. Warm up and do stretching exercises before and after running.
-Pace yourself when you participate in athletic activities
-Don’t underestimate your body’s need for rest and good nutrition
-If obese, lose weight

Dr. Marc Fink

P.S. Only a relatively few cases of heel pain require more advanced treatments or surgery.

Foot complications in diabetes are common yet the link between the two is not very well-known. Diabetes is a lifelong health condition in which the body’s levels of blood glucose and the hormone insulin are out of balance. Symptoms include increased thirst, increased frequency of passing urine and fatigue. There are two main forms; Type 1 in which the body doesn’t produce enough insulin Type 2 where either the body doesn’t produce enough insulin or the body’s cell no longer react to the insulin produced An inability to produce insulin or use it effectively results in raised levels of blood sugar (hyperglycemia). If present over a prolonged period, hyperglycemia is associated with damage to organs and tissue within.

Type 1 in which the body doesn’t produce enough insulin
Type 2 where either the body doesn’t produce enough insulin or the body’s cell no longer react to the insulin produced
An inability to produce insulin or use it effectively results in raised levels of blood sugar (hyperglycemia). If present over a prolonged period, hyperglycemia is associated with damage to organs and tissue within the body including the heart, blood vessels, nerves, kidney and eyes.

The risk factors for type 1 diabetes are still being researched but several have been identified for the commonest form, Type 2. These include a family history of the disease, being overweight, physical inactivity and unhealthy eating.

How does diabetes link to podiatry?

Foot complications in diabetes are common and account for more hospital admissions than any other diabetic complication. Foot ulcers present as one of the most significant pathologies and are associated with neuropathy (nerve damage) and/or peripheral arterial disease (poor circulation). These greatly increase the risk of amputation with up to 80% of amputations attributed to foot ulceration.

The prognosis for individuals with ulceration and amputation is poor with a five year mortality rate of 43-55% and up to 74% respectively. Podiatrists play a leading role in the management of ulceration providing treatments including wound debridement, dressing and pressure relief and it has been suggested 80% of amputations are potentially preventable through the provision of well structured, quality care.

Why is awareness important?

Optimizing blood glucose control is key and by providing regular foot checks.
The consequences of diabetes manifest slowly over a period of time. As a result, by the time they occur, it is too late and the focus of treatment is the prevention of ulceration and the subsequent consequences.

That is why patient education is so important from the outset and should be an ongoing process. Optimizing blood glucose control is key and by providing regular foot checks, this can be reinforced as well as warning those who are developing the complications.

What recent advances have you seen in the field?

One of the most recent advances has been in the prevention of foot ulceration. A multicentre study looking at how to prevent ulcers reoccurring, evaluated a new type of shoe.

The TrueContour insole is made from a combination of analysis of the plantar pressures beneath the foot and an impression of the patient’s foot. By combining the two, a specialized insole can be produced and the study demonstrated that it reduced the re-ulceration rate by three times.

Another advance is in measuring skin temperature. Ulcers are preceded by an increase in skin temperature and studies have shown that by measuring this and seeking help when there is a differential of four degrees can help to reduce the re-ulceration rate.

What are the challenges for the future and what findings do you hope we will see in the next 10 years?

Advances in predicting ulceration could lead to greater prevention and improving vascular surgery techniques would allow limb salvage.
There are so many challenges, it is difficult to know where to start. Identifying the causes and potentially preventing Type 1 diabetes would be a major breakthrough. Developing techniques that allowed autoregulation of blood sugar control would provide a more stable disease state and prevent many of the complications.

Dr. Marc Fink

P.S. As the line between medical devices and consumer electronics become more and more blurred, we will become more and more able to help our patients manage themselves.

Foot problems often start early in life. Children can develop problems with their feet from wearing ill-fitting shoes or from participating in sports activities.

Some children have inherited conditions that make them more susceptible to foot conditions, like flat feet. Find out why it’s important to care for your child’s feet starting today, and how you can ensure their ongoing foot health well into adulthood by seeing a podiatrist.

Your Child’s Feet

In the years leading up to their teens, children are still developing and growing andthat includes their feet. For a child who is under 12 years old, the bones in their feet are soft and vulnerable to damage that can last into adulthood. Some of the problems sometimes found in children are:

– Flat feet (also called fallen arches).
– Becoming pigeon-toed (walking with the toes pointing inward).
– Bunions and out-toeing.
– Ingrown toenails (usually due to tight-fitting shoes).
– Clubfoot (foot is twisted, preventing it from lying flat on the floor).

Keeping Their Feet Healthy

There are simple steps that you can take to help keep your child’s feet healthy. Here are a few important tips:

– Always buy well-fitting shoes that are made of quality materials and provide arch support. – Choose a lightweight shoe that has enough room at the toe.
– Feed your child a healthy, calcium-rich diet to aid bone development.
– Teach your child how to tie their shoelaces securely as early as possible in life.
– Take your child to see a podiatrist at the first sign of a problem, whether it’s pain or walking abnormally.

Importance of Seeing a Podiatrist

It’s recommended that you take your child for an appointment with a foot doctor soon after their first steps if the walking pattern seems strange or the feet and toes aren’t developing normally. Treatments are available that can correct the child’s walk and train the feet or toes into a proper position.

Call for an Appointment
Make it a priority to have your child’s feet checked if you have concerns. We see and treat many children in the practice.

Dr. Marc Fink

P.S.Children with strong, healthy feet avoid many kinds of lower extremity problems later in life. That’s why it is important to inspect your children’s feet periodically.

With the help of a podiatrist , diabetics can rest assured that they are in good hands. Foot problems are a major risk for those with diabetes. Because of this, diabetics must be monitored continuously to prevent or identify potential foot issues. With a comprehensive evaluation from a podiatrist, this is simple.

Understanding Diabetic Foot Care

With a diabetic foot, a wound the size of a blister can become a bigger problem. Diabetics commonly have reduced blood flow making injuries much slower to heal. When a wound doesn’t heal properly, it can lead to infection. Those with neuropathy issues where their foot becomes numb or loses sensations are at a greater risk for foot problems. This is because they are at an increased risk of wounds or infections. Any unattended cuts can become infected.

Another consequence of this neuropathy is known as Charcot Arthropathy. This is a condition when neuropathy allows fractures to develop in the middle foot leading to severe deformity in patients. It is for these reasons that an examination and regular check-ups with your podiatrist are necessary.

Diabetic Foot Care Tips

Podiatrists suggest keeping your feet away from heat, which can promote moisture. Never soak the feet either and keep them as dry as possible. Avoid using any adhesive products on your feet as this can increase the risk of tearing, leading to an open wound (and increased risk of infection). Take great care to trim toenails regularly. If you find an ingrown nail, contact your podiatrist immediately.

A podiatrist can offer countless diabetic foot care tips that will help prevent the incidence of foot problems from occurring. Schedule a comprehensive foot exam with a podiatrist as soon as possible!

Dr. Marc Fink

P.S. Diabetics should constantly be monitoring their blood sugar, know their Hemoglobin A1c and get a routine eye exam at least once per year.

A Stress fracture is generally an overuse injury. It occurs when muscles become fatigued or overloaded, and cannot absorb the stress, shock, and repeated impact. Fatigued muscles transfer that stress to the nearby bone and the result is a small crack or fracture.

Stress fractures in the bones of the foot are usually caused by over-training or overuse. They can also be caused by doing too much on hard surfaces, such as running on concrete or wood floors. Increasing the time or intensity of exercise too rapidly is another cause, as well as wearing improper footwear.

Women seem to be at greater risk than men are. This may be related to a condition called the “female athlete triad”. This is a combination of poor nutrition, eating disorders, and amenorrhea (infrequent menstrual cycles), that predisposes to osteoporosis ( thinning of bones ).

It should also be mentioned that stress fractures could occur for no known reason.

Many times the foot is swollen and painful without any history of injury. Standard X-rays will usually not show the fracture until 2-3 weeks after the original symptoms. A bone scan, CT scan, or MRI may be necessary to detect the stress fracture in the early stages.

The best treatment is rest and non-weightbearing. It may take anywhere from 6-8 weeks for complete healing to take place. Sometimes an anti-inflammatory medication (Ibuprofen, Aleve, or stronger ) is needed. In more moderate cases, an off-loading surgical shoe or walking boot is advised. In very serious or painful cases, non-weightbearing with crutches or knee roller can be used.

Dr. Marc Fink

P.S. Stress fractures can also give the same symptoms as bursitis, arthritis, tendonitis, and gout. Sometimes a blood test will be able to help determine gout and arthritis.

Ganglion cysts of the foot are benign, fluid-filled, soft-tissue masses that attach to tendon sheaths or joint capsules. The fluid tends to be thick, sticky, clear, and jelly-like.

Most ganglion cysts appear on the wrist, but a significant number also occur in the foot, usually the top. The term ganglion means “knot,” which describes these irregular, multi-walled, mobile masses underneath the skin. The most distinguishing feature of ganglions is their location around joints and tendons, although in rare cases they may found in bones or tendons.

The development of ganglion cysts may be rapid, or it may occur over many years. They may shrink, enlarge, or even disappear and reappear. The majority of them disappear within two years. Although not generally painful themselves, ganglion cysts may cause symptoms due to their proximity to other structures. They can be found in any age group, and women are three times more likely than men to suffer from them.

The first symptom will be a lump on the foot, either visual or by feel. The lump is most commonly on the top of the foot, but it can be located near any joint or tendon, and it may vary in size. Other symptoms may include:

Burning sensation (indicating the cyst is pressing against a nerve)
Pain (indicating the cyst is pressing on a nerve, joint, or tendon)
Limitation of motion (the cyst is pressing against a joint or tendon)
Skin irritation above the ganglion
Wearing shoes is painful due to the size of the cyst
While ganglion cysts are often painless and harmless, as with any growth, you should have yours checked by a podiatrist to rule out more serious issues.

The exact cause of ganglion cysts is still unknown. The most prevalent theory involves trauma to the affected area, which may result from a single, direct incident or from chronic overuse. This results in inflammation of the associated connective tissues, which then degenerate or liquefy into “ganglionic jelly.”

The diagnosis may be based on appearance and feel. Sometimes a light shone through the lump can indicate whether the fluid is more liquid or solid, which further helps with the diagnosis. Additional testing may include analysis of the ganglionic fluid, x-rays and/or ultrasound. The x-rays and ultrasound may show damage to surrounding structures (tendons, joints, bones, etc.); furthermore, the ultrasound is often diagnostic for ganglions. Should these tests be inconclusive, an MRI may be ordered.

Treatment of the ganglion is dependent on the symptoms you are experiencing. If you are not in pain and the cyst is small, your doctor may prefer merely to monitor the situation.

The simplest form of treatment is aspiration (or drainage) of the ganglion. A large-gauge needle is introduced to remove the fluid.

If the aspiration technique doesn’t work, surgery may be performed to excise the cyst. Depending on the size and location, this procedure may be done in the office or the hospital. It requires local anesthesia, sutures, bandaging, and possibly splinting, again depending on the size and location of the cyst. Post-operatively, rest and reduction of activities may be required. The benefit of the excision procedure is that it has a significantly higher success rate in preventing recurrence, although complications such as joint stiffness, scar formation, and infection are possible.

Dr. Marc Fink

P.S.Should any mass of the foot appear, you should contact your Podiatrist to have it evaluated.