Amputation Prevention – Keeping Your Feet Healthy

With Diabetes

Don Pelto, DPM

Central Massachusetts Podiatry, PC

Worcester, MA

Why should I listen?

You or a loved one will probably develop diabetes during your lifetime

1-4% of people with diabetes get ulcers every year and 15-25% will get one in their lifetime

15% of ulcers lead to amputation85% of amputations start as ulcers45% of people with an ulcer will die within 5

years

Poor Circulation - PAD

Neuropathy

Neuropathy

• Neuropathy– Medication Oral– Topical Medication– ENFB (Epidermal Nerve

Fiber Biopsy)

Foot Deformity - Bunions and Hammerotes

Foot Deformity – Callous / Corn

• Thickened skin caused by chronic rubbing or irritation of a bony prominence by the ground or shoe gear

Callous / Corn Treatment

• Trimming Callus• Callus Cream &

Pumice Bar• Padding• Decreasing friction • Don't use acid pads

Diabetic Ulcer

Diabetic Ulcer

Diabetic Ulcer

• 4 Reasons Why Won’t Heal• High Blood Sugar

• Poor Circulation

• Deeper Infection

• Walking on Wound

Diabetic Ulcer

Spencer SA. Pressure relieving interventions for preventing and treating diabetic foot ulcers. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD002302. DOI:

10.1002/14651858.CD002302.

Diabetic Ulcer

Ubbink DT, Westerbos SJ, Evans D, Land L, Vermeulen H. Topical negative pressure for treating chronic wounds. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD001898. DOI: 10.1002/14651858.CD001898.pub2.

Diabetic Ulcer

• Callus– Diabetic shoes

• Ulceration– VAC– Debridement– Dermal Skin Substitute– Platelet Rich Plasma

Charcot Foot

Edwards J, Stapley S. Debridement of diabetic foot ulcers. Cochrane Database of Systematic Reviews 2010, Issue 1.

Diabetic ShoesMost patient’s with DiabetesQualify for a pair of DiabeticShoes each year.

• Partial/Complete Amputation

• Previous Ulceration

• Pre-Ulcerative Callus

• Neuropathy with Callus

• Poor Circulation• Foot Deformity

Common Foot Problems

For people with and without diabetes

Plantar Fasciitis / Heel Spur

• Inflammation and partial tearing of a ligament band

• Spur may be present

• Pain first thing in morning

Plantar Fasciitis Treatment

• New shoes• Ice• NSAIDs• Night Splint• Stretching vs Deep

Tissue Massage

Plantar Fasciitis Treatment

• Steroid Injection– 25G Needle– 3cc Syringe– 1cc 1%

Lidocaine– 1cc 0.5%

Marcaine– 0.5cc Kenalog– 0.5cc

Dexamethasone

Flat Feet

• Congenital or acquired

• Pain may occur in the feet, ankles, knees or back

Flat Feet Treatment

• Supportive Shoes

• Orthotics

• Arizona Brace

Morton’s Neuroma

• Compressed Nerve

• Most often 3rd interspace

• Burning / pain on the ball of the foot or toes

• r/o stress fracture, metatarsalgia

Morton’s Neuroma Treatment

• Wide shoes• No high heel shoes• NSAIDs• Physical Therapy• Orthotics• Metatarsal Pad• Steroid Injection• Sclerosing Injection 4%

– 48cc 0.5% Marcaine with epi

– 2cc Dehydrated Alcohol

Hallux Valgus

• Painful bump secondary to increase IM angle

• Poor biomechanics• Hurts in shoes• Usually bump pain vs

joint pain• Wider shoes help• Orthotics slow or stop

progression and pain

Hallux Valgus Treatment

• Radiographs• Wider shoes• Padding, Bunion Bra• Trimming Keratoma• Corticosteroid Injection

• Bump vs Joint

• Orthotics slow or stop progression and pain

Tailor’s Bunion / Bunionette

• Bony deformity which is located on the outside part of the foot.

• The bump, bunionette or Tailor’s Bunion, can become very painful due to shoe irritation.

Note prominent 5th metatarsal head

Hallux Rigidus

• Arthritis of 1st MPJ• Poor biomechanics• Painful to walk

Hallux Rigidus Treatment

• Cortisone injection• Physical therapy• NSAIDS• Orthotics

Hammertoe Deformity

• Digital contracture can be flexible or rigid in nature

• Usually PIPJ• May have MPJ

dorsiflexion• May have callus• Pre-ulcerative in patients

with diabetes

Hammertoe Treatment

• Debridement• Padding• Shoe gear change

Athlete's FootAthlete's Foot

• Fungal infection (Dermatophyte).

• May occur anywhere on the foot and may burn and/or itch

• The affected areas of skin will often peel or may have small blisters

Athlete's Foot TreatmentAthlete's Foot Treatment

• Topical Antifungal – Cream vs Gel

• Topical Steroid• May be dermatitis• Biopsy if not

responding

Plantar Wart

• Human Papilloma Virus (HPV)

• Contagious• Usually plantar on

foot

Verruca Treatment• Debridement• Chemocautery• Laser• Topical treatments• Oral Cimetidine for

pediatric usage (30-40Mg/Kg in 3 divided doses)

• Liquid Nitrogen not very effective on thick plantar foot skin

Ganglion Cyst

• Benign soft tissue mass which arises from a weak area in a tendon lining or joint

• Cyst is often filled with a gelatinous fluid

• Cyst may change size depending on irritation

Ganglion Cyst Treatment

• Aspiration

• Cortisone Injection

• Trauma

• Pressure

Eczema/Fissures

• Skin inflammatory condition

• Worse in winter

• Make sure not ulceration

Ezema/Fissure Treatment

• Cream

• Pumice Stone

• Off-loading Boot

Eczema/Fissure Treatment

Ingrown Nails/Paronychia

• Painful to edge of nail with pressure or tight shoes

• Erythema, edema, purulent exudate

Ingrown Nail Treatment

• Antibiotic• Massaging Nail

Edge• I&D• Phenol & Alcohol

(P&A)

Onychomycosis• Dermatophyte• Often seen with skin

manifestations• Usually acquired but may

be inherited• May be caused by trauma

Onychomycosis Treatment

• Debridement• Topical/Oral

Antifungal• Laser • Nail Avulsion• Matrixectomy• Nail Biopsy

Fungal Laser

• Kills the pathogens that cause toenail fungus (Onychomycosis).

• Painless-no anesthesia needed.

• No side effects.

• Does not harm the nail or skin.

• Usually only one treatment required.

• Shoes and nail polish can be worn immediately after treatment.

Nail Injury

• Chronic injury (i.e. athletic activities)

• Isolated injury (trauma)

• Nail bed laceration

Nail Injury Treatment

• Watch and wait

• Nail avulsion

• Puncture

Subungual Exostosis

• Bone and cartilage growth under the great toe nail

• Pain may arise if pressure is placed over the area

Subungual Exostosis Treatment

• Shoe Modification

• Toe Cap

• Nail Avulsion

• Cortisone Injection

• Exostectomy

Haglund’s Deformity / Retrocalcaneal Exostosis

• Prominent bone on the back of the heel.

• Back of the heel is irritated by shoes and activity.

Haglund’s Deformity / Retrocalcaneal Exostosis Treatment

• Open Backed Shoes

• Steroid Injection around Bursa

• Orthotics

Fractures

• 5th Metatarsal – Difficulty healing

• Digital

• Calcaneus

• Stress Fracture

Fracture 5th Metatarsal

Fracture Treatment

• Surgical Shoe

• CAM Walker

• Bone Stimulator

• Buddy Taping

• MRI vs CT

Thank You

Don Pelto, DPM

Central Massachusetts Podiatry, PC

Worcester, MA

don@worcesterfootcare.com

(508) 757-4003