Diabetic Foot Care: Preventing Amputations

I've learned from reading all of your comments how concerning it is to be diabetic and see all these amputations. I want to assure you that amputations do not happen overnight. And it doesn't just happen because of diabetes alone. Often times there are early clues and many situations are easily corrected. Here's an example:

A callus builds up pressure causing the skin to break down. Shaving this down regularly and wearing appropriate diabetic shoes can prevent this callus from becoming an ulcer. Open wounds or ulcers are beginnings infections and amputations. Let's prevent that!

A callus builds up pressure causing the skin to break down. Shaving this down regularly and wearing appropriate diabetic shoes can prevent this callus from becoming an ulcer. Open wounds or ulcers are beginnings infections and amputations. Let's prevent that!

A long time diabetic patient presented for her first diabetic foot check. She states walking a lot at home, cooking and doing housework often wearing no shoes. She's developed a callus but doesn't see the podiatrist until "it really hurts." Unfortunately, she has the late stages of diabetes that affects the nerves in the feet, so she has some numbness as well. She is older too so cannot bend over to see the bottom of the feet and has blurred vision so cannot see clearly. 

Can you see how all of the combined issues in this case make this particular patient more vulnerable to foot infections? How so, you ask?

1. Having diabetes "for a long time." As soon as you are diagnosed with diabetes, you should see a podiatrist right away. Foot specialists can tell you what your particular risks are and make recommendations. It could be as simple as caring for dry cracked feet, foot fungus or more serious like having a prior amputation. 

2. Only waiting to see a doctor until it really hurts. The problem with this philosophy of waiting until it gets really bad is this, it's probably really bad. Prevention is key. I repeat, PREVENTION IS KEY. I have patients deathly afraid of doctors so when they finally get to me, well I only have bad news for them. The good news is podiatrists, myself included, are very diligent about preventing any level of amputation. We are on your side. Do not be afraid. And if you are afraid of one podiatrist, there are other, many thousands of others.

3. Numbness in the feet. This is the number one reason why many patients delay care. They simply do not feel a problem because they have neuropathy. Without the gift of pain, one does not know they are walking on a thumb tack or other sharp object and overtime this gets ignored, infected and you can imagine the domino effect. 

4. Not being able to see. Our older patients simply cannot see due to diabetic retinopathy (eye damage). So it will be difficult for them to report any problems if they cannot feel or see their feet.  

I hope to prevent as many amputations as I can but I can't help if I don't know who you are. Keep sending me your questions! Thanks for reading.

 

 

What I wish for everyone I meet in the Emergency Department

Whoopsie doodle, looks like I missed the entire month of April to blog! Needless to say I am happily busy in my practice in sunny Northern California. So busy that I am seeing a preventable trend in the Emergency Department (ED) on patients I am called in for and hope to be able to help some of you or your loved ones suffering from diabetes related foot problems. 

IF YOU HAVE DIABETES...please establish care with your local podiatrist. We can point out early signs of problems such as pressure points, blisters, calluses and ulcerations and provide recommendations to preventing infection and ultimately loss of limb. We can provide prescriptions for diabetic shoes and custom inserts and offer recommendations based on your foot type and activity level.

The most recent set of patients I have seen in the ED have had a sore for more than one week that was left ignored or self treated and, sadly, resulted in an amputation of part of the foot. This is often necessary to save the leg but also could have been prevented early on. 

I'M A DIABETIC, WHY SHOULD I SEE A DOCTOR WHEN I HAVE NO FOOT PROBLEMS? Excellent question! Not all diabetic patients will have foot-related problems but for some who develop neuropathy (loss of sensation) in the feet, you may not have the pain signals alerting you that you stepped on something or have a callus that is creating a sore underneath. Leaving this ignored is how infections brew and spread. Better to prevent than to wait for something bad to happen. 

Email me with your questions and I'll share the answers to benefit our readers. 

 

Heel Pain 101

Image from https://www.foothealthfacts.org/conditions/heel-pain-(plantar-fasciitis)

Image from https://www.foothealthfacts.org/conditions/heel-pain-(plantar-fasciitis)

Plantar fasciitis, used to be called heel spurs but is a misnomer, affects many people. It is caused by an inflammation of the fibrous band on the bottom of your foot that may be from having flat feet or very high arches.

The good news is pain can be managed conservatively in the majority of people. The bad news? Nothing good will come easy and it take consistent practice to prevent the pain from getting worse. Here are some freebies for you if you suffer from heel pain:

1. Pain first thing in the morning when you step down? Before getting out of bed, stretch your arch by extending your knee and dorsiflexing the foot. You can also use a towel to help with this stretch. Warm up for a few minutes every day. 

2. Pain still there through the day? Take a break and repeat the stretches. Use tennis or gold ball to massage the plantar fascia. 

3. Pain at the end of the day too? You may need to take a closer look at your shoes and invest in durable, supportive shoes that provide support to the arch. If the shoes fold in half, that's no good. If they are completely flat like the current trendy shoes, that won't work either. Walking barefeet will make it worse as well. What you can do is take a frozen water bottle and massage the arch out again. The ice will be very nice. 

Rest, Ice, Night Splints, Better Shoes & Orthotics are usually very successful in relieving pain. Surgery is a last resort. 

I'd like to send a special shout out to Rist Roller for providing me a  sample mini foam roller. I use foam rollers in general for my back so it made sense to have one for foot pain. This type of product is perfect for massaging out the plantar fascia in heel pain syndrome. Check them out. *I do not get any sponsorships whatsoever if you decide to purchase. They just seem cool.*

Wishing you all freedom from foot pain!

Reflecting on the last year in internet-land

I started this website as a place to collect and share my thoughts about patients I encounter (of course, with their permission, de-identified to protect their privacy & HIPPA laws), including some challenging cases that I failed at and some that I am most proud of. Whatever the situation, I vow to never abandon people who trust me to help them, however long the ride may be. These limbs are attached to beautiful people who have revealed their most vulnerable state to me and truly count on me to care for them. I find deep satisfaction in building these relationships and hope to continue in doing so. 

Along the way, I have engaged with dynamic people offering their pearls and sharing their personal struggles with me, whether they are patients or other health care providers. I want to thank you, the reader, for dropping by and opening up to me. I hope we will continue this curious journey we call life together and learn about all the different ways there are to heal people like you and me. In turn, I will share my struggles too. 

My husband & I working together in the operating room on a mutual patient. This counts as date night, doesn't it? :)

My husband & I working together in the operating room on a mutual patient. This counts as date night, doesn't it? :)

This website's 1 year anniversary is dedicated to my hubby who has seen me struggle to figure out my identity and purpose in a profession dominated by men. In training, I've been mentally beaten down by superiors, figuratively thrown under the bus by colleagues, punished by having necessary training experiences taken away from me, mandated to having one-on-one intimidation meetings, essentially outcasted for one reason or another...of course this list can go on and on but I won't dwell on it because that has passed. While inside though, I felt my morale was withering away and that I couldn't get through it another day, let alone another year. I started telling myself it is not worth it. I can't do this anymore. I can't do medicine. I can't help people.

The most harmful words to myself: "I can't."

And then one day I thought to myself I wouldn't accept this to be. I was determined to complete my training and then continue on with another year of fellowship training. I changed the conversation in my head from "I can't" to "I will." I will make this work. I didn't want to give up on patients I could help and I didn't want to give up on myself. 

The most rewarding experience is when patients are traveling distances just to see me and they thank me for saving them from the crippling effect of an amputation. There are days that the only salvation are words of kindness and I am thankful I am able to make it out the trenches to hear them now. 

As I reflect on this past year and the challenges I face, one thing stands out. There is power in kindness to others and most importantly, to yourself. Despite your battles, the one inside your head is the one you must learn to overcome.

"Whether you think you can or think you can't, you are right." Henry Ford   

Charcot? Osteomyelitis? Both? A Case Review

Gradual bone destruction of the midfoot after standard treatment with IV antibiotics

Gradual bone destruction of the midfoot after standard treatment with IV antibiotics

I inherited this patient from a colleague from what I thought would be a simple case. It started out as a middle aged poorly controlled diabetic with a foot infection. After surgical debridement, we were not sure if the bone was also infected so took a bone sample. The results were also inconclusive so together with the infectious disease specialist, we agreed that we should treat it as if it was osteomyelitis (bone infection) since this patient had recurring foot infections in the past. After 7-8 weeks of IV antibiotics, the patient developed bony destruction at the midfoot. 

What to do next?

Cases like this keeps me up at night for days at a time. I worry about the patient's deteriorating health, possible loss of job, and mental decline. The patient is at a risk for a below knee amputation since the antibiotics did not help all that much and surgical resection of the midfoot would leave it very unstable. If the midfoot continues to collapse, a plantar ulceration could result and then more surgery. 

Could this have been prevented? Bone infection is difficult and there has been no easy answer to "curing" chronic bone infection. Antibiotics can quiet it down but the infection will linger and acute flare ups can always recur. There's no definite duration for therapy, it is based on the idea that bone takes at least 4 weeks to remodel so 4-6 weeks of antibiotics became the gold standard of treatment along with monitoring of bloodwork. This patient received longer duration of therapy and was still not cured of the bone infection. The risk of longer treatment is kidney damage, cost, and other adverse effects of the drug. 

The plan for this patient is another round of IV antibiotics but realistically, another surgery is likely, whether it be a radical midfoot wedge resection or a below knee amputation. This will be dependent on the patient and what they want to endure. 

Email me your thoughts and what you have had success with. Let's discuss. 

 

Nonhealing Diabetic Toe Ulcer

I received this patient as a second opinion for a nonhealing diabetic foot ulcer located at the bottom of the great toe and the patient had been treated for at least 4 months. Off-loading and local wound care was not sufficient and the wound would never completely heal. I had to consult a good friend who I trusted to have seen more of these then I had. There are many approaches to this problem and I wanted something very simple and we both agreed that an in-office flexor tenotomy was the way to go. This took no more than 5 minutes to perform, from sterile prepping to wound closure. After one week of the procedure, the wound healed. Although not pretty, both the patient and I are happy with the results. 

Things I learned from this case & hope residents (and aspiring medical students) take away from my posts:

- If the wound does not change or improve after a month of the same treatment, you must try a different approach. Don't be afraid to try something new. Of course, weigh the risk vs benefit to what you choose to do.

- Consult as many people as you need to, read as much as you can, and use all of your resources. Don't give up too soon!

- Be clear and honest with the patient. I often find myself saying "I am not sure if what I do will work perfectly, but we need to try something different because the current treatment is not working. I want you to get better and I'm sure you do too." If I sense the patient does not trust me (yes, it happens), I am more than happy to recommend other providers. I need the autonomy to do what is necessary but I also need the patient's cooperation and set the appropriate expectations. 

Naturally, when patients heal and they don't need me anymore, a piece of me is sad that I may never see them again. But  oftentimes, that is a good thing. 

Skin Grafts, So Many! But One Reigns Supreme

My favorite thing about my job is surgery. This is not to say that I want to cut people all the time. In fact, many people are not surgical candidates and the mere mention of the word surgery will turn off a lot of my patients. Why? Well, I presume it is the work of the media who sensationalize the trauma of surgery rather than the benefits of it. But that is a realm I will not be diving into today. Or ever. 

What I do hope to accomplish is to educate people who indeed need surgery of the risk versus benefit. At the end of the day, the patient has full control on how they want to live and how they want doctors to help, for better or for worse.

Back to my favorite thing that I enjoy doing to help patients with nonhealing wounds, particularly diabetics, are skin grafts. Imagine the last time you scraped your knee from falling. These usually heal very well because the injury is small and superficial. It may take a week or so to completely epithelialize (become skin). What if the scrape became infected, became larger or deeper, and is not likely to heal in a few weeks? What options do we have?

I've mentioned in a prior post the differences of the skin-substitutes (allografts) versus a split-thickness skin graft (STSG which is a thin layer of skin from your own body, usually thigh or calf). Some products are designed to stimulate your own cells to regenerate a nice tissue layer to fill in the defect. Others claim to be "as good as skin." I have yet to find this to be true so I tend to go straight to the STSG (best option!) when the wound bed is well prepared to accept it. Plus, it's more cost effective with less than 1% donor site complications. See picture below. 

Top: lateral ankle wound with a well prepared wound bed demonstrating red granular tissue with minimal space defect. Middle: STSG applied to the wound bed, approximately 2 weeks post-op. Bottom: STSG fully healed, image taken at 2 months.

Top: lateral ankle wound with a well prepared wound bed demonstrating red granular tissue with minimal space defect. Middle: STSG applied to the wound bed, approximately 2 weeks post-op. Bottom: STSG fully healed, image taken at 2 months.

When Patients Say "Just Cut it Off"

As the year is coming to an end, our practice finds an increase in surgery demand with folks wanting to maximize their insurance benefits. That also mean getting peculiar requests such as amputations. 

Why would anyone make such a request? Without having to go into too much science, you already know that your feet is needed for day to day activity and it has to support your entire body all the time. I was a weird kid and wanted to experience what it was like to have only one functional leg. So I'd hop around on one leg for a few hours at a time and it didn't take long before I was exhausted. Granted I didn't have crutches or a wheelchair, only my imagination. And I thought, man this would totally suck if it really happened.

But you know it does happen. Children born with a missing limb or needing an amputation are incredibly resilient. They adapt very well, putting most of us adults to shame. Adults who have non-traumatic amputations have a harder time adapting. Walking with one leg increases our energy expenditure (makes our heart work harder) because we're doubling the remaining leg's workload to support our entire body. 

There are legitimate reasons to get an amputation. Trauma, degloving injury, pain out of proportion that has exhausted conservative measures (CRPS, PVD), infection, etc. Often time there is no question about the necessity of an amputation. 

I had a patient who got a small infection in their foot from stepping on a piece of glass and it went ignored for some time. She is diabetic, her daily fasting blood glucose is frequently over 250, and needless to say she has neuropathy, that is no feeling to her feet from the damage of high sugar levels. After having the infection drained, she has an open wound that will take a long time to heal due to a compromised immune system, also a complication of diabetes. She then told me, "just cut off what you need to so I can move on."

A heel ulcer from neuropathy

A heel ulcer from neuropathy

In the patient's mind - cut off the problem, I need to go back to work. 

In my mind - whatever I cut it'll take longer to heal and I will be seeing her for a very long time.

I think at times what I want and what the patient wants are not always parallel. I want the patient to take her poorly controlled diabetes seriously. She is at a very high risk of an amputation among other things like blindness, kidney failure, and heart problems. What she wants is to go back to work right away. The reality is, whichever road we take, amputation or continuing wound care, it will be a long one. Her body is not equipped to heal as fast as a non-diabetic so "just cutting it off" is not the solution to her problem. 

Things I tell patient to think about when they undergo an elective (non-urgent) below knee amputation.

- Prothesis? Can you afford it? Will your insurance pay for it? If not, can you manage living in a wheelchair for the rest of your life?

- Problems to the other leg - new sores will develop and within 5 years, you will have wound problems and possibly another amputation and possibly you may not live that long

- Stump pain - the stump may still break down and you may still need more surgeries. That's a common complication for diabetics.

There is no easy fix for a diabetic wound but with close monitoring from multiple specialists including you primary medical doctor, nutritionist, endocrinologist, vascular, cardiovascular doctor, and your podiatrist, this can be managed. You don't have to "just cut it off."

Weird Toenails

Every now and then, more often then I'd like to admit, I run across a patient with something so peculiar that I just have to snap a picture of it. Check out the pattern of growth to this toenail. What do you think it is?

It's so intriguing, like if it wasn't on a body part it might be a cool mixed media art to put up in the living room to act as a conversational piece. Or not. 

Dilemma: Deciding Limb Preservation vs Amputation

This is an inside look of the internal conversation I have with myself. Yes, I talk to myself. A lot and out loud. 

It is my priority to give patients control in their treatment plan. There are many options in deciding how to proceed with a foot problem, whether it be nonsurgical or surgical or even considering a second/third/millionth opinion. I, myself, like options too so I always offer this to patients. Sometimes the decision is easy. For example, an ingrown toenail that waited too long to see the light of day that is now painful, red, swollen and the nail is piercing the skin in a really weird way. What options do I give? I present options and it's consequences:

1) Do nothing. But you have to live with the pain and it will get worse. 

2) Cut the nail out. It'll make you feel better but it might also grow back the same way. A non-commital level of care. A needle does enter your toe to inject a local anesthetic so you don't feel pain during the procedure. 

3) Cut the nail out and make sure it doesn't grow back. Using a chemical to burn the root of the nail has about 95% of success of never growing back. For the (un)lucky small percentage of people who experience recurrence, we can repeat the procedure. It will drain while your body is reacting to the chemical for 2-4 weeks. People are able to return to normal activity with little to no pain right away. 

These are relatively easy solutions, you either want it gone permanently or not. But I was struck with another type of problem with a patient who has a bone infection. These are more tricky. I'll present you a case that I see often but am always disappointed with the options.  

A 70+ year old male presents with a callus to the left foot at the head of the 1st metatarsal. It has been red, swollen, painful for many months and recently got worse. He delayed care because he continues to work in order to support his family. He has a history of rheumatoid arthritis and smokes cigarettes heavily with no intention of quitting. His joints have gradually moved over time and now he has to cut a hole in his shoe to fit his foot in it. His xrays from the emergency room were suspicious for bone lesions but the patient was sent home with follow-up in my clinic. 

When I saw the patient, he looked sick and had difficulty walking. He was given antibiotics but it didn't seem to do much for him. I shaved down the callus and found an ulcer underneath it. I then ordered an MRI and the results were unfortunately positive for osteomyelitis (bone infection). So what's next?

At the follow-up appointment, the family admits the patient continued working despite my recommendations to stay off of it. But of course, life goes on and bills need to be paid whether our body understands it or not. So naturally the infection looks worse and now these are our options:

A rheumatoid foot with a severe bunion deformity and associated ulcer at the bony prominence. The brown color is betadine paint on the ulcer (not seen here).

A rheumatoid foot with a severe bunion deformity and associated ulcer at the bony prominence. The brown color is betadine paint on the ulcer (not seen here).

1) Do nothing. The infection will get worse, it will spread, and he will lose more parts of his body than desirable. 

2) The most conservative approach in treating bone infection in the foot is 6 weeks of IV antibiotics. Although no evidence exists that 6 weeks is the magical number, that has been common practice for a very long time so we'll just leave it at that. What this really means to the patient is that they'll have to get a PICC line (peripherally inserted central catheter) placed in their arm, keep it clean, and go to a facility or have home health do the antibiotic injections several times a week. This does not guarantee complete resolution of the bone infection, it sometimes keeps it at bay but is a viable option in many instances. This is limb-preserving.

3) However, if there is an associated bone deformity, like a bunion as seen in the picture, then treating it conservatively will not take away the mechanical problem. The bony bump rubs against the ground or shoe abnormally so an ulcer can re-develop and we'd be at the same place again. Leaving us this option: amputation of the infected bone, which would be the big toe and the bone behind it (1st ray amputation). This is also limb-preserving but at a higher level. 

Some may say, yea just cut it off and move on. Unfortunately, it is not that simple. The technical part of "cutting it off" is indeed straightforward but I don't take this lightly. When it comes to cutting off the big toe and the bone behind it, yes we are definitively removing the infection and it will not come back. But what patients need to know is the aftercare and biomechanical consequences of taking away the part we place the most pressure on while walking for propulsion. 

The aftercare, ideally, is to stay off of the foot and be in a protect boot until it heals. In immunocompromised people (diabetics for example) it will take longer than normal to heal, maybe 4-6 weeks. In healthy compliant individuals, it'll be more like 2-3 weeks. 

The biomechanical consequence of removing the primary propulsive part of your foot is that even when the amputation site heals, the adjacent toes will start to contract and new sores can occur. (Think of having 5 people pulling a heavy box, then one person decides to quit so the remaining 4 has to put more energy into pulling the box.) When the remaining tendons pull harder on the remaining toes, the toes hammers. It is common to see the tip of the remaining toes develop a callus and hide an underlying ulcer if left ignored. 

The patient must discuss his choices with family and I strongly encouraged them to be present at their next office visit. It is a lot of information for anyone but something, rather than nothing, must be done.

What would I recommend? Based on his desire to return to normal activities of daily living quickly (he wants to continue working as a laborer), amputation would be the best option as it is the most definitive solution for the current problem. He will need to see a podiatrist regularly for maintenance thereafter. 

What else would you recommend?