In the last two issues of Practice Perfect, we discussed the difficulties of preventing diabetic foot complications. We reviewed the statistics that demonstrate the seriousness of the problem and the need for prevention and covered two options, including education and prescription shoewear. The research has yet to demonstrate that education prevents ulcers and amputations, but it seems foolish not to teach our patients how to protect themselves. Knowledge is power, as we know. Prescription shoes though, have proved their benefits, but only when patients actually wear them, which is usually not often enough. The methods described so far rely on the patient to effect successful prevention. What if physicians employed methods that essentially eliminated the need for patient cooperation from the picture? Would this improve outcomes?

Regular Foot Care

Let’s first talk about something highly common for most podiatrists: regular foot care. For many podiatrists this “bread and butter” practice component consists of toenail and callus debridement. When my students work with me in clinic, they often present these patients as “just nail trimming.” This drives me crazy. I view these regular visits as “diabetic surveillance,” a chance to intervene earlier in the process. Is this not what you’re really doing when these patients come in? While debriding nails and calluses, we have the opportunity to make sure that there are no developing physical issues such as wounds, but also to educate and remind our patients how best to care for their feet.

A few comments are worthwhile here. First, podiatrists don’t trim nails – that’s the purview of pedicurists. We debride nails, which includes not only shortening the length, but also thinning the nail plate. This typically requires a device such as an electric burr or Podospray device. If this is not done, your patient is receiving substandard care. A thick toenail will increase pressure on the nail bed, leading to a subungual ulcer in a location that has almost no soft tissue between the nail and the bone. We should also be treating the nail fungus that is so prevalent in these patients.

Second, and perhaps more importantly, the podiatric visit should truly be focused on deformity and calluses. Callus and deformity are the body’s advertising methods that say, “Hey, you, podiatrist. Here’s where the next ulcer is going to happen!” These areas need to be offloaded and that offloading can literally change the course of the patient’s life.

Back in 1996, Murray and colleagues were the first to demonstrate that the presence of callus strongly predicts future ulcer formation.¹ They prospectively watched 63 diabetic neuropathic patients over a 15 month period. They found a relative risk of ulcer of 4.7 at locations of increased plantar pressure, 11.0 at callus locations and 56.8 if a prior ulcer in the same area. This makes perfect intuitive sense since increased focal pressure with resultant hyperkeratosis is the exact mechanism of both callus and neuropathic ulcer formation.