The Diabetic Foot

A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana.

Have Your Feet Inspected At EVERY Doctor's Appointment

2010-07-19T10:38:00.002-04:00

This week I would like to reinforce some advice that should go without saying, but often gets lost in the jumble of a busy doctor’s office. That advice is to have your feet inspected at every doctor’s visit. Obviously, those of you who see a podiatrist will have regular foot inspections. A few more can’t hurt. For those of you who do not have access to a podiatrist, the foot inspection by your family doctor, internist, or other physician is all the more important. During this inspection, any impending problems or active wounds and infections can be identified, and treatment begun. Obviously, this won’t be as detailed of an exam as the podiatry exam, but it will reveal critical issues that need to be addressed immediately. For those who receive regular foot inspections by their podiatrist, the inspections in between podiatric inspections can still be of benefit, as foot complications can occur at any time.

Many primary care physicians and internists will inspect their diabetic patient’s feet. Unfortunately, in the current state of medicine where there is a lack of family practices, many offices have to see high numbers of patients. This can lead to a prioritizing of medical issues, and the feet often get left out of this prioritization. As a diabetic, it is your health at stake here. Become proactive and remove your shoes and socks at every doctor’s visit. If they don’t look at your feet, lift them up and say to the doctor: “how do my feet look?” This exam should only take a few moments to identify any major problems, and will result in better overall health and mobility if problems are found that are addressed on a timely basis. Remember to do this with every doctor’s visit, even if you are already receiving care from a podiatrist.

Until next time,
Scott R. Kilberg DPM

www.inpodiatrygroup.com
thediabeticfoot.blogspot.com
thevideofootdoc YouTube channel

A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana.

House Shoes To Protect Diabetic Feet

2010-07-13T23:32:00.003-04:00

I often advise my diabetic patients to wear shoes around the home for protection from puncture wounds due to sharp objects that neuropathy will not allow sensation of. The typical response is usually “I wear socks in the home”. Unfortunately, this is not good enough. A splinter or piece of glass can penetrate a sock quite easily, and therefore the sock offers little protection outside of keeping the foot from floor dust. What diabetics need is a shoe or slipper with a thick enough sole to take the penetration of the usual group of household hazards, like splinters, needles, glass, staples, ceramic pieces, and small gravel stones fallen off of shoe tread. A dedicated house shoe, preferably of a roomy athletic variety, is an excellent choice for this purpose. By using a shoe only for the home, one can avoid tracking in dirt and grime from the outside world onto clean carpets. Other types of preferred shoes include clog-type shoes or sandals. My office carries the CrocsRx line of shoes, that feature a deep toe area and room to accommodate a protective diabetic insert if one is required. These shoes are not appropriate as the main outside shoe due to their lack of rigid support but serve quite well as a house shoe or for brief activity. A moccasin-style slipper is the next and last choice for a house shoe. However one must be careful not to use one that is too tight along the toes, or has a sole that is too thin or soft, which would defeat the purpose.

While no shoe can protect the foot from a two inch nail, the regular use of a dedicated house shoe can and will prevent typical household objects from penetrating the skin and causing infections.

Until next time,
Scott R. Kilberg DPM

www.inpodiatrygroup.com
myachingfoot.blogspot.com
thevideofootdoc YouTube channel

A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana.

A New Article On Diabetic Shoes and Medicare

2010-07-08T09:33:00.003-04:00

This week I thought I would share this article I wrote on a different site discussing the proper way to have diabetic shoes prescribed and dispensed in light of medical need and Medicare requirements for those of you who have Medicare cover the cost of these devices. Hopefully those following the right way to go about getting these shoes and inserts will help avoid fraud and waste in our taxpayer supported payment system that too many companies are trying to take advantage of with little regard for the needs of the patient.
Here is the link:
http://www.submityourarticle.com/articles/Scott-Kilberg%20DPM-5336/diabetic-shoes-107292.php

Until next time,
Scott R. Kilberg DPM

www.inpodiatrygroup.com
myachingfoot.blogspot.com
thevideofootdoc YouTube channel

A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana.

Why Do Diabetics Get Peripheral Neuropathy?

2010-07-05T15:01:00.002-04:00

A common question I encounter regarding diabetes is why does nerve damage develop in the majority of those who are diabetic? Today I would like to discuss two prevailing theories as to why diabetics develop peripheral neuropathy, and perhaps this can shed some light for everyone regarding the actual cause of the majority of foot disease in diabetics.

Diabetic neuropathy probably has two causes, each contributing to the overall disease of the nerves. One cause is chemical, and the other is due to circulation. The chemical cause starts essentially with the way glucose (blood sugar) is broken down into various chemicals. One of the by-products of glucose use in the body is a chemical called sorbitol. This chemical itself is not broken down by the body, and can accumulate if there is too much of it. When a diabetic has increased blood sugar, they will naturally have increased sorbitol. Sorbitol will accumulate in the nerve, and begin to harm its proper functioning. It will decrease a chemical in the nerve membrane vital to proper nerve signal transmission, and this leads to nerve injury and abnormal sensation. The other cause of neuropathy has to do with the way diabetes and increased blood sugar harms the circulation to the nerve. The circulation to the nerve has two different components. One involves microscopic circulation to the smallest parts of the nerve tissue, and the other involves the overall circulation to the nerve tissue as a whole (as well as other tissue). High blood sugar has an immediate effect on the smallest part of nerve circulation, and continued diabetes with insulin resistance (even if controlled) has an eventual effect on the circulation to the nerve as a whole (as well as other tissue). The loss of circulation to the nerve will increase stress on the nerve tissue, cause a loss of proper chemical functioning, and stimulate immune system damage. Over time, this damage can be progressive.

These two processes are believed to be the main reason as to why diabetics develop neuropathy. Research continues on other potential causes, and research continues on strategies to treat and possibly eliminate neuropathy. For now, the single most effective treatment is prevention of high blood sugar in the first place. Although the longer one is diabetic is still a factor in developing neuropathy, the more immediate nerve damage effect of high blood sugar is the most important factor, and is the most controllable one.

Until next time,
Scott R. Kilberg DPM

www.inpodiatrygroup.com
myachingfoot.blogspot.com
thevideofootdoc YouTube channel

A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana.

Neuropathy and Joint Replacement: A Bad Mix

2010-06-23T20:46:00.003-04:00

Did you know that uncontrolled diabetes can limit or even eliminate the potential to have an implant to replace arthritic joints in the feet? Joint replacement surgery in the foot and ankle is commonly performed to replace painful, arthritic joints that don’t function well. This is done when the destruction of joint surface is so severe that there is nothing else that can be done to stop the pain and restore motion. The two most common joints that require replacement are the big toe joint and the ankle joint. Joint replacement surgery of the big toe joint goes back over fifty years, and has encompassed a number of different designs and materials. Ankle implant surgery has not been around as long, and has had numerous challenges facing its designs. Current implants have demonstrated far more success as overall surgical skills and technology have improved.

These implants require certain prerequisites before their use should be considered. Chief amongst these are weight, bone quality, and general health. There is another consideration specific to diabetes. The presence of nerve disease, or neuropathy, can complicate the longevity of these implants. When a diabetic has neuropathy, the poor sensation contributes to excessive joint and bone pressure of the foot and ankle. This excessive pressure stems partially from the inability to subconsciously shift foot weight when protective special pressure sensors in the skin automatically send signals to the brain to slightly make this shift. A foot with neuropathy does not have the ability to provide this signal, and therefore the pressure on the foot, especially at major joints, becomes excessive. This excessive pressure can lead to break down of the bone in the joints. With an implant this means a break down of the bone surrounding the implant stems, which have already been weakened by the physical presence of the stems. What results is a cracking of the bone the implant sits in, leading to implant displacement out of the joint it was intended to replace. The only alternate to this implant is a surgical fusion of the joint. There are times when fusion is preferred to an implant anyway as a treatment for severe arthritis, however many surgeons prefer to have the implant available as an initial and viable option when the implant is properly indicated.

Uncontrolled diabetes quickly leads to this state of neuropathy. By keeping one’s diabetes under control, a diabetic with foot or ankle arthritis may keep their options open regarding surgical treatment. More subtle forms of diabetic neuropathy, such as those seen in people who have simply been diabetic for many years under good control, may not necessarily lead to this risk.

Until next time,

Scott R. Kilberg DPM

Can An Infected Ingrown Nail Turn Into An Amputation?

2010-06-09T10:03:00.003-04:00

Infections from ingrown toenails have been discussed in this blog before, but one thing I would like to concentrate on is the potential risk they pose for a more serious infection and ultimately the need for a toe amputation should that infection spread deep into the bone.

An ingrown nail is common, and it is not unusual for the skin next to the ingrown nail to become inflamed as a result of a minor toe injury or skin tear after an aggressive nail trimming. Bacteria becomes trapped under the inflamed skin, and a mild skin infection can soon occur, with pus and fluid developing between the nail and the swollen skin. This infection, most of the time, simply stays put and does not spread up the toe or deep into the inner tissue. Even in diabetics this is generally true, as I rarely see ingrown toenail infections become deep or widespread (and I see hundreds of these a year). However, it is quite possible for the bacteria under the skin surface to spread. This is especially true when people try to self-manage the infection at home, or try to live with the pain hoping it will eventually go away fearful of treatment. I have seen patients (especially kids who hide the symptoms from their parents) who have had a toenail infection for many months. Occasionally I have seen bone infections develop from this. Persistent infections significantly increase the chance of bacterial spread, even if it only around the nail. It should be known that the nail root actually generates from tissue just above the surface of the end toe bone, and any bacteria in that vicinity can potentially spread to the bone if given long enough. Bone infections in the toe respond poorly to antibiotics due to decreased blood flow to deliver the medication, and generally need bone removal and amputation of the tip of the toe (or worse if it has spread).

In summary, an infected ingrown toenail has the potential to spread the infection into the rest of the toe or the toe bone. Diabetics are less resistant to bacteria than non-diabetics, so this potential is greater. This infection spread is UNLIKELY BUT POSSIBLE. For this reason, as well as simply for the reason of receiving proper medical care, infected ingrown toenails should be treated and cured by a foot specialist. Temporary removal of the nail border and antibiotics simply delay the onset of symptoms again, and permanent nail border removal (of the ingrown side of the nail) is needed to ensure the condition does not return. This procedure is gentle, takes 10 minutes, and is easy to recover from.

Until next time,

Scott R. Kilberg DPM

A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana.

Tip's On Treating Summer Cuts and Scrapes

2010-06-04T13:03:00.002-04:00

Today I’d like to offer a quick tip on how to prevent serious foot and leg problems from arising out of small injuries like scrapes, superficial cuts, and opened blisters. Those of you out there who think nothing of these small skin injuries and let them dry away in the breeze happy to wear the scabs like a badge of honor.....think again. These types of minor skin injuries are common sources for bacteria to enter into the body, When high blood sugar or long standing controlled diabetes harms the body’s natural defense against bacteria, small cuts, scrapes, and blistered skin can become a launching ground for skin cellulitis, an infection that can potentially spread up one’s leg and into the blood stream. It happens commonly enough that hospitals are filled each year with diabetics who thought ‘it was only a scratch’.

When these mild skin injuries occur, quickly wash the area with soap and water, gently scrubbing the tissue to remove dirt and debris. Apply a thick layer of antibiotic ointment, like triple antibiotic ointment or bacitracin, to the skin and cover it up with a band-aid. this will accomplish two goals. The first is to keep out debris and small particles that may harbor bacteria (which the ointment may kill as well). The second goal is to keep the skin site moist. The dry scabbing process the body uses to heal injured skin is crude and imperfect, especially considering diabetes’ effect on tissue healing. By keeping the injured site moist under the band-aid, it will heal faster and with less scarring. Allow a few days for healing to progress. If the skin around the injured area becomes red or swollen, or if the skin is not healing after a few days, seek attention from one of your physicians (especially your podiatrist if the injured area is on the foot, as it may need other care such as shoe modification or wound care procedures). These simple steps may save your leg from serious complications.

Until next time,

Scott R. Kilberg DPM

A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana.

Nail Fungus and Laser Treatment: Worth the Cost?

2010-05-27T21:06:00.003-04:00

Nail fungus infection is common in diabetics It can create unsightly, and more importantly, painful nails that hurt when shoes are worn. With diabetics in particular, it can potentially lead to secondary bacterial infections, in which bacteria on the skin can take advantage of the fungal presence and cause an infection of its own. Bacterial infections in diabetics (as well as everyone else) are worse than fungal nail infections, and require immediate treatment. For this reason, most physicians will recommend treatment or at least management of nail fungus infections in diabetics. Historically, getting rid of nail fungus has been tough. Oral anti-fungal medications are available and are effective, but can in rare instances cause liver problems, so people with liver issues cannot take them. Topical anti-fungals have had mixed results. The medications sold in stores are useless for nail fungus, as they only work on the skin surrounding the nail. The prescription anti-fungal lacquer works in only a small number of people. A newer generation of oil based physician-dispensed anti-fungal solutions has show some good initial promise, and I have used these successfully in numerous patients. Unfortunately, they will not work for everyone. In light of all this difficulty in treating an infection that is easy to eradicate when it is only on the skin and not under the nail, a new therapy has emerged that uses laser light to destroy the fungus. But does it really work? Recently published research has not necessarily convinced me, although the therapy may eventually be a decent option if one can ignore the cost.

Let’s start with the basics. Lasers have been around for awhile, treating a variety of skin conditions. They sound futuristic and sexy, but the truth is that medical lasers are not Star Wars technology. They are large instruments with a flexible arm that emits a light wave that generally is not brightly visible like in the movies. These lasers destroy tissue by burning or vaporizing the tissue depending on the strength and kind of laser. The manufacturers of lasers for nail fungus have found a way to deliver the laser energy deep under the nail without burning the surrounding nail tissue and skin, in an effort to destroy the fungus itself. Early manufacturer studies indicated promising results, but you must always take manufacturer funded studies with a grain of salt when considering medical devices. Now, heres the kicker...

The procedure can cost up to $1000 cash (not insurance covered) depending on the geographic area, and may need to be repeated later.

A study just published in the Journal of the American Podiatric Medical Association has tried to determine the effectiveness of one of the lasers. The study followed people treated by the laser for six months (although it can take longer for a big toenail to complete its growth along the skin), and only followed a very small number of people. The results (in a study funded by the manufacturer) show a fair number of patients had clear fungus-less appearing nails growing out several millimeters from the skin edge where the nail grows from. This is often the visual marker that we use to determine how all fungal nail treatment is progressing, as it MAY indicate that fungus is dying and not invading new nail tissue as it grows. However, since the study only was conducted for six months, it is not clear if this represents real fungus destruction, or if it simply stunted fungal growth leaving live fungus still capable of destruction further down the nail. An additional microscopic study of the other edge of the nail showed actual fungus eradication rates to rise decently, but then inexplicably fall at 180 days. A longer follow-up time of a year or so might have given a better indication as to the actual longevity and effectiveness of the treatment. My preference is to see a study that follows the nail until it grows from the skin border to the end of the toe, and then tests the nail with a microscopic stain (I don’t place much stock in fungal cultures- too high of a rate of falsely negative tests due to the difficulty of growing fungus on a culture medium) to determine if the fungus is fully eradicated. Either the laser kills fungus or it doesn’t. There should not be this much variability like there would be with a medication study.

As you can see, the use of this new technology to eradicate stubborn nail fungus is not necessarily the next greatest thing. I would urge everyone to carefully consider the pros and cons of this rather expensive procedure that may in the end be no more effective than medication that is perfectly safe to use by most people. In my opinion, more research with a longer follow-up time and more patients enrolled in the study (run by researchers not affiliated with the manufacturers) is needed before it gets the blessing in my practice. If it’s ultimately shown to be highly effective, then it may be worth the cost. Right now though, well..... I’d wait and see.

Until next time,

Scott R. Kilberg DPM

http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=1076776182

A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana.

Skin Conditions Associated With Diabetes Part 2

2010-05-10T14:06:00.003-04:00

Continuing on from last week’s post, I will discuss two more skin conditions associated with diabetes.

Necrobiosis lipoidica diabeticorum:

This condition is a disease of the collagen material that gives structure to much of our soft tissue. The collagen degrades in the skin and fatty tissue underneath the skin for as of yet unclear reasons. It is possible that diabetic neuropathy harms small blood vessels that feed this tissue, or that cells involved with inflammation degrades the collagen. The end result is a red raised bump (which can be large) found usually on the shin. It will have a waxy center that can contain fine small bluish spider veins. About a third of them can form ulcers, or wounds, over the surface that need to be treated.

Under 1% of diabetics experience this condition, and it mostly occurs in women. Early stages can be treated with injected steroid medication, while older lesions need topical steroid medications. 10-20% of these bumps will resolve on their own after ten years. Unfortunately, controlling blood sugar does not seem to help improve the skin condition.

Pictures of this condition can be found here:

Eruptive xanthoma:

These itchy, pea sized skin lesions are seen when one has high blood sugar and high triglycerides (a form of fat in the blood stream). Firm, yellow, waxy bumps will form on numerous body surfaces, including behind the knee and legs. The lesions are surrounded by a red ring, and they itch.

Treatment involves controlling blood sugar and triglycerides. It is especially important to control the triglycerides, as significant cardiac and circulatory problems can occur from arteries clogged with fats. The lesions on their own will go away in a few weeks, so no medication is required.

Pictures of this condition can be found here:

http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=1015733544

Until next time,

Scott R. Kilberg DPM

http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=-211654459

A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana.

Skin Conditions Associated With Diabetes Part 1

2010-05-04T17:39:00.004-04:00

There are several skin conditions associated with diabetes beyond the usual dry skin one associates with the disease. Over the next few posts, I would like to present a few of these diabetes-associated skin conditions.

Let’s start with something called diabetic dermopathy. It was so-named as it was once thought that the presence of this skin condition could reveal undiagnosed diabetes on its own. Although we now know this to be untrue as non-diabetics can have similar symptoms, the name nonetheless stuck with the condition. Diabetic dermopathy is the one of the most common skin findings in diabetics. It is also called ‘shin spots’ or ‘spotted skin syndrome’. Between thirty and sixty percent of all diabetics have this condition. It usually appears in men over the age of fifty. The spots begin as pink areas one quarter to one half inch in diameter on the legs. These spots are round to oval in shape, and soon turn brown and slightly raised. They can resemble large freckles, and are usually seen on both legs. After about two years these spots will go away, to be replaced by others.

The actual disease causes swelling of the skin layers and thickening of the skin blood vessels. Red blood cells eventually leech into the skin, and essentially leave iron pigment, causing the discoloration. Treatment is not necessary as the spots resolve on their own, but some scarring of the remaining skin can take place.

Pictures of this condition can be found here:

Another common skin disease seen in diabetics is something called bullous diabeticorum. This condition is rare compared to diabetic dermopathy, but does occur with enough frequency to be worth mentioning. It affects one half of one percent of diabetics, and is seen only in adults between the ages of forty to seventy. In this condition, tight blisters form spontaneously in the hands and feet. Usually blisters are the result of injury or trauma, but with bullous diabeticorum this is not the case, as they appear without injury. The actual cause is not well understood, but three different types of blistering seems to develop. The first type contains sterile non-infected fluid. the second type contains bloody fluid, and typically leaves scars after healing. The third type consists of multiple blisters on sun exposed areas. The blisters may take several weeks to heal, but can reoccur.

Treatment for the blisters involves making sure any broken blister does not become infected. The use of properly fitting shoes to avoid excessive skin friction is vital to reducing complications.

Pictures of this condition can be found here:

http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=1965993185

Next week I will cover another couple of skin conditions associated with diabetes.

Until next time,

Scott R. Kilberg DPM

A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana.

New Research May Shed Light On How Wounds Have Difficulty Healing

2010-04-28T22:29:00.004-04:00

Some new research is about to be published from Loyola University that suggests something interesting about the wound healing process, and may have an implication in how wounds can be healed better. This research, according to a news article on the discovery, suggests that a part of the immune system that helps to destroy tumors and viruses may actually slow down the wound healing process. Mice who lacked these cells healed wounds better than normal mice with the cells. The way these cells slow the healing process is not understood, but if a way can be found to inactivate these cells, the ability to heal wounds, especially the infected wounds found in diabetics, may be improved. A follow-up study seems to be on the way to investigate how these cells can be turned off in the wound healing process. Although any real advancement in wound care from this study maybe far away, it certainly helps to shed light on the complicated process that governs wound care.

A link to the news article of this soon-to-be published study can be found here:
http://www.medicalnewstoday.com/articles/185774.php

Until next time,
Scott R. Kilberg DPM
www.inpodiatrygroup.com
myachingfoot.blogspot.com
A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana.

Don't Let The Warmer Weather Trick You Into Walking Barefoot At Home

2010-04-22T10:27:00.003-04:00

As the weather begins to warm, especially here in the northern part of the country, the desire to kick off one’s shoes and run around barefoot at home on the cool floors and carpeting begins to renew. The cool air and floor on the feet feel soothing, as opposed to the warm and confining shoes one has worn all winter. When you have diabetes, though, this is a luxury you cannot afford.

Previous posts have discussed the need for staying in one’s shoes or similar protective footwear at all times. This advice does not change with the seasons. Whether you think so or not, a majority of you diabetics out there have some form of peripheral neuropathy. Your feet do not have to be completely numb in order to have decreased sensation, and the greater risk for not noticing punctures into the feet that comes with this decreased sensation. Most people are fairly careful about not walking outside barefoot on the sidewalk, driveway, or streets. Most people also are careful not to walk on grass or in a park barefoot. I am still confused to this day as to why these same people who have been so careful elsewhere feel that the home is somehow insulated from the dangers of the outdoors.

No matter how clean one keeps their home, there will always be some object that can be stepped on and can cause skin damage, often without even being felt. The following list demonstrates some of these household dangers:

sewing needles, carpet tacks, broken glass or dish ceramics not completely cleaned up, toothpicks, fragments of gravel or mulch brought in by ones shoes, nut shell fragments, staples, loose hardware, small children’s toys, rawhide fragments from a dog’s chew toy, nail clippings, picture frame nails, fruit pits, loose floor threshold material, bottle caps, hard pet food, plaster or drywall fragments, splits in old hardwood flooring and basement floor fragments

As you can see, this list is fairly extensive, but not necessarily all-inclusive of the dangers the home can make for a diabetic’s bare feet. The majority of objects I have to surgically fish out of diabetic’s feet and treat for simple or complicated infections come from within the home, and not the great outdoors. So although that cool floor feels good, it can be wrought with danger that can potentially lead to a serious infection, or even amputation. Therefore, I would urge all diabetics to keep on those house shoes or soled slippers this spring and summer, and all year round for that matter.

Until next time,

Scott R. Kilberg DPM

http://apps.nccd.cdc.gov/DDTSTRS/default.aspx

A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana.

Great Website Detailing Diabetes Statistics and Trends

2010-04-15T22:20:00.004-04:00

I just came across this diabetes data and trends website run by the Centers For Disease Control. It looks like a great resource for comparing the incidence of diabetes from state to state and county to county. It also details diabetes presence in men and women, age groups, length of disease, and numerous other points of comparison. It is a good resource to see how your community compares with others around the United States, and may serve as a call to action for communities that may be demonstrating a serious problem with diabetes compared with their neighbors.

Until next time,

Scott R. Kilberg DPM

Diabetic Shoe Article Link

A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana

Helping Explain Diabetic Shoes To Family Doctors and Internists

2010-04-06T21:25:00.007-04:00

Family doctors and internists are well trained, and are dedicated to providing you with the best care possible. However, they are sometimes unfamiliar with the complex details that accompany Medicare's policies on diabetic foot care. This in particular applies to the true nature of and need for diabetic shoes. Unfortunately, family physicians and internists are the primary providers of diabetic care outside of endocrinologists, and their co-certification is necessary beyond the prescription from the podiatrist for you to obtain those shoes (if Medicare is to cover most of their cost). On occasion, I have had a family physician or internist refuse to co-certify the need for diabetic shoes in their patients, even if I, as the actual foot and ankle specialist, have identified the medical need for the shoes and have prescribed them. Unfortunately, there are many instances of medical supply companies and other entities fraudulently dispensing these shoes to every diabetic rather than only those who qualify. The physicians may be leery of using diabetic shoes in their patients for this reason, or they simply may not understand the reasoning behind their use. The link below will take you an article I wrote to family physicians and internists regarding diabetic shoes and their use in medical practice. If your podiatrist feels you should be in diabetic shoes, but your family doctor or internist is unable to co-certify the need for their use for whatever reason, you can print the article and share it with your physician to help explain the process. Make sure your podiatrist agrees with the information contained in it. While the information is accurate from a factual standpoint, your podiatrist may prefer to approach your family physician or internist in a different manner regarding the difficulty in co-certifying your shoes.

Scott R. Kilberg, podiatrist for Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana

The Importance of the ‘Diabetic Team’

2010-03-29T09:12:00.004-04:00

In recent years, a new trend has been emerging out of academic medical centers and large hospital settings toward the total care of diabetic patients. This trend encompasses the thought that if diabetics received specialized care by a group of physicians and medical staff all working together, the outcomes would improve and diabetic complications could be minimized. The results of this approach do seem promising.

Central to this way of approaching diabetic care is the physician actually treating the disease. This could be one’s family doctor, internist, or endocrinology specialist. The control of blood sugar is vital to preventing diabetic complications, and this physician is on the front line of this battle. This doctor may also be the one who is monitoring all the other problems diabetics experience, independent of their diabetes. This includes control of high blood pressure, cholesterol, heart disease, lung disease, and other related problems. If these conditions are severe, they may require their own specialty care in the form of a cardiologist (heart) or pulmonologist (lung). The care of these conditions usually covers the majority of disease that diabetics experience outside of diabetes itself.

From there, several other physicians become involved in a diabetic’s care. This includes the podiatrist, who’s specialty care of the foot and ankle is vital in preventing amputations, as well as the opthamologist, who will monitor and treat eye disease commonly seen in diabetes. The podiatrist in particular becomes a very important part of a diabetic’s care at this stage for several reasons. The first of which involves the podiatrist’s direct responsibility in keeping the feet healthy enough to continue activity, which helps lower blood sugar, as well as employment. Secondly, the podiatrist often serves as a monitor for poor leg circulation and nerve disease. Peripheral arterial disease, as well as peripheral neuropathy, is often first noticed by the treating podiatrist. In the case of peripheral arterial disease, the podiatrist will refer to yet another specialist, the vascular surgeon or interventional cardiologist, who will then restore circulation. Restored circulation prevents gangrene, and allows any wounds on the feet or legs to have a much better chance of healing. With painful peripheral neuropathy, treatment is often started by podiatrists, or a referral to a neurologist or back to the family physician/internist/endocrinologist is made.

When wounds are present on the feet or legs, the podiatrist is often the primary physician handling their care and healing. The expert treatment of a wound care center under the direction of a physician or wound care nurse practitioner is also used for wound healing when it is available, or when the podiatrist is unable to treat the wound based on state law and scope-of-practice restrictions. When the wounds become infected and need hospital or long-term outpatient care, the use of an infectious disease specialist is helpful in providing optimal care.

Kidney disease can also become a reality for uncontrolled diabetics, and the care of a nephrologist (kidney specialist) may need to be employed to help prevent the need for dialysis or kidney transplant.

Finally, several other health care professionals are used as an important resource to help treat diabetes. These professionals include diabetic educators, who counsel patients on all aspects of living with and treating diabetes, as well as dietitians, who help instruct diabetics on proper diet control.

While this seems like an enormous amount of physicians and other professionals involved in the care of one person, the benefits and improvement in care that this entire team can bring to a diabetic make it all worthwhile. When these professionals are communicating together as a team and coordinating their care as a team, the complications that do arise from diabetes can be kept at bay, or effectively treated when they appear. Each member of the team brings their own unique set of skills and knowledge, ensuring each diabetic is getting the best care possible. Hopefully, this team approach model becomes more standardized. Currently, most health systems need to rely on the outside referral system that starts with the primary care doctor or internist. These referrals can be scattered far and wide, and communication between the doctors is often minimal beyond a letter or phone call. When there is a dedicated system in place to bring a diabetic’s care all together, the effectiveness of care improves. Ideally this would be physically in the same building, but a team approach communicating effectively could allow for scattered offices as part of a system. Although many large hospital systems have this type of organization through joined electronic health records, the coordination of health care professionals strictly ensuring the special needs of a diabetic patient are met can improve a community’s health overall and minimize the devastation of diabetes.

Until next time,

Scott R. Kilberg DPM

A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana.

When A Foot Is Warm, Red, and Hot....

2010-03-16T21:57:00.003-04:00

During the daily foot inspection, there are several things that should prompt a diabetic to call their doctor or present to an emergency room. One of these is a red, draining wound. The other can indicate a problem of similar severity. When a diabetic notices a red, swollen, warm foot, even without a wound present, immediate attention is needed. The possible problems this could indicate are serious, and are listed below:

Infection- The foot can become infected through a variety of means other than through an obvious wound. Small fissures in between the toes can bring in bacteria, as can skin rashes, and bacteria left over from infections that never fully resolved after a wound healed over. This last situation is less common, but low bacteria counts deep in the foot tissue can become active again and infect the deep foot spaces and bone. Puncture wounds (like needles, splinters, and nails) do not leave large skin wounds, and if they are not felt a diabetic with neuropathy may not notice them. These objects can harbor bacteria, which can penetrate deep into the foot. If one does not remember an injury, then the first thing that must be considered when the foot is red, hot, and swollen is an infection. This is especially true if red streaks are noticed up the foot or leg, and/or if someone has nausea, vomiting, fever, or chills.
Fracture or Significant Sprain- Redness, warmth, and swelling are commonly found when the body injures itself, as a sign of inflammation. These symptoms are not always limited to just infections, which are different. Diabetics with neuropathy can injure the foot and ankle easier during twists and sprains without feeling the severity of the injury like non-diabetics do. As a result, serious injuries may not feel as bad as they should, and a fracture or serious sprain may be ignored. As one continues to walk on the injured part, the inflammation increases. Prompt attention and support is needed to prevent these injuries from causing long-term damage and structural issues that may limit walking.
Charcot Disease- For those of you following this blog, you will remember our discussion of Charcot neuroarthropathy. Check the post archive for a good review. This special kind of fracture is much more serious that a regular fracture, in that it will keep fracturing for a three month period or more before stopping if not addressed early enough. Treatment is needed right away with cessation of weight-bearing on that foot to prevent serious foot deformity in the future that can lead to chronic wounds and even eventual amputation. Unfortunately, this condition is often mistaken for bone infection in emergency rooms that do not have much experience in identifying Charcot disease, as the x-rays and superficial appearance of the foot in Charcot disease resembles that of bone infection. A physician who regularly treats this condition, such as a podiatrist, can diagnose Charcot disease without difficulty.
Gout and Other Joint Disease- Certain conditions can cause foot redness, warmth, and swelling that are not related to infection or injury. These conditions usually involve inflammation of joint tissue. This broad class of disease includes gout, rheumatoid arthritis, lupus, and other immune disease. These conditions are not severely threatening to the health of the foot, but can be very painful and need to be treated in a timely manner to reduce the pain. They can easily resemble a skin or joint infection, and a medical exam needs to be performed to ensure an infection is not present.

Until next time,

Scott R. Kilberg DPM

A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana.

Toe Amputation and Balance

2010-03-10T08:36:00.003-05:00

Unfortunately, toe amputations are not uncommon in the diabetic community. For a variety of reasons, toe amputations are sometimes necessary to prevent infection or disease from threatening the rest of the foot. Toe wounds develop as a result of corns, poor circulation, and nail damage. The toe has a limited blood supply compared with tissue of the rest of the foot, and the body has a tougher time getting oxygen and nutrients to the tissue to heal those wounds. This problem is amplified even further when one considers the effect diabetes has on the smaller blood vessels of the toes, as well as the contribution of large blood vessel blockage in the legs and poor blood flow that diabetics (among others) are more at risk for. Include smoking and you have a dangerous mix of problems for toe wound healing. Bacteria can take advantage of this, and toe infections are not uncommon. Due to the thinness of the toe tissue compared with the rest of the foot, many toe wounds can go so deep that they expose bone, which can easily become infected. Although many foot infections can be treated with oral antibiotics, the limited capacity of blood to deliver the medication to the toe tissue can hamper the medication’s effectiveness. Thus, the toe infection worsens and spreads towards the foot. When enough tissue damage has occurred, or when the infection threatens to spread to the rest of the foot in a deep and serious way, a decision must be made as to whether the toe can be saved. This is especially true when bone infection is present. If the toe cannot be saved, and the disease threatens the rest of the foot, it is only logical that the toe must be removed.

A common concern amongst those having one or more toes removed is how this removal will effect their balance. In short, the removal of a toe or several toes should have no effect on a person’s balance. The toes function somewhat differently than what most people assume. While it is true that the toes provide some stabilization of the foot when a person is pushing off the foot before moving the leg forward, the actual muscles that control side to side ‘balancing’ of the foot attach to the foot well before the level of the toes. The foot will still bend the same after a toe amputation, and all the parts of the foot needed for normal walking are still part of the foot. Even those with half a foot amputated still have a semi-normal walking pattern with normal balance. The control of real balance in the body is performed by the a part of the brain, with assistance from feedback of nerve fibers in the bottom of the foot and elsewhere. Together, this system works consciously and subconsciously to control the position of the body in its space, and to propel the body forward. The loss of one or all the toes has little to no effect on this system, and on its own does not make the foot ‘clumsier’ or less able to function.

Essentially the drawbacks of a toe amputation are little, as long as it heals properly, and the benefit of saving the foot from more serious disease cannot be overlooked. There should be no concern with walking or balance issues, and cosmetic concerns should be tempered by the relief that the rest of the foot and leg was made safe by the toe amputation.

Until next time,

Scott R. Kilberg DPM

A foot doctor serving the communities of Indianapolis, Noblesville, Fishers, Carmel, Westfield, and Fortville Indiana.

Diabetes and the heel pad

2010-03-04T13:45:00.003-05:00

A study recently published in Clinical Biomechanics looked into the ‘padding’ of the diabetic heel versus the padding in an otherwise healthy individual. This study, from CC Hsu and colleagues, demonstrated that the stiffness of the smaller chambers of fatty tissue was significantly decreased in diabetics compared with non-diabetics. These smaller chambers were superficial, and closer to the skin. A previous study by this same author had determined that the smaller chambers were important in supporting and cushioning the larger chambers below, or those closer to the heel bone. A deformity in these smaller chambers would have a direct effect on the integrity of the heel padding all the way to the bone. The larger chambers in this recent study were stiffer by comparison in diabetics than in non-diabetics. Whether or not this is enough to offset the decreased stiffness in the smaller chambers is unknown. Still this study essentially reveals that the ability of diabetics to withstand heel pressure is decreased, and it can be inferred that there is a stronger likelihood of heel sores in diabetics without even taking into account other the other usual factors like poor shoes, bone pressure, poor circulation, and poor glucose control. Diabetics simply by foot structure are more apt to develop heel wounds.

This has reinforced the need for diabetics to seek better heel padding in the form of cushioned shoes and shoe inserts. Diabetic padding with a material called ‘plastizote’ is still the gold standard for care. Perhaps in the future advances already begun in augmenting the heel tissue by artificial means may help reinforce the superficial heel fat pad itself. Current techniques are inconsistent, and have usually led to long term failure. Work is still needed, but the advance of biological material in surgery continues to make consistent strides.

Until next time,

Scott R. Kilberg DPM