I also call this lecture

I also call this lecture

GO BUCKS!!! My Background Cornerstone University Grand Rapids, MI Kent State University College of Podiatric Medicine (OCPM) Florida Hospital East Orlando 3 year surgical residency Lower Extremity Trauma Foot and Ankle Deformity Correction Surgery Management and Treatment of the Diabetic Foot Reconstructive foot and ankle surgery Most podiatrists have extensive training in Traumatic injuries of the foot/ankle/leg Treatment of diabetic foot complications/wound care

Pertinent Pointers for Physical Exam Vascular Palpate pulses Capillary fill time Skin texture and turgor Pedal hair growth Advanced Testing TcPO2 < 25 mmhg = decreased wound healing Arterial Doppler Segmental Pressures and ABI's Toe Pressures

Neurological Pertinent Pointers for Physical Exam Semmes Weinstein 10g monofilament for protective sensation 1 st, 3 rd, and 5 th toes and met heads, plantar arch, and heel Vibratory with 128Hz tuning fork - 1 st MTP and medial malleolus Sharp/Dull sensation Two point discrimination Light touch Proprioception of great toe position Advanced Testing EMG/NCV ENFD biopsy

Pertinent Pointers for Physical Exam Musculoskeletal ROM and EQUINUS Toe and forefoot deformities most risky Bone spurs and pressure points Advanced Testing X-ray MRI CT Bone scan/wbc scan

Pertinent Pointers for Physical Exam Dermatologic Hyperkeratotic lesions with intradermal hemorrhage = stage 0 ulcer Ulcerations evaluated by inspecting for erythema, edema, malodor, purulence, and warmth Some melanomas mimic diabetic foot ulcers Advanced Testing Skin/tissue biopsy Fluid cultures Superficial wound cultures are inappropriate

Charcot Neuroarthropathy red, hot, swollen

Eichenholtz Classification Prefragmentation (Stage 0) initial inflammation Acute or Fragmentation (Stage I) fracture and collapse Coalescence (Subacute) (Stage II) bony resorption Consolidation (Stage III) return of stable, usually collapsed, foot

Charcot Treatment Acute and subacute stages (0,I,II) NWB activity/offloading Until inflammation and swelling resolve Total Contact Cast or CAM boot Bisphosponates Coalescence stage (III) Initiate WB Accommodative orthotics Rocker bottom shoe Charcot Restraint Orthotic Walker (CROW boot)

Charcot Gout

SWOLLEN FOOT RED, HOT, (my cell is 239-703-5000 ;-)

So how should I treat my patients with peripheral neuropathy???

If not diabetic, absolutely! Should you work it up? If suspicion of infectious process or nutritional deficiency, treat appropriately and symptoms may resolve If patient is diabetic? Usually assume DPN ~90% of PN is caused by DM

Peripheral Neuropathy Etiology D iabetes A lcoholism N utritional = Vitamin B1, B6, B12, E G uillan-barre T oxic = Drugs, Lead, Arsenic HE reditary = Charcot-Marie Tooth, Refsum's dz, Friedrich's Ataxia R ecurrent = Chronic inflammatory demyelinating polyneuropathy A myloidosis P orphyria I nfection = HIV, leprosy, mononucleosis, Lyme, diptheria, untreated syphilis S ystemic = Uremic syndrome, SLE, hypothyroid, Sjogren's T umors = paraneoplastic, multiple myeloma

IRREVERSIBLE Diabetic Peripheral Neuropathy Prevention = tight glycemic control Intensive treatment à increased mortality risk (ACCORD study) HTN, hyperlipidemia, elevated BMI, and smoking MAY contribute to DPN Clinical trials focusing on disease modification have failed because we lack knowledge on the pathophysiology of DPN Gerstein HC, et al. Effects of Intensive Glucose Lowering in Type 2 Diabetes. N Engl J Med 2008; 358:2545-2559

My Treatment Protocol (Level V Evidence) Mild Moderate Severe Mild numbness or burning in toes No treatment or topical analgesics Partial or complete numbness which includes forefoot Mild constant dysesthesias Diabetic shoes and inserts Low dose pharmacotherapy + Vitamin supplementation Constant pain, loss of motor function, profound numbness Pharmacotherapy + Vitamin supplementation Physical medicine (PT, TENS, Ultrasound, Massage) DM shoes and custom inserts a MUST Experimental (Electronic signal transfer, Anodyne)

Bril V, et al. Evidence Based Guideline: Treatment of Painful Diabetic Neuropathy. Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2011 May 17; 76(20): 1758-1765

5 Year Mortality Rates Robbins JM. Mortality Rates and Diabetic Foot Ulcers. J AM Podiatr Med Assoc 98(6): 489-493, 2008.

If you don t already Refer to Your Favorite Podiatrist! l l l l Several studies have demonstrated decreased morbidity and mortality when podiatric surgeons are involved in the care of diabetic patients with and without ulcerations A 2011 study demonstrated that during the 2 years following the onset of an initial DFU, podiatric care lowered the cost of treatment under commercial plans by $13,474 and by $3624 on Medicare plans. Podiatrists reduce hospitalizations secondary to ulcer/infection, reduce the formation of DFU's, and reduce amputation rates We save limbs, but also subsequently save lives per the mortality statistics previously mentioned

3. Renal disease 2. CHF 1. Liver disease Remember that foot ulcer ALONE increases risk of mortality in diabetic population by 37% - Do not underestimate the morbidity and mortality of a foot ulceration Patients with DM and one of these systemic comorbidities should see a podiatrist at least every 3 months

Look for callouses, bony deformities, or areas of irritation on every diabetic foot Calluses with intradermal hemorrhage may be ulcerated Refer immediately Equinus increases forefoot loading pressure, early heel off, increased shear, prolonged stance phase

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