Ever wondered what exactly a podiatrist does, and why it’s so important for people with diabetes to have an annual check-up?
Podiatrists are responsible for foot management in five key areas, as described by the International Working Group on the Diabetic Foot:
1. Regular foot assessment (inspection and examination of the foot)
2. Identification of the foot at risk (early warning signs of damage)
3. Educating the patient and family members (includes education on footwear)
4. Management of non ulcerative illnesses in the foot
5. Management of the diabetic ulcer
The annual foot assessment by a qualified podiatrist is the single most important consultation to help you prevent a foot ulcer.
A podiatric assessment (30 to 45 minutes) involves testing the following systems in the feet: vascular (blood circulation), neurological (nerve function), dermatological (skin), orthopaedic (bones and joints) and footwear.
• Vascular assessment includes examining for present, diminished or absent pulses. (A hand-held vascular Doppler may be used in assessment.) It also includes testing for capillary refill time, temperature and colour changes. Further tests such as ankle brachial index (ABI) and claudication tests (calf muscle cramping) may be done. Remember that blood carries oxygen and nutrients to all tissues as well as carrying away metabolites and dead cells. Good blood circulation is vital to nourish nerves and muscles, as well as promote wound healing.
• Neurological assessment involves evaluating vibration perception with a 128Hz tuning fork, protective pressure with the 5.07 mono-filament, light touch, sharp/blunt differentiation , proprioception, hot/cold differentiation and joint reflexes. There are 3 different nerve systems in the body: sensory, motor and autonomic. Any or all of these nerve systems can be affected by diabetes and early warning signals can be picked up by the podiatrist when doing the neurological assessment of the foot.
• Dermatological checks for lesions (sites of injury), bruises, skin discolouration, blisters, fissures (cracks), anhidrosis (unnaturally dry skin), thin skin, migration of tissue, corns and callus, nail changes and infections, e.g. fungal infections. Fungal infections must be treated: toenail fungus distorts the nail plate, often causing ingrown nails. Spores from nail fungus can embed in the skin causing athlete’s foot. Athlete’s foot causes a break in the skin that can lead to a secondary infection with complications such as cellulitis and ulceration. With regular observation, an ulcer can be detected, treated or prevented by picking up telltale signs before it happens.
• Orthopaedic assessment involves checking the ranges of motion of the joints of the foot and ankle and noting any bony deformities or changes such as hallux abducto-valgus (bunions), hammer toes and claw toes. Changes in how well the joints move and/or bone alignment result in altered weight bearing leading to increased pressure on those parts of the foot. A podiatrist will be able to assess whether the foot architecture predisposes a patient to potential biomechanical problems, e.g. long second toe or a high arch. A podiatrist is qualified to prescribe and fabricate custom orthotics (shoe inserts) that will offload pressure on the foot.
• Footwear. Appropriate footwear is important as faulty or inappropriate footwear may result in ulceration due to pressure on skin that has lost protective sensation. You won’t necessarily know that you’ve lost protective sensation unless you have your regular podiatry foot assessment, since the neural measurements are very fine.
To be a good shoe, you need to consider that the inside of the shoe is in contact with the skin of your foot. The lining shouldn’t have any ridges or thick stitching edges that could chafe and cause pressure or friction. The shoe should be the correct length, width and girth, neither too loose nor too tight. It should hold on to your foot in at least two places: over the top of the foot and behind the heel. This is necessary so that the shoe will follow the foot as it moves.
Walking is the best exercise for your feet but the walking should be natural, using all the muscles of the foot in concert. Styles such as slip ons, backless flip flops or backless slippers are not suitable since they need extra muscle action (think of those toes curling or scrunching) just to try and keep the shoes on the foot! Not to mention the fact that normal walking (a rolling action from heel or heel-midfoot contact through to toe off) is replaced by a sort of shuffle as the person walks in flip flops, for example. This alteration of normal walking can cause unnatural pressure or friction on parts of the foot. Footwear should be highly flexible so that every part of the foot is exercised with every step. Hard soles can lead to increased pressure under the foot when walking.
Future posts about diabetes and feet:
- All the different types of shoes, both for women, men and children and why certain features are great for people living with diabetes and other features are to be avoided.
- Hints on handy foot exercises to keep blood circulation pumping, whether you’re at the office or waiting for the pot to boil at home in the kitchen, or sitting in front of the TV…
- The benefits and hazards of beauty shop pedicures as well as what moisturizer ingredients really work on hard skin on the feet (a guide to check labels and ask questions).
- And a quick checklist for foot problems – when to self treat (and how) and when to go get help in time…
– Anette Thompson, M Tech Podiatry (UJ) B Tech Podiatry (SA)