Preventing Foot Injuries In Diabetic Athletes

Author(s): 
By Mark A. Caselli, DPM

What You Should Look For During The Exam
The development and use of a foot management plan for the diabetic athlete can be an important tool in preventing foot injuries and serious lower extremity medical complications such as infections, ulcers and amputations.
A thorough lower extremity evaluation of the diabetic athlete is an essential part of establishing a foot management plan. The evaluation should include a medical and sports (athletic activity) history. One should also be on the lookout for peripheral neuropathy, circulation compromise and any biomechanical abnormalities. A history of prior infections or ulcerations of the foot has important predictive value with regard to the potential for future ulcerations and other pedal complications.
Each patient visit should include a thorough evaluation for peripheral neuropathy since neuropathy is the major component of nearly all diabetic ulcers. Using the Semmes-Weinstein 10-gram monofilament wire, you should take measurements at the following 10 sites: the first, third and fifth digits plantarly; the first, third and fifth metatarsal heads plantarly; the plantar midfoot both medially and laterally; the plantar heel; and the dorsum of the midfoot.
When the athlete loses normal sensation, he or she fails to be aware of excessive plantar pressure. When it comes to treating patients with sensory neuropathy, you should identify and protect areas of potential excessive plantar pressure, such as a plantarflexed metatarsal. One should also consider the increased potential for foot fractures when the diabetic athlete has an insensate foot. Consider obtaining X-rays after the patient participates in any strenuous sports activity such as a marathon. You should schedule a follow-up exam in two to three weeks given the possibility of a stress fracture, which might not be evident on the initial X-rays. A follow-up X-ray at that time is strongly recommended, especially if there are associated findings such as localized swelling and deformity.
One should perform a vascular evaluation to detect claudication or rest pain, a prior history of lower extremity arterial bypass surgery, abnormal pedal pulses, capillary return time and dependent rubor or palor on elevation. You may use a Doppler to determine the ankle-arm index. Determining circulatory status is important given the increased incidence of atherosclerosis in individuals with diabetes.
You must recognize and address structural pedal malalignments in the diabetic athlete, especially in the presence of sensory loss. Conditions such as hallux valgus, hammertoes and plantarflexed metatarsals create areas of increased pressure and potential tissue breakdown.

Advising Patients About Increases And Timing Of Activity
When it comes to increasing exercise activity, diabetic patients with the aforementioned conditions should do so in small increments. The goal of limiting the increase in activity time is to avoid the accumulation of the localized inflammatory effects in the areas of bony prominences. The athlete should check these areas of the foot after every exercise activity for increases in temperature. If he or she notes any “hot spot” area at night that is still present in the morning, this is an area of risk for the athlete.
Normal hyperemia from exercise should resolve within 30 minutes. For this reason, jogging workouts are often best divided into two intervals during the day, and performed every other day.

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