Essential Principles In Treating Diabetic Forefoot Ulcers

Jason R. Hanft, DPM, FACFAS, Daniel Hall, DPM, and Mikkel Jarman, DPM

   Conservative management of equinus includes a comprehensive regimen to reverse the contractures of the gastrocsoleus complex. This regimen may include stretching exercises, night splints and physical therapy. Several studies have demonstrated that using an appropriate stretching exercise routine as the primary treatment for equinus has a statistically significant improvement in ankle joint dorsiflexion in comparison to other modalities.12 As physicians, it is essential to document and demonstrate to patients the importance of adducting the foot 10-15 degrees to unlock the midtarsal joint during stretching exercises to allow for the greatest stretching benefit.11-13

   Surgical management of the equinus deformity, of course, consists of the highly debated tendo-Achilles lengthening and gastrocnemius recession. Both procedures have well documented benefits.14 Several studies, however, support the gastrocnemius recession as superior because it provides better healing potential, controlled lengthening of the entire posterior complex and avoids potential over-correction.15 In comparison to a gastrocnemius recession, there may be over-correction with the tendo-Achilles lengthening if one has not addressed the influence of the gastrocnemius soleus complex.15

Understanding The Impact Of Motor Sensory Neuropathy

Diabetic peripheral neuropathy is a multifocal disease process. Treatment is often devoted toward strict glycemic control and symptomatic treatment of sensory neuropathy.16 Pharmaceutical companies spend millions of dollars annually on research and development for treatments of sensory neuropathy aimed at the diabetic population.17 Motor neuropathy, on the other hand, has a much more subtle presentation. It often goes unexamined and the effects on the lower extremity consistently go unrecognized.18

   In a study of 169 consecutive patients with diabetes, Ishpekova and colleagues showed that nearly 60 percent of the patients suffered from motor sensory neuropathy in comparison to 18.6 percent with pure sensory neuropathy without the presence of detectable motor deficits.19 The most common manifestations of motor neuropathy in the lower extremity consist of atrophy of the anterior leg extensor musculature; atrophy of the plantar intrinsic musculature; hammertoe deformities secondary to a prolapsed metatarsal head and fat pad displacement; hallux valgus deformity; neuropathic ulceration; and gait instability.19

   With the culmination of all potential deformities and abnormalities stemming from motor sensory neuropathy, the risk of diabetic forefoot ulcerations increases exponentially. Additionally, Anderson and colleagues concluded in a previous study that “patients with diabetes have ankle weakness with a significant decrease in available dorsiflexion as a result of motor neuropathy associated with diabetes, and that the degree of weakness was related to the degree of neuropathy.”19,20

   Conservative treatment to accommodate the associated manifestations of motor neuropathy includes: diabetic shoes with custom moldable insoles; extra depth shoes; bracing and orthotics; or physical therapy for gait and strength training. One should initiate adjunctive surgical intervention in combination with conservative care in the presence of rigid hammertoe deformities to minimize the risk of ulceration or amputation. The current surgical recommendations regarding digital deformities triggered by motor neuropathy are a primary phalangeal joint arthrodesis or digital flexor tendon transfer.18 Prior surgical approaches often consisted of a more traditional arthroplasty. However, due to the overwhelming evidence of digital instability caused by motor neuropathy, many surgeons have proven arthrodesis to be more favorable.18

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