Dry skin, interdigital fissuring and forefoot plantar hyperkeratosis are all signs and symptoms that may predispose patients to forefoot ulcerations. A diabetic lower extremity examination may seem routine but documenting and addressing these seemingly small changes may deter the devastating effects of peripheral neuropathy. Moisture balance therapy, accommodative shoe gear and routine diabetic foot care remain important factors in the preventative care of the diabetic population.
Essential Principles In Treating Diabetic Forefoot Ulcers
Reducing plantar pressure and decreasing the strain rate improves wound healing. Decelerating the foot prior to contact and decreasing the time the foot is on the ground will decrease force over time.47 This can be a very difficult task if the proposed treatment does not properly offload and/or change the biomechanics of gait.
There are only a few devices that decelerate the foot prior to hitting the ground and decrease plantar weightbearing while walking. The literature supports the following devices: TCC, Charcot restraint orthotic walker (CROW), CAM boot, patellar tendon bearing brace, and ankle foot orthoses (AFOs).45,49 Not all patients may be candidates for these types of devices and reimbursement may at times pose problems. The key is to choose the best modality that can provide adequate offloading, allow for adequate padding in high-risk areas and facilitate a transfer of ground forces away from the wound site.
Unfortunately, due to the cumbersome nature of some of these devices, patient adherence has become a challenge. Patients often refuse the application of a non-removable cast or the costs associated with them. This leads to a less costly or removable less effective device to be chosen. Patents may be more tolerating and adherent with slight modifications to shoe gear, which they may already have some familiarity.50
Additionally, Wu and colleagues noted that the practical realities of daily practice can lead to the use of less effective offloading modalities. They found that “… although most specialists understand that amelioration of pressure, shear, and repetitive injury are principal tenets of diabetic foot ulcer care, the cost/benefit analysis, realities of maintaining a busy clinical practice, the available manpower, and reimbursement issues may influence clinicians to use less optimal pressure mitigation methods.”50
All providers should follow the same consensus recommendations for diabetic foot ulcerations when performing a comprehensive foot and ulcer evaluation. These fundamental components should include: history and physical examination, appropriate laboratory testing/screening, neuropathic and vascular assessment, and ascertaining nutritional status.28
Ulcer evaluation should consist of determining the duration, location and measurements of the wound as well as the presence of infection and previous treatment. Identifying the presence of infection and ischemia in the diabetic limb is vital in the algorithm to successfully treat diabetic forefoot ulcerations.
Dr. Hanft is the Director of Research for the Podiatric Residency Program and the Director of Podiatric Education at the South Miami Hospital in Miami. He is in private practice at the Foot and Ankle Institute of South Florida in Miami. Dr. Hanft is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Hall is a third-year resident at the South Miami Hospital at Baptist Health South Florida in Miami.
Dr. Jarman is a third-year senior resident at the South Miami Hospital at Baptist Health South Florida in Miami.