Discussing the case of a 78-year-old patient with diabetic neuropathy who presented with a swollen foot, this author notes how a disconnect between specialties made things worse, and how common sense conservative care can make a difference in this patient population.
Complications can happen sometimes even with the best provider intentions. A 78-year-old male with a history of long-term but well controlled diabetes mellitus presented and said he had not been completely aware of the degree of neuropathy in his feet. He knew there was some numbness but did not understand the extent to which he was lacking sensation. With no memory of any significant trauma, he noted a relatively sudden onset of a swollen left foot, ankle and leg. There was no pain but he gradually started to notice some difficulty ambulating. It was his wife who finally encouraged him to seek help. The path he followed was a correct one but needed more attention to detail.
His first stop was his primary care physician, who focused on the swollen leg. He had no significant pain but with unilateral swelling, his physician sent him for a venous duplex ultrasound. The results were negative for a thrombus and the ultrasound accomplished nothing.
After a few more weeks, he found his way to a podiatrist. The initial X-rays identified an obvious problem but it was very difficult to tell whether he had an acute or chronic issue. He was ambulating and easily able to perform activities of daily living and anything else he wanted. The main thing he noted was he needed to wear an extra arch support inside his shoe. Without it, he felt as though his foot was rolling in too much.
At the urging of friends and family, he sought another opinion from an orthopedist. The orthopedist gave recommendations regarding possible surgical options ranging from tendo-Achilles lengthening to midfoot osteotomy. This caused the patient to experience significant anxiety. Since he was functioning relatively well, at least in his mind, surgery was completely out of the question. As a result, the surgeon recommended an ankle-foot orthosis (AFO) in order to protect the foot and provide stability. Since the patient was worried about the foot and didn’t want it to worsen, this seemed like a reasonable option to pursue.
The patient subsequently visited an orthotist, who fabricated a gauntlet AFO. After waiting a few weeks for the AFO, the patient started to wear it as much as he could. He immediately noted discomfort associated with wearing the brace. He tried to stick with it due to the fact that the orthotist told him a progressive midfoot deformity would likely result if he did not wear the brace. The brace was large. His size 15 feet were already a problem to accommodate and a brace was going to make fitting a brace even more difficult.
The shoe store was his next destination. He had instructions to bring the brace with him. Finding shoes to fit the brace was a challenge. The length was challenging but with the brace taking up so much depth and width, he was forced to try on shoes that were much too big, making the right foot swim inside of the shoe. All he could do was follow the orders of the professionals guiding him but this was becoming very frustrating.
At that point, a minor complication occurred. After having had enough discomfort wearing the brace, he looked at his foot where it bothered him most and noted a blister developing in the arch. After searching the Internet and self-diagnosing Charcot, he became very scared and realized he needed even more help. That help was in the form of common sense.
Sometimes it takes true attention to detail in order to obtain optimal function. Medicine has become so specialized that we sometimes readily hand off what we don’t know or understand. In this particular situation, it would have made more sense to work from the ground up instead of starting at the leg and moving down to the ankle and foot and down to the ground. After clinicians determined that his situation was not acute and that he was not going to have surgery, comprehensive conservative care should have been the focus. Instead of trying to stabilize the foot internally with surgery, the focus should be on external stability with shoes, shoe modifications, orthotic devices and bracing.
The first step is a simple one: fitting him for a pair of shoes. The shoes should meet certain criteria that will help all conservative modalities succeed. Adequate length, width and depth, along with proper midfoot stability, are important considerations. If feet are dramatically different in size, then mismatched shoes are an option. If the deformity is significant enough, then one should fabricate custom shoes.
After obtaining appropriate footwear, then consider either an orthotic or a brace. This should be based upon his function.
X-rays indicated a Lisfranc dislocation in this patient. This has resulted in significant abduction of the forefoot and a large medial prominence in the midfoot. In other words, he had a transverse plane deformity. Fabricating a brace to control a transverse plane issue will only create shoe and friction-related problems. The brace needed to fit the shoe, which is straight lasted. The foot is abducted and the apex of the transverse deformity is where the blister occurred. The solution for this patient was shoes to fit both feet and accommodative orthotic devices that will alleviate pressure and friction from the prominent region of his midfoot.
The practice of medicine is divided into many specialties. However, the care of our patients is not always easily categorized. Many of our patients need several modalities that rely upon each other. To have many providers each only doing their own thing without the knowledge and expertise of other areas does not necessarily help the patient. The key to optimizing function is communication among specialties and trust in our colleagues to help the patient obtain the best outcome. That starts with common sense and sometimes something as simple as a properly fitted pair of shoes.
Dr. Levine practices at the Frederick, MD Division of The Foot & Ankle Specialists of the Mid-Atlantic. He is the Director of Physician’s Footwear, an accredited pedorthic facility in Frederick, Md. He is also the owner of the Walkright retail comfort shoe store in Frederick, Md.