The challenges of preventing foot and leg ulcers in our most vulnerable patients have always existed. However, the COVID-19 pandemic created a new set of concerns for podiatric physicians.
In May of 2020, I noticed increases in re-ulcerations of previously healed wounds, amputations, new lower extremity ulcerations and Charcot arthropathy cases in my practice. As social distancing and quarantine continued, I found many patients became less aware of daily microtrauma that led to skin breakdown, tissue loss and infection in their lower extremities.
Even my most astute patients did not realize that offloading foot pressure points while social distancing at home and maintaining edema control was prudent for managing and preventing lower extremity ulcers. Many patients had a false sense of security, thinking that their homes' safety would help them avoid common complications of neuropathy, vascular disease and poor glycemic control.
Before writing this blog, I reviewed the charts of 15 patients who either had a digital or ray amputation, a recurrence of a previously healed wound, a Charcot diagnosis with an ulcer or a new lower extremity ulcer. Out of the 15 charts I reviewed, very few of my patients could relate a history of trauma or any remarkable event that would cause ulceration. In fact, only two patients described a history of trauma. One patient had a puncture wound and the other had an open fracture after a frozen turkey fell on her foot when she was rearranging a packed pandemic freezer.
Three patients decided not to wear their compression stockings while quarantining. Two patients had ill-fitting house shoes and four high-risk patients did not wear shoes or slippers while quarantining at home. Two high-risk ulcer patients walked around barefoot while quarantining at home. One patient cited an inability to obtain new diabetic shoes during the pandemic and one patient sustained an injury while attempting to trim a callus.
Six out of the 15 patients stated that it was difficult to get an appointment with me once they realized something was wrong, mostly because my practice had to limit the number of patients due to social distancing. All 15 patients did not want to go to the emergency room once they developed an ulcer for fear of contracting COVID-19. Ironically, four patients acquired SARS-COV2 by the time of their initial visit with me concerning their ulcer.
Self-surveillance and monitoring as well as patient education are critical to prevent lower extremity complications, especially during the COVID-19 pandemic. In July 2020, my colleagues and I started performing telephone wellness checks as an adjunct treatment for our high-risk patients with ulcers.
Key aspects of the wellness checks included …
• Instructions on how to find online foot care tips and resources from the American Podiatric Medical Association (APMA) and the American Diabetes Association;
• Education about lower extremity inspection and self-examination;
• Encouragement of regular visits, either in-office or via telemedicine;
• Education on offloading and the importance of wearing diabetic shoes, slippers with thick soles and compression stockings at home;
• Asking patients to identify dangers in their home that could cause a lower extremity injury;
• Education as to what signs and symptoms would indicate an infection necessitating immediate treatment; and
• Encouraging our patients to be more responsible and proactive about their own health.
Our typical patients with high-risk lower extremity ulcers might have increased barriers during the pandemic that prevent them from accessing health care. It is essential to incorporate innovative but simple patient monitoring like wellness checks to successfully manage would healing at all stages. Although this will require physicians to be more diligent with patient monitoring, this small adjunct to your wound care will help prevent ulcer recurrence and/or ulcer deterioration.
Dr. Robinson is the Chair of and an Assistant Professor in the Department of Medicine at the Temple University School of Podiatric Medicine. She is a Diplomate of the American Board of Podiatric Medicine.