How Should a Diabetic Foot Ulcer be Treated?

The primary goal in the treatment of foot ulcers is to obtain healing as soon as possible. The faster the healing, the less chance for an infection.

There are several key factors in the appropriate treatment of a diabetic foot ulcer:

•Prevention of infection.
•Taking the pressure off the area, called “off-loading.”
•Removing dead skin and tissue, called “debridement.”
•Applying medication or dressings to the ulcer.
•Managing blood glucose and other health problems.

Not all ulcers are infected; however if your podiatric physician diagnoses an infection, a treatment program of antibiotics, wound care, and possibly hospitalization will be necessary.

There are several important factors to keep an ulcer from becoming infected:

•Keep blood glucose levels under tight control.
•Keep the ulcer clean and bandaged.
•Cleanse the wound daily, using a wound dressing or bandage.
•Do not walk barefoot.

For optimum healing, ulcers, especially those on the bottom of the foot, must be “off-loaded.” Patients may be asked to wear special footgear, or a brace, specialized castings, or use a wheelchair or crutches. These devices will reduce the pressure and irritation to the ulcer area and help to speed the healing process.

The science of wound care has advanced significantly over the past ten years. The old thought of “let the air get at it” is now known to be harmful to healing. We know that wounds and ulcers heal faster, with a lower risk of infection, if they are kept covered and moist. The use of full strength betadine, peroxide, whirlpools and soaking are not recommended, as this could lead to further complications.

Appropriate wound management includes the use of dressings and topically-applied medications. These range from normal saline to advanced products, such as growth factors, ulcer dressings, and skin substitutes that have been shown to be highly effective in healing foot ulcers.

For a wound to heal there must be adequate circulation to the ulcerated area. Your podiatrist can determine circulation levels with noninvasive tests.

Obtaining Proper Shoes Through Medicare

Over the years, I have found that unfortunately, one of the best kept secrets among patients with diabetes is the Medicare Therapeutic Shoe Program. People with diabetes are instructed that they need to make sure they wear proper shoes. This is a program that makes this possible! Per Medicare guidelines, patients who qualify can receive one pair of shoes per calendar year, and three pair of accomodative inserts. Three pair of inserts are allowed because over time, they lose their ability to cushion the feet. By dispensing three pair, patients can change the inserts every 4 months, thus insuring that they always have proper cushioning and support in their shoes. While not every diabetic patients on Medicare qualify for this program, the truth is that many do qualify, and there are many who qualify who are not taking advantage of this program.



For a shoe to qualify for the Medicare Therapeutic Shoe Program, it needs to meet certain criteria. These include:

• Have more interior depth than a normal shoe, which allows for at 3/16" accomodative insert.


• Must be made from leather or a material of equal quality


• Must have some form of closure (usually laces or a Velcro closure)


• Must be available in full and half sizes


• Must be available in at least 3 widths.
  

Many diabetic patients are concerned that the shoes will be big, heavy or unattractive to wear. This is simply not the case. The variety of shoes styles available means that it is extremely rare not to be able to find a pair of shoes that meets your need, both medically and aesthetically. On top of that, the shoes are designed to be comfortable!

To qualify for shoes, you need to be examined by your doctor to see if you meet Medicare's guidelines for receiving the shoes. Once it's determined that you qualify, a letter will need to be received from your primary care physician who will certify that you are diabetic and would benefit from receiving the shoes. This is one of the few programs that Medicare offers that is intended to be preventative. Studies have shown that by wearing proper shoes, the risk of developing an ulceration in the foot can be greatly reduced. In other words, you don't have to already have had a foot ulcer to qualify, you just need to be at risk of developing an ulcer. You also do not have to be on insulin to qualify.

Most offices will do a fitting, then order the shoes for you. Once the shoes are shipped to the office, you will be contacted for shoe dispensing. In our office, we recommend that you wear the shoes indoors until you are certain that they are right for you. If for any reason they are not, they can be returned for a more appropriate size or style.

If you have not taken advantage of this program, talk to your podiatrist & see if it is something that you would benefit from. And if you have received a pair of shoes in the past, perhaps it's time for a new pair. Your feet will thank you!

Podiatrists Save Diabetic Feet...It's Just What We Do

I had an experience yesterday that almost moved me to tears. In December I wrote about a gentleman who was incredibly close to losing his leg, if not his life (Here's the original post). Within a short time frame of days, he went from having a "minor" ulcer treated to a major infection of the foot which ended up with him losing two toes, but has retained the functional foot. Before the first operation, I had a conversation with the infectious disease physician caring for him who was insistent that my surgery was futile and he needed an amputation above his knee to save him. The patient and I discussed this and agreed that we wanted to try anyway.

During the first operation, I experienced an infected foot like I'd never seen before, even in my training. It was very apparent that the surgery didn't get rid of the infection like it should have. A few days later, another surgery with a toe amputated. The following week a third surgery with a second toe amputated. Then the miracle...

His fever dropped to normal, all the color came back into his face, his appetite returned. He looked healthy. He made a commitment to his wife, me, and most importantly, himself, to take this horrible time in the hospital and take charge of his diabetes. He did everything right to lower his blood sugar to normal levels. We sent him for Hyberbaric oxygen treatments which helped the residual minor infection to resolve and started to promote healing. As he was discharged, we put a negative pressure "VAC" dressing on his foot to further promote healing.

Our initial hope was to get the wound to the point that we could use a skin graft to close it. Yesterday, that changed. He is doing everything right, including being vigilant about controlling his diabetes. The bottom of his foot is close to healing on its own...without a skin graft! This is ideal, since that would make the skin much thicker and would minimize the risk of breaking open again. Thinking where we were just a few short months ago, I'm staggered to think that soon he'll be back to wearing shoes and even back to work with two functioning feet.

Good thing we decided not to take the easy way out by amputating the leg, don't you think?