Lower Extremity Neuropathic Disease (LEND)

Speaker A: 00:00:10

In the last two classes, we talked about management of lower extremity arterial ulcers and lower extremity venous ulcers. In this class, we're going to talk about management of lower extremity neuropathic ulcers.

So our objectives are to explain the pathology and risk factors for peripheral neuropathy and for neuropathic ulcers, to describe the clinical presentation of sensory neuropathy, motor neuropathy and autonomic neuropathy, and implications for screening, assessment to outline an appropriate management plan for the patient with a neuropathic ulcer, to include all floating glycemic control and topical therapy, and to describe or demonstrate the procedure for all floating with adhesive felt. So we're doing the video right now. You're going to complete the learning exercises.

And again, there's a very thorough chapter in the core curriculum for additional information and background reading. So we're going to begin with an overview of neuropathy, and we're going to talk about the pathology and the impact.

We're going to talk about in general, we're going to specify the impact of sensory neuropathy, how to screen for sensory neuropathy, motor neuropathy, how to screen autonomic neuropathy, how to screen the pathology of neuropathic ulcers, and implications for prevention. Specifically, painless repetitive trauma, pressure injuries, acute trauma from a penetrating oxygen burn and dry cracked feet.

All of these are incredibly common issues for our diabetic patients. So what is neuropathy? Well, the word tells you it obviously impacts on the nerves and it's some kind of pathologic condition.

So what you end up with is damage to the sensory, motor and autonomic nerves. That means you have compromised sensation. You're high risk for painless trauma because of damage to the sensory nerves.

Damage to the sensory nerves can also cause neuropathic pain. You've probably seen all the commercials on tv about neuropathic pain, and it truly is miserable.

Motor neuropathy causes altered foot contours, foot deformities, altered weight bearing, increased risk for callus and ulcer formation. Autonomic neuropathy can cause osteopenia, which places the individual at very high risk for fracture.

If the fracture is unrecognized, it can progress to a short, closed foot deformity. Autonomic neuropathy also causes reduced sweating and very dry feet. So breaking it down, if you have neuropathy, you get damage to the nerve cells.

Now, we tend to associate neuropathy with poorly controlled diabetes and chronic hyperglycemia and in our country, that is the most common reason for neuropathy. So we'll start with hyperglycemia.

When you have a patient who has chronically high glucose levels, what happens is you get glucose in the nerve cells. Within the nerve cells, that glucose is converted to sorbitol by an enzyme called aldose reductase. You know what sorbitol does?

Sorbitol attracts fluids. So now you have all this sorbitol in the nerve cell.

You attract fluid into the nerve cell, it causes intracellular edema that compromises nerve cell function and specifically the conduction of nerve impulses. So you get a nerve cell that's just not functioning normally. And look at the percentage of patients with diabetes who have significant neuropathy.

40%. Some individuals already have neuropathy by the time their diabetes is diagnosed.

So a very significant issue in individuals with diabetes, to the point that if I have a patient with diabetes, I assume they have neuropathy. Until I screen them and determine otherwise, what are the other factors that can contribute to neuropathy?

Any kind of ischemia that affects the nerve cells and the receptors. So you think about how critically important perfusion and oxygenation is to function of all organ systems and all structures.

Same thing is true of nerve cells, nerve receptors. So if you have patients with microangiopathy, they're very high risk for neuropathy. Now look at the diabetic patient.

One of the things that can happen in diabetes is damage to the blood vessels. So they're at risk for two reasons. First of all, persistent hyperglycemia and sorbitol in the nerve cell, that causes nerve cell edema.

Secondly, damage to the blood vessels that supply the nerve cells so that you get ischemic damage. There are other metabolic conditions that can cause neuropathy. A b twelve deficiency is a very common reason for neuropathy.

What about patients with spinal cord injuries, spina bifida, other neurologic processes? Yes. That results in damage to the nerve cells, failure of sensation, loss of motor control and loss of autonomic function.

So whenever you have neuropathy, whether it's caused by b twelve deficiency, whether it's caused by hyperglycemia, whether it's caused by some kind of ischemic pathology, almost always it will affect all three types of nerves, sensory neuropathy, sensory, motor and autonomic. So now we're going to talk about each of those in a little more detail.

We tend to think of neuropathy in terms of sensory neuropathy because that one has such a major impact. Patients can have one of two clinical presentations. One is they can have a lot of paresthesias. Paresthesias are burning, tingling sensations.

Sometimes they describe them as electric shock sensations. Sometimes they describe them as pins and needles.

So you think when you roll over your arm, on your arm at night and you wake up and you're waiting for blood supply to be restored, and you've got that pins and needles sensation, think how awful that is. People with paresthesias are living with pins and needle sensations.

Electric shock, burning, tingling sensations, sometimes the whole time they're awake, and sometimes it wakes them up at night. So paresthesias matter. If you have a patient with paresthesias, you want to get them in to see someone who can treat them with medication.

So your gabapentin and related medications are designed to treat paresthesias. We are more likely to deal with patients who present with progressive anesthesia.

So what happens is they have progressive loss of sensory awareness that is known as protective sensation. So this is how protective sensation works.

Think about how many times, and this is particularly relevant if you're female, how many times you found a really cute pair of shoes on sale. They don't feel great in the store, but we convince ourselves they'll stretch out, they'll be okay.

So we wear the shoes to some social event because they go with our outfit. We get a lot of compliments. So initially, we're kind of walking around proud of our footwear. But then what happens? Then we start to develop pain.

So we get blisters on our heels. Our toes are killing us, whatever. But we're aware that we are sustaining tissue trauma. So what do we do? We modify our activity.

Instead of walking around, we stand still, we sit down, we take off our shoes. Probably many of you have walked to your car with your shoes in your hand because no way you were going to get them back on your feet.

That's protective sensation. It made you stop. It made you sit down. It made you take off those offending shoes. But what if you had not had protective sensation?

What if you had neuropathy? Then you would have put those shoes on.

You would have marched around for however long that social event lasted, totally unaware of the trauma you were sustaining to your soft tissues.

You would maybe wear the same shoes again the next day unless you carefully inspected your feet when you got home and found all those areas of trauma. So protective sensation is just that. It warns you that something is wrong.

It warns you your shoes are too tight, your shoes are rubbing you're walking on hot pavement, the shower water is too hot. It warns you, and that allows you to take protective action to maintain the viability of your feet.

Once you lose that protective sensation, you're very high risk for painless trauma. Now, there is a difference between loss of protective sensation and a foot that is insensate with loss of protective sensation.

You may sustain minor trauma and not recognize it.

So like the trauma associated with poorly fitted footwear, but as long as I have some sensory function, I'll probably recognize if I step on something really sharp, if I step on a piece of glass, if I step on a nail, if I put my foot in the shower and the water is way too hot, and I'm sustaining a burn. Patients with insensate feet do not recognize that they have total loss of sensation. Those are the people who literally step on the nail.

It penetrates their shoe, goes into their foot, they don't know it, they keep walking. It's hard for us to even imagine. But those people don't know that they have nailed their shoe to their foot until they try to take the shoe off.

I had a patient who lost his leg. He had gotten a new shower head. He, instead of having a hot and a cold, you just regulated it on that central control mechanism.

He had turned it all the way to hot, didn't realize it was standing and talking to his wife. So he had 1ft in the shower in his turn, talking to his wife.

When he turns back around, he sees that his foot is bright red and the skin is peeling off. He lost his foot. He didn't feel anything. That's an insensate foot. So sensory neuropathy is progressive.

It starts with variable degrees of loss of protective sensation and can progress to a foot that is totally insensate. Now, if I ask a patient, do you have normal feeling in your feet, do you have normal sensation or do you have loss of protective sensation?

How am I going to know that I have loss of protective sensation? I'm going to say, yeah, I think so. I think I feel normally. So far as I know, we don't ask.

We do routine screening for our at risk patients, our diabetic patients. We use three things to do routine screening. The first is the monofilament. Sims Weinstein monofilament, specifically the ten gram or 5.07.

If you have done this before, you know exactly what I'm talking about. If you haven't done it, we will practice it when you come on site in bridge week. So you'll be practicing on each other.

So heads up before you come to bridge week. If you're female, you probably want to get a pedicure because. Because people are going to see your feet.

Okay, back to protective screening or routine screening. So how am I going to determine whether or not you have normal protective sensation? I'm going to take that monofilament.

I'm going to have you close your eyes. I'm going to touch the monofilament to your skin with enough force to make it bend into a c. It's not painful, but you can definitely feel it.

I'm going to test typically at ten points, the first 3rd, 5th toe pads, 1st, 3rd, 5th metatarsal, heads at mid foot, medial and lateral over the heel, unless it's obscured by callus, and on the dorsal aspect between the first and second toes. So here's the way it goes. I show you on your hand, I have you close your eyes, then I'm touching first top, no response. Third top, no response.

Fifth toe pad, no response. At this point I'm going to stop and say, have you felt anything so far? The patient might say, well, yes, but it didn't hurt.

Then I reiterate, it's not supposed to hurt. I just want to know if you can feel it. So tell me. Every time I touch your foot, it takes a minute and then, you know, do they have protective.

Do they have protective sensation? Have they lost protective sensation? The second thing I want to do is vibratory sense testing. And this is testing with a tuning fork.

So you're going to strike the tuning fork against the palm of your hand until you can literally feel it vibrating. Then you're going to test at the base of the great nail or over the bunion bum. The patient should feel that vibratory sense.

And if they say, yes, I feel it, then you tell them, tell me when it stops. You either wait until the vibration stops on its own or you pull the two sides of the tuning fork together to stop it.

Now, why does it matter if you have vibratory sense? Does that seem important to you? I mean, does it protect you on a daily basis? No.

The only significance of vibratory sense is that loss of vibratory sense is typically the first step down the neuropathic pathway. It's the first type of sensation to be lost. So maybe you still respond to the 5.07. On your last visit, you responded to vibratory sense testing.

On this visit, you do not respond to vibratory sense testing. So I would want to say to you, you've lost vibratory sense. You don't recognize the tuning fork anymore.

And then the patient's going to say, so does that matter? Why do I care? Because it tells me you're starting to develop neuropathy. We want to do everything we can to keep that from progressing. What can I do?

Tight glucose control, primarily. We'll come back to that. The third thing we want to test is position sense, also known as proprioceptive testing.

It tells you whether or not the patient knows where his foot is in space. Now, why does this matter? Well, think about when you're walking down steps and you're in a hurry.

Maybe you have something in your arms and all of a sudden you're aware that your foot is not really on the step. It's on the very edge of the step and it's hanging out in space.

You get that feedback immediately that allows you to reach for the side rail, lean back, compensate, regain your footing. Same thing if you're walking on irregular terrain and you start to stumble. You get feedback, you compensate.

So how many of you have experienced times when you almost fell, but you didn't because you got that feedback and you adjusted, you compensated, it protected you. People who lose position sense lose that proprioceptive awareness have to be very careful going down steps. They have to look and hold on.

They have to be careful when they're walking on irregular terrain. So how do you test for position sets? So you tell me to close my eyes, pretend this is my great toe.

You tell me you're going to move my great toe in different directions, and you want me to tell you what direction you move my toe. So then you might move my toe toward me, to my right, down to my left. And you want to see if I know in which position you place my toe.

If I do know, great. I'm low risk for falls. If I don't know, if you pull it this way and I'm like, down, you pull it this way, I'm like, to the left, put it this way up.

Then you have to counsel me. So every test we do has implications for patient management and patient education. And this kind of summarizes it.

If I lose vibratory sense, it means I have started down that neuropathic pathway. It precedes sensory loss. So I want to talk to the patient about tight glycemic control.

If my patient's middle aged or older, I'm probably going to mention b twelve daily because we all lose the ability to absorb b twelve normally as we age. And b twelve is critical to nerve function.

If I have a patient who has lost or is losing protective sensation, what are the things I need to teach them? First of all, if that person no longer has normal protective sensation, they should not be buying their shoes off the rack.

If you're diabetic but you have intact sensation, it's okay to buy your shoes off the rack because you'll know if they're too tight. But if you have loss of protective sensation, no, you should not buy your shoes off the rack. You need to have your footwear professionally fitted.

If you've lost protective sensation, absolutely essential that you always wear protective footwear whenever you're out of the bed because you're not going to know that there was something small in the carpet that you stepped on. You're not going to know that you might have injured your foot. So you have to protect your foot at all times.

And you cannot rely on your feet telling you when there's a problem. So you have to do daily foot inspections where you literally take off your shoes and socks and look at your feet.

If you've lost position sense, proprioceptive sense, I have to counsel you. Hang on. When you go down steps, watch when you're walking on irregular terrain. So this just shows you some wounds caused by sensory neuropathy.

In some cases, you have combination problems. The patient on the top left, he had no idea how he had gotten this wound. He's like, I don't know. I'm pretty sure it wasn't there.

In the morning, I didn't notice anything when I put on my socks and shoes. But when I took my socks and shoes off at night, they were all gummy. There was drainage. I don't know. And then I found this wound.

But when we inspected his footwear, there was a very tiny little pebble that had gotten stuck to the side of his shoe and was rubbing. So he started out with intact skin, but at the end of the day, he had a significant ulceration.

Protective sensation would have stopped him, forced him to take off his socks, take off his shoe, figure out what was rubbing against his foot. The patient on the top right now, that's a really scary slide.

That's a patient who has a through and through ulcer from stepping on a nail, not recognizing it. It went all the way through the foot. I know, it's so creepy, you can't even imagine. But it happens every day.

The patient on the bottom left, you see how all of the toes on the end are bruised or red. This patient was wearing shoes that were one half to one, full size, too small. They didn't feel too tight. In fact, they felt good to him.

And when we put him in the correctly sized shoes, he said, they feel too loose.

So one of the things that you find in working with patients with neuropathy is that they frequently go to smaller shoes because they can feel the pressure and it makes them feel secure. Again, you go back to the importance of professionally fitted footwear.

The patient on the bottom right has a combination of sensory and motor neuropathy. So you can see the toes are curled up. He has hammer toes, so now the toes are rubbing against the top of his shoes.

But he doesn't recognize that because of the sensory neuropathy. So a variety of trauma can occur as a result of sensory neuropathy. Now, motor neuropathy is damage to the nerves that control the muscles.

You get atrophy of the muscles, so it's going to cause foot and toe deformities, because when you get muscle atrophy, then what tends to happen is the flexor tendons take over and cause contractures. You get atrophy of the muscles controlling gait.

So you get abnormal gait, abnormal pressure points on the plantar surface of the foot, eventual callus formation. So let's just go through this and look at the illustrations. So, common foot and toe deformities are overlapping toes, hammer toes, claw feet.

So hammer toes are very, very common. Those are the flexion contractures of the toes that cause them to curl up like this, like you see on top.

When you get altered weight bearing, so you get atrophy of the muscles that control the gait, you get abnormal weight bearing. So now you get abnormal pressure points and abnormal areas where you get repetitive shear and friction.

The skin responds by forming a callus, trying to protect itself. So very common to see a callus surrounding a plantar surface ulcer, that's from motor neuropathy.

If you have the combination, as we've already said, you get unrecognized skin and tissue damage. How do you screen for motor neuropathy? You look at the feet you're inspecting for deformities.

You watch them walk, you can have them stand and do an impression on a piece of paper with underlying ink to see if they have abnormal pressure points.

You look at their shoes, you might not have that little, you know, device that allows you to do an imprint, but you can look at their shoes and you can see abnormal wear patterns on their shoes. Even better, look at their feet on the plantar surface and look for callus formation, which tells you abnormal repetitive shear infringement.

What about autonomic neuropathy? Well, this is damage to the nerves that control both the sweat glands and the blood vessels.

When you have autonomic neuropathy, you lose the ability to sweat normally. So you get dry, cracked feet and you can get fissure formation.

So if you look at the illustration on top, you see those deep cracks, those fissures and those deep cracks almost always extend through that callused epidermis into the dermis, create open wounds that, in turn present a risk of infection. So we need to deal with dry, cracked feet.

The other thing that can occur as a result of autonomic neuropathy is something called charcot's foot deformity.

Now, what tends to happen is that because of autonomic neuropathy, you get persistent vasodilation of the arterial vessels, so you get very high volume blood flow to the feet on a continual basis. Now, when I was first studying this, I'm like, well, that sounds like a good thing. How can high volume blood flow be a bad thing? Here's what happens.

High volume blood flow causes demineralization of the bones, thinning of the bones. The bones become so thick or so thin, rather, that very minor trauma will cause a fracture.

You're probably thinking, well, how does high volume blood flow cause thinning of the bones? It's similar to the impact of water on rock.

So when you think of the phenomenon of erosion, you think, well, water against rock, water's not going to do anything to rock. But what happens with water flowing over rock repetitively, day after day after day, you get erosion.

What happens to high volume blood flow against the bones in the foot, day after day after day demineralization, thinning of the bone, also known as osteopenia, and a foot that's very high risk for fracture with mineral, with minimal trauma. So think about this.

If you have very thin bones in your foot and you step off the curb raw, and you twist your foot and you get abnormal torsion forces, you can snap a bone. Remember, there's not one major bone in the foot.

No, there's 26 little bones that work together to provide support for you when you're walking or running. 26 little bones.

So if one of those bones is very thinned out, or if all of them are very thinned out and you step off at the wrong angle, easy to fracture one of those bones. Now, if you had intact sensation as soon as that happened, you would know, oh, my God, I've done something terrible to my foot. It's killing me.

So if you were with a group of people, you'd probably say, I think I might have broken my foot. I did something to my foot. They might say, well, can you walk on it? No, it hurts way too bad. Somebody's got to go get the car. Come and get me.

But if you have osteopenia and you have sensory neuropathy, you step off the curb, you get that fracture, you kind of look around to see if anybody saw you because you feel really embarrassed, you know, you look stupid. Nobody saw you. You just keep walking. Or if you are with a group of people and they're like, whoa, are you okay? You're like, yeah, I think I'm fine.

You don't have pain. Pain protects you in the face of any kind of injury. So if you get a fracture, you recognize the fracture, you immobilize the foot.

You allow that fracture to heal, then you get minimal changes long term in the bony structures. But in this patient who has sensory and autonomic neuropathy, typically the fracture is not recognized.

And so the patient continues to walk on that fracture, putting increasing stress on surrounding bones. And then what tends to happen is you get additional fractures. Eventually, you get total collapse of the bony architecture of the foot.

And you get this rocker bottom foot, known as charcoal deformity. And you can see what it looks like on x ray in the middle slide, and you can see what it looks like clinically in the bottom slide.

Now, ideally, we would teach the patient, check your feet every single day. If you see areas of redness, areas of heat, you've got to get that evaluated. You might have a fracture.

Because if we can help them recognize tissue damage, help them recognize the fracture, intervene appropriately, you can prevent the sequelae of massive loss of the normal architecture of the foot. Okay, so if you want to screen for autonomic neuropathy, you're going to look at the skin. You're going to assess skin hydration.

Do you have very dry or very wet feet? It's almost always very dry feet. Are there any fissures? You're gonna look at the foot contours, particularly on the plantar surface.

You're gonna look at patterns of weight bearing. Does it look normal? You're gonna teach patients to screen their feet every day and to be alert to any indications of trauma.

So daily visual assessment for erythema, daily skin temperature check using a skin thermometer. What they're looking for is a deviation from baseline. So if I test here and I get a certain reading. I test here, I get a certain reading. I test here.

I get a reading that's two degrees centigrade higher that suggests an inflammatory response. That suggests trauma. Let me recheck. Here, normal. Here, normal. Here, normal. Here, elevated. Here, elevated. I need to get it checked out.

Okay, so now let's talk about the pathology of neuropathic ulcers. Obviously, painless repetitive trauma is a very common reason.

It's almost always repetitive friction and shear pressure injuries are much less common. They typically occur over the heel if they occur only in bed bound patients. For your ambulatory patients, it's repetitive friction insurance.

Rubbing against the top of the shoe, rubbing against the heel, rubbing against the sides of the shoe, or this constant shear force that occurs every time we take a step. So, as we've said, it's going to be located on areas in contact with the footwear.

Sometimes the heels, due to friction, sometimes the tips and tops of toes due to friction. The plantar surface over the metatarsal heads because of repetitive shear and friction.

That's particularly common in older individuals because the fat pads that normally protect the metatarsal heads tend to thin. In the elderly population, they're much more at risk for repetitive trauma.

Over those metatarsal heads, you might see abnormal weight bearing due to altered foot contour. So you're looking, you're looking for evidence of problems. Do you see areas of damage? Do you see areas of callus formation? Are there wounds?

Wounds can occur between the toes, especially when the toes overlap or are very close together. Then you trap moisture and you get increased friction. And as we've said several times, callus is a frequent precursor to ulceration.

So if you see callus on the plantar surface, number one, you need to pare that callus down to make sure there's not an ulcer underneath. And number two, you need to be sure that that patient gets evaluated and fitted for appropriate footwear insults.

So let's talk about how we teach the patient to prevent painless trauma. And it begins with footwear. That's the best protection the feet get, right? So you need correctly fitting shoes.

If you have a patient with altered foot contours, they need to have an orthotist, somebody who has expertise.

Footwear fitting needs to evaluate their feet, evaluate the contours, look at their gait, look at their weight bearing patterns, select appropriate footwear and create customized insoles. What about heels? Heels are the worst thing that someone with neuropathy could select.

Even a two inch heel increases pressures over the metatarsal heads by 57%. So we encourage even our female patients with diabetes to avoid heels, except for very special occasions.

And if it's a special occasion, they're going to carry their heels in one bag, they're going to wear sensible shoes until they get to the event, put on their heels, minimize walking, and switch back to their sensible shoes before they walk back to their cardinal. If you have a patient who has had ulcers over the metatarsal heads, then you know they're very high risk to get more wounds.

And every time they take a normal step and get up and walk, you're going to do heel strike, you're going to come up over the metatarsal head, you can feel that shear and friction, and you're going to toe off. Those patients are going to do best if they're placed in shoes with rigid soles that minimize that flexion over the metatarsal heads.

They'll do better if they have shoes that have kind of a turned up tip, kind of a rocker bottom effect, because rocker bottom shoes protect the metatarsal heads and the top heads. That's where padorthist and orthotist come in handy. They know footwear, they know how to match footwear to feet with altered contours.

They know how to protect patients against ulcer formation.

So, number one, you spend a lot of time talking to people about footwear, how important it is to get it right, places they can go to have shoes correctly fitted to make sure they're in the right insole. Talk to them about limiting heels, and then you talk to them about checking their feet every day.

And they're looking for any evidence of injury, any evidence of fracture, any areas of inflammation. So they're supposed to uncover their feet, wait for 20 minutes, check the temperature at multiple points.

It's not the absolute temperature that matters. Deviation from baseline. So I check here, I'm going to make up numbers. Let's say I check here, I get 36 degrees centigrade.

I check here, 36 degrees centigrade. Check here, 35.8 degrees centigrade. Check here, 38 degrees centigrade. Check here, 38 degrees centigrade.

Okay, now I have an area where the temperature is two degrees, two degrees centigrade higher, two degrees centigrade. Four degrees Fahrenheit considers significant evidence of inflammation. That foot needs to be evaluated. So you want them in to be checked?

Somebody should be looking at their feet. We should be getting an x ray to rule out a fracture. Okay, so we've talked about repetitive stress. What about pressure injuries?

That occurs in bed bound patients with sensory neuropathy because they don't recognize that ischemic damage is occurring.

So if I have a patient with sensory neuropathy and they're bed bound, it's critical for me to teach them and their caregivers to protect the heels and the ankle bones. So when they're in the supine position, they should be in offloading boots.

When they're sidelined, they should either be in offloading boots or pillows to keep the ankles off the bed. What about pressure injuries in ambulatory patients?

Remember, most injuries in ambulatory patients are more due to repetitive friction and shear, not so much pressure.

You could get pressure damage from a toe box that is too narrow, where you have constant compression of the tissue over the bony prominences, over the bunion. Over the bunionette.

You will not get a pressure injury on the plantar surface because you would have to stand in place for a prolonged period of time, at least 2 hours. Nobody's going to do that. But you might occasionally get pressure injuries on the side of the foot.

Whether we're talking pressure injuries or friction shear injuries, one of the preventive measures is to break in new footwear gradually. So first of all, it should be professionally fitted. Secondly, leather or fabric is preferred because leather will give, fabric will give.

You don't want them wearing footwear that has some kind of plastic surface because it doesn't give. And finally, they should not put on a new pair of shoes, go off to work for 8 hours, and hope that nothing bad happens.

They should wear their new shoes to work and take the shoes they have been wearing, because the first time they wear the new shoes, it should just be 2 hours a day for about five days to see how well they tolerate that. Okay, you did okay for 2 hours a day. For five days. Okay, now 4 hours a day, then six, then eight. Break them in gradually.

Okay, so we've talked about repetitive shear and friction causing trauma. We've talked about pressure injuries. What about penetration by sharp objects? So you know how we always tell people, don't go barefoot?

There's all kinds of things that could damage your feet. People come in, they have needles in their feet, they're like, oh, hmm, that's a needle in my foot. I've got glass in my foot.

I've got some kind of foreign body in my foot that we're not even sure what is. How did it get there? You stepped on it and it penetrated the skin and buried itself in the soft tissue.

How do you protect against that kind of trauma, you always wear protective footwear. If you're out of bed, you should have protective footwear on your feet, and it should be basically hard soled or firm soled shoes.

Not just socks, not just slippers. Slippers are very well named because that's what you tend to do in them. So you want firm soled protective footwear.

You also want to teach people, shake after shoes before you put them on. Things end up in shoes. You know, if you have kids, you're going to end up with little Lego pieces in the shoes.

You could end up with stepping on a spider. All kinds of things end up in shoes. Shake them out before you put them on.

So one of the physicians who is just legendary in the field of diabetic foot care always insisted anytime his patients came in for anything, he made them take off their shoes and socks so he could check their feet. And most of your patients just knew this, and they just took off their shoes and socks and didn't argue with him.

But he had this guy one day, and he was arguing with him that he didn't have time. He had an important business meeting, blah, blah, blah. There was nothing in his shoes, et cetera, et cetera.

And so he said, well, if there's nothing in your shoes and you're in a big hurry, you better take them off quickly because you're not getting out of here until I look at your footwear and until I look at your feet and you'll notice I'm standing between you and the door. So the patient's grumbling, grumbling, grumbling. Takes off his shoes.

He is walking around on one of the little things you use to get your foot into the shoe. He's got one of those little metal things.

What are those things called that you just get your, you know, you used to get your shoe and your foot into the shoe. He had no idea it was there. He had sensory neuropathy. So it's critical you have to make a big deal out of all of these points.

Your shoes are your number one protection. Make sure they're fitted correctly. Make sure you're wearing them when you're out of bed. Make sure you shake them out before you put them on.

And finally, if you have neuropathy, do nothing. Do anything that could damage your tissue. Don't do any bathroom surgery.

Don't take your pocket knife to that corn or that callus, which people do every day of the week. So you have to make a big deal about it. Check temperature, shake out your shoes. Put your shoes on. Don't do bathroom surgery.

Have professional nail care done. Finally, dry, cracked feet, you're at risk for fissure formation. Then that's a perfect pathway for bacterial invasion.

So you teach patients to use pumice stones or emery boards. We talked in an earlier class about the option to use vinegar water soaks ten minutes, two to three times a week.

Talked about the importance of checking temperature and drying well between the toes and then making sure that you use very heavy duty moisturizers to typically you're going to use humectants.

So either your lack hydrin, which is your urea based, or atractane or petrolatum, something that's really going to help you deal with that very dry skin. Okay, so in summary, for part one, and then we'll move right ahead into part two. Three types of neuropathy, sensory, motor and autonomic.

How do you screen for sensory neuropathy? You check for protective sensation with the monofilaments. You check for vibratory sense with the tuning fork.

And you check for position sense by moving the toes back and forth. Motor neuropathy can result in foot deformities. Altered gait screening is all about inspection.

You're looking for deformities, you're watching them walk, you're checking wear patterns, you're looking for calluse formation. Autonomic neuropathy can result in very dry skin and fissure formation. So you're going to look at your skin, you're going to check for fissures.

It can also result in thinning of the bones because of high volume blood flow. So you're going to look for any evidence of altered contours.

You're going to teach the patient to inspect their feet every day and to be very alert to areas of warmth, increased temperature. That foot needs to be checked. Preventing neuropathic ulcers. It's all about footwear.

Daily foot inspection, keeping the skin soft and checking temperature daily. So now we're going to move into part two of neuropathic ulcers and we're going to talk about the characteristics of neuro ischemic ulcers.

We're going to talk about the Wagner classification system very briefly. That's not a major focus. We're just going to mention it and we're going to focus on what it is we do to manage neuropathic ulcers.

What do we do to eliminate repetitive trauma? What are our options for offloading? Reinforce the importance of glycemic control. Talk briefly about topical therapy and patient education.

So some of this you've heard already.

Now, one thing you already know is that neuropathic ulcers are very common in the diabetic population, and lower extremity arterial disease is also relatively common in the diabetic population.

So you might very well have a patient who comes in with, quote, a diabetic foot ulcer, and it might be a combination of neuropathy and lower extremity arterial disease. So, bottom line, most of your patients with neuropathic ulcers are also high risk for lower extremity arterial disease and ischemic ulcers.

So whenever you're doing your assessment, in addition to doing sensory motor assessment, you're going to do a vascular assessment, you're going to check skin, hair, nails. Do they look normal, abnormal? What about pulses? Do you have good pulses or your pulses non palpable and you can barely hear them with the Doppler.

What does your abi say? Very important to know whether you're dealing with neuropathic ulcer alone or with a neuro ischemic ulcer.

So if you've got neuropathy, but they've got great blood flow, their foot's warm, they've got great pulses, their ABI is normal, then your focus and management is on offloading and glucose control. If you've got combined disease, you have to focus on improving perfusion in addition to offloading and maintaining glucose control.

So if you have evidence of ischemia in a patient with a neuropathic ulcer, critical to initiate a vascular consult so that you've got vascular on board, they're going to be determining whether or not any intervention is required.

But if there is coexisting ischemia, it's going to make you think twice about doing any debriefment or recommending any debriefment if you have significant ischemia. So your ABI is less than 0.5. If your pulses are non palpable, your wound is covered with dry eschar. There are no signs and symptoms of infection.

You're not going to debride until the vascular workup is complete, until you know that you have enough blood flow to promote healing. So back to the same things we talked about under arterial disease and ischemic wounds.

When you talk about neuropathic ulcers, what are the characteristics? Well, with lower extremity wounds in general, location is probably the biggest giveaway. So where are arterial wounds located distally?

The distal toes and foot or areas of trauma that didn't heal? Where are venous ulcers located between the ankle and the knee, areas where the perforator system is likely to fail. What about neuropathic ulcers?

They're going to be located in areas exposed to repetitive trauma and rubbing, like the tips and the tops of the toes, the sides of the feet, areas in contact with the footwear that frequently are exposed.

Repetitive rubbing and plantar surface typically over the metatarsal heads where you get abnormal weight bearing, abnormal shear and friction every time they take a step. With neuropathic ulcers, the edges are usually very well defined. You can usually draw a little line around the edges.

So very defined, shallow crater formation, the wound basis typically red. Unless you have coexisting ischemia.

They have typically moderate amounts of exudate and very, very common to find callus formation right around the wound and sometimes obscuring the wound. Because, remember, the body's first response to repetitive trauma is to form a callus to try to protect itself.

Now, here's that Wagner classification system again.

I don't want you to get lost in this, but it's very helpful to know the basics because a lot of physicians, surgeons and hyperbaric centers do use this. So great.

Zero means there is no wound, but the patient is known to be at risk because they have callus or there's evidence of a healed ulcer or there's presence of bony deformity. Grade one is partial thickness. So there's definitely skin loss, but it does not extend into the fat or the deeper tissue layers.

Grade two, full thickness. Now you've got extension into the fat. Grade three, you've got infection of the bone, of the soft tissues, maybe a combination.

Grade four, at least one digit is gangrenous. In grade five, the foot is gone. It is not salvageable, and they're going to have to do an amputation and disarticulation.

Okay, so now let's talk about management of neuropathic ulcers. And the most critical thing is to eliminate the repetitive trauma.

So if you have a bed bound patient and they have a heel pressure injury, of course you want to get the heel off the bed. If I have toe ulcers. So they're on the tips of the toes, the tops of the toes.

I want to make sure that the shoes they're wearing have a toe box that's wide enough and deep enough to protect the toes. So I might refer them to that. Orthotis or pajorthis. If I have a plantar surface ulcer, like over the metatarsal heads, I have to, to offload.

I have to make sure that when that patient is walking, they are not causing shear or friction stress against the surface of the wound. So I have to do offloading. Here are the options.

Total contact cast, like you see at the top is the gold standard, removable cast walkers like you see at the bottom. We're going to talk about offloading with adhesive felt, and we're going to talk about why half shoes are not usually a good option.

So let's talk about total contact casts.

So when they do total contact casting, what they do is they pad all the bony prominences, they dress the wound, they apply the cast, and then they put the walking plate on the hind foot so that you're effectively offloading the metatarsal heads and the toe pads, which is where neuropathic ulcers typically are. Now, at this point, total contact casting is considered the gold standard for offloading a plant or surface wound.

And this is why, as they say in the literature, it promotes compliance. Well, I think it requires or enforces compliance because you can't just take the cast off. But notice how high the healing rates are. 89.5%.

That's great. So, yes, I would consider that gold standard as well.

Definitely the highest healing rates significantly reduces plantar surface pressures and protects the whole foot and leg against trauma. There's a reason that you don't always see patients in total contact casts, and that is the. They're time consuming to apply.

You need a very skilled clinician to do it. Casting is contraindicated if the wound is infected or ischemic, or if the depth is greater than the width.

And there are definitely safety issues, because if you think about a cast with a walking plate, that's going to put weight bearing on one leg very different than the other. And a lot of these people have gait issues to begin with.

So what if you have a patient, they have a plant or surface wound, they're not a good candidate for a total contact cast for one of those reasons. Or maybe you don't have anyone who can do it, then the next best thing, based on current data, is to use a removable cast walker.

And so a lot of you have worn these for musculoskeletal injuries. So you know that what they are, there's a. It's a boot device.

It has a hard outer shell, it has some kind of accommodative padding over the planter surface, and it gives a slight rocker bottom effect that helps to offload the metheads and the toe pads. So the good things are, yes, you can use these.

When a total contact cast is not feasible, you can send them to be fitted for a removable cast walker, but the healing rates are not nearly as good. As you see, it drops from 89% to 65%. Why is that? Probably because they're removable.

So the advantage is they're removable for sleep and bathing and wound care.

And the disadvantage is the removable nobody really wants to be wearing a cast all the time, or these heavy boots, and nobody wants to stop and put one on when they get up during the night to go to the bathroom. So unless your patient's very well educated and really gets it, this might not be as effective.

On the plus side, it is a one time charge for the payers. So if they have a good pay, your source, they can probably get it paid to for. You do have that hard outer shell, so you have protection for the foot.

Like we've said, it can be removed, which is both a plus and a minus.

Some of them, the crow walker and the DH Walker, have healing rates that are comparable to the total contact cast because they are definitely rocker bottom.

And what I'm showing you in the little illustration on bottom is that the planter surface padding for some of these devices has little removable foam pegs, and you can pluck them out to give additional offloading. What about half shoes? Now, this is always mentioned in the literature, but you just look at this and you see a lot of disadvantages.

So on the plus side is a sandal with an elevated heel platform. So it offloads the metatarsal heads and allows the patient to remain ambulatory, sort of. It does have accommodative padding.

They're relatively lightweight. You can remove them for wound care, sleep and bathing, but first of all, you can remove them. So compliance can be an issue. Healing rates drop again.

And look at them. There's no protection for the toes or the dorsum of the foot, and there's major safety issues related to altered gait.

So you would be, you would really think very carefully before you would use a half shoe. So what could you do if the patient wasn't a candidate for total contact casting, or you didn't have anyone to do it?

Maybe they could afford a removable cast walker. You can do this very simple offloading procedure with adhesive felt, and you'll practice this when you come on site for bridge week.

So basically what you do is you cover the wound with clear plastic film, like oxide or tegaderm.

You mark the wound with lipstick, and then you press the foot against the paper side of adhesive felt so that you create an impression of where the wound is and where the felt needs to be cut out. And then, as you can see here, it's kind of like a keyhole or u shaped cutout. So you try to avoid that donut effect.

After you do the cutout and you shape the piece of adhesive felt to the foot, then you apply it directly to the plantar surface. You dress the wound, you secure the dressing with wrap gauze, and then typically, you can put them in their athletic shoes.

Now, the reason this works is because adhesive felt is very dense. So even if you put all of your weight on it, it doesn't compress. So it lifts the patient up off the wound. And that's all you have to do.

Stop the year, stop the phretion. Now, do we need more data on this? Absolutely.

But what we do know from anecdotal reports and from case series is that this can be very effective when you have a patient who's not a good candidate for total contact casting. Okay? So offloading, priority number one. Priority number two, tight glucose control. Ideally, you keep glucose levels between 100 and 140.

We've already spent a lot of time talking about the negative effects of hyperglycemia on healing and the prevention of infection.

So, glucose levels over 180, white blood cells are in a coma, glucose levels over 140 compromised, collagen synthesis, keratinocyte migration, all of those things. But it has to be the patient's choice whether you're talking offloading, glycemic control, smoking cessation.

So you want to sit down and say to the patient, let's talk about what would be involved in getting this wound to heal. Let's talk about your goals in terms of wound management. I hear you say that your goal is to get this wound to heal.

Do you realize that would require you to, number one, stay off of the wound. Either wear a boot or we can use adhesive felt, but we have to get you off the wound. It would require you to control your glucose levels.

Is this a good time for you to take on those? So they have to know how important it is.

They have to determine, okay, is healing this wound important enough to me that I'm ready to consistently wear that offloading device, consistently control my glucose levels. Now, topical therapy, not so different from moist wound healing. So is basically manage your exudate, maintain a moist wound surface, right?

But especially when you're managing a diabetic foot ulcer.

Absolutely critical to eliminate all of the necrotic tissue as soon as possible, because studies have shown that this is critical to healing of a diabetic foot ulcer. As long as there's necrotic tissue in the wound bed, you're locked into that inflammatory cycle and the wound is going nowhere.

The longer it's locked in that inflammatory cycle, the more likely it is that you're going to get an infection that further compromised the tissue and that tips the balance to amputation so early, aggressive debridement, aggressive management of infection.

So if there's a tunneled wound, there's a extensive soft tissue infection or the wound is not progressing, that patient probably needs an MRI or a bone scan to rule out osteo. If there is soft tissue infection, you need culture based antibiotic therapy.

And in many settings for diabetic foot ulcers, clinicians routinely use antimicrobial dressings just to reduce the risk of infection. We've already talked about how important it is to pair callus so that you can expose any hidden wounds, and so you establish open wound edges.

We keep talking about the importance of patient education. You think about the patient with a diabetic foot ulcer.

In the end, it's going to be their responsibility to manage the wound and to prevent recurrence. So it's critically important for them to understand why all floating matters and to understand the specifics.

One clinician explained to his patient, you can stay off your wound 23 hours a day, and if you walk on it for that last hour, for 30 minutes, you've undone all the good you did. All floating has to be consistent. So we've got to figure out a way that will work for you. Glucose management matters.

Wound healing does not proceed if glucose levels are not controlled. Wound care matters.

And finally, once we get this thing healed, you've got to be so careful with that foot because you do not want this wound to come back. So you've put your whole management plan together. You've educated your patient. You've got them in an offloading boot or adhesive felt.

They're working hard on controlling their glucose levels. You've got an appropriate wound care plan in place. You've eliminated necrotic tissue.

You've treated infection, your many gene exudate and keeping the surface moist. But the wound is very slow to respond. What else can you do? You're going to go back to, to one of your active wound therapies.

You're going to look at the ones that were specifically tested against diabetic foot ulcers. And you're going to think, well, maybe I should use a matrix dressing and provide a scaffolding for the cells.

Maybe I should think about exogenous growth factors, that gel that was produced by recombinant DNA technology because that was actually tested on diabetic foot ulcers. So maybe I should think about that.

Maybe I should think about a dermal tissue replacement that brings fibroblasts to the site, as well as a lot of growth factors to stimulate healing. Or if it's pretty shallow, maybe I should think about a bilayered skin equivalent.

And finally, if I'm worried about ischemia, I should think about hyperbearing follow up care. Absolutely critical, or they'll be right back with another wound. So should I go back to wearing the shoes I was wearing when I got this wound?

Of course not. Will I? Unless you make a big deal out of it. Probably.

So as I approach healing, I should be evaluated by a podorthist or an orthotist to assure proper footwear once my wound is healed. And I should not go from offloaded to walking wherever I want to walk, that is new tissue, baby tissue.

So you have to treat it very carefully so you gradually increase walking time, just like you gradually increase time wearing new shoes. Most patients are going to need customized footwear. Most of them need extra depth shoes. They might need customized insoles.

And all of that has to be accompanied by daily inspection to see how am I doing. How do my feet look? Do I have any areas of redness? What happens when I take the temperature?

Are there any areas where the temperature is two degrees centigrade higher? Then I need a professional to evaluate my feet.

You should be aware that Medicare covers one pair of diabetic shoes and three pairs of molded insoles per year. But you have to have a prescription. The prescription has to be written by the care provider managing that patient's diabetes.

But a lot of people don't even know about that. So you might have to educate them that that is a benefit they have.

So in summary, when you're managing neuropathic ulcers, critical to do vascular assessment to rule out any coexisting ischemia. Characteristics of neuropathic ulcers common locations, plantar surface tips, tops and between toes, heels and other areas in contact with footwear.

Typically they have well defined edges, they're typically moderately exudative. They have a red wound base, unless they're also ischemic. And callus is very common. If you had to drill down management of neuropathic ulcers.

It would come down to this. First of all, eliminate trauma, offload the ulcer.

Secondly, assure tight glycemic control, doing and providing topical therapy and moist wound healing.

Your focus is on early aggressive debridement, immediate treatment of any infection, and if you're going to get long term positive outcomes, it's all going to come back to patient education, follow up and appropriate footwear. Thanks.