Anti Diabetic Patients

Problems with felt padding

In this early case from the mid-1980s an 80-year-old woman with type 2 diabetes of 20 years' duration developed a corn over her left 1st metatarsal head. She attended a podiatrist who debrided the corn, applied a felt pad to deflect pressure, and told the patient on no account to remove the pad for 3 weeks. After 1 week the foot became painful but the patient refused to allow the pad to be removed. Three days later she was taken to casualty by her daughter. Deep necrosis had developed under the felt pad and she underwent extensive soft tissue debridement and amputation of the first ray. The foot healed in 9 months.

Key points

• Opaque coverings or padding should be lifted regularly to inspect feet which lack protective pain sensation

Clinical Signs Foot Preulcerative

Fig. 3.6 Heavy callus containing speckles of blood indicates a preulcerative state.

Callus Ischaemic Foot

Fig. 3.5 Callus debrided to expose white macerated layer and speckles of blood.

• Unequivocal advice should be given to patients to seek help immediately if their feet deteriorate

• For many years we refrained from using adhesive felt padding on high-risk diabetic feet. We now use felt padding as a temporary measure while insoles are awaited, but always advise the patient to lift the padding and check beneath it at regular intervals and review the patient frequently.


Plantar callus is a characteristic feature of the neuropathic foot and its potential for causing ulcers should never be underestimated. Callus concentrates pressure on the plantar aspect and increases the risk of ulceration more than 11-fold. Callus is the most important preulcerative lesion in the stage 2 foot. On the neuropathic foot it is usually hard and dry because of reduced sweating due to autonomic neuropathy. When neglected and allowed to accumulate, it causes pressure necrosis and ulceration of the underlying tissues. Good blood flow is probably necessary for exuberant callus formation.

Callus also develops on the neuroischaemic foot, but it is thin and 'glassy' and rarely causes ulceration. We do not recommend that areas of thin glassy callus on ischaemic feet be debrided unless they develop rough areas which can catch on clothing, are causing pain or develop signs of underlying problems. The practitioner must be aware that the layer of callus may be very thin, that the texture of ischaemic callus is glazed and slippery and that without great care the scalpel blade may slip. Callus in nail sulci should also be cleared with great care when patients are ischaemic. It is very important not to traumatize the ischaemic foot: underoperating should be the rule.

Fig. 3.5 Callus debrided to expose white macerated layer and speckles of blood.

Fig. 3.6 Heavy callus containing speckles of blood indicates a preulcerative state.

Preulcerative callus

Clear warning signs become apparent when callus becomes too thick and ulceration is imminent. These include:

• Callus with small speckles of blood within it where individual capillaries are damaged by pressure and begin to leak

• A deeper layer of white, macerated callus within callus (Fig. 3.5) only exposed by sharp debridement of the superficial layers

• An intraepidermal bulla full of clear fluid, but the underlying tissue is intact.

Emergency treatment to remove callus and reduce the excessive mechanical forces by means of footwear adaptations should be undertaken without delay.

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