Management

The aim of management is to ensure that:

• Patients do not develop risk factors for diabetic foot ulceration

■ If risk factors do develop, they are detected early and patients placed in stage 2

• Common foot problems that can occur in the general population are efficiently treated and do not lead to tissue breakdown even in the absence of neuropathy and vascular disease.

The following components of multidisciplinary management are important for stage 1 patients.

Mechanical control

• To encourage the use of suitable footwear, discourage inadequate footwear and thus prevent subsequent deformity and callus formation

• To keep the foot intact by treatment of non-ulcerative pathologies. There is no such thing as a trivial lesion of the diabetic foot; all foot problems need early diagnosis and appropriate intervention.

Metabolic control

To prevent or delay the development of neuropathy, microvascular and macrovascular complications

Educational control

• To encourage healthy foot care/footwear habits and detect ignorance or non-compliance early

• To make provision for intellectual deficit and psychological and social problems. Behaviour modification is an important component of care (Fig. 2.1a,b). Because stage 1 patients have no ulcers, infection, gangrene or ischaemia, there is no need for wound, microbiological or vascular control to be addressed.

Onychogryphosis Cut
Fig. 2.1 Neglected nail (a) before and (b) after cutting.

Mechanical control

Mechanical control is achieved by wearing the correct footwear and also by the recognition and treatment of common foot problems.

Footwear

Advice on buying shoes

Stage 1 patients may obtain their shoes from shoe shops or mail-order catalogues, though it is probably best for the foot to be measured and the shoes sized and tried on, or bought 'on approval' and checked by a health-care professional. Staff of shoe shops can be taught which footwear is suitable for diabetic feet. Normal feet swell when the patient has been on his feet a lot, so shoes are best bought towards the end of the day.

For everyday wear, house shoes and for when the patient is on his feet a lot, selection should be made according to the following principles (Fig. 2.2):

Fig. 2.2 A high-street man's shoe.

• Toe box is roomy to avoid pressure on toes and borders of foot

• Heel cup should fit snugly

• Shoe lining should be smooth

• Shoe should fasten with lace or strap to hold foot back in shoe

• Court or slip-on shoes should be avoided except for special occasions

• Trainers are useful if they are sufficiendy long, broad and deep, with cushioned soles and a built-in rocker, and are worn with the laces fastened. However, there are many inadequate trainers and deck shoes on sale which have thin soles, a lack of cushioning, and no rocker built in

• Wearing socks reduces friction within shoes

• Socks should be non-constricting with no tight band around ankle or calf

• Socks with prominent seams should be worn inside-out

• Socks should be made of absorbent materials such as cotton

• If shoes cause pain, callus, red marks or blisters then they do not fit properly and should be discarded (Fig. 2.3a,b)

• In hot climates, sandals may be worn: however, they give little protection against trauma and the foot is not held firmly in place, resulting in excessive shear. Wearing 'good' shoes will prevent or delay the onset of footwear-related deformity, and prevent callus from developing by reducing the mechanical forces applied to the feet.

Features of a bad shoe include:

• Slip on style, which causes pressure on the forefoot

• High heels, which reduce the range of toe dorsiflexion and can lead to hallux rigidus

• Thin-soled shoes, which make the foot sensitive to any unevenness of the ground.

Unsuitable Footwear For Diabetes
Fig. 2.3 (a) Red marks on toes followed (b) wearing unsuitable shoes with no proper fastening and narrow toe box.

If shoes are the wrong size or wrong style, they can cause permanent damage to the feet, resulting in deformity and callus.

Common foot problems

In maintaining mechanical control, it is important to diagnose foot problems including:

• Nail problems

• Fungal infections

• Bullosis diabeticorum

• Chilblains

• Malignancy

• Inflammatory skin diseases

• Hyperhydrosis

Nail problems

Cutting nails may present problems. However, many people in stage 1 will be able to cut their own nails (Table 2.1).

Table 2.1 Patients who can safely cut their own toe nails

Patients who can safely cut their own toe nails Have pain-free normal nails with no pathology Can see feet clearly Can reach feet

Have been taught correct nail cutting techniques

They should be taught the correct techniques for cutting normal nails as follows:

• Nails should be cut straight across or in a gentle curve

• The corners should not be cut out

• The nail plate should not be cut in one piece: a gentle 'nibbling' technique should be used

• The nail should not be cut so short that the seal between nail and nail bed is broken

• The nails should not be left so long that they can catch on the socks, risking trauma

• The nails should be cut regularly

• The nails should be cut after the bath, when the nail plate will be softer and more flexible and easy to cut

• If nail cutting is difficult or painful, patients should seek professional help.

There is no reason why any health-care professional should not cut normal nails in diabetic stage 1 feet, but proper nail nippers should be provided for staff, who should be taught correct techniques as explained above.

Onychauxis

Onychauxis is thickening of the nail without deformity, and follows an insult to the nail bed. Regular filing will reduce the thickness of the nail. Without regular reduction onychogryphosis will develop.

Onychogryphosis (ram's horn nail) This is thickening of the nail with deformity. The causé is an insult to the nail bed. Treatment can be palliative or surgical. Palliative treatment consists of regular reduction of excessive thickness of the nail plate at 3-monthly treatment intervals.

If only one nail is affected and the patient dislikes the need for regular treatment, the nail plate can be removed under ring block local anaesthesia. If the exposed nail bed is treated with topical phenol the nail will be replaced by a fibrous plate which does not need regular reduction and has a cosmetically acceptable appearance. However, this procedure is invasive and should not be carried out on ischaemic feet.

Onychogryphosis
Fig. 2.4 Onychogryphosis.
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