A 56-year-old male patient with type 2 diabetes diagnosed at the age of 44 years attended the outpatient diabetes clinic. He had been treated with insulin since the age of 53 years, with excellent results (HBA1c: 6.7%). He had background diabetic retinopathy.
On examination, the patient had severe diabetic neuropathy with complete loss of sensation of pain, light touch and temperature; his vibration perception threshold was 40 V on both feet; Achilles tendon reflexes were absent. Peripheral pulses were normal and the ankle brachial index was 1.2 bilaterally. Temperature of the feet was normal; the skin was dry, with normal hair and nails, while mild vein distension was noted. Severe atrophy of the intrinsic foot muscles (lumbrical and interossei) — due to motor neuropathy — resulted in an imbalance of the foot muscles, and cocked-up toes (claw toes) (Figure 3.6). Such an appearance is so typical, that the diagnosis of peripheral neuropathy can be made by inspection of the feet alone.
A claw toe, the most common deformity in diabetic patients, consists of dor-siflexion of the metatarsophalangeal joint, while the proximal interphalangeal and distal interphalangeal joints are in plantar flexion (Figure 3.7). Shifting of the fat pads underneath the metatarsal heads to the front leaves the metatarsal heads exposed; high plantar pressures develop under metatarsal heads. This patient did not have problems with his feet. He was educated in appropriate foot care and instructed to wear suitable footwear with a toe box large enough to accommodate the deformity.
Keywords: Muscle atrophy; peripheral neuropathy; claw toes
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