A 48-year-old female diabetic patient with type 2 diabetes diagnosed 6 months before her first visit, and treated with sulfonylurea, was referred to the outpatient diabetic foot clinic because of an ulcer on her right foot.
The diabetes had been adequately controlled but the patient was already exhibiting signs of diabetic complications, such as background retinopathy and neuropathy. On examination, she had a right convex triangular foot, with an ulcer under the head of the fifth metatarsal head following callus formation at this site (Figure 3.15). She had symptomatic diabetic neuropathy, exemplified by a burning sensation in the feet, which was especially exacerbated at night; peripheral pulses were palpable and the ankle brachial index was 1.0 bilaterally. Small muscle atrophy of the feet was noted, as well as dry skin and loss of feeling of a 5.07 monofilament; vibration perception threshold was 30 V.
A plain X-ray showed a convex triangular foot deformity (Figure 3.16). This deformity is characterized by convergence of first and fifth toes, and claw deformities of the central three toes. The first and fifth metatarsals are short and diverge. Both longitudinal and transverse plantar concavities are accentuated, and the second and third metatarsals are fixed in excessive equinus
from this level. Cavus feet balance on the heel and the central part of the metatarsal paddle. This deformity may cause high pressures over the metatarsal paddle during walking.
Debridement was performed and appropriate footwear and insoles were prescribed (Figure 3.17). A suitable insole relieved pressure strain from the sole of the patient's foot by redistributing pressures. High plantar pressures can be seen on the graph produced by insole pressure sensors (Parotec system, Germany) (Figure 3.18), when the patient used her own shoes (Panel A), and after the prescribed insole and shoe were used (Panel B); pressures applied to the sole of the patient's foot during heel strike, mid-support and push-off phase of walking with the patient's original shoe (left graph), and with the custom-made insole (right graph) are shown in Panel C.
After 6 weeks the ulcer heeled completely (Figure 3.19).
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