Figure 3.17 Extra-depth shoes and custom insoles for routine chiropody treatment. She was being treated with insulin. The patient had hypertension, advanced background retinopathy which had been treated with laser in both eyes, and diabetic nephropa-thy (urine protein: 2.6 g/24 h). On examination, she had severe diabetic neuropathy and gross ankle edema due to nephropathy. Peripheral pulses were normal and the ankle brachial index was 1.1 on both feet. Mild hallux valgus, claw toes, overriding of the second to the third toe and lateral drip of the toes were observed (Figures 3.20 and 3.21). Callus formation at the inner aspect of the first and on the second metatarsal heads was noted. Fat pads on the first, second and third metatarsal heads were displaced distally to the base of the proximal phalanges due to clawing of the toes. A superficial painful infected ulcer at the dorsum of the second toe was also present, due to overriding and clawing of the toes. Debridement of the callus was carried out. The patient was put on clindamycin for 2 weeks. Treatment with frusemide 40 mg daily was also commenced to reduce edema. Extra depth
shoes and orthotic insoles were prescribed in order to reduce the pressure on the plantar area and the friction from the shoes on the deformed toes.
The correct shoes and orthotic insoles are often enough to reduce the risk for foot ulceration in the majority of the patients with foot deformities and loss of protective sensation. In addition, edema has a detrimental effect on the foot at risk, as it reduces local blood supply and has been associated with increased risk for ulceration. Therefore, reduction of ankle edema is recommended for patients at risk for ulceration.
Beyond diabetic nephropathy, other causes of ankle edema in diabetes include heart failure and diabetic neuropathy. Edema due to neuropathy is not rare. This form of edema results from sympathetic denerva-tion, which leads to loss of the vasomotor reflex upon standing, arteriovenous shunting and increased capillary pressure. Neuropathic edema responds to the administration of the sympathomimetic agent ephedrine.
Keywords: Hallux valgus; toe overriding; claw toes; edema
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