Ask The Podiatrist

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Volume 15 · Issue 4 · July/August 2005 | Download PDF

by Neil M. Scheffler, DPM, FACFAS

Ask Podiatrist 01
1. What is a podiatrist? What kind of training is required to become one?

Podiatrists are physicians specially trained in the care of the foot and ankle, including the diagnosis and treatment of problems and diseases of the foot and ankle. They may provide both surgical and nonsurgical care.

Podiatrists attend college, followed by four years of podiatric medical school. Most podiatric physicians then go on to specialized residency programs. Podiatrists are sometimes referred to as foot doctors, foot and ankle surgeons, or podiatric surgeons.

Most states require completion of a 1- to 3-year postdoctoral residency program and continuing medical education (CME) for license renewal. Certification by the American Board of Podiatric Surgery requires

  • Graduation from podiatric medical school
  • Completion of an approved podiatric surgical residency
  • Practice experience, including surgical case submissions
  • Written and oral examinations.

2. When a person loses a leg because of diabetes or peripheral vascular disease, isn’t it likely that the other foot is also already damaged and might soon require amputation?

The remaining limb is certainly at risk. Both nerve damage and poor circulation are generally bilateral, meaning in both feet.

Studies have shown that from 9 to 20 percent of people with diabetes who had already experienced an amputation underwent a second amputation within 12 months of the first surgery. Five years after the first surgery, 28 to 51 percent of amputees with diabetes had undergone a second amputation. But you don’t have to be in this group. Common sense and good preventive care can preserve what you have. You must protect that remaining limb!

3. One of my legs has already been amputated as a result of diabetes? I don’t want to lose my other leg. What should I do?

Begin by treating your remaining limb as if it were made of gold. That is how valuable that leg is to you.

There are several things you can do to minimize the risk of losing your other leg, but you should at least do the following:

  • Establish a relationship with a podiatrist, preferably one who specializes in diabetic foot problems.
  • See your podiatrist regularly and follow his or her instructions.
  • Examine your foot daily, and report problems, such as ingrown toenails, red spots, cuts, or other wounds, to your podiatrist at once.
  • Never walk without a shoe protecting your foot.

If you have vascular disease, nerve damage or deformities, such as a bunion or hammertoes, special care may be needed. Your podiatrist will explain this care and should outline a plan to help you keep your remaining limb healthy. He or she may request consultations with other health professionals, such as neurologists or physiatrists for nerve disorders and vascular surgeons for problems with circulation.

4. I have peripheral vascular disease. Do I need to do anything special to protect my legs from amputation?

Yes. The decrease in blood flow to your feet and legs puts you at an increased risk for amputation. Several things might help you avoid this outcome, however.

It should go without saying that any tobacco use is out of the question since tobacco decreases blood circulation even further.

If your doctors say that it is OK, exercise, such as walking, will help increase circulation or at least maintain the current levels.

Your podiatrist may also ask you to schedule more appointments with him or her than other patients do. In addition, he or she will probably want to cut your toenails rather than have you risk injury by doing this yourself. Appropriate shoe choice is also important, and your podiatrist can help you with this as well.

Since there are also medications and surgical procedures that may help get more blood to your feet, a consultation with a vascular surgeon may be advisable.

5. I have diabetes, and a small sore has developed on my foot. Do I really need to go to the trouble of seeing a podiatrist? Isn’t that overkill?

Stop reading this, and call your podiatrist now! When you call to make an appointment, be sure to say that it is urgent – that you have a wound. Tell the office that you also have other complicating factors (diabetes, circulation problems, a previous amputation). Even doctors with a full schedule of appointments will understand and squeeze you in or at least give you advice over the phone until you can be seen.

A foot ulcer precedes 85 percent of amputations. Appropriate and early treatment of foot wounds increases the likelihood of healing these wounds. Waiting even a few days can be disastrous.

6. Are there any new circulation-enhancement treatments or wound-care therapies available that are especially useful for preventing the amputation of a second leg?

Improvements in medical care seem to occur almost daily.

Advances in the diagnosis of peripheral vascular disease include refined tests, such as digital subtraction angiography, which allows small vessels to be seen. Once these small vessels of the feet are viewable, bypass surgery may be possible. Minimally invasive procedures, such as arterial stenting and peripheral plaque excision, are also available to those patients whose condition is appropriate.

New wound-care therapies include wound-healing gels, new wound dressings, vacuum pumps to apply continuous suction to the wound, and even artificially grown skin to cover wounds and speed up healing.

7. Are there any surgical techniques that can help people with diabetes once a nonhealing ulcer appears on their foot?

There are many surgical procedures that can be considered for nonhealing wounds.

If a wound, for example, is not healing because of pressure from an underlying bony prominence, this piece of bone may be cut out or moved to reduce this pressure. A bunion (an enlargement of bone behind the big toe) with an overlying ulcer would be an example of such a projection.

If a wound is not healing because of a lack of circulation, a vascular surgeon may be consulted to operate on the arteries to bring more blood to the area.

Surgical debridement (cutting away) is often necessary to remove dead or contaminated tissue from a wound. This may convert the wound from a chronic, stalled, nonhealing ulcer to a fresh wound that can now go on to heal.

8. Since I lost one of my legs as a result of diabetes, I’ve noticed that my remaining leg is really taking a beating. It has to support the weight of my body more than it did when I had both legs, and it also seems that the way I walk now causes more stress on my remaining leg. Isn’t this dangerous? If so, what can I do?

Increased stress upon your remaining limb certainly puts it at greater risk. You need to discuss this issue with your medical team. Your prosthetist may be able to tweak your prosthesis to give you a more normal gait. Your physiatrist (rehabilitation specialist) and physical therapist also may have suggestions. Perhaps a course of physical therapy would help strengthen weak muscles. Your podiatrist will advise you about shoe and sock selection and specialized innersoles for your shoes that can help protect your remaining foot.

9. My father has diabetes and wears open-toe shoes. He also rarely checks his feet to see if any sores are forming. How can I motivate him to follow his doctor’s orders for preventing additional amputations?

This is a tough one; advice from family members is often ignored. I used to say that my children were not hard-ofhearing; they were hard-of-listening.

Make sure you tell your father’s podiatrist the problem and enlist his or her help in emphasizing appropriate shoe gear.

I would also suggest that you give your father a gift – a membership in the American Diabetes Association (ADA) and in the Amputee Coalition if he isn’t already a member. Then, along with the Amputee Coalition’s bimonthly magazineinMotion, he will receive the ADA’s monthly magazine Diabetes Forecast. This publication is always full of valuable information on diabetes management and periodically includes information on foot care and shoes. Sometimes, the repetition of advice from multiple independent sources is finally heeded.

For Additional Information

The American College of Foot and Ankle Surgeons
http://www.acfas.org

The American Podiatric Medical Association
http://www.apma.org

The American Diabetes Association
http://www.diabetes.org

About the Author

Ask The Podiatrist 01Neil M. Scheffler, DPM, FACFAS, is a podiatrist in private practice in Baltimore, Maryland. He is a fellow of the American College of Foot and Ankle Surgeons and is board-certified in foot and ankle surgery. Dr. Scheffler is a past president, Health Care& Education, Mid-Atlantic Region, American Diabetes Association. He is the attending podiatrist for the Prosthetics Clinic, Sinai Hospital of Baltimore.