International Consensus and Practical Guidelines 335 336 The Foot in Diabetes International Consensus and Practical Guidelines 337 338 The Foot in Diabetes International Consensus and Practical Guidelines 339 340 The Foot in Diabetes International Consensus and Practical Guidelines 341 342 The Foot in Diabetes International Consensus and Practical Guidelines 343 344 The Foot in Diabetes [...]... fall on incorrect areas of the traumatized foot A dressing on the ulcer may destroy the ®t of the shoe, causing increased pressure to occur at the site of the dressing, and this may increase the anoxia and tissue breakdown at that 352 The Foot in Diabetes Figure 22.1 A total contact cast that has been bivalved (a) The use of a football sock as a liner to replace the minimal padding used to make the cast... to demand care The resultant problems are virtually the same as those seen in diabetes In leprosy, as in diabetes, the autonomic involvement causing altered skin physiology makes the skin more prone to trauma from stress, bumps or dehydration Together with many other neuropathies, these diseases have several problems in common The most important is the so-called ``non-healing ulcer'' In 1877 John Hilton1... of a fracture involving the dorsal surface of the foot A mid-tarsal osteotomy to realign the foot resulted in a functional non-ulcerating foot that could be shod with a normal shoe An extra resilient insole ensured no recurrence of the ulceration (c) Photograph taken about 4 years after the surgery The Foot in LeprosyÐLessons for Diabetes 359 ulceration in the future Basic surgical principles should... walking is undertaken3 This is a slowly graded daily increase in the duration of walking allowed, starting with only 3±5 minutes at a time, with the foot checked for hot spots 2 hours after the walk If there is no heat and swelling, the duration of walking can be regularly increased until the patient is walking for 40 minutes at a time without problems Persistent heat and swelling will indicate that the. .. may be partly attributable to better documentation and to an increase in the prevalence of diabetes but, in percentage terms, they are of an order of magnitude greater than increases in the prevalence of diabetes Given that the increase in the prevalence of diabetes is expected to continue8, we must expect a concomitant increase in the numbers of amputations and thus progress toward achieving the objective... set in the St Vincent Declaration becomes even more imperative The Foot in Diabetes, 3rd edn Edited by A J M Boulton, H Connor and P R Cavanagh & 2000 John Wiley & Sons, Ltd 364 The Foot in Diabetes In Chapter 1, Ward reminds us that the problems posed by diabetic foot disease in wealthy countries pale almost into insigni®cance compared with those faced in the poorer countries, and yet it is in the. .. nerve problems in diabetes usually affect only the intrinsic muscles In many patients the intrinsics have already atrophied through disuse and a degree of clawing has resulted even before diabetes was diagnosed The risk of ulceration on the plantar surface of the metatarsal heads, as well as over the proximal interphalangeal joints where they tend to rub the shoe uppers, increases as the toes become... SOAK the feet and legs in plain water every day This remains a controversial point in diabetes but is used by some clinicians treating diabetes1 0 In leprosy, as stated above, it has been shown time and time again that soaking is bene®cial5 Dryness is very obvious when people walk barefoot or wear open sandals, and a dry atmosphere constantly increases the dehydration of the skin In leprosy clinics... yet leaving them mobile, ¯exing the metatarsal joints and so spreading the stresses of weightbearing It reduces the risk of 348 The Foot in Diabetes ulceration The excessive stresses caused by muscle imbalance in the lower limbs may stimulate excessive callus formation and may result in ulceration In leprosy, many of the consequences of muscle imbalance are minimized by tendon surgery and, in my experience,... John Hilton1 wrote: ``pain was made the prime therapeutic agent After injury, pain suggested the necessity of, and indeed compelled The Foot in Diabetes, 3rd edn Edited by A J M Boulton, H Connor and P R Cavanagh & 2000 John Wiley & Sons, Ltd 346 The Foot in Diabetes man to seek for, rest'' Because of the damage to sensory nerve pain ®bres, these patients lack the natural sparing re¯ex that makes . Guidelines 339 340 The Foot in Diabetes International Consensus and Practical Guidelines 341 342 The Foot in Diabetes International Consensus and Practical Guidelines 343 344 The Foot in Diabetes 22 The. ``non-healing ulcer''. In 1877 John Hilton 1 wrote: ``pain was made the prime therapeutic agent . . . After injury, pain suggested the necessity of, and indeed compelled The Foot in Diabetes, . could eliminate the constant need for new footwear by straightening the toes yet leaving them mobile, ¯exing the metatarsal joints and so spreading the stresses of weightbearing. It reduces the risk