December 14, 2017
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Diabetes in Real Life

Daily foot care can prevent later problems

What should a person with diabetes be doing on a daily basis to ensure good foot health?

Neuropathy, vasculopathy and a faulty immune system affect the feet of patients with diabetes and can lead to needless and preventable foot pathology. People with diabetes on a daily basis should be visually and manually inspecting both their feet and their shoes. The foot inspection is to identify a crack in the skin or a locally red swollen or warm area. The shoe inspection is to identify any defect in the shoe itself and any foreign objects in the shoes.

People with diabetes who notice dry skin on their feet or legs due to autonomic neuropathy should apply a urea-based moisturizing lotion. They also need to wear appropriate socks and shoes for their activities. They should practice preventive foot care to avoid developing foot ulcers from the combination of sensory neuropathy and mechanical, chemical or thermal trauma. Foot ulcers can lead to infection, hospitalization and the most dreaded complication of the diabetic foot, amputation. People with diabetes have a list of recommended tasks they are to perform daily to manage their foot health. They should be aware of any changes to their foot health, and if they find a problem, they should seek professional attention promptly.

Every person with diabetes should have a yearly comprehensive diabetic foot exam by their foot specialist that includes a monofilament test.

What are the most common foot problems?

A quick list of the most common foot problems includes those of the nails; keratosis, or corns and calluses; bone and joint deformities; and nerve and heel pain. No matter what the foot problem, visiting a podiatrist for a comprehensive diabetic foot exam, X-rays and laboratory tests is the first step to resolution.

The most common foot problem involves the toenails, which can be thick or discolored, ingrown or deformed. Trimming toenails can be difficult and often not realistically possible for people with diabetes, who should seek professional care for nail trimming and medical treatment of mold yeast or fungal nail infections. I have witnessed patients with diabetes who unknowingly have cut the end of their toes off while trimming their nails. How does this happen? The reasons include poor vision, poor lighting, poor eye-motor coordination, and inappropriate and nonsterile instruments. A person with diabetes who has nail problems and poor vision should have professional foot care by a chiropodist.


Endocrine Today, November 2017

In this issue, Susan Weiner, MS, RDN, CDE, CDN, talks with podiatrist Mark Hinkes, DPM, about foot problems that commonly affect people with diabetes.

Prevention & Recovery

Why orthotics make for happy feet

From pain reduction to performance enhancement, show your feet some love with orthotic inserts.

A trip to see a Canadian Certified Pedorthist is your first step to happy, healthy feet. These experts in lower-limb anatomy and biomechanics, assess your gait and specialize in making custom foot orthotics and modified footwear. From feet, back and knee aches, to performance and comfort upgrades, your lifestyle and medical history are considered. "We look at posture, the range of motion in your joints and the activities you enjoy participating in, to see if your biomechanics are contributing to your pain," says Peter Morcom, President of the Pedorthic Association of Canada. After a thorough assessment, "we use video to show you exactly what your gait looks like, and how and if modified footwear can help."

When it comes to foot orthotics, there are two main functions. The first helps to decrease excess motion in an over-pronated foot, often called a flat foot. The second, most commonly used with high rigid arches, provides equal weight distribution and shock absorption. Foot orthotics come in all shapes and sizes, and are made from a variety of materials, from plastic to EVA foam to graphite. While any foot type can benefit from an orthotic, not every foot will need one. An appointment with a Canadian Certified Pedorthist is the easiest way to assess your challenges.

Off-the-Shelf Versus Custom

If you're looking to increase comfort, performance, and even if you're experiencing some pain, a simple, off-the-shelf orthotic might be your best bet, and your quickest solution. The more affordable cost is also a plus, ranging between $30-$100. "These products can be a great test, or trial period, before you go the custom route," says Morcom. But because there are many different products on the market, a consultation with a Canadian Certified Pedorthist is still an important part of understanding which type of orthotic is best for you. Just like custom options, off-the-shelf products can vary in arch-height, amount of cushioning and stiffness or rigidity.

With custom orthotics, you get better control and patient specificity. Once your gait and lower limb assessment is complete, a pedorthist will cast your foot using either plaster, a foam mold or 3D laser scan. While off-the-shelf and custom foot orthotics may look similar in the end, the precision that goes into the casting process allows for lots of specialized additions. "There are benefits like forefoot posting, for example, which can change the actual angle your foot rests at, or metatarsal pads and many other personalized adjustments," says Morcom. While the cost is significantly higher for custom, $350-$650, they are often covered by benefit plans and have a much longer lifespan.

The Feet Sheet

  Off-the-shelf Custom


 Not covered by benefits


 Often partially or fully covered by benefits

 Life  Span

 1 year

 5+ years
 Wait  Time  Immediate  Two weeks from assessment
July 19, 2016
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5 Gnarly Foot Problems All Runners Can Relate To — And How To Fix Them


Slipping on a new pair of flats or heels, it’s safe to assume you’re going to end up with a blister at the end of the day. Runners have the same expectation—that guaranteed foot unhappiness will ensue—after a long run or a few months training for a race.

While spending lots of time on your feet in any situation can lead to some nagging pain, there are some ~special~ things about running that doom your dogs. “There’s a sheer repetitive nature to running, where you’re constantly doing the exact same motion over and over and over again,” Lori Weisenfeld, D.P.M., a New York City sports podiatrist, tells SELF. “Also, we sweat a lot when running, and sweat and friction combined are not the best combo.” And here’s a reason to dislike hills even more: “Even if it’s not a monumental one, slightly going up or down puts stresses between [your shoes] and your feet.” All these factors combined make runners particularly prone to some gnarly foot problems.

Wearing a good pair running sneakers that fit you properly is your first line of defense. “The proper sneaker is absolutely essential when you’re running,” Weisenfeld says. But if we’re being honest, even the most perfect pair of kicks won’t make you immune to runners’ feet. Here’s how to handle the most common issues.

1. Blisters

Plain and simple, blisters are caused by friction. If you’re prone to them, it means your foot is moving around too much in your shoe. This could be because you’re not wearing the right size, or you’re not wearing the right socks. Weisenfeld says to look for sport-specific socks with a lot of cushioning and made with synthetic materials (not 100 percent cotton or wool “because that will absorb the moisture but not allow it to evaporate”). She recommends the running socks from Thorlo. If you get blisters in between your toes, try rubbing Vaseline in between them before slipping into your socks, or use a blister block stick like Body Glide Foot Anti Blister Balm.

If a blister is tense and painful, Weisenfeld suggests draining it with a sharp, sterilized instrument. “On the roof of the blister but close to where it attaches to the skin, lance the blister so all the fluid comes out.” If you use a tiny pinhole, it will most likely seal up and fill up again, she adds, so use something a little thicker so it can fully drain. Just don’t rip the top layer of skin off—no matter how tempting it is. “It acts as the body’s natural biologic dressing for the blister, so the best thing to do is leave that in place.” If a blister elicits a throbbing pain or turns red, it could be a sign of infection.

2. Calluses

If this hardened mass of skin tends to build up on your heels, it’s probably from the edge of your shoe rubbing against the back of your foot. If your callus resides on the side of your big toe, it can be from wearing too-tight shoes or your running form, Weisenfeld explains. “If you over-pronate, your arches roll inward and as that happens, you’re rolling onto the big toe when you’re pushing off.” Over time, a big ol’ callus can form.

If calluses are a problem for you, make sure your shoes are wide enough across the front so there’s no pinching. Weisenfeld also recommends switching to a more supportive and stabilizing shoe to stop your foot from rolling, and wearing good running socks that wick away sweat and reduce friction. They might not look so great in sandals, but calluses are usually harmless and shouldn’t be painful. If they’re bothering you, Weisenfeld recommends gently filing them down with a pumice stone twice a week in the shower and moisturizing with a foot cream. If one hurts, it could be that a blister has formed underneath. It could also be a corn or a wart, not actually a callus. If a callus is dry, red, and cracking, it could be a sign of chronic athlete’s foot. All these scenarios deserve attention from a chiropodist.

3. Thickened toenails

Ever notice your toenails seem thicker and harder to cut than they used to? That’s their response to the constant banging and pressing against your shoes. “Nails will respond to constant repetitive trauma by thickening up,” Weisenfeld explains. If you’ve had some bruising, sometimes the nail will start to regrow before the old one has grown out or fallen off, causing an unnatural thickness. This can also be confused for fungus, so if your nails appear very thick and dense, see a foot doc to make sure it’s not something that needs to be treated with antibiotics. They may want to thin the nail out, too, especially if it’s causing you pain or discomfort.

4. Black toenails

Oftentimes, a bruised, black toenail is often the result of ill-fitting sneaks. “If shoes are old and floppy and stretched out, your toes are more likely to start slipping and jamming into front of the shoe,” Weisenfeld says. This trauma can cause bruising between the nail and the nail bed. “Once blood or even clear blister fluid gets under the toenail, it separates the nail from the nail bed and it won’t reattach. In that spot, the nail is dead.” If your entire nail is black, a full new toenail will eventually grow in. Weisenfeld says it takes about a year for a new big toenail to completely grow in.

If the nail hurts, you can try to drain the blood, but this may be best left to a physician or chiropodist. “It won’t save the nail, but it will relieve pressure and pain. “To stop feet from sliding as you pound the pavement, try custom insoles that lock them in place. If you ever just have a persistent black spot on your nail and there’s no pain, visit a chiropodist to rule out skin cancer.

5. Ingrown toenails

An ingrown nail looks (and feels) like the nail is piercing the flesh around it. “Your body doesn’t care it’s a nail, it just knows something’s poking that doesn’t belong there, so it acts like it’s a foreign body,” Weisenfeld explains, leading to pain and infection. Running isn’t the most common cause of ingrown toenails, but if you’re prone to them, it can make things worse: An ill-fitting shoe and repetitive pressure on your big toe can push it into the skin around it, especially if your nail tends to curve downward. You should never try to remove an ingrown nail yourself—it can seriously damage it and make it become more infected (talk about gnarly)—so be sure to book an appointment with a chiropodist to get it properly taken care of.

Addressing The Rising Concern Of Antibiotic Resistance With Surgical Prophylaxis

Currently, the United States Centers for Disease Control and Prevention estimate that antibiotic resistance is responsible for more than 2 million infections and 23,000 deaths annually.2 The direct cost of antibiotic resistant infections is an estimated $20 billion and indirect costs due to loss of productivity are an estimated $35 billion.

A recent study by Teillant and colleagues at the Center for Disease Dynamics, Economics and Policy examined the potential consequences of increased antibiotic resistance on the 10 most commonly performed surgical procedures.3 The authors predict that antibacterial resistance may threaten the safety of many surgical procedures.

In this study, the researchers first reviewed published literature to determine the current efficacy of prophylactic antibiotics to prevent infections in the 10 most common surgical procedures.3 They then modeled the effect of reducing the effectiveness of antibiotic prophylaxis by various amounts from 10 to 100 percent. The study showed that currently, an estimated 38.7 to 50.9 percent of pathogens that cause surgical site infections are resistant to standard prophylactic antibiotics. They predicted that a 30 percent reduction in antibiotic efficacy due to the development of drug resistance would result in 120,000 additional surgical site infections and 6,300 additional surgery-related deaths.

The authors conclude that increasing antibiotic resistance presents a significant threat to the safety of many common surgical procedures.3 They highlight the need for further research as to how one should modify prophylactic antibiotic administration to combat the rising incidence of antibiotic resistance.

Kristine Hoffman DPM
Podiatry Today Magazine

Friday, 10/30/15 | 716 reads


1.      Center for Disease Dynamics, Economics and Policy, and the Global Antibiotic Resistance Partnership. The State of the World's Antibiotics 2015. Available at .

2.      Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2013. Available at .

3.      Teillant A, Gandra S, Barter D, Morgan DJ, Laxminarayan R. Potential burden of antibiotic resistance on surgery and cancer chemotherapy antibiotic prophylaxis in the USA: a literature review and modelling study. Lancet Infect Dis. 2015; epub Oct. 15.

May 18, 2016
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Diabetes affects 30 million people in the US and more than 415 million people worldwide. Diabetes Association


The big picture: Diabetes, Diabetic Foot Ulcers, Peripheral Artery Disease and Limb Loss Visualized


The top 10 diabetes nations 
International Diabetes Federation /


Worldwide trends in diabetes from 1980 to today


Diabetes kills more people annually than breast cancer and AIDS combined.

American Diabetes Association, 2009


Two thirds of all new cases of type 2 diabetes are diagnosed in low- and middle-income countries, such as Mexico, India, China and Egypt.

Pharmacoeconomics, 2015


Diabetes reduces a woman’s chances of employment by 50%

Pharmacoeconomics, 2015


If diabetes were a country, it would be the 4th largest in the world

International Diabetes Federation /


80% of people with diabetes are from low and middle income nations

International Diabetes Federation, 2012


The number of people with diabetes is increasing in every single nation

International Diabetes Federation/World Health Org 2012


Half of people with diabetes don’t know they have it.

American Diabetes Association / International Diabetes Federation, 2012


Quiet. Slow. Deadly. Expensive: Chronic Diseases Account for 75% of our Healthcare Costs.



25% of all medical care is consumed by 1% of the population and nearly 50% is consumed by 5%.
AHRQ, 2013


1 Day with #Diabetes in USA:  5000 diagnosed, $670M, 280 lives, 200 limbs. We can do better. Today.
American Diabetes Association, 2014


Seconds Count: Every 7 seconds someone dies from diabetes. Every 20 seconds someone is amputated.

International Diabetes Federation /

Armstrong, et al, Diabetes Care 2013


The cost of diabetic foot ulcers is greater than that of the five most costly forms of cancer

Barshes, et al, Diab Foot Ankle 2013


The cost to heal a complex diabetic foot ulcer is between 3 months and 6 years’ salary depending on nationality

Cavanagh, et al, Diabetes Metab Res Rev, 2012


Diabetic Foot Ulcer patients are twice as costly to US Medicare as those with diabetes alone

Rice, et al, Diabetes Care, 2014


Inpatient care constitutes nearly two thirds of insurance costs for diabetic foot ulcers
Rice, et al, Diabetes Care, 2014


The estimated annual US Burden of Diabetic Foot Ulcers is at least $15 Billion
Rice, et al, Diabetes Care, 2014


By 2030, at least 550 million people will have diabetes- approximately 10% of the world’s adult population.

International Diabetes Federation (IWGDF), 2011


There are now approximately 86M people with pre-diabetes in the USA
That’s the total population of 30 states. 
American Diabetes Association, 2014
2010 United States Census


The population of diabetes in the USA is greater than the population of the nation’s 10 largest cities.
American Diabetes Association, 2012
2010 United States Census


Today with Diabetes In America: 200 Lives, 200 Limbs, 86 million at risk.
American Diabetes Association 2014


The population of Diabetes in Arizona (home of SALSA) would make it the fourth largest city in the state.
American Diabetes Association, 2012
2010 United States Census


60-70% of those with diabetes will develop peripheral neuropathy, or lose sensation in their feet.

Dyck et al.  Diabetic Neuropathy 1999


More than 90% of people with diabetic peripheral neuropathy are unaware they have it.

Bongaerts, et al, Diabetes Care, 2013


Up to 25% of those with diabetes will develop a foot ulcer.

Singh, Armstrong, Lipsky.  J Amer Med Assoc 2005


The yearly incidence of diabetic foot ulcers ranges from 2% to 32%, depending on ADA risk classification
Boulton, Armstrong, et al, Diabetes Care 2008
Lavery , et al, Diabetes Care  2008
Sibbald, et al, Adv Skin Wound Care, 2012


More than half of all foot ulcers (wounds) will become infected, requiring hospitalization and 20% of infections result in amputation.

Lavery, Armstrong, et al.  Diabetes Care 2006


Diabetes contributes to approximately 80% of the 120,000 nontraumatic amputations performed yearly in the United States.

Armstrong et al. Amer Fam Phys 1998


“Every 20 seconds, somewhere in the world, a limb is lost as a consequence of diabetes”

DFCon11, Bakker (after Boulton),

Boulton, The Lancet (cover), Nov. 2005


After a major amputation, 50% of people will have their other limb amputated within 2 years.

Goldner. Diabetes 1960

Armstrong, et al, J Amer Podiatr Med Assn, 1997


More than half of people with  osteomyelitis of the heel will undergo high level amputation

Faglia, et al, Foot Ankle Int, 2013


The relative 5-year mortality rate after limb amputation is 68%. When compared with cancer – it is second only to lung cancer (86%).  (Colorectal cancer 39%, Breast cancer 23%, Hodgkin’s disease 18%, Prostate cancer 8%)

Armstrong, et al, International Wound Journal, 2007


Median time to healing for diabetic foot wounds: 147,188, and 237 days for toe, midfoot and heel ulcers.

Pickwell, et al, Diabetes Metab Res Rev, 2013


People with a history of a diabetic foot ulcer have a 40% greater 10 year mortality than people with diabetes alone.

Iversen, et al, Diabetes Care, 2009


Every 30 minutes a limb is lost due to a landmine, Every 20 seconds, a limb is lost due to diabetes.

Bharara, Mills, Suresh, Armstrong, Int Wound J, 2009


Having a wound immediately doubles one’s chances of dying at 10 years compared with someone without diabetes

Iversen, et al, Diabetes Care 2009


One third of patients seeking care for ischemic wounds die unhealed
Elgzyri, et al, Eur J Vasc Endovasc Surg, 2013


For people on dialysis receiving an amputation, 2 year mortality is 74%

Ndip, et al, 2012, Diabetes


Diabetic foot ulcers double mortality and heart attack risk while increasing risk for stroke by 40%
Brownrigg, et al, Diabetologia, 2012


Chronic wounds affect some 8 million Americans each year. That’s one wound every 3.8 seconds in the USA, alone.
Harsha , 2008 and Tomic-Canic 2010


Each $1 invested in care by a podiatrist for people with diabetes results in $27 to $51 of healthcare savings.

JAPMA, 101(2), 2011


Podiatry care not only reduces amputation risk, but also dramatically impacts rate of hospitalization and reulceration
Gibson, et al, Int Wound Journal, 2013


Podiatric medical care in people with history of diabetic foot ulcer can reduce high level amputation from between 65% and 80%
Gibson, et al, Int Wound Journal, 2013


Instituting a structured diabetic foot program can yield a 75% reduction in amputation rates and a near four-fold reduction in inpatient mortality
Weck, et al,  Cardiovascular Diabetology, 2013


When footcare is removed from a population with diabetes, there is a 37% increase in hospital admissions for limb threatening wounds and 45% increase in individual patient charges.

Skrepnek, Mills, Armstrong, Diabetes Care, 2014

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