Straightforward Principles for Management of the Diabetic Foot

Leslie Goldenberg, BSc, MD, FRCPC
Internal, Geriatric and Podologic Medicine
Assistant Professor of Medicine, University of Toronto
Medical Director, The Walking Mobility Clinics

The first principle in the care of the diabetic foot is to recognize the primacy of prophylactic care. Indeed, an ounce of prevention is worth the proverbial pound of cure, even in the patient who appears to be low risk and does not suffer from peripheral neuropathy or vasculopathy. Physicians and other health care professionals have a critically important role to play when it comes to educating their diabetic patients regarding daily foot care, with particular attention paid to the care of skin, nail and callus, proper footwear and strategies to prevent foot trauma and infection. Diabetes remains the most common cause of non-traumatic limb loss, and there is considerable suffering and economic impact associated with the management of chronic diabetic foot pain and sepsis. Two-thirds of diabetic amputations follow complications that are related to foot ulcers.

Pressure platform studies demonstrate that the patient placing a diminished load on the toes is an early finding in diabetic neuropathy. This reduction in the load on the toes leads to a corresponding increase in metatarsal head loads. In addition, there is a shift of loading on the forefoot, away from the medial side, with increasing load now borne under the mid-foot, a characteristic of weakness of the longitudinal arch (mid-tarsal loading).