The Foot and Industrial Consequences of Injury - Part 4

Sunday, March 27, 2005 | 0

This is the fourth and final article in a series of four by foot and ankle specialist, Dr. Jodi Schoenhaus. The first article contained facts about the human foot and possible ailments due to work-related injuries. The second article in this series reviewed facts about the human ankle. The third article discussed common work-related foot and ankle injuries. This article discusses diabetes and the foot, and ends with some final comments regarding rehabilitation. Earlier articles can be accessed by clicking on the title in the right side bar.

Part Four: Diabetes and the Foot

Diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. There are 18.2 million people in the United States, or 6.3% of the population, who have diabetes. While an estimated 13 million people have been diagnosed with diabetes, unfortunately 5.2 million people (or nearly one-third) are unaware that they have the disease. (source: American Diabetes Association)

Diabetes affects the lower extremity in many ways. Usually associated with diabetes is a condition called neuropathy, although neuropathy can stem from other conditions. The condition effects motor nerves (responsible for voluntary movement), sensory nerves (responsible for sensing temperature, pain, touch, and limb positioning) and autonomic nerves (responsible for involuntary functions such as breathing, blood pressure, sexual function, digestion).

As a result of damage to the nerve, a diabetic may have loss of muscle function, loss of sensations, and loss of tone of their blood vessels. This occurs in about 60-70% percent of people with diabetes. Poor healing capabilities, poor circulation, and lack of sensations lead to difficulty in managing open wounds, and can often lead to amputation if not appropriately treated with early intervention. Ulcerations are usually found on the plantar aspect of the foot, and are seen following trauma in the shoe, a minor blister or burn, or after stubbing of the foot.

Due to neuropathy, the patient will not feel anything abnormal and the condition may go undetected. Offloading high pressure areas is important in patients with diabetes and ulcerations as healing is extremely difficult if constant pressure is placed on the ulceration site with every step. Due to the extreme amount of force placed through the extremity with every step, wound care is needed usually twice a day with dressing changes and offloading. If an infection is present, the patient will require antibiotics and possible surgery. If the infection is in bone it is called osteomyelitis and will require either amputation or six weeks of IV antibiotics.

Another condition that is associated with diabetes mellitus is called Charcot neuroarthropathy. In patients with Charcot disease the joints of the foot fracture and collapse. With diseased states of neuropathy, mixed with chronic microtrauma and hyperemia, a percentage of diabetic patients are affected with this condition. This causes the foot to deform and can lead to ulcerations and amputations. In Charcot disease, early detection and intervention is crucial for limb salvage. Treatment modalities include early immobilization, custom molded orthotics, custom molded shoes, and possibly surgical intervention.

Rehabilitation

Many of the conditions discussed above will require a form of rehabilitation for increased strength and range of motion following recovery from an injury. Joint stiffness, muscle atrophy, loss of proprioception, imbalance, and faulty gait mechanics will be present and thus the patient will require roughly four weeks of physical therapy, three times a week. Common physical therapy modalities are utilized and include massage, heat/cold, ultrasound, ionophoresis, strength, and active and passive range of motion. A work hardening program may be needed for some of the more debilitating injuries. During this rehabilitative period, the patient may return to work on restricted duties. The physician should delineate this.

The goal is to get the patient fully recuperated in a timely and cost effective manner, however it is crucial that a safe and sound work environment exists for the injured worker as well as their fellow co-workers. Once this occurs, the patient will be able to return to work without limited capacity.

Contributed by foot and ankle specialist, Dr. Jodi Schoenhaus of Total Orthopaedic Care, Ft. Lauderdale, FL. Dr. Schoenhaus can be reached at 954-735-3535.

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