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THE ART AND SCIENCE OF DIABETIC FOOT CARE
The human foot is a marvel of mechanical construction. It has 26 bones, 29 joints and
42 intrinsic muscles of the foot, various ligaments, a skin about 4 mm thick, exquisite
nerve supply and abundant vascularity with good collateral supply. It is an
adaptation from the quadruple status to an orthograde, that is, the erect status. It has
taken the feet away from the eyes. That makes it more difficult to notice and take
care, unlike the animals that can and do take care of their feet. The feet come
together and form an arch in the sagittal plane. The individual foot has a lateral,
lower, flatter arch meant for weight bearing and a medial arch which is higher, to
hold and shelter the blood vessels and nerves. The thick plantar aponeuroses hold
the arches in shape. The foot itself is held in shape by the interossii and lumbricals of
the foot and the long tendons.1
The Diabetic Foot Care aims at detecting the signs that could bring the diabetic foot
at risk of ulceration. Diabetic Foot Care aims to act upon the signs, to see that the
small (and what may seem miniscule) problems do not get larger, worsen and pose a
danger to the integrity of the foot and or to the life itself.
Diabetic Foot Care attempts to quantify the problems. The elements that can be
1. Pressure on Feet: The elevated plantar pressure is a major risk factor.2
2. The blood flow.
3. The sensitivity of feet for vibration, pain, touch, pressure, heat and cold.
4. Direct measures for autonomic neuropathy and its surrogate markers.
The quantification of the abnormalities can help in diagnosis, characterization and in
predicting the outcome for the assessed foot may have.3 This leads to an important
consideration in Diabetic Foot Care i.e. the prevention. Prevention and the
educational efforts are well known to maintain an intact foot. 4,5
The assessment is intimately linked with preventive actions that are eminently
possible. The prevention can be in terms of treating abnormalities like
hypertrophied nails or adopting the abnormalities of the shape of the foot resulting
in high pressure by special footwear to reduce it below the critical level of
breakdown. It is known that the dorsal injuries of the foot are also caused by
footwear in many instances.6 There is evidence that appropriate footwear reduces
plantar pressure and can help healing the ulcer.7, 8, 9, 10
Diabetic Foot Care also treats the abnormalities and foot lesions on an outpatient
basis most of the times. This in itself is a cost effective exercise that leads to
considerable degrees of cure and amputation prevention.5
Diabetic Foot Care services thus lift a very considerable burden in terms of time, can
prevent hospitalization for patients, reduces the rate of amputations saving the clinic
and the hospital time, the costs etc. Costs are particularly important because
inpatient care for foot lesions is among the most frequent cause of admissions and
long stays and is costly.11
In India, there was a need of Diabetic Foot Care trained medics or paramedics which
is only partially fulfilled. There are some structured courses but we need more
widespread availability and more people trained for taking care of diabetic foot in
formal institutions. This scenario may look depressing but Diabetic Foot Care (and
teaching how it could be done) is not a complex high technology subject but a
simple, eminently transferable skill to persons with some science background.
Therefore what is really required is the awareness to recognize this need and actively
involve professionals in learning diabetic foot care.
Lastly, it is necessary to recognize that while Diabetic Foot Care works best with the
support of the diabetes team of a physician, a surgeon, a nurse trained in diabetes
care and others, Diabetic Foot Care is teamwork.
1. The Diabetic Foot. Edited by Bowker and Pffeifer, Sixth Edition, Mosby 2001.
2. The Diabetic Foot. Edited by Bowker and Pffeifer, Sixth Edition, pp 125,
3. Diabetic Neuropathy by Peter Dyke and P K Thomas, 2nd edition, pp 125,
WB Saunders & Company 1999.
4. Stokes IAF, Faris IB, Hutton WC: The Neuropathic ulcer and the loads on foot
in diabetic patients. Acta Orthop Scand 46:839-847, 1975.
5. Valente LA, Nelson MS: Patient Education for diabetic Patients. An integral
part of quality health care. J Am Podiatr Med Assoc 85:177, 1995.
6. Apelqvist J, Larsson J, Agardh C-D: The influence of external precipitating
factors and peripheral neuropathy on the development and outcome of the
diabetic foot ulcers. J Diabetes Complications 4:21-25, 1990.
7. Sanders JE, Greve JM, Mitchell SB, Zacharia SG: Material properties of
commonly-used interface materials and their static coefficients of friction
with skin and socks. J Rehabil Res Dev 35: 161-176, 1998.
8. Pieti DL, Watkins Pj, Foster AVM,Edmonds ME: Do new EVA moulded
or trainers efficiently reduce the high foot pressure in the diabetic foot?
[abstract 87], Diabetes 45(suppl 2):25A, 1996.
9. Perry Je, Ulbrecht JS, Derr JA, Cavagnah PR: The use of running shoes to
reduce plantar pressures in patients who have diabetes. J Bone Joint Surge
10. Lemmon D, Shiang TY, Hashmi A,et al; The effect of insoles in therapeutic
footwear: a finite element approach. J Biomech 30:615-620, 1997.
11. Rayappa PH,Raju KNM, Kapur A, Bjork S, Sylvest C, Dilip Kumar KM.
Economic Cost of Diabetes Care: The Bangalore Urban district diabetes study.
International Journal of Diabetes in Developing countries (1999) 19:87-96.