Peripheral nerve damage is blamed solely as a result of diabetes. This presentation takes a hard look at the evidence, asks and answers the hard questions to show that diabetes should be the last consideration after all other causes are eliminated. Learn more at www.GraMedica.com.

1. Diabetic Peripheral Neuropathy
A Critical Look Separating Fact from Fiction
Michael E. Graham, DPM, FACFAS, FAENS

2. What is a Peripheral Nerve?
A peripheral nerve is a extension
from the central nervous system
(CNS-brain and spinal cord) whose
function is to carry electrical
impulses either towards the CNS
(sensory information) or away from
the CNS (motor function).

3. What exactly is “neuropathy?”
(nerve cell)

4. Neuropathy is defined as
the progressive loss
of nerve fiber function.

5. Peripheral Neuropathy
Peripheral neuropathy is therefore loss of nerve
fiber function in the peripheral nerves (nerves
outside of the brain and spinal cord.)
Normal Nerve Abnormal Nerve

6. Diabetic peripheral neuropathy
has been defined as:
“The presence of symptoms and/or signs of
peripheral nerve dysfunction in people with
diabetes after the exclusion of other causes.”
Boulton, AJ, et. al, Diabetic Neuropathy. Med Clin North America, Jul 1998:82(4): 909-929.

7. Unfortunately, no one pays much
attention to the last and most
important part of that definition:
“after the exclusion of other causes.”

8. Peripheral neuropathies are reported to be the most
common complication of diabetes mellitus (DM).
Fact:

9. It is believed that up to 50% of both
Type I and Type II diabetics have some
degree of peripheral neuropathy.

10. Strange Fact
Type I diabetics are potentially affected with this nerve
condition after decades of chronic uncontrolled blood sugar
levels,
while
Type II diabetics can have signs/symptoms of
neuropathy after only a few years of diagnosis.
(Seems like it would be the other way around?)

11. Type I diabetics don’t usually develop
signs/symptoms of peripheral neuropathy
until they are in their 40s/50s.
The average age of diagnosis of Type I DM is 14 years old.

12. Type II diabetics aren’t usually
diagnosed until they are middle age or
older (50 years +)
Unfortunately, that number is getting younger due to an
increase in type II pediatric diabetes.

13. Signs and/or symptoms of
peripheral neuropathy usually begin
in the toes or the ball of the foot.

14. The loss of sensation on the bottom
of the foot is NOT a good thing.

15. It leads to all sorts of problems.

16. And it’s more complicated than
just the loss of feeling.

17. There is also painful neuropathy.

18. Neuropathy severely affects the
quality of one’s life.

19. Besides living with severe pain

20. There are secondary effects including
• Foot ulcers-
– Typical cost to heal a foot ulcer is $8,000
– Typical cost to heal an infected ulcer is $17,000
• Falls
• Fractures

21. But the worst thing is:
WARNING:
The next side is graphic.

22. Amputation

23. It is estimated that someone loses a
leg every 18 minutes as an ultimate
complication from neuropathy.
Average cost for a below-knee amputation (BKA) is $45,000
There are 80,000 BKA performed/year
Usually the opposite limb develops an ulcer within 18 months
58% go on to have a BKA of the residual limb within 3-5 years.

24. Anything and everything needs to
be done to combat this
progressive nerve disorder.

25. The unfortunate
fact is that once a
patient presents
to a doctor with
nerve symptoms
the first thought
the doctor has
is:

26. DIABETIC NEUROPATHY!

27. At that point the case is closed.

28. “Sorry, we can’t do much for you.”

29. It will only get worse.

30. Sure, you can try to keep
your blood sugar under
control.

31. You can take vitamin
supplements and wear
cushioned shoes.

32. Keep coming back for check-
ups so that we can monitor
how bad it is getting.

33. If you develop painful
neuropathy we will offer
you pills to mask the pain.
Have you ever taken a look at the possible
side-effects of those pills?
You might be surprised.

34. What is it about diabetes that leads
to the destruction of nerves in the
feet and hands?

35. The fact is - we really don’t know.

36. There is quite a bit of confusion as
to why and there are several
theories.
Only thing is that none of them have
really been proven.

37. DM peripheral neuropathy
is blamed on:
• Long-term high blood sugar levels
• High cholesterol
• High blood pressure
• Smoking
• Increased height (taller than normal?)
• High exposure to ethanol
• Genetic factors

38. Diabetes isn’t the only disease that
affects the peripheral nerves.

39. There are several other forms of
neuropathy including:
• Alcohol consumption
• Chemotherapeutic medicine
• COMPRESSION of the nerve
• Familiar (parent/grandparent)
• Idiopathic (can’t figure out why, can’t blame it on anything
else)

40. Besides the co-finding that you also
have a family history of
neuropathy, you have been
diagnosed as being “pre-
diabetic”, Type I or II diabetic, had
chemotherapy, drank beer for too
many years, or we don’t know why
you have it…

41. … are there different findings as far
as the signs or symptoms of
neuropathy?

42. In other words, there is
not one symptom or finding
that links the cause of nerve
damage to diabetes, genetics,
alcoholism, known or unknown
reasons.

43. We don’t say “oh you have
diabetic neuropathy because you
have pain or loss of feeling in
your big toe” or “if you have pain
or loss of feeling in your little toe
it is related specifically to
chemotherapy”.

44. Peripheral nerve facts
• Nerves outside of the spine are capable of
repairing themselves when damaged.
• Nerves are able to withstand up to a 6% strain
without being affected.
• Nerves can be slightly flattened without long-
term damage.

45. What about nerves that are constantly
being over-stretched while at the same
time being flattened and compressed?

46. And this happens-
day after day,
week after week,
month after month,
year after year.

47. Another fact:
An overwhelming majority of
individuals suffering with peripheral neuropathy
are over 40 years of age.

48. The majority of those cases are in patients
over 50 years of age.

49. Let’s shift our focus to dysfunction
of nerves on the bottom of the foot.

50. Walking is the second
most common
conscious function of
our body.

51. Average person takes
6,000 steps a day
42,000 steps a week
168,000 steps a month
2,016,000 steps a year
40,320,000 steps in 20 yrs
80,640,000 steps in 40 yrs
120,960,000 steps in 60 yrs

52. Remember earlier we learned that
most diabetics (either Type I or Type
II) don’t develop peripheral
neuropathy signs/symptoms until
they are 40 years old or older.
Anyone 40 years old has on average
taken over 80,000,000 steps.

53. Did you know there is
one main nerve
collecting all of the
sensations from the
bottom of the foot?
Tibialis posterior nerve

54. All of the nerves
from the bottom
of the foot travel
toward the spine
from behind the
inner ankle
bone.
Tibialis posterior nerve

55. The exact area
where the nerves
from the bottom
of the foot travel
to the ankle area
is a very
potentially
dangerous area.

56. There are 2 tissue
tunnels where the
nerves transition
from a horizontal to
vertical orientation.

57. There is a reason why I am
pointing this out- keep going.

58. Hindfoot alignment is very important
for many things but especially when it
comes to these 2 tunnels.

59. There is a strong correlation
between foot neuropathy and
faulty foot mechanics.

60. Normal Abnormal
When the ankle bone (talus)
dislocates (partially) on the heel
bone (calcaneus) there is a dramatic
and very bad effect on the nerves
within those two tunnels.

61. The partial dislocation of the ankle bone on the heel
bone has been scientifically shown to:
cause pathologic over-stretching of the nerve(s)
&
abnormally increase the pressures within the tunnels
The Effect of HyProCure Sinus Tarsi Stent on Tarsal Tunnel and
Porta Pedis Pressures.
Journal of Foot and Ankle Surgery, Volume 50, (1) Pages 44-49, January 2011
Effect of Extra-Osseous TaloTarsal Stabilization on Posterior Tibial Nerve
Strain in Hyperpronating Feet: A Cadaveric Evaluation
Journal of Foot and Ankle Surgery, Volume 50, (6), Pages 672-675, November 2011

62. A misaligned hindfoot leads to
constant compression
and
overstretching of the nerves
while standing.

63. And a misaligned hindfoot leads to
intermittent damage
with every step taken.

64. Walking is supposed to be so good for
you. That is, unless you have misaligned
feet!
There are hidden dangers of walking!

65. Many people with peripheral
neuropathy will tell you that the
symptoms aren’t so bad or even non-
existent when they first get out of bed in
the morning …

66. …but the longer they are on their
feet then the symptoms get worse.

67. WHY?
Because when they were laying down and off
their feet the nerve was not being
overstretched nor compressed.
Upon weightbearing the nerves were being
crushed and over-stretched.

68. Other individuals with painful neuropathy at
night have often gotten out of bed and
started walking round and round until finally
the pain in their feet went away.

69. The reason why the pain was worse
after they had been off their feet
was that the nerves were “waking
up” and walking around made them
go “back to sleep”.

70. Generally speaking, the medical
establishment has always been
against any surgical option.

71. The problem with typical nerve surgery is
that nothing is done to realign the foot.

72. Arch supports may be beneficial, but for
many patients these devices just end up
pushing on the nerves and make their
symptoms worse.

73. A somewhat new and more
importantly, scientifically proven
internal option now exists.

74. HyProCure ®
Extra-osseous, extra-articular,
talotarsal fixation device.

75. HyProCure ®
is a titanium stent that is inserted into a naturally
occurring space (sinus tarsi) in between the ankle &
heel bones. This minimally invasive soft tissue
procedure instantly maintains the natural opening of
the sinus tarsi while restoring the normal motion and
alignment of the hindfoot bones.

76. Did you know…

77. HyProCure ®
has been used safely and effectively in thousands
of pediatric and adult patients since 2004.
Extra-Osseous Talotarsal Stabilization using HyProCure in Adults: A
5 Year Retrospective Follow-up
Journal of Foot and Ankle Surgery – Vol. 51 (1), p. 23-29, 2012
Stabilization of Joint Forces of the Subtalar Complex via
the HyProCure Sinus Tarsi Stent
Journal of American Podiatric Medical Association, Volume 101 No. 5, Pages 390-399, Sept/Oct 2011

78. HyProCure ®
+ =
is the only extra-osseous talotarsal stabilization
device that works with the normal
biomechanics, unlike other devices that work
against the normal function and often leading to
failure of the device.

79. HyProCure ®
is the only medical treatment that has been
scientifically proven to decrease the pressures within
the tarsal tunnel and porta pedis while at the same
time decreasing the strain on the nerve.
The Effect of HyProCure Sinus Tarsi Stent on Tarsal Tunnel and
Porta Pedis Pressures.
Journal of Foot and Ankle Surgery, Volume 50, (1) Pages 44-49, January 2011
Effect of Extra-Osseous TaloTarsal Stabilization on Posterior Tibial
Nerve Strain in Hyperpronating Feet: A Cadaveric Evaluation
Journal of Foot and Ankle Surgery, Volume 50, (6), Pages 672-675, November 2011

80. Every effort must be considered to
eliminate any factor that could lead to
the destruction of peripheral nerves.

81. We have followed their advice of:
early detection
frequent physician visits
strict diabetic control
but the disease still remains and often gets worse.

82. The need for early surgical
intervention is important.
While standing, walking, or
running the nerves to the
bottom of the foot are being
destroyed.

83. Eventually, a critical threshold is
reached where the nerve is unable
to heal itself.

84. While we can’t ignore that fact that high blood
sugar, excessive alcohol consumption, and the
other potential causes must be controlled or
eliminated, we also cannot ignore the simple
facts of the trauma inflicted on the nerve as a
result of the faulty foot alignment.

85. The risk benefit analysis of the
HyProCure® option shows that the
benefits are far greater than any
potential risks.

86. To learn more about
neuropathy, misaligned
feet, HyProCure® and to find a
specialist near you…

87. Please visit:
www.HyProCure.com