Introduction
November is Diabetes Awareness Month. Diabetes, particularly type 2 diabetes, comes accompanied by a host of comorbidities that directly impact the type and effectiveness of care required in treating the lower extremity, specifically the foot and ankle. Podiatrists are trained in the recognition of these comorbidities as well as their influence in outcomes of treatment. In this article, we will examine prevalent comorbidities and relate them to the anatomical considerations of foot and ankle pathology and where issues in successful treatment can possibly arise.

Diabetes is essentially a systemic abnormality of insulin regulation or the body’s ability to process sugar correctly. This irregularity leads to many other organ issues that can then manifest in the lower extremity. In effect, the lower extremity mirrors systemic disease. The patient complaints and condition that can appear in a podiatrist’s office can be related to conditions that affect their whole body. The most common comorbidities related to diabetes that intersect with podiatric medicine and patient care are obesity, heart disease, cerebrovascular disease, peripheral arterial disease, kidney disease, neuropathy, retinopathy, immune system compromise, and mental health issues.

How do each of these comorbidities affect foot and ankle pathology in a holistic sense?

• Obesity decreases balance and agility, and generally makes mobility more difficult and falls more frequent.
• Heart disease leads to shortness of breath, mobility issues, and circulatory problems.
• Cerebrovascular disease is directly linked to heart disease and stroke risk. Patients who suffer strokes most commonly live with restricted ambulation and spasticity that make formerly simple tasks such as inspecting one’s feet very difficult, if not impossible.
• Peripheral arterial disease is intimately linked to heart disease and presents complications such as slow or nonhealing wounds in the foot and ankle that in a patient with normal circulation would not be problematic.
• Kidney disease is a consequence of compromised circulation; and specific to foot and ankle pathology, it presents issues such as the ability of the body to correctly process adequate dosages of antibiotics and effectively resolve infections of the foot.
• Diabetic peripheral neuropathy is perhaps the most common of the comorbidities that affect the foot and ankle: Neuropathy eliminates or dampens our response to painful stimuli. Therefore, what might normally be a painful blister or stepping on a nail may go unrecognized until a wound becomes infected and requires urgent treatment.
• Retinopathy affects vision and increases fall risks as well as complicates the ability of an individual to do daily foot inspections. This act, in a preventative sense, helps anticipate and avoid situations that could cause foot or ankle injury.
• Compromised immune systems in diabetic patients makes fighting and resolving infections much more challenging than in nondiabetic patients. This can lead to longer hospitalizations and more disruption in daily life due to wound care and dressing changes required as well as increased visits to doctors.
• It should come as no surprise that patients with diabetes that also suffer from any or multiple comorbidities have a higher prevalence of mental health issues such as depression and anxiety. It is challenging and disheartening to have a foot and ankle condition that can be complicated and lead to lengthy and protracted care due to the associated comorbidities.

Case Study
A modified case example will illustrate just how the comorbidities of diabetes create challenging management issues for patients and podiatrists alike.

A typical case involves a patient with an ingrown nail with cellulitis. The nail needed to be removed so that her infection would not worsen and risk osteomyelitis (bone infection), sepsis, amputation of the toe, or amputation of the leg below or above the knee. The podiatrist removed the nail and yet the patient went on to develop an infection that was treated by other care providers in the hospital environment. Due to peripheral arterial disease, the patient had previously had a popliteal bypass graft that subsequently occluded leaving her with little to no blood flow below the knee, which later caused the patient to undergo an above-knee amputation.

Prior to the podiatrist’s treatment, this patient suffered two cerebral vascular incidents (strokes) which caused left-sided weakness, further complicating daily mobility as she required a walker for ambulation. This severely reduced mobility made even routine care of the feet and nails challenging. The patient also had kidney disease which required monitoring and adjustments to antibiotic dosages during the treatment of the ingrown toenail infection as well as required consultation with an infectious disease specialist.

Due to the patient’s history of coronary artery disease, she had previously undergone a CABG (coronary artery bypass graft) procedure, numerous cardiac catheterizations, and angiograms and was very deconditioned and unhealthy with a poor quality of life in general. In addition, she suffered from depression and mental health challenges that complicated her ability and desire to comply with recommended care throughout the entire treatment process.

Conclusion
Diabetes and its related comorbidities create important and challenging patient care and management considerations for podiatrists and all health professionals. Comprehensive medical education of these issues by practitioners and proactive patient and family education by all health professionals can assist in mitigating these issues. This awareness helps reliably ensure that most patient complaints that generate a visit to a podiatrist can be effectively resolved within a multidisciplinary team approach. The primary foot and ankle pathology as the presenting complaint with the backdrop of diabetes as a systemic multiorgan condition and the associated comorbidities, require a comprehensive knowledge and appreciation of all factors in achieving successful patient outcomes.

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Source: ProAssurance "ProVisions"; May 2024

The information contained on the PICA Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. In the event any of the information presented conflicts with the terms and conditions of any policy of insurance offered by ProAssurance Insurance Company of America, the terms and conditions of the actual policy will apply. All information contained on the blog is subject to change.