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Diabetic Foot

of diabetic foot problems

  • 1% of the UK population is diabetic
  • 12% of diabetic admissions are with foot problems

Pathology

  • 33% of diabetic foot ulcerations are neuropathic, 33% are ischaemic and 33% are of a mixed nature

  • Symmetrical distal polyneuropathy
  • Involves motor, sensory and autonomic systems;

Autonomic

  • Autonomic involvement has 2 effects:
  • Reduced sweating, leading to dry plantar skin which can fissure
  • Alteration of normal autoregulation of the microcirculation; thickening of the basement membrane of the capillaries, AV shunting, loss of sympathetic tone, loss of postural vasoconstriction and increased peripheral flow

Sensory

  • May be painful or painless
  • Those with painful neuropathy don't tend to get ulcers
  • Painless sensory neuropathy causes stocking distribution sensory loss. Reduced ability to sense pinprick, light touch and vibration.
  • Probably the main factor leading to ulceration.
  • The neuropathic foot is therefore a warm, dry, insensitive foot with clawed toes and increased pressure under the metatarsal heads. Veins are often distended

Motor / Myopathy

  • Motor involvement causes weakness of the intrinsic muscles causing imbalance between the long flexors and extensors, causing a cavus foot and claw toes.
  • The weight bearing contribution of the toes decreases and the fat pad under the metatarsal heads is drawn forwards, decreasing cushioning and increasing vertical and shear forces. The metatarsal and heel pads are atrophied for unclear reasons.


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