Diabetes presents significant long-term risks to the lower limbs, primarily due to peripheral neuropathy and peripheral arterial disease. High blood sugar levels damage nerves, causing a loss of protective sensation, meaning a patient may not feel pain from a cut or blister. Diabetes also narrows blood vessels, reducing circulation and the body’s ability to heal wounds or fight infection. A podiatrist manages these combined risks, focusing on preventative care and immediate treatment to maintain mobility and prevent severe complications like amputation.
Routine Screening and Risk Assessment
The comprehensive annual foot examination is the foundation for preventative care. This exam involves a detailed inspection of the skin for small cuts, blisters, calluses, or fissures the patient may not have noticed due to nerve damage. Structural deformities, such as bunions or hammertoes, are also noted because they create high-pressure areas prone to skin breakdown.
A neurological assessment uses a 10-gram monofilament applied to the foot to test for the loss of protective sensation (LOPS). If the patient cannot feel the light pressure, they are at an increased risk for developing a diabetic foot ulcer. Circulation is assessed by palpating pedal pulses (dorsalis pedis and posterior tibial arteries) or measured objectively using an Ankle-Brachial Index (ABI).
Based on these findings, the podiatrist assigns a risk category determining the frequency of follow-up visits, which may range from annually to every one to three months. During these routine visits, the podiatrist safely manages thickened nails and debrides calluses, which are areas of concentrated pressure and precursors to ulceration. Performing this maintenance in a clinical setting is safer than at-home care for patients with LOPS, preventing accidental injury from improper trimming.
Management of Acute Foot Complications
The podiatrist manages acute foot problems, most commonly diabetic foot ulcers (DFUs). Treatment begins with aggressive debridement, which is the precise surgical removal of all non-viable or dead tissue from the wound bed. This procedure reduces the bacterial load and exposes the healthy tissue needed for healing.
Following debridement, the primary goal is total off-loading, removing all pressure from the ulcer site to allow for tissue repair. This is often achieved using a Total Contact Cast (TCC), which evenly distributes weight across the lower leg, immobilizing the foot and protecting the wound. For ulcers with underlying infection, the podiatrist identifies the pathogen and initiates antibiotic therapy, sometimes coordinating with an infectious disease specialist.
The podiatrist also manages severe bone and joint destruction, such as Charcot neuroarthropathy, where the bones of the foot weaken, fracture, and collapse. In the acute inflammatory phase, the foot is immobilized, typically with a TCC, to prevent further damage and joint collapse. If the resulting severe deformity creates a high risk for recurrent ulceration, reconstructive surgery may be recommended to stabilize the foot’s architecture. Prompt management of acute complications is necessary to avoid progression to deep infection or osteomyelitis, which often necessitates amputation.
Therapeutic Footwear and Custom Orthotics
Specialized footwear is a necessary intervention for patients at moderate or high risk for foot complications. Therapeutic shoes are designed with extra depth and width to accommodate foot deformities and custom inserts without creating harmful pressure points. They also feature a seamless interior to prevent friction that could easily become a blister or an ulcer on a foot with nerve damage.
Custom orthotics are molded specifically to the patient’s foot and are distinct from generic store-bought insoles. These devices redistribute pressure away from bony prominences or areas with a history of ulceration. For patients with a severe deformity, such as Charcot foot, a custom-molded boot like a Charcot Restraint Orthotic Walker (CROW) may be prescribed for maximum total contact support. The goal of these devices is to stabilize the foot and reduce the vertical pressure force that breaks down skin.
Integrating Podiatric Care with Overall Health Management
Successful diabetic foot care requires continuous communication and collaboration with the patient’s entire healthcare team, including the primary care physician, endocrinologist, and vascular specialist. The podiatrist regularly shares clinical findings, such as the progression of neuropathy or diminished circulation, prompting other specialists to adjust medication or order further diagnostic tests. This integrated approach ensures foot health is treated as an integral part of overall diabetes control.
A significant portion of the podiatrist’s role is patient education, empowering the patient to take an active role in their health. Patients are taught the importance of daily self-inspection, using a mirror to check the soles and between the toes for any breaks in the skin. Instructions also cover proper foot hygiene, such as moisturizing the skin while avoiding the areas between the toes, and recognizing early warning signs. The podiatrist reinforces that good blood glucose control is directly linked to preserving nerve and vascular function, unifying foot health and systemic health goals.