When I was a resident, I saw a middle-aged man, “Charles,” who came into the hospital after playing a round and a half of golf. When I looked at his right foot, he had an ulcer in the shape of a golf tee. He had played the entire day with a golf tee in his shoe and only noticed when he found drainage on his sock. The story sticks in my mind because he was the first person I ever had to tell that he might have to have his foot amputated. It turned out that he had been diagnosed with diabetes, but he never complained about his feet so nobody ever checked them. He never complained because he had neuropathy, so he never felt anything.
We know that foot exams can be lifesaving for patients with diabetes. Recognizing this, St. John Hospital and Medical Center in Grosse Pointe Woods, Michigan, initiated a Performance-Improvement Continuing Medical Education project to encourage internal medicine practitioners to do comprehensive foot exams for their diabetic patients. Using American Medical Association methodology, the project included baseline reports about foot exam performance, an educational intervention and a reminder tool for use in practice. The project led to a significant increase in the percentage of patients who received an annual foot exam and improvements in the percentage who received a comprehensive foot exam. This is good news in light of an Institute for Preventive Foot Health/NPD survey that revealed only 46 percent of patients with diabetes reported having foot screenings with their doctor in 2012.
A podiatrist is often the first person to hear about the strange sensations that may signal neuropathy. A routine foot exam in the primary care office would bring these symptoms to light. This is especially important because some people experience peripheral neuropathy and nerve damage before they’re diagnosed with diabetes.
A foot exam can go a long way toward uncovering a lesion or other signs, such as numbness, that could signal the need for prompt intervention. It can also reveal other issues that may interfere with the person’s quality of life or ability to be active. A recent survey by the American Podiatric Medical Association (APMA) found that close to eight in ten Americans have experienced a foot problem, and half say that problem has affected their quality of life.
Small issues can lead to big problems
Deformities such as bunions and hammertoes can cause pain and limit activity when a patient is wearing shoes that don’t fit properly. The shoes rub on these bony parts, causing pain, corns and bursitis that interfere with mobility. Many people don’t report the pain and aren’t aware that it takes only a few seconds to remove a corn. Similarly, thinning of the fat pads on the bottom of the feet — the result of age and activity — means patients may be walking on bony areas, which is also painful.
By checking between the toes, doctors may uncover lesions, scaling, macerations, lacerations or infections. Fungal nails and skin infections should also be treated. Many doctors believe this is a cosmetic problem, but fungal nails can lead to skin infection, cellulitis and ulcers underneath the nail. Many fungal infections in the feet look similar to dry skin and calluses. Fissures in the skin can easily become infected and lead to cellulitis.
Looking more deeply: Feet and body systems
The APMA survey also shows that people with regular foot problems tend to have other health conditions. The feet can offer a window into those issues. The feet may present signs of circulatory problems — anything from painful varicosities to peripheral edema, cold digits and lack of digital hair. Swelling in a toe or joint could indicate inflammatory arthritis. In addition to neuropathy, conditions such as drop foot can indicate neurological conditions, vitamin deficiencies or drug effects.
Malignant melanoma may arise in the feet. Melanomas beneath the nail represent only three percent of melanomas among Caucasians but 15 to 35 percent of those among African Americans. Dermatologic conditions may also signal systemic problems. Podiatric consultations may help uncover these conditions. Skin lesions on the feet and lower leg may be associated with lymphomas, diabetes, gastrointestinal diseases, autoimmune disease, thyroid disease, kidney disease and many other pathologies.
A basic exam
A simple visual foot exam in the primary care office can uncover any musculoskeletal deformities such as bunions, hammertoes, flat feet or bony prominences. A brief skin exam can reveal lesions, fissures, rashes, macerations, corns or lesions that may need biopsy. A quick vascular exam is as simple as palpating pedal pulses, feeling skin temperature, observing for peripheral edema and looking at skin color. For a diabetic patient, a Semmes-Weinstein monofilament wire test, which takes just a few seconds, can reveal loss of protective sensation. A quick glance at the patient standing and taking a few steps can reveal poor balance, difficulty walking and risks for falling. Ask patients about any pain related to their feet or any difficulty getting around.
An appropriate referral
Patients with diabetes are routinely referred to an eye doctor for retinopathy. However, many don’t know they might need to see a podiatrist for complications of diabetic neuropathy. Charles was lucky that he received treatment and did not have to undergo amputation. But that’s not the case for many others. According to the American Diabetes Association, most foot amputations are preventable with regular care and proper footwear. A timely foot exam in the primary care office is part of that care. It can detect diabetic neuropathy and encourage patients to do daily foot inspections and have regular foot exams to help avoid the development of an ulcer that, left untreated, could be life- or limb-threatening.
Lori Weisenfeld is a podiatrist who blogs at Primary Care Progress.