Biomechanical concepts in the treatment of ulcers in the diabetic foot

The diabetic patient and the associated pedal abnormalities pose a particularly challenging problem for the doctor from both a management and a prevention standpoint. The sequellae of diabetes mellitus have both neurologic and vascular origins. Neurologically, the diabetic is predisposed to peripheral and autonomic neuropathy, while vascular aberrations may manifest anywhere in the arterial network. Secondary breakdown of cutaneous and osseous structures are the direct result of a chronic insensitivity to pain and a faulty healing mechanism. Healing is, at best, delayed due to this inborn error of glucose metabolism. Ulceration in the diabetic patient remains one of the most troublesome complications of diabetes mellitus. The most diligent and expeditious treatment will fall short nonetheless, if the patient has not been completely educated concerning his affliction. The association of patient education and the response to therapy cannot be overstressed. The diabetic should be educated concerning proper foot care and should be made aware of the serious complications that may result from improper hygiene and pedal neglect. The patient should not assume a passive role in the treatment, but rather, actively participate in his recuperation and rehabilitation. Frankly, it is the patient's understanding of the disease process as it affects the foot and his willingness to accept part of the responsibility for his foot care that will determine the ultimate success of the treatment. The biomechanical considerations that follow the primary management of the acute presentation of diabetic lesions, are aimed at preventing further breakdown and lesion formation by minimizing the adverse effects of gait or ambulation. Biomechanical methods of treating or preventing neuropathic diabetic ulcers have been examined. The conventional medical management of neuropathic and angiopathic ulcers includes antibiosis, local debridement, and bed rest. Due to today's lifestyle, complete bed rest is not always convenient for the patient and even cooperative patients may neglect to use crutches or minimize the problem of their ulcer due to the absence of pain. The methods discussed afford the patient a more normal lifestyle; however, proper patient compliance is required. Patients who use the total contact cast must be willing to keep their weekly appointments zealously and report any problems pertaining to their treatment. After the ulcer has been closed, the patient and doctor must realize that the battle is only half over. Steps must be taken in order to deter one of the most frequent complications, reoccurrence of the ulcer.(ABSTRACT TRUNCATED AT 400 WORDS)