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How To Avoid Foot Amputation

5.07 Semmes-Weinstein monofilament test

The following is a true story for many patients.

Before the Amputation

When he was diagnosed with diabetes a year ago, he remembers his first thought was of people he knew with diabetes who have had their foot amputated. He was afraid that he was next in line, so when his doctor told him to watch his diet, and to exercise… he cut out some carbs, and started going on walks around the neighborhood. Everything is going well so far, he felt better, and he has been doing his best to control his blood sugars. They are not perfect but have improved.

One day, as he is walking around the kitchen floor preparing breakfast, he discovers small drops of blood on the clean white tiles. “This is strange”, he thought. He does not have pain anywhere in his body that would cause bleeding, so where did the blood come from? He needs to get ready for work so he finishes his breakfast, and goes to take a shower. In the shower, he discovers blood again in the running water. After a full body check, he discovers a blister on the bottom of his left foot. It does not hurt and does not look like a wound or a cut, so he put a bandaid over it and hurries off to work. He finishes his work, arrives home that evening, immediately removes his shoes to massage his aching feet. To his horror… there is blood all over his left sock. He rips off the blood soaked socks to find that the blister has gotten bigger, and his left foot is now red and swollen. He gives the blister a good squeeze, and out pours a stream of pale yellow liquid. It is now late into the evening, he realizes that he needs to do something. If he goes to the emergency room, it might be the next morning before he even gets to see a doctor, so he decides the best course of action would be to take care of it himself. Thinking this might be an infection, he tries to kill the bacteria by pouring hydrogen peroxide on his foot, and then soaks it in a tub of warm salty water. The blister seems to have stopped draining, so he slaps on a bandaid and goes to sleep. It is now 6 a.m., he wakes up in a cold sweat, feeling feverish, and his left foot now aches more than yesterday. Blood has soaked through the bandaid and stained his bed sheets. He decides it is time to seek professional help, so he calls in sick and visits the local emergency room. After several hours, he finally sees the doctor.

The doctor looks at his patient’s foot. A barrage of tests and x-rays were performed. Another doctor then appears and is introduced as the surgeon.

What went wrong?

He could not believe how he got himself into this very situation he was trying to avoid. His blood sugars have been improving gradually, he was exercising and dieting like his doctor told him to. What exactly did he do wrong?

The answer is that he has neuropathy, a condition where the nerves in his feet are no longer working. He did not realize that the tingling and burning pain followed by numbness was something to be concerned about.

Pain is your friend.

Test for foot neuropathy

He had a callus deep enough to form a blister and bleed, but yet he didn’t feel it. People with neuropathy may step on a rusty nail and never notice it. A staggering 50% of all patients with diabetes will eventually develop neuropathy. That is why it’s important to see your doctor regularly so they can check your feet’s sensation. The test for neuropathy is a simple test using a monofilament. It looks like a short piece of fishing wire. The doctor presses this wire against your foot at several locations to see if you feel it and if you don’t, it means you have neuropathy.

To avoid foot amputation, check for foot calluses.

Blood in the blister tells us there is an ulcer.

Check your feet daily, even twice a day if you do a lot of walking/standing for work or for leisure. You want to look for calluses. Calluses are thickening of skin, typically found on the bottom of our feet. They are caused by shear and high pressure. Calluses need to be offloaded, so the pressure spot won’t progress into an ulcer. Offloading can be done with special inserts or shoes prescribed by any doctor. The callus can be shaved down by a foot specialist in their office. The important thing is to check your feet often, and if you see a callus, go see a doctor. When calluses don’t get taken care of, they will form into blisters. The blister will turn into blood blisters. The blood blister will turn into ulcers. An ulcer is a wound, an opening in the skin which connects the dirty outside.

Animation showing how a callus can turn into a blood blister, creating an ulcer.

If you suspect infection, don’t procrastinate.

If you suspect you have a problem, seek medical attention urgently. I’ve seen a lot of patients in the hospital who admit that they were concerned about a foot infection for days, even weeks. Seeking help sooner gives your medical team a greater chance at saving your foot!

In summary:

Dr Haywan Chiu, DPM Haywan Chiu

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