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Unresolving heel issues in diabetes patients

Discussion in 'Diabetic Foot & Wound Management' started by Deka08, May 6, 2014.

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  1. Deka08

    Deka08 Active Member


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    Hi folks, I have hit a bit of a wall with 3 patients who are all different and yet seem to have similar threads running in each case. I appreciate you taking the time to read this, it’s a long one, but necessary to do it justice.

    The first, Mrs A, is a 62 year old lady with diabetes, depression, hypertension, OA, epilepsy. She has been seeing me for a few years now for routine foot care. Over the last 3 years she has been having, with increasing frequency, extravasated blisters on the postero-dorso-medial aspect of her heels. The left is in a weight bearing situation, but the right is more dorsal to the weight bearing line. The right heel area has blistered and broken down into a wound previously, it is currently healed and this is the area that I am more concerned about. This lady has well controlled diabetes, good pulses, triphasic, intact protective sensation. We have tried a lot of things – footwear, accommodative orthoses, engo patches. The only thing that helps is felt stuck to the foot to deflect pressure/irritation.
    The 2nd is Mr B, a 60 year old male, diabetes, hypertension, hyperlipidaemia. He has a history of left foot charcot arthropthy (stable), left 2nd amputation. The left foot is painful through the lateral midfoot, although with the correct footwear (which is difficult as he has a size 14 EEE foot) and orthotics we can reduce his pain and make it more comfortable. The right foot heel is once again the area of concern. Over the last 4 months this area (posterior – dorso-medial heel above the weight bearing area) has been getting increasingly painful. Over the last month excruciating. There are defined nodules that are red and angry and very tender to touch. We have x-rayed and ultra sound that have revealed nil. We had him reviewed by the endocrinologist last week and he has referred for an MRI. Nothing much has helped him so far.
    This brings me to the 3rd. Mrs C is a 68 year old lady with diabetes, hypertension, OA. He has a history of Charcot arthropathy (stable – both feet), left foot 5th ray amputation oct 2013 – the resulting wound is nearly healed, and ironically, I am not too concerned about this foot. The right heel, which had been sore for about 4 months – unresponsive to any padding in shoe or on foot, displayed the same redness, tenderness, nodular like appearance – in the same spot. About 6 weeks ago this actually broke down into a wound. No weight bearing pressure, no identifiable rubbing or irritation. It was like the inflammation in the heel caused the skin to breakdown. The wound has stayed the same, not progressing or regressing at all.

    All have the same painful tender nodule like inflamed area. All have Diabetes type 2 on tabs and insulin, hypertension. I should add that I am currently part time private, part time public. All 3 have seen me privately originally. Mrs C is now entirely in the public system, the other 2 hover between the 2. They have all had access to our HRFC, and have had multiple sets of eyes on their feet, not just mine.
    My concern is that Mrs A and Mr B are going down the same path as Mrs C and possibly going to breakdown. I am thinking maybe fat pad inflammation or herniation, but i understand that this is actually quite rare, would I really get 3 in a small population? Has anybody seen anything like this? I could sure use some help with these ones. Happy to answer any further queries.
    Thanks.
     
  2. cormy7

    cormy7 Member

    Have you questioned them about what pressure relief they have while in bed on a night I know this May be a simple solution but I had a patient with diabetes with palpable pulses but neuropathic and a blistered area to the right medial calc above the plantar surface which then ulcerated I put her into a foam heel suspension Boot on a night and it healed and she has thankfully had no further problems. Any pictures would be helpful if you have any ?
     
  3. Deka08

    Deka08 Active Member

    Thanks cormy,
    I have pursued that with Mr B but not the others. I don't believe it is the cause (just a feeling in my bones), but i will see through any suggestions, even if tried before. If it is the cause, the suspension boot is a good fix and cheap, I'll get a couple and see. I am working on photos, just have to establish some consent for that.
     
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