04/18/2018    Robert D. Phillips, DPM,

The Importance of Examining Legs:

I would like to commend the thoughtful letters
written by Dr. Forman (4/14/18), Dr. Silver
(4/18/18) and Dr. Jacobs (4/16/18). All bring to
the fore the important facts that diabetes not
only has a negative effect on all the systems in
the foot, but that decrease in the utilization of
the foot also accelerates the impact of the
disease on the other body systems.

Certainly, the main goal of any podiatrist
treating the diabetic patient is to increase the
activity level of the patient. Many years ago, I
heard Dr. Root talk about no longer thinking of
geriatric foot care as trimming calluses and nails
and moisturizing the skin. Instead he stated that
a major focus should be the prevention of falls.

This concept needs to be updated to include
diabetic foot care. A required journal read of all
medical students who rotate in our wound care
externship is “Cavanagh, Peter R., Guy G.
Simoneau, and Jan S. Ulbrecht. ‘Ulceration,
Unsteadiness, and Uncertainty: the Biomechanical
Consequences of Diabetes Mellitus.’ Journal of
Biomechanics 26 (1993): 23-40.” This now classic
article (cited now 254 times since) should create
no doubt in the physician’s mind that diabetes is
as much a biomechanical disease as an endocrine
disease.

The fact that any diabetic would have a callous
should point to a biomechanical issue that needs
to be addressed by the podiatric physician, and it
is unconscionable in my opinion that a significant
amount of E/M time isn’t spent in identifying the
etiologies of the callous.

I recently contributed to another podiatric
magazine, a brief overview on the biomechanical
issues that the diabetic faces, from changes in
the biomechanics of every body tissue, to the
changes in muscle mass(which changes start long
before any detection of deficit using a 10g
monofilament), to changes in proprioception and
changes in muscle firing patterns, all of which
markedly impairs normal walking and increases the
risk of falls.

I agree totally with Dr. Jacob’s statements that a
33% E/M use should be the norm for podiatry. Let
us hope that this time next year we will have a
consensus in the profession that less than 33% E/M
use is definitely below the norm.

Robert D. Phillips, DPM, Orlando, FL

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