12/22/2023    Martin Pressman, DPM

Are We Failing our Diabetic Patients? (Rod Tomczak, DPM, MD, EdD)

Thank you, Dr. Tomzak for reminding me of the
mentorship of my classmate Dr. Allen Jacobs and my
professor Dr. James Ganley. Both of whom, among
others, contributed greatly to my practice of
podiatric medicine and surgery. The medicine
portion of my 47 year practice was as
intellectually challenging for me as the surgical
side and just as important to patient outcomes.
Actually many times, more important for the patient
than a straight toe or a fused first TMJ. It was
Jim Ganley who simply by example, demeanor, and
intellect, taught us what it is to be a physician
and surgeon. His emphasis on history and physical
examination and the pearl that “diagnoses hide in
plain sight” brings me to this discussion.

If you Google incidence and prevalence of PAD in
diabetics you might notice that at age 45 the
incidence of PAD in diabetics ranges from 20 to 30
percent depending on the study.

This means up to 3 in 10 of these diabetic patients
have PAD. These patients may have no symptoms and
palpable pulses. If we do not make that diagnosis
early, we definitely failed that patient. Noting
lack of hair growth and palpable pulses and doing
nothing else but diabetic foot care is failing the
patient. The standard nomenclature for podiatric
vascular examination should erase the term
“palpable pulses”.

The use of the zero to four palpability scale does
not emphasize the importance of the ABNORMAL plus 1
pulse. Our vascular examination should be looking
for stenosis and abnormal Doppler signals if we
want to diagnose PAD early. Pulse pressures in
palpable vessels can be low and monophasic
indicating a proximal stenosis.

My point is that all of us should use Doppler flow
analysis for our vascular examination of at risk
patients. The examination of the DP, PT peroneal,
and popliteal arteries with a hand held 8mhz
Doppler looking for monophasic sounds, will
certainly benefit our at risk diabetic patients and
adds 3 minutes to our “Diabetic foot exam” without
increasing the cost. Auscultation (Doppler) trumps
palpation for vascular screening. We need to look
at our “standard of care” and raise the bar a bit.

Martin M Pressman, DPM, Summerville, SC

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