AMPUTATION ALERT: "Diabetic foot ulcers are common, complex, and costly--and they are sinister in that they come on quietly. ...".

• Author: Armstrong, David G.
• Position: MEDICINE & HEALTH

WHAT IF someone told you that there is a disease you could catch where you could not feel any symptoms coming on--and that this occurs every 1.2 seconds somewhere in the world? What if you were stricken with this disease and, because of it, had a five percent chance of losing a limb within a year and a 50% to 70% chance of dying in five years? What if you were told that this problem costs more than the five most-expensive cancers in the U.S. but that far less than 1/1,000th of comparative Federal and private funding is spent on attacking it?

You have just been introduced to the diabetic foot ulcer. While the problem may strike at the end of the body, far away from the heart or brain, its effects are far-reaching. I have spent my career treating and researching the lower extremity complications of diabetes. I believe our society could eliminate immeasurable suffering if we collectively paid more attention to this problem.

Foot wounds are ugly. The ages of patients are "bimodal," in that there is one population of people who are old and getting older. However, with more and more people being diagnosed with type 2 diabetes earlier, there is a population that is younger than ever being afflicted with wounds, infections, and amputation. About 27,000,000 people in the U.S. have diabetes, and about 500,000,000 worldwide.

Diabetic foot ulcers develop because people with diabetes slowly lose the "gift of pain"--that is, they lose feeling in their extremities. This occurs first--and generally most profoundly--in the feet. Once this occurs, people with diabetes might wear a hole in their foot, just as you or I might wear a hole in a sock or shoe. This "hole" is called a diabetic foot ulcer.

About half the time, the ulcer will become infected. This increases the risk of further tissue damage and, in the face of frequent vascular disease, high-level amputation. Often all of this occurs with few, if any, symptoms . . . until it is too late.

On a positive note, studies have suggested that high-level amputations seem to decrease when interdisciplinary care is in place. Interdisciplinary teams consist of podiatric and vascular surgeons, the so-called "Toe and Flow" model. The concept is simple: these two specialists can manage a great deal of the medical, surgical, and biomechanical aspects of healing and aftercare.

When we add core physical therapy to this, then the threesome--what we in the field call "Toe, Flow, and Go"--is quite effective. For example...