Canadian Medical Alliance for the Preservation of the Lower Extremity
Prevention of Wounds
It is far easier to prevent a wound than it is to get one closed after it has developed.
So how can you avoid developing neuropathic ulcerations?
1) Control the Cause of your Neuropathy
For many causes of neuropathy, in this case meaning sensory loss, it's easier said than done. It's difficult to control a genetic predisposition to neuropathy, or a neuropathy that resulted from Lyme disease, for example.
But for many causes of neuropathy, there may be something you can do. If you have diabetes, for instance, a tight control of sugar can slow the progression of neuropathy, because the cause of diabetic neuropathy is directly correlated to the damage caused by high concentrations of sugar in the nerve.
If the cause of your neuropathy is alcohol toxicity, curtailing alcohol is the obvious way to slow or stop the progression of the disease. Nutritional deficiencies are also treatable. And controlling one’s autoimmune disease may slow the progression. In cases where nerve compression is causing neuropathic symptoms, surgical decompressions may improve symptoms.
The gist is to address the cause.
2) Address biomechanical forces
Neuropathic ulcers are caused by a combination of neuropathy and a pathological force like pressure or friction (shear). So even if you cannot control the cause of your neuropathy, you can address the other side of the ulcer by addressing the mechanical forces that caused your ulcer. This means having your feet assessed by a medical practitioner with a very good understanding of biomechanics. In most cases, a podiatrist (foot doctor) with a specialty in the field of biomechanics and diabetes would be most appropriate. There may be other appropriate practitioners versed in biomechanics in your community as well.
Unfortunately, in many jurisdictions in Canada, there may not be any podiatrists, which may leave patients vulnerable. Further, in Canada, there is no minimum training required to make an orthotic or diabetic footwear, so in many cases patients may not be getting someone sufficiently trained to assess and address their biomechanical issue.
A lot of medical practitioners may also make devices, as well, as a way to augment income. However, not many medical specialties have a lot of biomechanical training.
And too often a family physician simply writes a prescription for the assessment and biomechanical decisions to be made by individuals with little actual medical training or understanding of the forces that would tend to make a foot break down into an ulceration.
So try to make certain you have an appropriate referral.
Look for experts in the foot specifically. Look for board certifications. Look for expertise in wounds. Get more than one opinion.
The third thing you can do to avoid ulcerations if you are at risk is to keep your eye on your own feet. That means daily inspections of your own feet. Perhaps it means inspections performed twice daily. Look for issues with your nails. Look for calluses and corns—where ulcers usually start. Look for any breaks in the skin or abrasions. Keep an eye out for dry or macerated (excessively wet) skin. These are areas susceptible to break down.
You may require a mirror to see your soles.
And examine the contents of your shoes for any foreign object that may cause skin damage. Always wear socks. Make certain your shoes fit appropriately. Keep your skin appropriately moist with moisturizers.
If you cannot bend to examine the bottom of your feet, use a mirror. If your vision is poor, ask family members for assistance. Identifying problems early, before a problem develops, is key.
It’s also good policy to have your family doctor examine your feet on every visit. Don’t wait for your doctor to ask, take off your shoes and socks, and ask him or her to take a look as part of your regular exam.
4) Routine Foot Care
It’s important, too, to keep your foot conditions under control. Keep your nails cut at an appropriate length. Don’t cut down the sides. If you’re developing corns or calluses, see a podiatrist to have them addressed, as ulcers usually start in these areas of pressure and friction.
Your podiatrist, family physician, diabetic foot specialist or neurologist should also monitor you regularly for the development or progression of neuropathy. If there is no sign of issue, you may need this performed yearly. If there are signs of neuropathy, you may need more regular visits.
If you’ve had an ulcer in the past, but are currently stable, or if you cannot attend routine foot care tasks, perhaps you’d need to be seen every 6-12 weeks.
Foot care nurses may also be appropriate for regular assessment and foot care if you have them in your area.
5) When to be Extra Careful
If you have had an ulcer, or particularly if you’ve had a partial foot amputation, be particularly careful. Patients in these categories are at a much higher risk for further issues.
How can you avoid leg ulcerations?
Leg ulcers are commonly caused by arterial insufficiency or peripheral artery disease (PAD), meaning too little blood getting down to the lower extremity, and venous insufficiency--a difficulty in the return of the blood to the heart, creating swelling to the extent of stretching the skin that ulcerations form.
Arterial ulcers make up about 15% of leg ulcers. Arterial ulcers can be avoided by doing the things that prevent poor circulation.
This means cessation of smoking.
It means controlling one's weight.
It means controlling blood sugar.
It means controlling one's cholesterol.
It means controlling one's blood pressure.
And it means getting proper nutrition and exercise.
When circulation is already poor, patients can see a specialist in circulation known as a vascular surgeon. A vascular surgeon is a physician may be able to provide an increase in blood flow through medical and surgical intervention.
Venous ulcerations make up nearly all other leg ulcers, over 80%.
The centerpiece of both avoiding and treating venous ulcerations involves compression. Removing the fluid distention removes the cause of the ulceration. Medications like diuretics may also help remove fluids from the body.
Compression is usually achieved through over-the-counter or measured stockings that provide a pressure gradient to move the fluid up and out of the leg. Compressive dressing wraps may also be used in some cases.
Leg elevation throughout the day is often helpful as well.
Medications to help blood flow and diminish the potential for clots may also be used.
And addressing varicose veins, sometimes through injections or surgical intervention, may also prevent venous leg ulcerations.
In all cases of ulcerations, it is much better, much safer, much easier, and much less expensive to prevent the ulcer than it is to try treating it after it forms.
This page written by Dr. S A Schumacher
Surrey, British Columbia Canada