Evaluating and Managing Foot Pain and Neuropathy in Diabetics Dr. Leslie Goldenberg B.Sc., M.D., F.R.C.P.(C)., A.B.I.M., F.A.G.S Medical Director, Walking Mobility Clinics Assistant Professor, U of T Faculty of Medicine

Presenter disclosure Dr. Leslie Goldenberg Relationships with commercial interests: Medical Director of Walking Mobility Clinics

Program disclosure of commercial support Dr. Leslie Goldenberg No commercial support

Mitigation of bias Dr. Leslie Goldenberg Not applicable

Neuropathy and gait

Neuropathy and gait

neuropathies Sensory polyneuropathy clinically encompassing a spectrum from subclinical sensory loss to the totally asensate foot (distal symmetric small fiber neuropathy) Autonomic neuropathy with trophic changes, distal hair loss and dry skin Sensory motor polyneuropathy with distal weakness of longer duration (much less common than sensory neuropathy)

neuropathies 4. Painful distal sensory neuropathy Painful proximal diabetic neuropathy or lumbosacral radiculoplexus neuropathy Femoral neuropathy with diabetic amyotrophy associated with quadriceps wasting

neuropathies Acute painful diabetic neuropathy (reversible insulin neuritis) Single neuropathy especially of the peroneal and posterior tibialis nerve; third nerve, intercostal nerve roots and median nerve (mononeuropathy) Local pressure palsies and entrapment neuropathies

neuropathies Part of the syndrome of mononeuritis multiplex Chronic inflammatory demyelinating polyneuropathy Restless leg syndrome associated with diabetes

neuropathies ‘Too tall’ neuropathy 14. Acute quinolone neuropathy

Local Pressure Palsies & Entrapment Neuropathies Uni or bilateral peroneal palsy with foot drop Tibial neuropathy in medial tarsal tunnel Anterior tarsal tunnel syndrome Plantar and calcaneal branch entrapments Buttock sciatica/piriformis syndrome

Toxic Neuritis in Diabetics Acute insulin neuritis Acute Quinolone neuritis Flagyl neuropathy Statin induced neuropathy Pyridoxine (Vitamin B6) neuritis

Proprioception Role of proprioception and proprioceptive loss in balance

Clinical screening ‘quickies’: the one minute neuropathy exam Arise without arm recruitment Heel and toe raises Single leg balance Assess sway with eyes closed – static gait

Clinical screening ‘quickies’: the one minute neuropathy exam Dynamic gait – tandem Turn – Kneel – Deep tendon reflexes Tuning fork – 10 gram pressure – light toe touch Clues from visual inspection (autonomic, claw toes, intrinsic minus, trophic)

Blood Testing Screen for Neuropathy Co-Conspirators ESR, ANA, ENA-Panel (SSA + Bab) Serum protein Electrophoresis and Urine for light chains HIV and Lyme Serology Anti Hu antibodies Cryoglobulins, Mercury, HbAIC, B12 and Pyridoxine Urine porphyrins

Neutriceutical Therapy B1 – Benfotiamine 600mg B2 – Riboflavin 8mg B6 – Pyridoxine 50-100mg B12 – Methylcobalamine 4000ucg R – alpha lipoic acid 300 units Metanx (B6, B12, Folic Acid) combo Neuropathy Support Formula Consider B-50’s & B-100’s Zinc 75mg tid, Vitamin C 500 mg/d

Diabetic Ulcers – Topical Transdermals Clindoxyl gel or BenzaClin Diltiazem 5%, 15% Pentoxifyline 10% Misoprostol 0.0024%, Phenytoin 5% Timolol 0.5 Humulin 40 units/gram Santyl collagenase Iodosorb Inodine Flamazine Polysporin complete, Ozonol antibiotic Mupirocin 2% ointment Metronidazole 1%, 2% PCCA-PLO, Delivera, Lipoderm

Painful Neuopathy – Topical Transdermals PCCA-PLO, Delivra, Lipoderm Diclofenac 15% or Ketoprofen 20% DMSO 5% Ketamine 5%, Gabapentin 6% Amitriptyline 10%

NNT – Numbers Need to Treat TCA’s – 1.4 NMDA antagonists – 1.8 Dilantin – 2.2 Tramadol – 3.3 Neurontin (gabapenin) – 3.7 Lyrica (pregablin) – 4.5 Capsaicin – 5.0 SSRI’s – 6.7