1. 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

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

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

4. Mitigation of bias
Dr. Leslie Goldenberg
Not applicable

5. Neuropathy and gait

6. Neuropathy and gait

13. 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)

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

15. 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

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

17. neuropathies
‘Too tall’ neuropathy
14. Acute quinolone neuropathy

18. 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

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

20. Proprioception
Role of proprioception and proprioceptive loss in balance

21. 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

22. 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)

23. 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

24. Neutriceutical Therapy
B1 – Benfotiamine 600mg
B2 – Riboflavin 8mg
B6 – Pyridoxine mg
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

26. Diabetic Ulcers – Topical Transdermals
Clindoxyl gel or BenzaClin
Diltiazem 5%, 15%
Pentoxifyline 10%
Misoprostol %, 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

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

28. 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