Hi, this is Dr. Matt Garoufalis. I'm a podiatrist, and I practice in Chicago. I have a private practice in Chicago, and I was involved in the VA system for 39 years. I was at 2 VAs here in Chicago. I was the associate chief in one, I was a residency director, so I did the whole gamut of teaching, educating, doing the administration stuff, and of course, because I'm also a past president of the American Podiatric Medical Association, I was deeply involved in the politics of medicine as well. 

But my passion is teaching residents and students and working with them in wound care. I didn't think it was going to be wound care for me, but I thought it was going to be sports medicine like many other folks. But once I got to the VA and fell in love with those people and helped them with their wounds, it was wound care all the way and limb salvage. 

Diabetic foot neuropathy is an unfortunate consequence of having diabetes. Up to 50% of the patients that have diabetes will get some form of diabetic neuropathy. A lot of it has to do with diet, a lot of it has to do with control of their diabetes, but sometimes it just happens despite the fact that those patients are well controlled and eating well. It just is because the diabetic patient, their chemistry changes, and the way that they break down different products changes in their body and doesn't work the same as a nondiabetic patient. As a result, there's certain byproducts of the way things are broken down that contribute to the breakdown of the nervous system, and eventually they get different forms and different stages of diabetic neuropathy. So it's something that we want to keep an eye on with these patients and we do screenings all the time. And as they become neuropathic, we want to be able to educate them on ways to prevent the consequences of neuropathy. 

Unfortunately, diabetic foot ulcers are probably the end stage product of diabetic neuropathy. When a patient has diabetic neuropathy, they lose the ability to feel. They lose the protective sensation of pain. So they don't know if they've stepped on something sharp. They don't know if they're walking with a rock in their shoe or a folded up sock in their shoe or if they have a different kind of a pressure bearing on the bottom of their foot that has resulted in a blister. And so, being not able to understand pain and as a result, react to that pain, causing them to take a look at their foot or to change the way they walk or to take their shoe off and see if there's something in there, they don't realize it, and so they get a wound. And once they get a wound, then, because of all these changes I mentioned earlier in the diabetic environment, they're more prone to that wound ulcerating and not healing appropriately. So once a patient has diabetic neuropathy, there's a whole checklist that we want to go over with them that they need to do every day, and maybe several times a day, to protect themselves against the consequences of injury. 

There's lots of screening measures that are available. Typically, the ADA says that patients who are diabetic should be screened once a year. And indeed, yeah, that's right. That's the minimum level. I like to say 2 times a year, and in the VA it's probably a little bit more often than that. But when we do a diabetic foot examination, we use a 10-gram monofilament to test for neuropathy. We can also test sharp and dull sensation. We can test the patient's reflexes, and we can even use vibration as a test to determine at what stage the neuropathy is.

So there's lots of different ways that we can evaluate if the patient has neuropathy and to what extent their neuropathy is present, and once we have determined that, then we have to ask the patient, okay, is this a painful neuropathy? Are you having pain with this, or is it just a loss of sensation? 

And there are medications out there that of course we can give the patient to help them with this. First of all we do want to make sure that they're under control as far as their glucose goes; that's primary importance because that can help to limit the effects of neuropathy. There's topical medications like capsaicin, and now there's different varieties of capsaicins that can be used topically. And then there's oral medications that can be used as well. There's pregabalin and gabapentin that can be used. There's tricyclic antidepressants that are used. And these can be used in combination or separately. And if the patients are really a lot of pain, we can go to things like nerve stimulation and things like that. 

So there's a variety of different ways to treat diabetic neuropathy once it's diagnosed, and it's a very individual regime. Each patient is treated a little bit differently and has to be monitored a little bit differently, and because neuropathy is a condition that changes over time, many times these medications that we provide for the patients also have to be changed with time and, therefore, monitored on a regular basis.