“The pressure must go!”

Treating diabetic foot ulcers is no easy matter. Avoiding amputations, preventing the formation of new ulcers, and keeping the patient’s quality of life at the highest possible level – these are the main objectives pursued by Dr. med. Katrin Reuter-Ehrlich from Jena.

“The vast majority of foot wounds develop because of pressure that patients don’t even notice!”Dr. med. Katrin Reuter-Ehrlich

It’s a Thursday morning in July 2018. It’s only a little after eight , but the outpatient foot clinic at the Diabetes Center at Ernst-Abbe-Platz 3-4 in Jena, Germany, is already pretty crowded. Dr. med. Katrin Reuter-Ehrlich began setting up the foot clinic back in 2005. Today, the joint medical practice offers wound consultations on Tuesday and Friday mornings, as well as follow-up consultations on Thursday mornings. “Patients with newly formed wounds are considered emergency patients and are naturally given appointments on other days on short notice,” says Reuter-Ehrlich, a specialist for internal medicine and also a diabetologist. Patients who come to the Diabetes Center generally have their feet examined in order to identify possible nerve and circulatory disorders. “After all , our goal is to prevent the formation of wounds and ulcers to begin with,” Reuter-Ehrlich explains.

Healing wounds by relieving pressure

Reuter-Ehrlich’s first patient of the day has a name that fits him: Frank Riese (Riese means giant in German) is 2.06 meters tall. His shoe size is 46 and he’s come to the center for a follow-up examination. His latest wound, which is located above his metatarsal head (MTH) 1 on the right , remains healed, as it was when he came for his last appointment two weeks earlier. Riese, 56, came to see Dr. Reuter-Ehrlich for the first time in June 2015 because wounds located below the MTH 1 on both sides had not healed after nine months, despite his having received wound treatments. “I wore flipflops when I moved in September 2014,” is how he explains the way the wounds came about. Dr. Reuter-Ehrlich immediately gave him surgical shoes and cushioning with an adhesive felt to take pressure off the wound. “The wound on his right foot was healed a week later,” Reuter-Ehrlich reports. “This is a classic situation: The wound treatment is really good, but the wound doesn’t get smaller. Then you take steps to effectively reduce pressure and the wound heals.” Diabetes patients with polyneuropathy (PNP), which is a type of nerve damage that often occurs in the early stages of diabetes, lose their ability to feel pressure, temperature changes, and pain in their feet , which means they don’t notice it if their shoes get too tight. “The most important thing to do when treating diabetic foot syndrome is therefore pressure relief, pressure relief, and more pressure relief, provided the patient’s circulation is sufficient ,” Reuter-Ehrlich explains.

“We discover nerve disorders in one out of every four early-stage diabetics.”Dr. med. Katrin Reuter-Ehrlich

Riese was actually already wearing custom-made orthopedic shoes when he showed up at the clinic for the first time, but the shoes were too short and the cushioning was too narrow. “I have all my patients show me all the shoes they wear,” says Reuter-Ehrlich. “That’s because if the shoes don’t fit right , it’s only a matter of time before the next wound develops.” PNP leads to dry, cracked skin in many diabetic patients, whose natural cushioning on the balls of their feet also deteriorates. Eventually toes become misaligned as well. Patients’ normal ready-made shoes no longer fit them and put pressure on their feet , although they usually don’t notice this. That’s why it’s so important to wear foot orthoses that relieve pressure – in most cases along with special shoes, diabetic therapeutic shoes, or even custom-made orthopedic shoes. Reuter-Ehrlich personally checks all prescribed orthoses and shoes after patients have worn them for four to six weeks. “Then I look at the feet to see if any pressure points have formed,” she explains. “I also ask patients whether they’re having any problems with their shoes, and if necessary I get in touch with the orthopedic shoemaker.”
Dr. Reuter-Ehrlich is satisfied with Frank Riese’s feet today, but not with his blood sugar level. The doctor and patient therefore discuss changing medication doses and agree on an appointment date for the next follow-up examination.

Temperature differences as a warning signal

While Frank Riese is putting on his custom-made shoes, Ingrid Fuhrmann, 89, is being weighed in the next room, where her blood pressure is also taken and her blood sugar levels are measured. Fuhrmann recently had two toes amputated. “Unfortunately, it couldn’t be avoided,” says Reuter-Ehrlich. “Still , patients are usually able to deal with such minor amputations after everything heals. Fortunately, major amputations due to DFS – that is, amputations above the ankle – have decreased over the last few years.”

“The failure of the sensitive nerve fibers means the foot no longer sounds an alarm. That’s what makes this so serious.”Dr. med. Katrin Reuter-Ehrlich

Fuhrmann’s ulcers are photographed and data on the location, size, and depth of the wound, as well as the condition of the surrounding area and the wound bed, are documented on a computer. Dead tissue and scabs are removed and the wound is freshly bandaged. A small skin thermometer is used to take the temperature on both feet. “It’s also very easy to notice temperature differences with your hands, and if one foot is warmer than the other you need to find out why,” Reuter-Ehrlich explains. “For example, impaired circulation can be the reason for a cold foot , or an infection could cause a foot to feel warm.” The condition of Ingrid Fuhrmann’s feet today is “very good under the circumstances.”

Alarm no longer sounded

“I’ve known Ingrid Fuhrmann since 2008,” says Reuter-Ehrlich. “She had severe foot deformities when she first came to me. She was already wearing custom-made orthopedic shoes, but they had a hard leather cushioning. Her polyneuropathy either hadn’t been noticed or it wasn’t taken into account when she was fitted for the shoes.” It only became clear very slowly that her polyneuropathy was not exclusively being caused by her diabetes. “We discover nerve disorders in one out of every four early-stage diabetics,” says Reuter-Ehrlich. Polyneuropathy can affect many things. For example, it damages motor nerves, which leads to foot misalignments and thus inappropriate mechanical stress as well. The impairment of autonomic nerve fibers reduces sweat production; the skin becomes cracked and more prone to infections. “The failure of the sensitive nerve fibers leads to lack of sensation, which basically means the foot no longer sounds an alarm if there’s pain or pressure,” says Reuter-Ehrlich. “That’s what makes this condition so serious: most foot ulcers develop because of pressure that patients don’t even notice, and therefore don’t react to.” This lack of sensitivity is therefore an important component of training sessions conducted for diabetics at the Diabetes Center. The sessions also address key aspects of the condition, secondary diseases, nutrition, movement and exercise, medications, the need to perform daily foot inspections, and potential pitfalls such as scorching from hot sand on a beach in the summer or from heaters in the winter.

“Fortunately, major amputations due to DFS have decreased over the last few years.”Dr. med. Katrin Reuter-Ehrlich

Interdisciplinary cooperation

Ingrid Fuhrmann suffers repeatedly from foot wounds. When she first visited Dr. Reuter-Ehrlich in 2008, she had a plantar blister on her left big toe that had been there for a month. She also had a callus with internal bleeding on the ball of her foot , which had already been significantly worn away. “That’s a typical secondary condition for diabetic polyneuropathy,” says Reuter-Ehrlich. “The muscles and fat under the metatarsal heads deteriorate. You can feel the soft cushioning on the balls of healthy feet. When we treat diabetics with worn cushioning on the ball of their foot , we touch every metatarsal head – we squeeze the skin between the ankle and sole very hard. This is important for determining whether the patient needs a soft cushioning to relieve pressure.”

With Ingrid Fuhrmann, the goal is to relieve not only the pressure exerted on her feet from external forces: “Patients who suffer from edemas, whether as a result of venous insufficiency, lymphedema, or cardiac insufficiency, also experience problems with internal pressure,” says Reuter-Ehrlich. “In such a situation, I need to make clarifying consultations and then decide on an appropriate treatment. “We always have to look at the person as a whole. You can’t run a diabetic outpatient foot clinic without intensive interdisciplinary and interprofessional cooperation!”
For example, no wound or ulcer will heal if a patient has circulatory problems, which is why good cooperation with vascular specialists is a must. A practice-based surgeon, for example, can treat patients with claw toes by performing a miniscule surgical procedure on the ligaments that will provide permanent pressure relief. In addition, feedback from a podologist who has found calluses that always form at exactly the same location would indicate to Reuter-Ehrlich that the pressure relief achieved to date is insufficient.

Determining the causes of wounds

“If a patient comes to us with a wound, we always ask them how the wound developed,” Reuter-Ehrlich reports. Most of them say they don’t know, which leads us to suspect that they might have a problem with their shoes.” When Reuter-Ehrlich examines her next patient , the cause of the wounds on his heels, which have almost completely healed, immediately becomes clear to her. Eberhard H. has had diabetes for 20 years. Although he has experienced the typical skin changes and the cushioning on the balls of his feet has worn away, he has been wearing the proper therapeutic shoes and diabetes-adapted foot orthoses for years “and actually has fantastic feet.” In the spring of 2018, he was hospitalized with pneumonia and an accompanying sepsis. As a result of poor positioning, he developed pressure ulcers on both heels – and this was not the first time the team at the Diabetes Center had encountered something like this. His healing process is now being routinely monitored; cream is applied to his feet and his wounds are bandaged. Reuter-Ehrlich and Eberhard H., 82, also discuss his insulin treatment , as he recently began experiencing very high blood sugar levels in the evening. After being given a new appointment to have his wounds checked, as well as a prescription for a different type of insulin, Eberhard H. goes home and Dr. Reuter-Ehrlich heads to another room to examine her next patient. More likely than not , she’ll be talking to that patient about pressure and methods to effectively relieve it …

Images: Frank Steinhorst, Bauerfeind