Gary Rothenberg is a Clinical Assistant Professor in the Department of Internal Medicine at the University of Michigan School of Medicine in Ann Arbor. He previously served as the Attending Podiatrist and Residency Director at the Miami VA Medical Center in Florida. Jeffrey Page is a Professor at the School of Podiatric Medicine at Midwestern University in Glendale, Arizona. At the time the article was written he was the Interim Chief and Residency Director of the Phoenix VA Medical Center. Rodney Stuck is Professor of Orthopaedic Surgery and Rehabilitation at Loyola University Medical Center and Hines VA Medical Center in Illinois. Charles Spencer is a Rehabilitation/Wound Care Physical Therapist at the Salt Lake City VA Medical Center in Utah. Lonnie Kaplan is a Staff Podiatrist at the Coatesville VA Medical Center in Pennsylvania. Ian Gordon is a Vascular Surgeon at the Long Beach VA Medical Center in California. Correspondence: Gary Rothenberg (gmrdpm@gmail.com)
Author disclosures Gary Rothenberg serves as a Consultant Medical Director for Podimetrics. All other authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Treating preulcerative lesions urgently and aggressively. Callus and other preulcerative lesions often cause progressive tissue damage and poor outcomes. When identified, these lesions should be promptly treated to ensure best outcomes.24
Recognizing the limits of patient self-examinations. Comorbidities such as visual impairment and reduced joint mobility often preclude patients from completing rigorous self-examinations of the foot, which is especially critical while collecting subjective history from the patient during triage of inflammation. A caregiver or spouse can help inspect the foot during outreach and provide additional context.36
Interpreting a benign foot on examination. Because RTM has been demonstrated to detect inflammation preceding a foot ulcer as many as 5 weeks before presentation to the clinic, some veterans may have few signs or symptoms of acute risk during examination. Often, the damage is to subcutaneous tissue resulting from repetitive microtrauma. Research suggests that clinical examination in these cases is often unreliable for identifying the earliest signs of risk, such as palpation to identify subtle temperature changes secondary to inflammation.37 If a patient has refractory inflammation requiring examination and presents with an otherwise unremarkable foot, it is an opportunity to evaluate whether the patient’s shoewear remains appropriate or has worn out, to communicate the veteran’s ongoing elevated risk, and to educate on the importance of diligence in daily foot self-examinations, daily use of the foot temperature monitoring, and continued off-loading until the inflammation resolves.
Communicating the distinction between healing and remission. Although healing is the goal of wound care, patients should be educated that the underlying disease remains after epithelialization. In some cases, tissue deep to the skin has not completed remodeling, and the patient is at acute risk of recurrence. Remission is a powerful metaphor that better describes the patient’s ongoing risk to encourage continued healthy routines and diligent self-care.38Considering the entirety of both feet for recurrence. Critical risk factors for diabetic foot complications, such as peripheral neuropathy and PAD, exist in both limbs, and patients with a history of wounds often develop new complications to different ipsilateral locations, or in as many as 48% of cases, to the contralateral foot.35 For best outcomes, detected inflammation should be treated aggressively independent of whether the location coincides with an area of previous concern.
Encouraging adherence, routine, and empowerment. Advanced diabetes mellitus and neuropathy may impact a patient’s executive function, and multiple studies have reported that patients at risk for inflammatory foot diseases exhibit fatalism toward their foot care and outcomes.39-41 Consistent education, encouragement, empowerment, and establishment of positive routines are needed to ensure high adherence with all preventive care regimens, including RTM.
Case Presentations
The following case series illustrates many of these clinical best practices and characterizes the potential benefits of RTM to veterans within the VA.
Case 1: Prevention After Healing
A veteran underwent a Chopart amputation and was recommended to use the mat after healing was perceived. Immediately on use of the study mat, the patient was found to have inflammation to the surgical incision (Figure 1). Clinical staff was alerted to the findings, and the patient was instructed to limit further walking and continue off-loading in his removable cast walker, per protocol. The inflammation of the operative foot quickly reduced, and the patient continued healing successfully, potentially avoiding incisional dehiscence and possible postoperative infection.
