Ep.26 Diabetes: The Crucial Role of Foot Strength with Matt Dilnot

Hang tight as we journey into the intricate world of foot strength, diabetes, and what this means for podiatry. Today, we're unearthing the connection between diabetic patient's foot strength and the risk of ulceration with Matt Dilnot, a Podiatrist at Melbourne Foot Clinic and Clinical Educator at La Trobe University. Matt's astute insights from research in this area crack open neuropathy and motor control issues. This is about the physiological response which leads to the weakening of the intrinsic foot muscles in diabetics.

We're also bridging the gap between musculoskeletal medicine and diabetes care in this thought-provoking dialogue. Matt's take on maintaining mobility and strength around toes for patients with diabetes is for all podiatrists. We also rewind to a study from 1989, illuminating the association between toe deformity and ulceration risk in diabetic patients. So, whether you're a podiatry professional or simply keen to understand how to minimize ulceration risk, this episode holds the keys to unlocking those insights. Ready for a deep dive into the diabetic foot and its strength? Let's get started!

Holewski, J. J. et al. (1989) ‘Prevalence of foot pathology and lower extremity complications in a diabetic outpatient clinic.’, Journal Of Rehabilitation Research And Development, 26(3), pp. 35–44. Available at: http://www.ncbi.nlm.nih.gov/pubmed/2666642

Mueller, M. J. et al. (2003) ‘Forefoot structural predictors of plantar pressures during walking in people with diabetes and peripheral neuropathy’, Journal of Biomechanics, 36(7), pp. 1009–1017. doi: 10.1016/S0021-9290(03)00078-2.

Cheuy VA, Hastings MK, Commean PK, Mueller MJ. Muscle and Joint Factors Associated With Forefoot Deformity in the Diabetic Neuropathic Foot. Foot Ankle Int. 2016 May;37(5):514-21. doi: 10.1177/1071100715621544. Epub 2015 Dec 14. PMID: 26666675; PMCID: PMC5111819.

Podcast link https://feeds.buzzsprout.com/2195785.rss

@mattdilnott

m.dilnott@melbournefootclinic.com.au

Melbournefootclinic.com.au

@simplythebestpodiatry

@jasonagosta

jason@ ja-podiatry.com

ww.mytoepro.com.au

Transcript

Speaker 1: 0:02

Music. There's some great studies now that have shown that people who have the pre-diabetic and postpone the treatment of their diabetes have massive reductions in foot strength. And now this is not because they've got neuropathy. This is not because their nerves and their motor controls stop functioning because they're diabetic. This is a response to the change in their physiology, in their body that actually causes wasting of intrinsic muscles in their feet.

Speaker 2: 0:35

Thanks for tuning in to Simply the Best Pediatry. I'm Jason Agosta and that was Matt Dillknot, pediatrist at Melbourne Foot Clinic and Clinical Educator at La Trobe University. We are following on from last week's Foot Strengthening episode and focusing on the diabetic foot and the role of foot strength. And moving on talking about foot strength, we are talking people with diabetes and Matt Dillknot is going to enlighten me again, being the most intelligent man in pediatry, I was told more recently hey Matt, hey Chase, I'm not sure whether diabetes is sort of a special area of yours, is it?

Speaker 1: 1:23

I can't claim to be a specialist in diabetes, but I did actually do my original honours research in diabetes, so I spent a bit of time in the Alfred Hospital doing research on mono filaments. That's a long time ago, but we've spoken before about the importance of having toe strength and shifting loads away from the forefoot.

Speaker 1: 1:52

And this, I think, is one of the really important parts of diabetes. I get really excited about it, actually, because I feel like there's such a hole in this area that has not been addressed, and I think it may also be partly because of the fragmentation of pediatry into those who do sports medicine and biomechanics and those who do diabetes care and do wound care and I know that they do have skill sets around offloading padding wound dressings all sorts of wonderful things.

Speaker 1: 2:36

But I think the fragmentation of those two areas is that we're not getting that cross fertilisation of the knowledge that we've developed in musculoskeletal medicine could actually come across into the management of people with diabetes. Now I'll give you again. I know in the last episode we talked about old research, but I'm going to do the same again now, because the stuff that was published in the past was so much better. Of course, wasn't it, jason? But no, it was actually paper published way back in 1989, and by an author by the name of Halevsky. That was in the Journal of Rehabilitation Research and Development, and he made the observation that approximately 30% of people with diabetes have clotoid clotot deformity.

Speaker 1: 3:33

But what was interesting is that they represent 85% of people with ulceration. So when you walk into a room and it makes obvious sense to us, but you walk into a room and you are deciding whether you're going to do a diabetes assessment or not on that particular patient, you walk in and you see straight toes or clotos, it changes the risk factor for that person straight away. 85% of people with ulceration have got claw toes. So in other words, if you don't have claw toes, your risk of ulceration is incredibly low. You could have terrible circulation, you can have terrible neuropathy, but if your toes are straight, you actually distribute low differently and you end up with lower forces and you don't ulcerate. So no one ever told me that when I was a student. It's the plant of pressure.

Speaker 2: 4:27

It's the plant of pressure. It's the plant of pressure Exactly.

Speaker 1: 4:31

You just overload those tissues and the tissues can't respond and recover fast enough, for all sorts of reasons of course, but that particular narrative information is really useful in when we go to assess patients. So for those podiatrists out there who are assessing patients, don't forget just to make a note of toe position as one of the things that's going to suggest whether that person is at risk or not.

Speaker 2: 4:55

That's MTP prominence, isn't it? Yeah, exactly.

Speaker 1: 4:58

Now going on further from that is the fact that podiatrists aren't routinely maintaining that mobility and strength around those toes. So if someone wants you have those patients who come and see you for their diabetes assessment and they want to be proactive to reduce their risk of ulceration in the future and so many times as podiatrists we're still like, wow, just come and see me in another year's time or two years time, we'll measure your monofilaments and your vibration stuff. Don't worry about doing anything Because at the moment you've got no problems at all. I feel like I want to be proactive. I want to get that person something to do to reduce their risk Now, besides actually managing their diabetes. Well, one of the things we can simply do is maintain the mobility of the MTPJs, maintain the strength in their toes and maintain the alignment of their toes. If we can do that, we're at least doing something that's got some evidence to suggest we're going to reduce the risk of ulceration that they can participate in Now. Whether they choose to do that or not is another thing, but I think at least it's not just sitting on our hands waiting for something to happen in the future. We're actually guiding them to do something useful. So I just get my patients to mobilize their feet at night, just in front of the TV or whatever it may be, just mobilizing their toes, maintain that flexibility in their joints. I get them doing the valet manoeuvre we talked about earlier at the earlier episode, doing strengthening of their toes. Just simple things like that, I think, are really, really useful.

Speaker 1: 6:27

Now I will actually refer to some other researches quickly, because it does not all the good stuff was done in the past.

Speaker 1: 6:36

There was actually a really important paper that I would like to refer to, by a guy by the name of Victor Chewy or Shwey I'm not quite sure how you pronounce Chinese, but CHEUY.

Speaker 1: 6:49

We published a paper in Foot and Ankle International 2016. The reason this paper is particularly useful is because this guy was the first to come up with a clear answer as to why some people get clawtoes and why some people don't. He talked about basically the changes, the intrinsic muscles in the forefoot and how there was a very strong correlation between wasting of the intrinsic muscles in the forefoot and clawing of the toes. So I would be very keen to refer people back to that or to go and look that paper up and learn about it, because this is something I give to the students whenever I get the opportunity, because the students had all the say to me, oh, this person's got clawed toes. And I say, well, why is that happening? And they don't have any idea why that is. And I think we've actually got some good paper, a good paper now, or papers around now that are actually giving you some good evidence as to why this is actually happening.

Speaker 2: 7:44

So when we see that foot though with the clawed toes, so the toes are extended prominent MTP, that does coincide often with ankle, aquinas or limb. It does. A bit of inability to dorsiflex Absolutely. Oh, you read my mind because of muscle wasting.

Speaker 1: 8:05

Yeah, so I think I think there is basically a bit of a an interesting pattern here whereby, as we get, typically when muscles waste, particularly the calf muscle, it will shorten. So as we get shortening of the gastrocs, and so in diabetes we have a really, really high rate of Aquinas. Ultimately we get shortening of the of the gastrocs. This causes an Aquinas. This then leads to the next problem, which is ground clearance. And so, in order to clear the ground, we need to pull our toes back in order to clear the ground, and we need to offer, obviously lift the foot through the tibialis anterior and extended to the longus, pulling the foot up to help clear the ground, and subsequently those muscles have to work extra hard to pull those toes up to clear the ground, and so we start to get pulled up into that dorsiflex position of the toes.

Speaker 2: 9:07

Right, so we're talking tendon contracture over a period of time. Correct, absolutely.

Speaker 1: 9:11

That's right. So we've got this wonderful setup occurring where the calves are getting short, causing an Aquinas, the extended to the longus is having to work harder. It pulls the toes up. There is no chance that these intrinsic muscles and of course when we've got diabetes, we are wasting those intrinsic muscles there's no way that they're going to be able to overpower those extensors. So it is such. Another important part that we should be maintaining with these patients is how do we keep those gastrocs long? How do we keep them strong and long and flexible earlier on? Don't wait until the horse has bolted and it's 20 years down the road. We want to be treating those patients as soon as possible to stop them from developing Aquinas in the first place.

Speaker 2: 9:58

So this gets back to what you said earlier. Sorry for interrupting. Just to reiterate what you said earlier is someone comes in a diabetic and they might be traveling, okay, but there is plenty to do, absolutely.

Speaker 1: 10:12

Exactly With low limb strengthening and foot strengthening.

Speaker 1: 10:15

Exactly. So it's not complicated either. You can say here's okay, what we need to do is just get you into good habits around maintaining calf length, calf strength, maintaining your mobility and your forefoot. By doing these things we're going to help reduce your risk of developing high pressure areas in the long term. That stuff on ankle Aquinas and extensors from longest contracture and intrinsic being overpowered, that biomechanical process we've sort of been guessing at for years and years as to how it comes about. But this is the first paper which I would, as I say, strongly advise people to have a look at, which actually helps to. They said yes, we can now see the basic chain of events that's actually happened.

Speaker 2: 10:58

With Angela Hone here, the general biomechanics one. Can we strengthen feet and diabetes without?

Speaker 1: 11:03

We can. The only drama with it is obviously it's the way. The issue is that we can increase the strength of people with neuropathy and with wasting. It's just whether you can reverse the process.

Speaker 2: 11:18

Well, yeah, there's only a 5% increase in muscle volume, it says.

Speaker 1: 11:23

A 50% increase in strength. I think the thing was this is only a small paper, but it at least gave us a glimmer of hope. It was only eight weeks, it was a fairly small study, but it showed that you can actually reverse. In people with peripheral neuropathy you can actually change, and so I think for a lot of time we just give up and just think, oh well, there's nothing we can do.

Speaker 2: 11:46

Yeah.

Speaker 1: 11:47

Okay, but I think it said that we could actually. We can actually start to work our way out. I think in the early stage someone's been pre-diabetic. They've sort of done the wrong things, haven't looked after themselves. You catch them early. You can actually start doing foot strengthening and help to reverse that.

Speaker 2: 12:03

That's the magic there, though, isn't it, as you mentioned?

Speaker 1: 12:06

I think so yeah.

Speaker 2: 12:07

That's the way, as I mentioned. Yeah, we need to get them. And get them on the lengthened strengthening yes, exactly, literally. Yep. Okay, matt, we might have to leave it there. Thank you so much for joining me. I'm just going to reiterate it the most important thing is the toe strengthening to distribute load at the forefoot. That's what we're really sort of earmarking here. Absolutely, exactly. All right, thank you once again. I really appreciate you coming on with me.

Speaker 1: 12:38

Thank you, good on you.

Speaker 2: 12:41

Thanks for tuning in. Check the show notes for more details and links. We can also follow and support the show. There are some great references there on this episode of Foot Strength and the Diabetic Foot. Thanks for listening. We'll see you in the next episode.