Diabetic Peripheral NeuropathyA Critical Look Separating Fact from Fiction

Michael E. Graham, DPM, FACFAS, FAENS

What is a Peripheral Nerve?

A peripheral nerve is a extension from the central nervous system (CNS-brain and spinal cord) whose function is to carry electrical impulses either towards the CNS (sensory information) or away from the CNS (motor function).

What exactly is “neuropathy?”

(nerve cell)

Neuropathy is defined asthe progressive loss

of nerve fiber function.

Peripheral Neuropathy

Peripheral neuropathy is therefore loss of nerve fiber function in the peripheral nerves (nerves outside of the brain and spinal cord.)

Normal Nerve Abnormal Nerve

Diabetic peripheral neuropathy has been defined as:

“The presence of symptoms and/or signs of peripheral nerve dysfunction in people with

diabetes after the exclusion of other causes.”

Boulton, AJ, et. al, Diabetic Neuropathy. Med Clin North America, Jul 1998:82(4): 909-929.

Unfortunately, no one pays much attention to the last and most

important part of that definition:

“after the exclusion of other causes.”

Fact:

Peripheral neuropathies are reported to be the most common complication of diabetes mellitus (DM).

It is believed that up to 50% of both Type I and Type II diabetics have some

degree of peripheral neuropathy.

Type I diabetics are potentially affected with this nerve condition after decades of chronic uncontrolled blood sugar levels, while

Type II diabetics can have signs/symptoms of neuropathy after only a few years of diagnosis.

Strange Fact

(Seems like it would be the other way around?)

Type I diabetics don’t usually develop signs/symptoms of peripheral

neuropathy until they are in their 40s/50s.

The average age of diagnosis of Type I DM is 14 years old.

Type II diabetics aren’t usually diagnosed until they are middle age or

older (50 years +)

Unfortunately, that number is getting younger due to an increase in type II pediatric diabetes.

Signs and/or symptoms of peripheral neuropathy usually begin in the toes or the

ball of the foot.

The loss of sensation on the bottom of the foot is NOT a good thing.

It leads to all sorts of problems.

And it’s more complicated than just the loss of feeling.

There is also painful neuropathy.

Neuropathy severely affects the quality of one’s life.

Besides living with severe pain

There are secondary effects including • Foot ulcers-– Typical cost to heal a foot ulcer is $8,000– Typical cost to heal an infected ulcer is $17,000

• Falls• Fractures

But the worst thing is:

WARNING:The next side is graphic.

Amputation

It is estimated that someone loses a leg every 18 minutes as an ultimate complication from

neuropathy.

Average cost for a below-knee amputation (BKA) is $45,000There are 80,000 BKA performed/year

Usually the opposite limb develops an ulcer within 18 months58% go on to have a BKA of the residual limb within 3-5 years.

Anything and everything needs to be done to combat this

progressive nerve disorder.

The unfortunate fact is that once a patient presents to a doctor with nerve symptoms the first thought the doctor has

is:

DIABETIC NEUROPATHY!

At that point the case is closed.

“Sorry, we can’t do much for you.”

It will only get worse.

Sure, you can try to keep your blood sugar under control.

You can take vitamin supplements and wear cushioned shoes.

Keep coming back for check-ups so that we can monitor how bad it is

getting.

If you develop painful neuropathy we will offer you pills to mask the

pain.

Have you ever taken a look at the possible side-effects of those pills?

You might be surprised.

What is it about diabetes that leads to the destruction of nerves in the feet and hands?

The fact is - we really don’t know.

There is quite a bit of confusion as to why and there are several theories.

Only thing is that none of them have really been proven.

DM peripheral neuropathy is blamed on:

• Long-term high blood sugar levels• High cholesterol• High blood pressure• Smoking• Increased height (taller than normal?)• High exposure to ethanol• Genetic factors

Diabetes isn’t the only disease that affects the peripheral nerves.

There are several other forms of neuropathy including:

• Alcohol consumption• Chemotherapeutic medicine• COMPRESSION of the nerve• Familiar (parent/grandparent) • Idiopathic (can’t figure out why, can’t blame it on anything

else)

Besides the co-finding that you also have a family history of neuropathy, you have been diagnosed as being “pre-diabetic”,

Type I or II diabetic, had chemotherapy, drank beer for too many years, or we don’t know why you have it…

… are there different findings as far as the signs or symptoms of neuropathy?

In other words, there is

not one symptom or finding

that links the cause of nerve damage to diabetes, genetics,

alcoholism, known or unknown reasons.

We don’t say “oh you have diabetic neuropathy because you

have pain or loss of feeling in your big toe” or “if you have pain or loss of feeling in your little toe

it is related specifically to chemotherapy”.

Peripheral nerve facts

• Nerves outside of the spine are capable of repairing themselves when damaged.

• Nerves are able to withstand up to a 6% strain without being affected.

• Nerves can be slightly flattened without long-term damage.

What about nerves that are constantly being over-stretched while at the same time being flattened and compressed?

And this happens- day after day,

week after week, month after month,

year after year.

Another fact:An overwhelming majority of

individuals suffering with peripheral neuropathy are over 40 years of age.

The majority of those cases are in patients over 50 years of age.

Let’s shift our focus to dysfunction of nerves on the bottom of the foot.

Walking is the second most common conscious

function of our body.

Average person takes

6,000 steps a day42,000 steps a week168,000 steps a month2,016,000 steps a year40,320,000 steps in 20 yrs80,640,000 steps in 40 yrs120,960,000 steps in 60 yrs

Remember earlier we learned that most diabetics (either Type I or Type II) don’t develop peripheral neuropathy signs/symptoms until they are 40 years

old or older.

Anyone 40 years old has on average taken over 80,000,000 steps.

Did you know there is one main nerve collecting all of the sensations

from the bottom of the foot?

Tibialis posterior nerve

All of the nerves from the bottom of the foot travel

toward the spine from behind the inner ankle bone.

Tibialis posterior nerve

The exact area where the nerves from the bottom of the foot travel to the ankle area

is a very potentially

dangerous area.

There are 2 tissue tunnels where the nerves transition

from a horizontal to vertical orientation.

There is a reason why I am pointing this out- keep going.

Hindfoot alignment is very important for many things but especially when it comes to these 2

tunnels.

There is a strong correlation between foot neuropathy and

faulty foot mechanics.

When the ankle bone (talus) dislocates (partially) on the heel bone

(calcaneus) there is a dramatic and very bad effect on the nerves within

those two tunnels.

Normal Abnormal

The partial dislocation of the ankle bone on the heel bone has been scientifically shown to:

cause pathologic over-stretching of the nerve(s)&

abnormally increase the pressures within the tunnels

The Effect of HyProCure Sinus Tarsi Stent on Tarsal Tunnel and Porta Pedis Pressures.Journal of Foot and Ankle Surgery, Volume 50, (1) Pages 44-49, January 2011

Effect of Extra-Osseous TaloTarsal Stabilization on Posterior Tibial Nerve Strain in Hyperpronating Feet: A Cadaveric EvaluationJournal of Foot and Ankle Surgery, Volume 50, (6), Pages 672-675, November 2011

A misaligned hindfoot leads to constant compression and

overstretching of the nerves while standing.

And a misaligned hindfoot leads to intermittent damage

with every step taken.

Walking is supposed to be so good for you. That is, unless you have

misaligned feet! There are hidden dangers of walking!

Many people with peripheral neuropathy will tell you that the

symptoms aren’t so bad or even non-existent when they first get out of bed in

the morning …

…but the longer they are on their feet then the symptoms get worse.

WHY?

Because when they were laying down and off their feet the nerve was not being

overstretched nor compressed. Upon weightbearing the nerves were being

crushed and over-stretched.

Other individuals with painful neuropathy at night have often gotten out of bed and

started walking round and round until finally the pain in their feet went away.

The reason why the pain was worse after they had been off their feet was that the nerves were “waking up” and walking around made them go “back to

sleep”.

Generally speaking, the medical establishment has always been

against any surgical option.

The problem with typical nerve surgery is that nothing is done to realign the foot.

Arch supports may be beneficial, but for many patients these devices just end up pushing on the nerves and make their symptoms worse.

A somewhat new and more importantly, scientifically proven internal option now exists.

HyProCure®

Extra-osseous, extra-articular, talotarsal fixation device.

HyProCure®

is a titanium stent that is inserted into a naturally occurring space (sinus tarsi) in between the ankle & heel

bones. This minimally invasive soft tissue procedure instantly maintains the natural opening of the sinus tarsi while restoring the normal motion and alignment of the

hindfoot bones.

Did you know…

HyProCure®

has been used safely and effectively in thousands of pediatric and adult patients since 2004.

Stabilization of Joint Forces of the Subtalar Complex via the HyProCure Sinus Tarsi StentJournal of American Podiatric Medical Association, Volume 101 No. 5, Pages 390-399, Sept/Oct 2011

Extra-Osseous Talotarsal Stabilization using HyProCure in Adults: A 5 Year Retrospective Follow-upJournal of Foot and Ankle Surgery – Vol. 51 (1), p. 23-29, 2012

HyProCure®

is the only extra-osseous talotarsal stabilization device that works with the normal biomechanics, unlike other devices that work against the normal function and often leading to failure of the device.

+ =

HyProCure®

is the only medical treatment that has been scientifically proven to decrease the pressures within the tarsal tunnel and porta pedis while at the same

time decreasing the strain on the nerve.The Effect of HyProCure Sinus Tarsi Stent on Tarsal Tunnel and Porta Pedis Pressures.Journal of Foot and Ankle Surgery, Volume 50, (1) Pages 44-49, January 2011

Effect of Extra-Osseous TaloTarsal Stabilization on Posterior Tibial Nerve Strain in Hyperpronating Feet: A Cadaveric EvaluationJournal of Foot and Ankle Surgery, Volume 50, (6), Pages 672-675, November 2011

Every effort must be considered to eliminate any factor that could lead to the destruction of peripheral nerves.

We have followed their advice of:early detection

frequent physician visitsstrict diabetic control

but the disease still remains and often gets worse.

The need for early surgical intervention is important.

While standing, walking, or running the nerves to the

bottom of the foot are being destroyed.

Eventually, a critical threshold is reached where the nerve is unable

to heal itself.

While we can’t ignore that fact that high blood sugar, excessive alcohol

consumption, and the other potential causes must be controlled or eliminated, we also cannot ignore the simple facts of

the trauma inflicted on the nerve as a result of the faulty foot alignment.

The risk benefit analysis of the HyProCure® option shows that

the benefits are far greater than any potential risks.

To learn more about neuropathy, misaligned feet, HyProCure® and to find a specialist near

you…

Please visit:

www.HyProCure.com