Tenderizing the Foot

In 1995 the United States Public Health Service called a conference to discuss the increasing problem nationwide of amputation of the foot in patients with diabetes. The conference was planned to be the start of a federal program that was to be called ‘‘LEAP,’’ for lower extremity amputation prevention. This program now provides a folder of information about foot ulceration prevention and treatment to any physician or clinic in the United States that treats diabetic patients. The LEAP program does a good job of emphasizing that neither diabetes itself nor the loss of sensation of itself causes the breakdown in a foot which is neuropathic. The breakdown is caused by excessive mechanical stresses that impinge on the surface of the foot and are repeated on the same spot until tissues break down. The program goes on further to describe ways of evaluating both the degree of sensory loss and the areas of the foot which are likely to receive the highest stresses. The program also demonstrates how localized areas of high stress in walking can be modified. Footwear designed to spread the stress of walking more evenly lowers the level of stress on prominent areas most prone to ulceration. The program also tells the patient that even with these precautions, he or she must limit the amount of walking or running, because repetitive stress is cumulative, and long hikes or runs may still result in ulceration even when proper shoes are worn. What LEAP fails to do is to is to help the patient to know what amount of walking is excessive, or to be able