Diabetic Foot Care & Nerve Treatment in Michigan

Watch Dr. Tom Biernacki DPM explain diabetic foot care, ulcer prevention, and what every diabetic patient should know about protecting their feet.

Why Diabetic Feet Require Specialized Care

Diabetes mellitus alters foot physiology through two independent but synergistic mechanisms. Understanding both is essential to understanding why a problem that seems minor — a blister, a callus, a missed toenail cut — can escalate to amputation in days to weeks in a diabetic patient.

Peripheral Neuropathy: The Loss of Protective Sensation

Chronic hyperglycemia causes axonal degeneration through advanced glycation end-product (AGE) accumulation, oxidative stress, and endoneurial microvascular injury. The result is length-dependent peripheral neuropathy — the longest nerve fibers are damaged first, so the feet are affected before the legs. Approximately 50% of patients with Type 2 diabetes have clinically significant neuropathy at the time of diagnosis.

The critical clinical consequence is loss of protective sensation (LOPS). A patient without protective sensation cannot feel a pebble in their shoe, the heat of a hot sidewalk, or the friction of an ill-fitting shoe. Injuries that a non-diabetic patient would notice and address within hours go undetected for days, allowing pressure necrosis, colonization, and infection to develop unchecked.

Neuropathy also involves autonomic fibers, causing anhidrosis (reduced sweating), which leads to chronically dry, fissured skin that is vulnerable to bacterial entry. Motor neuropathy causes intrinsic muscle atrophy, producing hammertoe and claw toe deformities that create high-pressure bony prominences — exactly where ulcers develop.

Peripheral Arterial Disease: The Impairment of Healing

Atherosclerosis of the tibial and peroneal arteries is substantially accelerated in diabetes — diabetics develop PAD 10–15 years earlier than non-diabetics and have 2–4× higher prevalence. Reduced arterial perfusion impairs every phase of wound healing: oxygen delivery for aerobic metabolism, immune cell delivery for infection control, and growth factor signaling for tissue repair. A wound that would heal in 2 weeks in a healthy patient may not heal at all in a patient with severe PAD and LOPS.

The combination of neuropathy (you cannot feel the injury) plus ischemia (you cannot heal the injury) creates the conditions for the cascade: minor trauma → painless ulcer → bacterial colonization → deep infection → osteomyelitis → amputation.

Semmes-Weinstein Monofilament Testing

The Semmes-Weinstein 10-gram (5.07) monofilament is the standard clinical tool for detecting loss of protective sensation. The monofilament, when buckling, delivers exactly 10 grams of force — the threshold at which protective sensation is present. Testing is performed at 10 standardized plantar sites (great toe pulp, plantar surface of each metatarsal head, midfoot, and heel) while the patient’s eyes are closed.

Interpretation: Inability to detect the monofilament at 4 or more sites (IWGDF threshold) indicates clinically significant LOPS and markedly elevated ulcer risk. Multiple studies demonstrate that inability to detect the 10g monofilament correlates with 7-fold increased risk of foot ulceration. This test should be performed at every annual diabetic foot exam and flagged in the chart as a risk stratifier.

Ankle-Brachial Index (ABI) Vascular Screening

The ankle-brachial index compares systolic blood pressure at the ankle (posterior tibial or dorsalis pedis artery) to the brachial artery pressure. A normal ABI is 1.0–1.4:

• ABI 0.9–1.0: Borderline; early atherosclerosis possible
• ABI 0.6–0.89: Mild-moderate PAD; monitor, risk factor management
• ABI 0.4–0.59: Moderate-severe PAD; vascular surgery referral for claudication assessment
• ABI <0.4: Critical limb ischemia — urgent vascular surgery consultation
• ABI >1.4: Non-compressible (calcified) vessels — common in diabetes; toe-brachial index (TBI) or transcutaneous oxygen (TcPO₂) required for accurate vascular assessment

Every diabetic patient with an active wound or ulcer should have ABI assessed. Attempting to heal an ischemic wound without restoring perfusion is futile and dangerous.

The Annual Diabetic Foot Exam: What We Assess

The annual comprehensive diabetic foot exam is a covered Medicare benefit (G0245 initial exam, G0246 subsequent exam) and a quality measure in all major payer value-based care programs. Our exam protocol includes:

• Dermatological assessment: Skin integrity, moisture, callus distribution, fissures, maceration, interdigital spaces (tinea pedis, soft corns), ulcers or pre-ulcerative lesions
• Musculoskeletal assessment: Foot deformities (bunions, hammertoes, Charcot deformity, rocker-bottom), joint range of motion, bony prominences, equinus contracture (reduced ankle dorsiflexion — a major contributor to forefoot ulceration)
• Neurological assessment: Semmes-Weinstein 10g monofilament (10 sites), 128 Hz vibration tuning fork at hallux, ankle reflexes, pinprick/temperature if small fiber neuropathy suspected
• Vascular assessment: Posterior tibial and dorsalis pedis pulse palpation; ABI if pulses diminished or absent, or if there is any wound
• Footwear inspection: Current shoe fit and construction, foreign bodies, excessive wear patterns indicating pressure distribution abnormalities
• Risk stratification: International Working Group on the Diabetic Foot (IWGDF) risk category 0 (no LOPS or PAD) through 3 (prior ulceration or amputation)

Diabetic Nail Care: Why It Matters More Than You Think

Toenail care in diabetic patients requires clinical expertise, not home self-care in patients with neuropathy. The risks:

• Ingrown toenail (onychocryptosis): In a non-diabetic patient, an ingrown nail is painful — so they seek care. In a neuropathic patient, it may be painless and progress to paronychia, cellulitis, and osteomyelitis of the distal phalanx before it is noticed. Routine preventive nail debridement reduces this risk.
• Onychomycosis (fungal nail): Thickened, opaque, crumbly fungal nails create pressure against the nail bed in shoes, causing sub-ungual ulceration. Treatment with topical antifungals (efinaconazole 10%, ciclopirox) or oral terbinafine (with LFT monitoring) reduces this risk.
• Home nail trimming injuries: Cutting too close in neuropathic feet causes inadvertent skin breaches. We instruct patients with LOPS to have nails trimmed professionally at each podiatric visit — never cut nails into the corners.

Therapeutic Footwear: The Diabetic Shoe Benefit

Medicare and most payers cover extra-depth diabetic shoes and custom-molded insoles annually for patients with documented diabetes and at least one of: peripheral neuropathy with LOPS, peripheral vascular disease, history of foot ulceration, pre-ulcerative callus, poor circulation, or foot deformity. This is the Medicare Therapeutic Shoe Bill (Section 4072, 1993 — DMEPOS codes A5500–A5513).

Therapeutic footwear requirements for diabetic patients:

• Extra depth: At least 3/16 inch additional depth throughout the shoe to accommodate custom insoles and toe deformities without creating pressure points
• Seamless or padded interior: Seams are friction points; smooth or padded linings eliminate the #1 cause of blisters in insensate feet
• Wide toe box: Accommodates bunions, hammertoes, and swollen feet without lateral compression
• Firm heel counter: Prevents rearfoot collapse and improves proprioceptive stability
• Custom-molded insoles: Total-contact design distributes plantar pressure across the entire foot surface, reducing focal metatarsal head pressures by 30–50%

Off-the-shelf “diabetic shoes” without custom-molded insoles provide far less protection than properly fitted therapeutic footwear with total-contact insoles.

Risk Stratification and Visit Frequency

Not all diabetic patients need the same frequency of podiatric care. We follow the IWGDF risk stratification model:

• Category 0 (no LOPS, no PAD): Annual podiatric exam; patient education on daily self-inspection
• Category 1 (LOPS or PAD but not both): Every 6 months; shoe assessment, callus management
• Category 2 (LOPS + PAD, or LOPS + foot deformity): Every 3 months; high-risk foot management
• Category 3 (history of ulcer or amputation): Every 1–3 months depending on active pathology; highest recurrence risk group — 40–65% ulcer recurrence within 5 years

What Patients Often Get Wrong

• Walking barefoot at home: “I’m just in the house” is the explanation for many of the ulcers we treat. The majority of diabetic foot injuries happen at home, not outside. Neuropathic patients must wear protective footwear indoors and outdoors at all times.
• Using over-the-counter corn and callus treatments: Salicylic acid pads and corn removal liquids are chemical cauterizing agents — appropriate for patients with intact sensation who can monitor for tissue damage. In neuropathic feet, these products can cause full-thickness chemical burns that progress to ulcers. Never use on diabetic feet.

Red Flags — Seek Same-Day or Emergency Care

• Any open wound, blister, or skin breakdown on a diabetic foot: Should be evaluated within 24–48 hours — never “wait and see”
• Red streaking up the leg from a foot wound: Ascending lymphangitis — same-day evaluation, possible hospitalization for IV antibiotics
• Fever with a foot wound: Systemic sepsis from wound — emergency department
• Hot, swollen, red foot WITHOUT an open wound: Consider acute Charcot neuroarthropathy — catastrophic if walked on; same-day urgent evaluation required
• Black or dark tissue anywhere on the foot: Gangrene — emergency vascular surgery referral
• Sudden painlessness of a previously painful wound: May indicate progressive necrosis — urgent evaluation

Care at Balance Foot & Ankle

Our Howell office provides comprehensive diabetic limb-preservation care. Every diabetic patient receives risk stratification at the first visit, a structured annual exam protocol, Semmes-Weinstein monofilament and ABI vascular assessment, callus debridement, nail care, and — where indicated — diabetic shoe fitting with custom-molded insoles (Medicare-covered with appropriate documentation). We coordinate directly with your primary care physician, endocrinologist, and vascular surgery team to ensure no gap in your care.

Call (810) 206-1402 or book a diabetic foot exam online. Our Howell office serves patients throughout Livingston County, and Bloomfield Hills serves Oakland County and metropolitan Detroit.

Howell: 4330 E Grand River Ave, Howell MI 48843  |  Bloomfield Hills: 43494 Woodward Ave #208, Bloomfield Hills MI 48302