Diabetic Foot Care & Nerve Treatment in Michigan

Watch: Dr. Tom Biernacki on protecting diabetic feet — daily care, the warning signs to watch for, and how to prevent ulcers and infections.

Why diabetes is so hard on your feet

Three things go wrong with the feet in diabetes — and they compound each other dangerously:

• Peripheral neuropathy: Chronic high blood sugar damages the small nerves in the feet. Half of long-standing diabetics have measurable neuropathy. You lose the ability to feel pain, temperature, and pressure. A blister, a tack, a pebble in your shoe — your foot can be wounded without you knowing.
• Peripheral arterial disease (PAD): Diabetes accelerates atherosclerosis. Smaller arteries below the knee become narrowed or blocked. Less blood flow means wounds heal slower and infections spread faster.
• Impaired immune response: Hyperglycemia impairs white blood cell function. An infection that would be a minor cellulitis in a non-diabetic can become limb-threatening within days in a poorly-controlled diabetic foot.

When you combine “I can’t feel my foot,” “my circulation is reduced,” and “my immune system is impaired,” you have a foot that can lose tissue silently and decay quickly. This is why the diabetic foot is treated as its own medical specialty — not a cosmetic concern.

The annual diabetic foot exam — what it actually looks for

A real diabetic foot exam is more than “let me look at your feet.” Following American Diabetes Association and IWGDF (International Working Group on the Diabetic Foot) guidelines, my standard exam includes:

Neuropathy screening (10-gram monofilament + 128 Hz tuning fork)

The 10g Semmes-Weinstein monofilament test is the gold standard. I touch the filament to specific sites on each foot — if you can’t feel it at any of those sites, you have loss of protective sensation (LOPS), which is the strongest predictor of future ulceration. Adding a 128 Hz tuning fork test (vibration sensation) increases sensitivity.

Vascular assessment (pulses, ABI if indicated)

I palpate the dorsalis pedis and posterior tibial pulses, check capillary refill, and look for skin color changes, hair loss, and trophic skin changes. If pulses are diminished or you have symptoms of claudication, I order an Ankle-Brachial Index (ABI) and refer for vascular surgery evaluation if abnormal. Untreated PAD will not heal a wound — vascular workup before debridement when needed.

Structural assessment (deformities, callus, prior amputations)

Hammertoes, bunions, prominent metatarsal heads, prior amputation sites, Charcot deformities — each is a pressure point that will eventually break down without offloading. Hyperkeratotic calluses are the most predictive single physical finding for impending ulceration: a callus is a wound in slow motion.

Skin & nail assessment

Fungal infections (tinea pedis, onychomycosis), interdigital maceration, fissures, dry skin, and ingrown toenails all create portals for bacterial entry. Each gets addressed at the same visit.

Risk stratification

I assign every diabetic patient an IWGDF risk category:

• Category 0: No LOPS, no PAD. Annual screening.
• Category 1: LOPS but no PAD or deformity. Screen every 6-12 months.
• Category 2: LOPS + PAD or foot deformity. Screen every 3-6 months. Therapeutic shoes/orthotics indicated.
• Category 3: LOPS + history of ulcer, amputation, or end-stage renal disease. Screen every 1-3 months. Aggressive offloading and surveillance.

Your risk category determines your follow-up cadence and what kind of preventive interventions are appropriate. Medicare reimburses these stratified visits when documented correctly.

Prevention — what actually reduces amputation risk

The 2023 IWGDF guidelines on diabetic foot prevention specify five core elements that have Level A evidence for reducing ulceration and amputation risk:

1. Therapeutic footwear (custom diabetic shoes + inserts)

For patients with LOPS and at least one of (prior ulcer, partial amputation, foot deformity, or severe callus), Medicare covers one pair of therapeutic shoes plus three pairs of custom-molded or heat-moldable inserts per calendar year under the Therapeutic Shoe Bill. Properly fitted diabetic shoes reduce repeat ulceration by 50% in high-risk patients. I fit these in-office and submit the Medicare paperwork directly.

Critical caveat: generic “diabetic shoes” from a catalog without a custom insert don’t work. The insert is the active offloading component. A diabetic shoe with a flat factory insole is a $250 sneaker.

2. Routine professional foot care (debridement of callus + nail care)

For Medicare beneficiaries with neuropathy + specific qualifying conditions, professional foot care every 9 weeks is covered. Calluses get pared down, ingrown nails get addressed before they ulcerate, and the skin gets inspected by a trained eye. Multiple RCTs show that regular podiatric care reduces ulceration and amputation rates in high-risk diabetics by 60-80%. This is one of the single most cost-effective preventive interventions in medicine.

3. Patient education + daily self-inspection

Every patient with LOPS gets a structured education session: check both feet daily (use a mirror or a family member), look between toes, never walk barefoot, test bath water temperature with a hand before stepping in, wear seamless socks, never use heating pads or hot water bottles on feet, never use OTC corn or wart removers (they contain acids that burn through neuropathic skin). Boring but lifesaving.

4. Prophylactic surgery for high-deformity pressure points

For patients with recurrent toe ulcers from hammertoes, a percutaneous flexor tenotomy in the office takes 5 minutes per toe and prevents the cycle of ulceration. For severe bunions causing recurrent medial 1st MTP ulcers, prophylactic bunionectomy is occasionally warranted. The bias has historically been to avoid elective surgery in diabetics — but in selected patients, a small planned operation prevents a much bigger emergency one later.

5. Glycemic control and vascular optimization

This is endocrinology and vascular surgery territory — but it’s the foundation. Hemoglobin A1c < 8% (preferably 7%), aggressive smoking cessation, statin and antiplatelet therapy for known PAD, blood pressure control, and weight management. I coordinate with your primary care physician and endocrinologist on these targets. None of the foot-level interventions work as well in the setting of A1c > 10% and continued smoking.

If you already have a diabetic foot ulcer — what proper treatment looks like

A diabetic foot ulcer is a medical emergency, not a band-aid problem. Standard of care has 4 pillars:

1. Sharp debridement

The callused/devitalized edges of the wound get sharply debrided weekly until clean granulation tissue is visible. Multiple RCTs confirm that adequate debridement is the single highest-leverage intervention in ulcer healing. Wounds that are not debrided do not heal — period.

2. Offloading

Pressure on the ulcer site is what caused it and what keeps it open. Total contact casting is the gold standard, with healing rates of 80-90% at 6 weeks for plantar ulcers. Removable boots (CROW walker, post-op shoe) work when total contact casting isn’t feasible — but compliance is the biggest factor. You cannot heal a foot ulcer by walking on it.

3. Infection management

Any concern for infection (erythema, drainage, fluctuance, systemic symptoms) gets cultured and treated with appropriate antibiotics. Deep/bone infections (osteomyelitis) need MRI and often surgical debridement. Bone exposed at the base of an ulcer is osteomyelitis until proven otherwise.

4. Vascular optimization

Wounds don’t heal without adequate blood flow. If pulses are diminished, ABI or toe pressures are obtained, and if abnormal, vascular surgery referral for revascularization (angioplasty/stent or bypass) precedes major debridement.

Advanced wound therapies — including bioengineered skin substitutes (Apligraf, Dermagraft), hyperbaric oxygen therapy in selected cases, and negative pressure wound therapy — are used as adjuncts when the basic 4 pillars aren’t enough. None substitute for the basics.

Charcot foot — the diabetic foot emergency most people have never heard of

Charcot neuroarthropathy is a destructive process where the bones and joints in the foot fragment and collapse — often within weeks — in a patient with severe neuropathy. The foot becomes warm, red, and swollen but typically painless. It’s frequently mistaken for cellulitis or DVT.

The signs:

• Sudden warmth, swelling, and redness in one foot — often without significant pain
• Temperature difference of 4°F or more between feet
• Recent minor trauma or unusual activity
• Existing severe neuropathy

If untreated within weeks, the foot collapses into the “rocker-bottom” deformity, which leads to recurrent ulceration and high amputation risk. Treatment requires immediate immobilization in a total contact cast and complete non-weight-bearing for 2-4 months minimum, followed by months in a CROW walker. Caught early, Charcot can be arrested before structural collapse. Missed for 6 months, it can mean reconstructive surgery or amputation.

If you have diabetes and a warm, swollen foot — even if it doesn’t hurt — go to the emergency room or call us same-day. This is one of the few diabetic foot conditions where hours matter.

Medicare coverage — what’s covered and how to access it

Medicare covers more diabetic foot care than most patients realize:

• Annual diabetic foot exam (LCD G0245/G0246): Covered for patients with diabetic neuropathy and loss of protective sensation
• Routine podiatric care every 9 weeks: Covered with qualifying conditions (LOPS + specific systemic indicators)
• Therapeutic shoes + 3 pairs custom inserts per year: One pair of shoes + three pairs of inserts annually for qualifying high-risk patients (Therapeutic Shoe Bill)
• Custom AFO bracing for Charcot or severe deformity: Covered when medically necessary
• Wound care visits, debridement, and dressings: Covered with documentation of medical necessity
• Vascular workup and revascularization: Covered when indicated

At Balance Foot & Ankle we handle the Medicare credentialing and documentation in-house. Most patients with diabetes pay nothing out of pocket for routine preventive foot care beyond their standard Medicare deductible.

When to call a podiatrist — Howell & Bloomfield Hills appointments

Same day / urgent — call us or go to the ER if you have diabetes plus any of:

• Any new wound, blister, or cut on your foot
• A foot that suddenly becomes warm, red, and swollen (rule out Charcot/cellulitis)
• Drainage, foul smell, or pus from a wound or under a callus
• Sudden change in foot color (pale, purple, black)
• Fever combined with any foot wound

Within 1-2 weeks if:

• You’ve been newly diagnosed with diabetes and have never had a diabetic foot exam
• You have known neuropathy and haven’t been seen in >6 months
• You have hammertoes, bunions, or calluses that are getting worse
• Your current shoes or inserts no longer fit well or are visibly worn
• You need Medicare-covered therapeutic shoes or inserts

At Balance Foot & Ankle we run a dedicated diabetic limb-preservation program with same-day appointments for active wounds and 9-week scheduled follow-up for routine preventive care. Dr. Tom Biernacki, DPM, FACFAS has 20+ years of experience preventing diabetic amputations across both Howell and Bloomfield Hills locations.

Frequently asked questions

How often should a diabetic see a podiatrist?

Annual exams at minimum for every patient with diabetes — even without neuropathy. With neuropathy, every 6 months. With neuropathy plus PAD or foot deformity, every 3-6 months. With a history of ulcer or amputation, every 1-3 months. Your podiatrist will assign your IWGDF risk category and set the cadence.

Can I trim my own toenails if I have diabetes?

If your vision is good, your neuropathy is mild, and you can safely use clippers — yes, cut straight across with a clean clipper. If you have any visual impairment, severe neuropathy, vascular disease, ingrown nails, or thickened/fungal nails, leave nail care to a professional. Medicare covers routine nail care every 9 weeks for qualifying patients.

What should I do if I find a blister on my foot?

Do not pop it. Clean gently with soap and water, apply a non-adherent dressing, offload pressure on it (a roomy shoe or post-op shoe), and call your podiatrist within 48 hours. A blister in a diabetic foot is a pre-ulcer — proper management at this stage prevents the next 6 weeks of wound care.

Are diabetic socks worth it?

Yes — seamless, padded, moisture-wicking socks reduce friction and pressure points. They’re cheap insurance. Avoid socks with tight elastic at the top (constricts circulation) or thick seams over the toes.

What is the difference between diabetic shoes and orthopedic shoes?

Medicare-approved therapeutic shoes (“diabetic shoes”) are specifically designed with extra depth, soft seamless interiors, and the ability to accept custom inserts. Orthopedic shoes are a broader category — many work as diabetic shoes but not all are Medicare-coded. The defining feature of a true therapeutic shoe is its compatibility with a custom-molded insert.

Can diabetes reverse neuropathy?

Generally not, but progression can be slowed. Tight glycemic control (A1c <7%), smoking cessation, blood pressure and lipid control, and physical activity all slow neuropathy progression. Some patients report symptom improvement with these measures; the underlying nerve damage typically remains. There is no FDA-approved drug that reverses diabetic neuropathy.

How long does a diabetic foot ulcer take to heal?

With proper offloading, debridement, vascular optimization, and infection management — most uncomplicated plantar diabetic foot ulcers heal in 6-12 weeks. Wounds with osteomyelitis, severe PAD, or chronic poor offloading can take 3-6 months or longer. About 25-50% recur within 1 year, which is why prevention after healing is just as important as the original treatment.

The bottom line

If you have diabetes, your feet are your most vulnerable organ system after your kidneys and eyes — and unlike those, foot complications are almost entirely preventable with regular professional care. Medicare covers most of what you need: annual exams, routine care every 9 weeks for qualifying patients, custom therapeutic shoes and inserts, and wound care when needed. The single most useful thing you can do this week if you have diabetes and haven’t had a podiatric exam in over a year is to schedule one. The visit takes 30 minutes; the downside of skipping it can be years of your life.

— Dr. Tom Biernacki, DPM, FACFAS

Diabetic Foot Care Resource Library

• Best EMS Foot Massagers for Diabetic Neuropathy
• Diabetic Shoes Covered by Medicare
• Does Cigna Cover Diabetic Foot Care in Michigan?
• Diabetic Foot Care Routine Checklist

Related foot & ankle care

• Toenail & Skin Conditions
• Orthotics & Footwear
• All Foot & Ankle Conditions

More questions we get asked

• Burning feet syndrome (Grierson-Gopalan)