My husband needs surgery to stabilize his foot from diabetic-related deformities. But the surgeon says the ulcers on the bottom of his foot must be treated first before surgery. They are sending us to physical therapy. We’ve tried everything at home. What else can a PT do that we can’t for this problem?

Diabetic ulcer healing can be a real challenge for patients and families alike. Sometimes, despite all efforts, the diabetes works against the patient and the ulcer progresses. Surgery can’t be done with an open wound like that because of the risk of infection.

The physical therapist can offer a combination of treatment interventions that work together to overcome the delayed healing effect of the tissues. The first step is always to make sure the patient is experiencing good, stable (daily) control of blood sugars. This is accomplished through medication, diet, and exercise. Of course, with severe foot deformities and open wounds, exercise can be difficult. But it’s not impossible. That’s what the therapist will help you figure out.

Proper foot care is part of the big picture. With ulcers already present, the task is to keep them from getting worse or adding new ones. Foot care includes a wide range of activities such as daily inspection, protection to minimize trauma, and reduction of weight bearing. This is the piece that the patient is responsible for and compliance is essential for a good result.

Anyone with loss of sensation from nerve damage called peripheral neuropathy is advised to avoid soaking the feet. There is a danger of burns and prolonged exposure to warm water leaves the skin susceptible to fungal infections. Whirlpools and hot tubs are not allowed and baths are not advised (showering may be best). Bathing and soaking remove the protective barrier from the skin and can lead to other infections, especially if there are cracks from dry skin due to decreased circulation.

The therapist will also teach your husband how to control activity levels and decrease shear forces on scars from previous ulcers (if there are any). Orthoses (molded shoe inserts) are often used to redistribute or move pressure away from a blister, sore, or other area of pressure. Soft, moldable orthoses are preferred to the rigid orthoses used by patients with other types of foot problems.

The therapist will find the best off-loading techniques for the treatment of neuropathic ulcers. For example, total contact casting (TCC) is one very effective way to treat neuropathic plantar ulcers.

Total contact inserts (TCI) and metatarsal pads can be used to reduce stress on the bottom of the foot, thereby preventing skin breakdown and ulceration. The TCI reduces excessive pressures on the bones of the foot by increasing the contact area of weight-bearing forces. Metatarsal pads act by compressing the soft tissues around the metatarsal heads. By doing this, the pads take direct pressure off the metatarsal heads.

This is just a partial list of things the therapist can offer you and your husband. It may be best to seek the services of a therapist already working in a diabetes clinic or diabetes education center (or otherwise specializing in this area). But if this is not available in your area, then ask around and find someone who is tuned in to the special needs of the patient with diabetes.