Dr. Jacoby explains neuropathy and how it relates to heel pain and diabetes.
Let’s talk about heel pain, diabetes, and neuropathy. Let’s try to define what this is and why is it so prevalent. When I was first in practice, this was not a very common question to be asked. Today, the number of people that have diabetes in the Western world is exponentially climbing. It is the biggest problem, not only in America, but in the rest of the world.
India, in fact, has the highest number of diabetics because of their diet. They imported our diet. Now they have the problem. Asia–the same problem. It’s pandemic; it’s all over the world. But how is it affected? Why would it even be considered in heel pain in the differential diagnosis? That has to do with the word neuropathy.
Neuropathy means a problem with the nerve. There’s three issues that I think from my experience that cause nerve problem in the diabetic population. Number one, glucose, sugar, when it rises in the blood it spills over into the nerve, and when sugar gets inside a nerve, it pulls in a substance called sorbitol. Sorbitol is a alcohol sugar, and it’s hydrophilic. And what I mean by that is it pulls in water. Water swells the nerve. When nerves go through a tunnel, they get trapped.
The second phase is, and I think women will love this phrase because it’s a cooking phrase, it’s called the Maillard reaction. Maillard reaction is a cooking phrase, and what it means is when you take a protein such as soft tissue–skin, tendon--and mix it with a sugar, it binds together, and I will give you an example.
When we cook a turkey at Thanksgiving, you are basting the turkey, which is protein, collagen, with sugar. It makes it crispy; it makes it brittle and non-pliable. That’s what happens to our nerves. That’s how you get wrinkles. That’s how you get cataracts. All those diseases are related to that process.
So when you think about it, Americans are slowly cooking themselves to death. They are raising their internal temperature and the collagen, soft tissue with sugar, makes us brittle. That’s what makes your bones brittle; that’s what makes your cartilage brittle, but especially your nerves. That’s the number two factor.
Number three–they call the nitric oxide pathway. It’s a complicated biochemical pathway, but the bottom line is again related to diet. Nitric oxide is what dilates our blood vessels. Without nitric oxide, we cannot get blood flow to a part, and if we don’t get blood flow to a nerve, we call that hypoxia. The nerve starts to die, and when it starts to die it starts to tingle; that’s a symptom. That’s telling us we don’t have enough oxygen to the nerve.
Heel pain may be that first symptom. It’s not just trauma. If the foot or the heel is starting to get numb, tingling pain, that could be the first sign. So how do we diagnose that? A blood test. We have a blood test for sugar; if it is elevated, you have diabetes. With 50 percent of the patients I have that have those symptoms have a negative blood test.
What are the other treatments? We have a new test which is a biopsy of the skin which we can tell if you are losing—epidermal innervation density biopsy is what it’s called--and it’s telling you that you are losing nerve fibers. That’s an important diagnosis that can stop this process because you could have heel pain or even back to the fungus toenail.
The yellow toenail may be the first sign. This is a substance that we are looking at right now, the association that I am involved with, with peripheral nerve surgeons we are looking at the biochemistry of the early markers of diabetes. We don’t want to know that you have diabetes in the end phase; anybody can treat that. We want to know the early phases.
Right now in the United States, there’s 100,000 amputations a year that patients have with diabetes, and they are taking medication to get rid of this numbness and tingling. Those medications do nothing for this disease. We have to get early, early treatment. One hundred thousand amputations is a ridiculous number in this day and age. That’s just in the United States. There’s a couple hundred thousand in the rest of the world. This is a pandemic disease.
There are early treatment protocols that you can find. Go to the Web. All this information I am talking about has been published. Our Association of Extremity Nerve Surgeons which is comprised of podiatrists, orthopedists, neurosurgeons, Ph.D.s, people who are involved in this disease or trying to stop this. Dr. Lee Dellon who is probably the world’s greatest peripheral nerve surgeon from Johns Hopkins is the one who started this organization. He is the one who taught me and 350 other doctors.
I am impassioned about this process. We have not had one amputation, and I personally have been doing this almost ten years. In the face of other doctors who are having amputations that are primary endpoint. This is the most serious disease on the face of the planet.
In addition to that, Medicare, which is bankrupt, I don’t have to tell you that. We need healthcare reform. Healthcare reform is--talking about empowerment–women’s empowerment. Change your diet. You don’t need a doctor to stop this disease process; you need to change your diet. That’s empowerment.
I am an interventionist. I intervene when the disease is already taken hold. I don’t want to amputate anybody’s leg. President Obama said that the doctors get $30 to $50,000 a year or per case to amputate a leg, which is absolutely untrue. Doctors in Scottsdale here get $500 to $1000 to amputate a leg. That’s the actual cost, but it does cost $50,000 for an amputation with all the peripheral things that go on. There’s no reason to amputate a leg. We need to prevent the things that cause that.
So I agree with President Obama; we need to change the paradigm. We need early intervention. We need to change the diet, but if you do have problems with your nerves and they are causing all these problems, see a doctor who is trained in the intervention of these problems. And our organization, the Association of Extremity Nerve Surgeons, is that organization, and we’ll post that on the website so you can find a doctor in your area that does this. If you are faced with an amputation or loss of limb, and you have diabetic neuropathy, seek one of these doctors out.
About Dr. Jacoby, D.P.M.:
Dr. Richard Jacoby, D.P.M., graduated from the Pennsylvania College of Podiatric Medicine. He completed his residency at Parkview Hospital, Philadelphia, specializing in foot and ankle surgery. Board certified by the American Board of Podiatric Foot and Ankle Surgeons, he is currently president of Valley Foot Surgeons in Scottsdale, Arizona. In addition, Dr. Jacoby is chairman of the board of Healthcare Networks of America.
Dr. Jacoby has been named the 2010 President of The Association of Extremity Nerve Surgeons.