Between 1990 and 1998, diagnosed diabetes in the United States increased by 33%. [1] Chiropractic care has much to offer patients who have diabetes.

Because of circulatory concerns, diabetes patients often develop extremity problems and symptoms -- most commonly of the feet. [2,3] As the diabetic process continues, neuropathy can lead to sensory difficulties, which often allows poor shoe fit, excessive pressure and friction, and even injuries to go undetected. [4-6] The eventual result is skin ulcerations, infections (which do not heal readily), and finally amputation in some cases. [7,8]

When treating a diabetic patient, it is the chiropractor's duty to evaluate the circulatory status in the extremities, and provide advice to help prevent the development of foot ulcers. In most people the foot is seldom symptomatic, and this is particularly true in the case of patients with a history or tendency to diabetes.

*** Shoe fit. Proper shoe selection can be critical in avoiding excessive frictional stresses to sensitive foot tissues. [9] The last on which the shoe is built must match the shape and length of the foot. The vamp and the heel counter need to provide support without being too restrictive and irritating. The size and shape of the toe box are critical, and prominent seams or stitching can rub and chafe, with disastrous results. Adjustable closures, such as full laces, can adapt to the changes in foot size and shape that occur during the day, and Velcro-type tabs are very helpful for patients who have difficulty in lacing and tying knots. Slip-on styles are usually not recommended for patients with diabetes, due to the lack of adjustability and the need for a tight fit.

*** Nutrition. Dietary modifications and vigilance over food intakes are required when dealing with a diabetic condition. Supplementation with vitamins, minerals, and other products can be very useful, depending on each patient's personal condition and food habits.

*** Circulation. Circulatory status must be maintained at all costs -- through proper nutrition, regular exercise, and protection from injury. Lower extremity exercise is critical. Just regular walking can stimulate the pumping of blood and fluids through the system and prevent pooling and stasis. Gentle massage along with elevation of the legs and compression stockings (when necessary) are useful adjuncts.

*** Shock absorption. An important consideration is preventing damage to the heel pads and absorbing the stresses of walking. The diabetic foot is particularly sensitive to the three-to-five g's of force which it must endure with every footstep. Normal shocks and stresses can result in damage and injury to sensitive diabetic feet. The sole of the shoe (insole, midsole, and outsole) must be made of materials which are comfortable, durable, and shock-absorbing.

*** Breakdown prevention. Custom-made, flexible foot orthotics are valuable, and should be considered early in the treatment of a patient with diabetes. In the initial stages of the condition, an orthotic which is supportive of normal foot biomechanics is useful, as long as a special, shock-absorbing material such as Zorbacel is provided. Effective orthotics encourage efficient foot and lower extremity biomechanics, while at the same time diffusing pressure stresses and preventing tissue breakdown. The ideal orthotic should be designed to be very comfortable and shock absorbing, while still providing full corrective support for foot alignment and dynamics. Such an orthotic will allow your patient to continue to be active and to exercise regularly.

In the final stages of diabetic foot problems, a purely accommodative orthotic is all that can be tolerated. This type of "compromise" orthotic will absorb shock and prevent pressure sores, but it does not support the arches and biomechanics of the foot. In this case, cut-outs and "divots" must be incorporated to allow the broken-down foot to function without excessive pressure on individual areas. It is much better to intervene early in this process and to prevent (or at least slow down) the development of this late stage.

The importance of proper shock absorption and shoe fit for the diabetic patient cannot be overstressed. Chiropractors who treat patients with diabetes must consider their need for comfortable, flexible foot orthotics which will provide support and forestall future biomechanical and tissue breakdown.

1. Mokdad AH, Ford ES, Bowman BA et al. "Diabetes trends in the U.S.: 1990-1998." Diabetes Care 2000; 23:1278-1283.

2. Kosak GP, Hoar CS et al. "Management of Diabetic Foot Problems." Philadelphia: W.B. Saunders, 1984.

3. Bild ED, Selby JV et al. "Lower extremity amputations in people with diabetes, epidemiology, and prevention." Diabetes Care 1989; 12:1.

4. Harkless LB, Dennis KJ. "You see what you look for and recognize what you know." Clin Podiatr Med Surg 1987; 4:331.

5. Gibbons WG, Freeman D. "Vascular evaluation and treatment of the diabetic." Clin Podiatr Med Surg 1987; 4:337.

6. Huntley A. "The skin and diabetes mellitus (photoessay)." Dermatology Online Journal 1995; 1(2):[http://matrix.ucdavis.edu/DOJvol1num2/diabetes/neuropathy.html]

7. Pecoraro RE et al. "Pathways to diabetic limb amputation: basis for prevention." Diabetes Care 1990; 13:513-521.

8. Levin ME, O'Neal MW, eds. "The Diabetic Foot," 3rd ed. St. Louis: C.V. Mosby, 1983.

9. Dyck PJ, Thomas PK et al., eds. "Diabetic Neuropathy." Philadelphia: W.B. Saunders, 1987.