A 53 year old female is presented in a diabetic foot clinic with a superficial ulcer on the lateral side of the right fifth toe. She has been diagnosed with diabetes 6 years previously and has been adequately regulated with a 4 daily insulin regimen. Prior she had been seen by her general practitioner, but he was unable to find the cause. While attending our clinic she was screened for the presence of any risk factors. She was diagnosed with nerve damage, as she was unable to feel the 10 gram monofilament. The vascular status was intact; normal pedal pulses and an ankle brachial index of 1.05 on both limbs. There were no signs of infection and a plain X-ray did not reveal any underling osteomyelitis. She did not know when she first noticed the lesion, but a few weeks earlier she had noticed some blood stains on her socks. Her foot wear was examined extensively, but they were regarded as adequate foot wear. There were no indentations in the shoes and also the insides were without any irregularities. Therefore, it was concluded the causative agent must have been a trauma of unknown etiology. Possibly, it was an unnoticed object that had been present in her shoe. It was for the intern that talked to her more extensively on a separate occasion that revealed the most likely cause of her ulcerated fifth toe. While discussing her hobbies, she replied she was very much into ball room dancing. Every Tuesday evening she and her husband went to a local community center where they practiced the art of ball room dancing. The intern then asked whether she had specific dancing shoes. The lady answered she always wore her “good” shoes that she was wearing when she visited her doctor, but on Tuesday evenings she ad her special dancing shoes. When she was instructed to take these shoes along at her next visit to our clinic, we found the cause of her ulceration. All through the week she wore shoes with a wide toebox, except on Tuesdays. While dancing she has pointy shoes that made her toes cramp up allowing for pressure and friction to cause an ulcer. Her ulcer healed fairly quickly and she was provided with education on foot wear. It was stressed that not wearing adequate shoes for only a short period of time could be sufficient to cause considerable damage. After she had been instructed on what type of foot wear was suitable for her and still enabled her to make her dancing moves, she did not ulcerate any more.
Lesson to be learned: “Always examine the shoes extensively and beware that all shoes worn by the patient are inspected”.
William van Houtum