Peripheral diabetic neuropathy may result in pain, loss of sensation, and muscle weakness. Autonomic neuropathy may involve the gastrointestinal, cardiovascular, and genitourinary systems, resulting in related symptoms and complications. Diabetic neuropathy is treated by maximizing glycemic control and addressing related symptoms. Pain related to diabetic neuropathy is treated with tricyclic amines and anticonvulsant medications. Titrated doses of nortryptline or carbamazepine are most effective in treating chronic nerve pain associated with diabetic neuropathy. Opioid therapy is not recommended as it is an acute pain management therapy, and NSAIDS (ibuprofen) have no therapeutic benefit with neuropathic pain. Foot ulcers and amputations are complications of diabetes that are frequently related to neuropathy. The risk of amputation is associated with the following conditions: peripheral neuropathy with a loss of sensation, evidence of increased pressure (erythema, hemorrhage under a callus), peripheral vascular disease (absent distal pulses), severe nail disease, and a history of foot ulcers. Screening for diabetic neuropathy should include monofilament testing.
Footwear recommendations for diabetic inmates should consider the following:
• The current version of the BOP standard-issue work shoe addresses most concerns of diabetic and non-diabetic inmates.
• The institution is required to provide an inmate with a properly fitting work shoe. Tennis shoes and other recreational footwear are solely the responsibility of the inmate.
• Inmates with severe neuropathy are best served with protective footwear, such as steel-toed work shoes or boots, that minimize the chance of an incidental foot trauma that could cause a diabetic ulcer. Extra-wide, extra-deep toe boxes will reduce the risk of irritation to feet with deformities and/or impaired sensation. Only rarely will a tennis shoe be the most appropriate choice for a diabetic inmate.
• Medically ordered footwear should be considered in certain circumstances, including the following:
• Inmates with symptomatic foot deformities (e.g., large bunions, pronounced hammertoes, etc.) where regular-issue shoes of the appropriate size and width are causing significant skin irritation or ulceration.
• Inmates with Risk Category 2 or 3 (as determined by the LEAP Diabetes Foot Screen). This includes those with a loss of protective sensation with either high pressure (callous/deformity), or poor circulation; or history of plantar ulceration, neuropathic fracture (Charcot foot) or amputation.
• Inmates with significant vascular disease as suggested by claudication, absent dorsalis pedis or tibialis posterior pulses, or other studies.