The Foot in Diabetes

The patient passes the foot exam, then tells you their toes burn at night. We read a new American Limb Preservation Society paper on putting the neuropathy guidelines into practice alongside the review it cites eight times, and ask why it never mentions corneal confocal microscopy, the tool that review calls "the most pertinent modality for early detection".

In this episode:
- Why small nerve fibres matter: the earliest to degenerate, with the greatest potential for repair
- Corneal confocal microscopy in plain terms, the idea of screening corneal nerves alongside diabetic eye screening, and the caveats its own authors give
- Why the 10 g monofilament is not recommended as the sole test to diagnose neuropathy
- Scoring tools: TCNS, MNSI and NDS
- Five risk classification schemes side by side, and why a clinic should pick one (we walk through IWGDF)
- Footwear, skin temperature monitoring and supplements
- Painful neuropathy: reduction not elimination, and when to switch drug class
- Opioids, and the ADA's view of tramadol and tapentadol
- Why the implementation section is the weakest part of the paper
- Three changes for Monday

Chapters:
00:00 Cited eight times, and one omission
01:25 Small fibres: first to go, first to recover
02:44 What the paper cites the review for
03:54 Corneal confocal microscopy in plain terms
05:53 "The most pertinent modality for early detection"
06:31 The caveats
08:07 Scoring tools: TCNS, MNSI and NDS
08:56 The monofilament: not the sole test
10:12 Ruling out peripheral artery disease
10:44 Risk classification: five schemes, pick one
13:33 Footwear and skin temperature monitoring
14:35 Supplements
15:14 Painful neuropathy: reduction, not elimination
16:40 When a drug fails: same class or a different class
17:29 Opioids
18:11 Implementation: the weakest section
19:00 Author disclosures
19:28 Three changes for Monday
20:38 Closing thought: an eye scan before the foot clinic

Sources:
Burgess J, Frank B, Marshall A, et al. Early Detection of Diabetic Peripheral Neuropathy: A Focus on Small Nerve Fibres. Diagnostics (Basel). 2021;11(2):165. Open access.
DOI: 10.3390/diagnostics11020165

Rogers LC, Lepow BD, Armstrong DG, et al. Diabetic Peripheral Neuropathy: Implementing Guidelines into Practice. J Am Podiatr Med Assoc. 2026;116(5):84. Open access.
DOI: 10.3390/japma116050084

Free for clinicians: the Teaching Document for LimbWise Module A1, Foundations of the Diabetic Foot.
https://store.thefootindiabetes.com/free/a1?utm_source=spotify

This episode is for education only. It is not medical advice and does not replace your own clinician or your local protocols.

The voices in this episode are AI-generated (Google NotebookLM), discussing the two papers above. The episode was reviewed by Rob Menzies, who is responsible for its content.

This episode explores peripheral arterial disease as a spectrum of nine distinct phenotypes, each shaped by different underlying comorbidities, anatomical patterns, and management priorities. Rather than treating PAD as one uniform diagnosis, the discussion shows how diabetic PAD, renal PAD, hypertensive PAD, dyslipidaemic PAD, smoker-related disease, polyvascular PAD, inflammatory or autoimmune PAD, hypercoagulable PAD, and structural or mechanical PAD each present differently and demand different diagnostic and referral strategies.
The episode also connects these phenotypes to the realities of diabetic foot care, including neuropathy masking ischemic pain, delayed wound healing, ulcer progression, infection risk, amputation prevention, and the need for coordinated multidisciplinary limb-salvage pathways. It is aimed at clinicians and MDT members who assess lower-limb risk and want a more precise, phenotype-driven way to think about ischemia

A hot, swollen foot that does not hurt. A normal X-ray. A diagnosis missed for weeks. This episode is about the diabetic foot complication that is very treatable when caught early, and devastating when it is not: Charcot neuro-osteoarthropathy.

We break down the four things that decide whether a patient keeps their foot or loses it. First, why a hot, swollen, neuropathic foot should be treated as Charcot until proven otherwise. Second, why an MRI sees what a plain X-ray cannot, and how to tell Charcot apart from a bone infection. Third, why the total contact cast is still the cornerstone of treatment, and why even standing on the foot too much can undo it. Fourth, how the way a service is built, rapid access and same-day referral, often matters more than any single clinician’s knowledge.

Whether you are a clinician who sees feet, or someone living with diabetes and reduced sensation, the message is the same and worth remembering: if one foot suddenly becomes hot, swollen or a different shape, get it seen the same day and keep the weight off it.

Clear, practical, and grounded in the current evidence, including the 2023 international guidelines.

Please note: this episode uses an AI-generated voice. The clinical content is researched and reviewed by Rob Menzies.

The Foot in Diabetes — Episode 2: Peripheral Arterial Disease and Limb Ischaemia in Diabetes

In Episode 2 of The Foot in Diabetes, we explore one of the most critical — and frequently missed — drivers of diabetic foot complications: peripheral arterial disease and limb ischaemia.

Drawing on the latest evidence and the 2023 guidance from the International Working Group on the Diabetic Foot, we discuss why vascular disease behaves differently in diabetes, why delayed recognition continues to push patients toward avoidable amputation, and what clinicians need to know to identify high-risk patients earlier.

From vascular assessment and referral pathways to multidisciplinary limb salvage strategies, this episode focuses on one central question:

How do we recognise vascular compromise early enough to prevent catastrophic outcomes and save limbs?

You’ll hear why the “renal foot” is more than just “diabetic foot plus CKD”: uraemia, mineral–bone disorder, medial arterial calcification, PAD, diabetes, and dialysis‑related haemodynamic swings combine to create a uniquely fragile limb. The hosts unpack what this means at the bedside—late‑presenting ulcers, explosive infection, osteomyelitis, complex tissue loss—and why calciphylaxis sits in its own lethal category.
Expect clear explanations of why ankle–brachial index can mislead in ESRD, how dialysis modality might influence limb risk, and what the evidence really shows about revascularisation versus primary amputation in this group. The discussion keeps circling back to MDT pathways and realistic goals of care, so you can translate concepts into decisions on ward rounds and in dialysis units.
If you work in nephrology, vascular surgery, diabetes, podiatry, or a high‑risk foot service—and you want a sharper mental model for recognising and managing the renal foot—this episode is built for you.