Case 56: Improved Leg Function and Relief of Pain in Toes

A diabetic for over twenty years and a past smoker for 30 years, this 69 year old man had a history of hypothyroidism, carotid surgery, three small strokes, bladder cancer and a prostate scraping. In March 1992, he had a partial colectomy for diverticulitis and developed red toes after the procedure. In spite of the conservative measures of his physicians, his toes continued to deteriorate and by December 1992, first the right foot and then the left foot developed black focal necrotic areas of the tips of the big toes. He was referred for boot treatments February 22, 1993 with pain in most of his toes and his walking distance limited to a slow one block.

Focal Necrosis of the Big Toes

Vascular assessment showed no palpable pedal pulses and a trace popliteal pulse in the left leg. In the right leg the dorsalis pedis was absent. Photoelectricplethysmographic tracings were flat in the left 2nd to 5th toes and were low in the right toes (he could not tolerate the presence of the probes on the big toes). His ankle/arm index was 0.67 in the left leg and 1.05 in the right. The pulse volume curve was low and rounded above the right ankle and grossly irregular above the left ankle. His Doppler arterial signals were fairly strong in the left peroneal and weak in the left anterior and posterior tibial arteries. In the right leg, the posterior tibial was strong at the ankle while flow was reversed in the anterior tibial. The tests were compatible with the presence of occlusive disease in the tibial vessels with additional small vessel disease in both feet. While light touch and vibratory senses appeared to be intact, modest concomitant neuropathic disease was suggested by increased two-point discrimination (7 cm), absent Achilles reflexes and his hammer toes. His BUN of 28 and creatinine of 1.3 mg/dl pointed to mild renal impairment. His EKG showed a complete right bundle branch block. His glycohemoglobin A1C of 8.5% pointed to inadequate control of his diabetes on his oral agents; he was started on insulin.

Both legs were treated in the Mini-Boot as an outpatient and did well.

Pain-free with Toenails Growing and Lesions Healed

While his legs did well, his gallbladder did not. On August 13th, he was found to have an acute gangrenous gallbladder and underwent an open cholecystectomy. Two weeks later, he had returned to South Jersey where he had a small stroke. In March of 1994, his feet relapsed. He presented on March 7th with 3-to-4 block claudication and focal ischemic painful spots on his right 3rd and left 1st toes. His glycohemoglobin A1C was 6.4%. He rapidly responded to Mini-Boot therapy. In May 1995, he reported he was playing golf but required a cart to get around the course. On January 15th, 1996 (0/15 in photograph) he presented with painful spots on his left big toe, which again healed with boot therapy. His legs then continued to do well up to the date this report was posted in our case histories, November 1996. His walking had been limited by fatigue rather than claudication

January 15th, 1996: His left big toe had developed a small ulcer and a focal black spot at the base of the teonail.

Both Feet Doing Well and Normal in Color

Comments: This man suffered foot pain needlessly almost a year before friends referred him for boot therapy. What else could have been done for him so safely, cheaply and effectively?

Follow-up: He had come to us with years of uncontrolled diabetes and generalized arteriosclerosis. He improved his glucose control with insulin therapy but still had his diffuse arteriosclerotic disease. He next had a syncopal episode and was found to have an intermittent Mobitz II heart block. A pacemaker was inserted on November 18th, 1996. Perhaps with new energy and more walking, he again developed an ulcer on his left first toe in March 1997. His ankle/arm index was found to be 0.69 in the right leg and 0.43 in the left. He took another course of Miniboot and Long Boot therapy and healed the toe. He was encouraged to ride both a mobile and/or stationary bike, depending on the weather, in lieu of booting. His feet again did well for a few years allowing him to take a trip to Alaska. His foot troubles began anew in May 2000.

May 19th, 2000: He presented with a swollen painful ruborous right foot suggestive of gout. Note the extreme pallor of the toes; the toe PPG curves were flat. Colchicine provided no relief.

His uric acid was 7.1 mg/dl and his sedimentation rate 75 mm/hr. The second toe appeared especially ischemic and was subsequently noted to be blue and draining a small amount of pus. Stenotrophomonas maltophilia, Coagulase-negative staphylococcus and mold were recovered on culture. He was thought to have ischemic breakdown of his second toe with a secondary infection that was spreading through his foot. His right ankle/arm index has fallen off to 0.49. He was started on Cipro on May 19th and gentamicin was injected into his foot prior to his Miniboot therapies. He was advised to boot daily until his status was stable and his foot out of danger. He received in May nine Miniboot treatments, in June two Miniboot treatments and ten Long Boot treatments and in July eighteen Miniboot treatments and fourteeen Longs. After July 24th, his Medicare was discontinued due to the confusion regarding the Circulator Boot and the ECP devices (Circulator Boot vs ECP). His increased risk for surgery (his cerebrovascular disease, heart disease, kidney disease) and the fact that his noninvasive testing suggested he had diffuse disease that would not lend itself well to vascular reconstruction were discussed. Still, Medicare would pay for hospitalization, arteriography and bypass and he could not afford outpatient boot therapy. An arteriogram was performed on July 31st. A 60% focal stenosis was noted in the left common superficial femoral artery. The left superficial femoral was occluded but the popliteal reconstituted and there was two vessel runoff. The right superficial femoral was patent but densely calcified and moderately diseased. There was complete occlusion of the right trifurcation over 5 cm with reconstitution of the peroneal which was continuous to a high grade stenosis distally. The right posterior tibial reconstituted distally also. The radiologist commented he saw no good opportunity for either angioplasty or bypass. A vascular surgical consultation was obtained nonetheless and a bypass was performed on September 13th.

September 6th, 2000: Color had been restored in his toes. He had stable gangrene of the second toe and had the option of continuing boot therapy in hopes of a successful autoamputation of the toe. He could not afford it.

November 7th, 2000: Now almost two months after his bypass, the second toe has changed little. The color in the distal foot has faded, but when the foot was raised 12 inches above the examining table, the toes blanched entirely; the bypass was lost.

He was provided with Sea Soaks containing appropriate antibiotics to use as cleansing soaks. The dead portions of his toe were debrided leaving the bare drumstick of his proximal phalanx. Reganex was prescribed in hopes of stimulating tissue closure. In January 2001, he was hospitalized for bronchiolitis, a rash and a Staphylococcus infection of his foot. The foot seemed to be holding and the toe slowly healing. However, on April 4th, the pulse volume curves of the foot and calf were found to be low-to-flat and his venous filling time had increased to 90 seconds. His blood flow had fallen to a critical level. He was advised he should return to the vascular surgeon and/or restart as much booting as he could afford. He managed 11 treatments through May and June. The vascular surgeon had little to offer except leg amputation which the patient appears resigned to have after he spends some time at the Jersey shore.

May 10th, 2001: The whole foot had become cold and ruborous. The skin on the lateral foot was breaking down.

May 22nd, 2001: The breakdown was enlargening. He began some booting but hardly enough. He was in constant pain.

August 24th, 2001: He continued the various medical maneuvers offered by his physicians (exercise as tolerated, cleanliness, bandage changes, analgesics etc.) and went to his summer residence at the shore. The cold areas of his foot slowly mummified. He continued in pain.

August 24th, 2001: His heel broke down also. He developed fever and malaise taking him to a hospital near the resort where immediate leg amputation was recommended. He preferred to return home for the procedure.

Comments: This man has suffered all of the complications of diffuse arteriosclerosis. He has had expensive and painful problems. With intermittent outpatient boot therapy, he was able to maintain both legs for seven years. Had he been able to continue his boot therapy after July 2000, it is possible we might have healed his toe. His bypass failed and his medical therapies seemed to be gaining some ground before his critical falloff in May 2001. His is an interesting case to consider. He was referred initially because his physicians had offered him no effective treatment. He had a lot of boot therapy over seven years likely at a cost considerably below that of an average hospitalization... and was active and ambulatory. In lieu of more boot therapy, Medicare paid for multiple subsequent hospitalizations (the bypass, the foot infection/bronchiolitis, the resort shore admission, his leg amputation and his admission to the rehabilitation hospital) that likely would have been avoided with continued boot therapy. With his disabilities, he will be lucky if he is ambulatory on a prosthesis and may be expected to require additional home nursing and potentially custodial care. Further, the loss of his right leg and his lack of booting endangers the ischemic left leg. Many of these problems, of course, are covered by Medicare.