The first thing I do when I look at most new patients feet is observe the condition of the skin. Is the skin firm? Is it filled with fluid (edema), is it discolored, is it covered with fungus… etc., do the toenails have fungus, etc.?
However, if it is a man’s foot and legs which I am looking at, the first thing I might look for is ‘hair;’ hair on the foot, hair on the ankles, hair on the knuckles of the toes and lower legs. As 70% of the people whom enter my office are diabetic, it makes sense right from the beginning to look for signs of type II diabetes. Of course, their Intake should tell me that; however, often we find that many patients are ‘pre-diabetic.’ Many, including myself, are diagnosed with peripheral neuropathy 5 years BEFORE the diagnosis of diabetes, in fact! Next, we, usually, examine and measure the calf muscles; noting, if they are equal in size. This is compared to other testing factors to tell ‘which’ leg might be more adversely affected. Actually, it IS possible to have a better score on one leg/foot than the other; but, have that ‘better’ leg, be more adversely affected with muscle atrophy or other issues. And, through treatment, or the patients diet, ‘good or bad sides,’ may even switch, from time to time.
Next, observation is made as to if the skin on the legs or feet are cracked and dry or not. Diabetic ulcers or sores are looked for, measured and recorded/photographed as well; even on those patients who are not diabetic (as, this could be in indication that they are pre-diabetic or fully diabetic and not know it). By photographing the sores, we can accurately gauge how well or fast the sore might be healing.
We can learn a lot just from looking at the feet. If the tissue is blue or purple, it will lead to the next question: “Do you smoke?” Or, as stated in previous Blogs, “were you ever a skier or a pilot, etc.” We need to attempt to find the cause of the lack of circulation to the feet. If the feet are purple, that is certainly an indication that the blood is just ‘pooling’ down in the feet and there is little circulation.
At this point, we turn to what is known as Toronto Clinical Scoring. If the patient is diabetic, we use a standard test; however, if the person is not, we use a modified version of it. So, what exactly is a Toronto Clinical Scoring Test; and even more important, what is a MODIFIED Toronto Clinical Scoring Test?
Toronto Clinical Scoring Tests were originally devised to check on the ability to sense ‘sensation’ in the foot or leg; mostly, to determine if someone was suffering from Sensorimotor Neuropathy. The physician or clinician tests for cold, cool, heat, pin prick and other issues and records their findings. A totally healthy foot/leg scores 74 points; and points are judged by sensation on a scale of 0 to 10; with minus 5 given for any ‘hyper’ sensitivity. This test is very effective. However, during our years of service performing this test, we have found it to be just as accurate and effective for ‘non-diabetics’ as well; we have just ‘modified’ this test to include hands and fingers, arms, toes. Even the face is checked to see if sensitivity is just as keen on one side as the other; as often it has been found that a stroke or small TIA could affect the results of the test. If one has had a stroke or TIA, then sensitivity is going to be lower on the side with the stroke; i.e; testing scores will be lower on the side with the stroke.
Generally speaking, if one scores the same up and down a leg and foot, but still has symptoms of pain or numbness (not to mention burning or tingling) or even restless leg syndrome, the results tend to dictate symptoms of ‘long nerve’ neuropathy – meaning, the ‘long or longest’ nerve in the body. But, when the nerves test differently from one spot to the other on the leg and/or foot/toes (or with the hands/fingers and arms), one is more likely to have short nerve neuropathy. Some of the same symptoms, such as hypersensitivity may be present in either form; as can a few other symptoms.
Is it possible to have BOTH long and short nerve issues? Most certainly. In testing, we start looking for issues like hypersensitivity. In a regular diabetic test, we might take off 5 points if the foot is a bit ‘overly sensitive’ to cold or merely running the tip of a pen or Wartenberg Wheel up the bottom of the foot. However, we might take of an additional 5 points, for a total of 10, if the foot is also unusually sensitive to cold or other touch. Pain can come from both issues as well; this is one reason, we tend to ‘double check’ ourselves and treat at least once for each short and long nerves. Whichever treatment seems to work better, tends to indicate which neuropathy tends to be the most prominent.
Through the use of this test, we can generally determine what course of action is required for treatment; to RESTORE, MANAGE and MAINTAIN ones reduced symptoms.
Of course, there is much more to determining what is needed besides just a single test; balance issues and testing may be required as well… such as Berg Balance Testing or even examination of the back. We might even check sensitivity to pressure and trigger points; or muscles which have not only ‘shortened’ and are pulling on the spine, but are adding ‘unnoticed edema’ to the back as well.
But, the ‘Modified Toronto Clinical Scoring Test’ is instrumental in determining the ‘type’ of nerve neuropathy. The ’cause’ of the neuropathy is quite a different matter; and, depending upon our findings, ‘assorted modalities’ might be in order in addition to a change of diet or lifestyle.
Next Blog: Berg Balance Testing.