What is the recommended treatment for a diabetic patient with a leg sprain?

Treatment of Leg Sprain in Diabetic Patients

For diabetic patients with a leg sprain, immediate offloading with a removable knee-high device is recommended, along with meticulous foot care and glucose control to prevent complications. 1

Initial Assessment and Management

• Perform a comprehensive foot evaluation including inspection of skin, assessment of foot deformities, neurological assessment (10-g monofilament testing with pinprick, temperature, or vibration testing), and vascular assessment including pedal pulses 1
• Initiate offloading of the affected limb as soon as possible to prevent progressive deformity and potential skin ulceration 1
• Apply the RICE protocol (Rest, Ice, Compression, Elevation) with special considerations for diabetic patients 2, 3
• Monitor blood glucose levels closely as injuries and inflammation can affect glycemic control 4

Offloading Options (In Order of Preference)

1. Non-removable knee-high offloading device (first choice):

   • Provides immobilization and pressure redistribution
   • Prevents patient non-adherence to treatment
   • Results in faster healing times 1

2. Removable knee-high device (if non-removable device is contraindicated):

   • Can be removed for bathing or skin examination
   • Should be worn at all times when weight-bearing
   • May lead to delayed healing due to potential non-adherence 1

3. Well-fitted walking shoes or athletic shoes (for mild cases):

   • Should cushion the feet and redistribute pressure
   • Particularly appropriate for patients with neuropathy or increased plantar pressures 1

Special Considerations for Diabetic Patients

• Foot Care: Encourage proper foot care including appropriate footwear, daily foot inspection, skin cleansing, and use of topical moisturizing creams 1
• Glucose Control: Maintain hemoglobin A1C to less than 7% to reduce microvascular complications 1, 5
• Neuropathy Assessment: Evaluate for diabetic peripheral neuropathy which may mask pain and lead to further injury 1, 5
• Vascular Assessment: Screen for peripheral arterial disease which may affect healing 1

Medication Management

• For neuropathic pain associated with the injury, consider:
  • First-line: Pregabalin, duloxetine, or gabapentin 1, 5
  • Alternative options: Tricyclic antidepressants (with caution in elderly) 5
• Avoid opioids for chronic pain management due to risk of addiction 5
• Continue antihypertensive medications despite potential concerns about decreased limb perfusion, as most patients tolerate therapy without worsening symptoms 1

Monitoring and Follow-up

• Schedule follow-up within 1-2 weeks to ensure resolution of symptoms and absence of complications 4
• Monitor for signs of diabetic myonecrosis, an uncommon but serious complication presenting as severe pain and swelling 6, 7
• Assess for skin breakdown or pre-ulcerative signs at each visit 1, 4
• Consider referral to a foot care specialist if the patient has loss of protective sensation, peripheral arterial disease, or history of lower-extremity complications 4

Complications to Watch For

• Development of Charcot neuro-osteoarthropathy, which requires immediate offloading 1
• Secondary bacterial infections requiring culture and appropriate antibiotic therapy 4
• Delayed healing due to peripheral vascular disease 8
• Progressive deformity if offloading is inadequate 1

Patient Education

• Educate on daily foot inspection and proper foot care 1
• Instruct on signs of worsening that require immediate medical attention 4
• Emphasize the importance of adherence to offloading devices 1
• Advise on smoking cessation to improve outcomes 1