REMEMBERING PROF. N.N. GUPTA WITH HIS LECTURE ON NUMBNESS OF THE FEET

 

Prof. N.N. Gupta was the Head of the Department of Medicine when we were in our clinical semesters in King George’s Medical College, Lucknow. He was always immaculately dressed in formal whites with a starched and ironed white apron and was a strict disciplinarian. He was so punctual that you could set your watch when his car would reach the Medicine portico. His Chief Resident would receive him and his teaching round would start almost immediately. He looked keen and sincere and was an extremely meticulous person and a passionate teacher.  Unlike the spontaneity of Prof S.N. Chakraborty, his classes appeared to be choreographed and rehearsed to perfection. His Senior Resident would come first and after taking our attendance, would write on the blackboard the topic and the skeletal framework of the upcoming lecture. Then NNG, as he was fondly called, would come and deliver invariably an outstanding lecture. He would always start in time and finish in time, ask a few questions, mostly to his team of residents and postgraduate students, and leave. This is one of his lectures which I could salvage from my notes on “Management of Numbness of Feet’.

 

That feeling of numbness in feet and toes can be caused by a variety of conditions. Numbness is often accompanied by a tingling feeling, or crawling of ants, or pins and needles sensation, or simply walking on cotton or inability to feel the ground/floor. Patients have different ways of expressing this sensation. The cause may not be serious - it can be as uncomplicated as paresthesia (foot 'falling asleep'), however, it may be as serious as diabetes, multiple sclerosis, or a symptom of a much more serious condition. Whatever the cause may be, it's essential to address the numbness in feet. Avoiding doing so may affect your ability to walk.

 

Typical causes of numbness  

Numbness of the toes generally occurs due to conditions that affect the nerves or blood vessels of the foot. The most common causes of toe numbness include:

·        Compressed nerves of the foot from footwear

·        Injury to the foot

·        Nerve damage (neuropathy)

·        Poor blood circulation to the foot, usually due to diabetes and peripheral vascular disease

·        Diabetes

·        Irritation of nerves in the lower back (possibly due to a herniated inter-vertebral disk)

·        Frostbite

·        Stroke

·        Multiple sclerosis

·        Vasculitis (inflammation of the blood vessels)

 

Diagnosis

A detailed patient history is mandatory

·        History of Diabetes

·        When was Diabetes detected

·        History of glycemic control

·        History of target organ involvement

·        History of hospital admissions

·        History of previous foot involvement

Both legs and feet are to be inspected carefully

·        Dorsal and ventral aspects

o   Skin - Healthy, intact or cracked / Dry or shiny/ Turgor and texture/ hair loss

o   Blisters, Bunions, Corns, Calluses

o   Colour change with position – palor on elevation, rubor on dependency

·        Digits and Web spaces

o   Nails Normal and shiny or thick, dry, brittle / Pink in colour or discoloured

o   Fungal infection in nails or web

o   Ischemia

o   Gangrene

o   Nail beds clean and supple or dirty and rough

o   Ac. or Ch. Paronechoea

·        Deformities

o   Toes - Hallux valgus, Hammer toe, Claw toe, Prominent Metatarsal head

o   Forefoot and ankle - Flat foot, High medial arch, Rocker bottom foot, Charcot foot

·        Vascular examination

o   Peripheral pulses

o   Subpapillary venous plexus filling time (N</=3sec.)

o   Colour changes – Cyanosis, Dependent rubor, Erythema, Gangrene

o   Oedema

o   Temperature gradient

·        Neurological examination

o   Light touch – cotton wool

o   Two-point discrimination

o   Pain – pinprick

o   Vibration perception – tuning fork

o   Temperature perception – hot & cold

o   Deep tendon reflexes – ankle and knee

o   Babinski test

·        Examination of footwear

o   Is it well fitting and well padded?

o   Is it abnormally worn out at any site?

o   Is the sole padded and soft or thin and hard?

o   Are the dangerous pressure points or foot ulcers sufficiently offloaded?

o   Is the footwear front closed?

Very vital information is hidden in the footwear the patient is wearing and wecannot afford to miss them.

 

Management

Dealing with occasional numbness

1. Exercise - Sitting or standing in one place for a long time may cause numbness. To counteract the problem, stimulate circulation in the foot by asking the patient to move around. A short walk, or moving the foot while sitting down, will help too. In addition, bear in mind the following:

·        To begin with, regular exercise can help prevent numbness. So be sure to incorporate physical activity into your daily schedule.

·        If high impact exercises, such as jogging, causes numbness in the feet and toes, try lower impact exercises, such as swimming or cycling.

·        Before starting workout, advice to stretch well, wear appropriate shoes and exercise on level surfaces.

2. Change positions - Certain sitting positions may cause numbness in feet. Ask the patient to avoid sitting on their feet or sit cross legged  for a long period of time. Should they have to sit for long hours, they should elevate their feet periodically to increase the blood flow.

3. Avoid wearing excessively tight clothing - Pants, socks or other tight garments worn on the lower part of the body might restrict blood flow to the feet, causing numbness.

4. Massage the foot - Massaging the area of the foot that feels numb will help increase circulation and reduce the effects of occasional numbness.

5. Keep feet warm - The cold may cause numbness and tingling. Reduce the effects by staying warm with a pair of woolen socks, or heating pad or heated blanket.

6. Wear the right shoes - High heels or shoes that pinch the toes may cause numbness in the feet. This may also arise from wearing shoes that are too small for the patient’s feet, especially while exercising. They should opt for comfortable shoes that fit well.

7. Ask them to seek emergency treatment if their foot numbness is accompanied by symptoms such as weakness, paralysis, loss of bladder or bowel control, or slurring of speech.

8. Pregnancy may also cause swelling in the feet and toes, which could result in numbness. This is reversible and can be addressed by exercises and warmth.

 

Dealing with Numbness Related to Diabetes

1. Get a diagnosis - Chronic numbness in the feet and toes is often due to diabetes. The feeling of numbness occurs because it damages both the nerves and causes poor circulation in the feet. Numbness is usually one of the first symptoms of diabetes, so be sure to get Blood sugar estimation done, both fasting (11 hours fasting) and post prandial (1 ½ hr. PP). It can be extremely serious for a diabetic, as they may not be able to feel pain, which may be caused by heat, punctures or blisters in the feet. In addition, due to the restriction of blood to the feet, diabetics' feet heal at a slower pace. Consequently, infection is a serious concern. With scarce blood supply the bacteria get the liberty to proliferate in a pharmacological sanctuary.

2. Manage diabetes - The best way to prevent circulation issues and neuropathy is to keep the blood glucose levels in check.

·        Check blood sugar levels regularly.

·        While the numbness in feet may make it difficult to exercise, the patient should try to stay active. Aim for 40 minutes of exercise / brisk walking each day.

·        Eat well. Opt for a healthy, balanced diet that includes fruits, vegetables, whole grains, beans, fish and low-fat dairy.

·        Drastically cut down fat from your patient’s diet.

·        Avoid food that triggers blood sugar spikes - primarily anything sweet.

·        Insist on regular use of prescribed medicine and insulin.

·        Smoking can make the symptoms of  diabetes worse. Suggest quitting..

3. Lose weight - Obesity can be a contributing factor to numbness in the feet and toes. Consequently, losing weight will help alleviate the symptoms. In addition, it may also help lower blood pressure (which may also have an effect on the numbness).

4. Use products designed for diabetic foot care - Compression hose and socks help stimulate circulation, thereby decreasing numbness. Special lotions that contain capsaicin, may also be applied in order to relieve the numbness. Protective and well padded footwears are a must. Patients should never remain bare feet.

5. Avoid analgesics – NSAIDs are to be avoided in diabetics as their kidneys are at risk.

 

Dealing with chronic numbness, caused by other conditions

1. Treatment for injuries - Numbness can occur as a result of injuries to the feet, toes, ankles, head or spine. In which case, an orthopedist, neurologist or surgeon may help treat the injury and relieve the numbness.

2. Enquire about medications your patient is already taking - Numbness may also be caused by chemotherapy drugs and many other prescription drugs. If they experience numbness after starting a new medication, your patient should go back to the doctor who prescribed them. On this note, it is important to never stop taking your medication without talking to the prescribing doctor first.

3. Add vitamin supplements - Numbness may also be caused by a lack of vitamin B12 or other vitamins.

4. Prescribe medication for chronic conditions - Numbness in your feet and toes may also be a symptom of a number of underlying conditions, including multiple sclerosis, arthritis, Lyme disease and more. In which case, it is important that you treat and take medication for the underlying condition.

5. Reduce alcohol consumption - A numbing sensation in the limbs, particularly the feet and toes, may also be caused by heavy alcohol consumption.

Prof. N.N. Gupta was a wonderful clinician and even his bed side teachings were something we all looked forward to. He would make his residents demonstrate clinical signs like shifting dullness, systolic murmur, Adson's Test and we were expected to try the same tests during our evening ward teachings. Those were the days when we learnt how precious our time was with the patient, and how important it was to respect him and thank him for his cooperation. Prof. N.N. Gupta always greeted every patient and never failed to hold his hands, even when he was talking to us. He would invariably thank them before leaving their bedside. Every patient felt like a V.I.P and profusely praised him and his team. This was his way of stamping brand KGMC in our minds and hearts.