Diabetes Amputation Prevention: What Your Doctor Isn't Telling You

About This Blog

In 1993, Hurricane Andrew took everything. A million-dollar podiatry practice in Miami, a house, and a swimming pool in the backyard. When the storm cleared, Dr. Mark Hinkes packed up and took a position at a VA hospital in Roanoke, Virginia. He walked into the waiting room on his first day and stopped cold. He had never seen so many people with one leg in one room in his life. He said to himself: Mark, you're in trouble.

In this episode of Fountain of Vitality, host LaMont Leavitt sits down with Dr. Mark Hinkes, a retired podiatrist with 42 years of clinical experience and former chair of the Preservation Amputation Care and Treatment (PACT) Program in the VA Medical System. Together they walk through how diabetic foot ulcers form, why most amputations don't have to happen, and what the healthcare system keeps getting wrong about diabetic foot care.

 How Ulcers Form 

People with chronically elevated blood sugar develop small vessel disease. The smallest blood vessels narrow and close off over time, cutting circulation to the brain, heart, kidneys, eyes, and feet. When they fail, the nerves that depend on them begin to malfunction in three distinct ways: sensory neuropathy, which means a person can no longer feel pressure or pain in their feet; motor neuropathy, which affects walking and can produce toe deformities; and autonomic neuropathy, which causes dry, cracked skin that becomes a direct portal of entry for infection.

The third ingredient is trauma, and it can come from almost anywhere. A tight shoe. A dropped ketchup bottle. Walking to the mailbox barefoot across hot asphalt. Over-the-counter corn removers containing salicylic acid, which Dr. Hinkes notes has no brains and eats through healthy skin just as efficiently as dead tissue. Even seeking warmth is a risk: patients with poor circulation often fall asleep against a heating pad and wake up with a thermal burn they never felt. Combine failed circulation, malfunctioning nerves, and any one of these triggers, and the result is a wound.

 The Sock Stain Scenario 

Too many people discover their ulcer the same way. They come home, take off a shoe, and see a stain at the bottom of their sock. They pull the sock off and find a hole in their foot. They didn't step on anything unusual. They felt no pain. They have no explanation. And now they are looking at a wound that, left untreated, can progress to infection, hospitalization, and amputation.

Dr. Hinkes calls this a nightmare, not a dream, because the general public doesn't associate a foot wound with a life-threatening event. But the numbers clarify the stakes fast. A foot ulcer happens somewhere on this planet every second. A lower extremity amputation is performed every 20 seconds. In the time it takes to watch a one-minute video, 60 new ulcers have formed and three limbs have been lost.

 The 85% Rule 

The leverage point in all of this is the ulcer itself. Eighty-five percent of all lower extremity amputations are preceded by a diabetic foot ulcer. That means preventing the ulcer interrupts the entire chain: the infection, the ER visit, the hospitalization, and in some cases, premature death. Dr. Hinkes is direct about the math. Almost 80% of the people who lose limbs to diabetes didn't have to. The tools to prevent it exist. They are just not being consistently applied.

Vascular consultation is among the most underused interventions. When an ulcer resists healing, what the body often needs is better blood supply to the wound site. Dr. Hinkes calls blood "red gold." If enough oxygenated blood can reach the wound, the body's natural healing process can do the rest. But instead of ordering a vascular evaluation, too many providers skip the workup and move directly to amputation. Dr. Hinkes uses a direct word for why: greed.

 Where the System Breaks Down 

There is one endocrinologist for every 5,000 adult patients with diabetes in the United States. By default, 90% of diabetic patients are managed by their primary care provider. Primary care providers, Dr. Hinkes is careful to note, include many excellent and dedicated people. But the structure works against them. A typical appointment runs 10 to 15 minutes. Foot exams fall below hypertension and cholesterol on the priority list. Training in diabetic foot health is limited. Referrals to podiatrists or certified diabetes educators don't happen nearly often enough.

The result is that patients leave appointments without having their feet examined. They aren't educated about the risk. They don't know that a sock stain signals danger. They don't know that attempting to trim their own toenails, which Dr. Hinkes calls it "bathroom surgery," can result in bone exposure when vision, grip strength, and sensation have already been compromised by years of elevated blood sugar.

 The Software He's Building 

During his time in Nashville, Dr. Hinkes ran a five-year research project combining the American Diabetes Association's protocols with the International Working Group on Diabetic Foot's risk framework. The results were striking: amputations down 40%, healthcare costs down 62%. He retired in 2019. After about a year of unwinding, he started asking a different question. He could help one patient at a time when they were sitting in his chair. But there are 500 million people on this planet living with diabetes. Another 500 million have prediabetes. Who is going to help them?

His answer is decision-support software designed for use in primary care offices, administered by a nurse or nurse practitioner without requiring direct physician involvement. It generates a report that assigns the patient an internationally recognized risk category, identifies their specific risk factors for developing a foot ulcer, and provides recommendations for next steps. The doctor reviews the report and directs care. The foot exam that wasn't happening now has a vehicle for getting done.

 Key Takeaways 

• Chronically elevated blood sugar leads to small vessel disease, which causes three types of neuropathy: sensory, motor, and autonomic

• Sensory neuropathy means people with diabetes cannot feel injuries to their feet as they occur

• Diabetic foot ulcers are triggered by mechanical, chemical, or thermal trauma in combination with poor circulation and nerve damage

• A foot ulcer happens somewhere on Earth every second; a lower extremity amputation is performed every 20 seconds

• 85% of all lower extremity amputations are preceded by a diabetic foot ulcer

• Almost 80% of amputations in people with diabetes could be prevented with proper evaluation and care

• Vascular consultation is widely underused and, when applied early, can prevent the majority of amputations

• 90% of people with diabetes are managed by primary care providers who often lack the time, training, or incentive to perform foot exams

• Patients with compromised vision and sensation who attempt to self-trim toenails face serious injury risk, including bone exposure

• Preventing the ulcer is the leverage point that breaks the chain leading to infection, hospitalization, and amputation

Healthy Feet for People with Diabetes by Dr. Mark Hinkes (available on Amazon).

Listen to Fountain of Vitality at FountainofVitality.com. If this episode changed the way you think about diabetes and foot health, share it with someone who needs to hear it. And if you've been enjoying the show, a review on your podcast platform helps more people find it.

Follow the Fountain of Vitality podcast: Website: FountainofVitality.com | Tiktok: @FountainofVitalitypod | YouTube: @FountainofVitalityshow | Tumblr: @FountainofVitality | Facebook: FountainofVitalityShow | Rumble: Fountain_of_Vitality
| Instagram: @FountainofVitalitypodcast | Email: contact@FountainofVitality.com

Follow LaMont Leavitt: LinkedIn: @LaMontJLeavitt/ | Twitter/X: @ljleavitt1 |
InnoviHealth Website: innoviHealth.com

Follow Dr. Mark Hinkes, DPM: LinkedIn: @MarkHinkesDPM | Email: drhinkes@gmail.com

Dr. Mark Hinkes, DPM, is a retired, board-certified podiatrist with 42 years of clinical experience. He served as Chief of Podiatry and chair of the Preservation Amputation Care and Treatment Program in the VA Medical System, where he reduced amputations by 40% and healthcare costs by 62%. Now retired, he consults, speaks, and is developing decision-support software to bring standardized diabetic foot risk assessment into primary care offices worldwide.