As a recognition of the high standard of research work and the contributions made by the Centre to Diabetology in general, the WHO has designated the Diabetes Research Centre to and M.V. Hospital for Diabetes as the WHO Collaborating Centre for Diabetes. It is the only WHO Collaborating Centre for Diabetes in India. The Centre, in addition to pursuing the research studies, will also undertake national and international training courses in public health.

News And Events



Photo (Left) Ms. Dipika Pallikal, National Squash Champion is inaugurating the Podiatry Clinic of the centre. Dr.Vijay Viswanathan, Managing Director of the centre (right) can be seen. Photo (Right) Dr.Vijay Viswanathan is explaining about the foot scan machine to Ms. Dipika Pallikal.

                    Photo (Left) Luminoscope Qualitative Analysis. Photo (Right) Ms. Dipika Pallikal is being briefed about the new footwear DIASTEP.

About new Podiatry Clinic at Mylapore

The new foot care (Podiatry) clinic at M. V. Centre for Diabetes, Mylapore, offers an expansion of foot care services provided by experts at Podiatry clinic at M. V. Hospital for Diabetes, Royapuram. This Foot care clinic is a regional center where patients can be treated for a variety of conditions, including in-growing toe nail, fungal infections of the toe, callus, while providing diagnostic tests such as foot pressure measurements, detection of sensory loss in the foot and many more. This new Foot Care centre clinic provides routine integrated care of the feet of diabetic patients. The services of the clinic include education of the patient in practical aspects of foot care, early recognition of feet at risk and treatment of various foot problems in people with diabetes. Special advice will also be provided for selection of right type-of-footwear.

Several studies have shown that the regular wear of therapeutic footwear, foot education, and diabetic foot care, prevents ulceration, reduces re-ulceration and amputation. Apart from these, Customized insoles are prescribed to offload high pressures from the metatarsal heads and from other areas, which helps in reducing the risk of plantar ulceration. Recently, The M.V. Hospital for Diabetes, Royapuram, introduced DIASTEP a customized foot wear and also the manufacture of therapeutic insoles at its podiatry centre in Royapuram.


  • Shabana Tharkar, Vijay Viswanathan – Chennai Slim & Fit Programme (Awareness & Perceptions related to obesity among urban children & adolescents – TAPI Journal Vol 2, Issue 1, January, April, 2010.
  • Shabana Tharkar, Kumpatla Satyavani, P.Muthukumaran, Vijay Viswanathan – High Prevalence of Metabolic Syndrome and Cardiovascular Risk among police personnel compared to general population in India – JAPI – Vol – 56- November-2008.
  • Vijay Viswanathan, J. Janifer Jasmine, C. Snehalatha, A. Ramachandran. Prevalence of pathogens in diabetic foot infection in south Indian type 2 diabetic patients – JAPI, Vol. 50, Aug. 2002, 1013 – 1016.
  • Vijay Viswanathan, Uma Mahesh, M Jayaraman, K Shina, A Ramachandran. Beneficial role of granulocyte colony stimulating factor in foot infection in diabetic patients. JAPI, Vol. 51, January 2003.
  • Vijay Viswanathan, Sanjeev V, Kelkar DK, Seena R, Mamtha B Nair, A Ramachandran. Validation of indigenously made biothesiometer. The Asian Journal of Diabetology, 2003; 5(3): 13 – 14.
  • Vijay Viswanathan, HR Badrinath, C. Snehalatha, R.M. Bhoopathy , B. Mamta Nair, R Seena, M.P. Varadha Rani, A Ramachandran. Effect of treatment with the combination of Alpha – lipoic acid, chromium and inositol on diabetic peripheral neuropathy. The Asian Journal and Diabetology, September 2003, Vol. 5 (9); Pg. 9 – 15.
  • Vijay Viswanathan, Seena R, Mamtha B Nair, Snehalatha C, Bhoopathy RM, Ramachandran A. Nerve conduction abnormalities in different stages of glucose intolerance. Neurology India, 2004; 52 (4): 466 – 469.
  • Vijay Viswanathan, N. Thomas, N Tandon, A Asirvatham, Seena Rajasekar, A Ramachandran, K Senthilvasan, V.S. Murugan, Muthulakshmi. Profile of diabetic foot complications and its associated complications – A multicentric study from India. JAPI 2005; 53: 933 – 936.
  • Vijay Viswanathan. Diabetic nephropathy in type 2 diabetes: the Indian experience. JAPI vol. 49; December 2001, 1185 – 1187.
  • Vijay Viswanathan, B Mamtha Nair. Diabetic Nephropathy: The medical catastrophe in type 2 diabetes. Endocrine news letter, vol 11, No. 3, 2001.
  • Vijay Viswanathan, C Snehalatha, K Shina, A Ramachandran. Persistent microalbuminuria in type 1 diabetic subjects in south India. JAPI 2002; 50: 1259 – 1261.
  • Vijay Viswanathan, C Snehalatha, MP Varadharani, B Mamtha Nair, M Jayaraman, A Ramachandran. Prevalence of albuminuria among vegetarian and non-vegetarian south Indian diabetic patients. Indian J Nephrol 2002; 12: 73 – 76.
  • Vijay Viswanathan. Diabetes could cost you your kidneys, act now!. JAPI November 2003, vol. 51, 1043 – 1044.
  • Vijay Viswanathan, C Snehalatha, B Mamtha Nair, A Ramachandran. Validation of a method to determine albumin excretion rate in type 2 diabetes mellitus. The Indian Journal of Nephrology 13; 2003: 85 – 88.
  • Vijay Viswanathan. Diabetes could cost you your kidneys, act now!. JAPI November 2003, vol. 51, 1043 – 1044.
  • Vijay Viswanathan, C Snehalatha, B Mamtha Nair, A Ramachandran. Validation of a method to determine albumin excretion rate in type 2 diabetes mellitus. The Indian Journal of Nephrology 13; 2003: 85 – 88.
  • Vijay Viswanathan, C Snehalatha, R Kumutha, B Mamtha Nair, A Ramachandran. Impact of joint national committee VII recommendations on diabetic microvascular complications. JAPI 2004; 52: 873 – 876.
  • Vijay Viswanathan, C Snehalatha, R Kumutha, Muthu Jayaraman, A Ramachandran. Serum albumin levels in different stages of type 2 diabetic nephropathy patients. Indian J Nephrol 2004; 14: 89 – 92.
  • Vijay Viswanathan. Prevention of diabetic nephropathy: A Diabetologist’s perspective. Indian J Nephrol 2004; 14: 157 – 162.
  • Vijay Viswanathan, C Snehalatha, Mamtha B Nair, A Ramachandran. Comparative assessment of cystatin C and creatinine for determining renal function. Indian J Nephrol 2005; 15: 91 – 94.
  • Vijay Viswanathan, Sheethal Suresh, Mamtha B Nair, Snehalatha C, Ramachandran A. Microalbuminruia: A Risk factor for abnormal pulse wave velocity. Indian J. Cardiol 2005; 8: 9 -12.
  • Vijay Viswanathan, Sivagami, Seena Rajasekar. Diabetic Foot: An Indian Scenario. The Asian Journal of Diabetology (special issue), Vol 7, No.3, Pg 9 – 11, 2005.
  • Vijay Viswanathan. Management of diabetes in chronic renal failure. Indian J Nephrol 2005; 15, Supplement1: S23 – S31.
  • Vijay Viswanathan, P.T. Chacko, M. Lavanya, Priyanka Tilak. A Proof of Concept, preliminary study to determine the effect of yogasnas in controlling type 2 diabetes mellitus in newly detected subjects (when compared to metformin monotherapy). JAPI 2006; 54: 965 – 966.
  • Vijay Viswanathan, M.Clementina, B.Mamtha Nair, K.Satyavani. Risk of future Diabetes is as high with abnormal intermediate post-glucose response as with impaired glucose tolerance ? JAPI, Vol. 55, 833-837, December, 2007.

List of international publications

  • Shabana Tharkar, Karunanithi Kathiresan, Pintochan Abraham, Vijay Viswanathan, Development & Evaluation of a training programme on Primary Prevention of Diabetes for Primary Care Physicians – IJHR December 2009; 2(4): 305-314.
  • Shabana Tharkar, Vijay Viswanathan – Impact of socioeconomic status on prevalence of overweight and obesity among children and adolescents in urban India – The Open Obesity Journal, 2009,1, 9-14.
    Shabana Tharkar, Kumpatla Satyavani, Vijay Viswanathan – Cost of Medical Care among type-2 diabetic patients with a co-morbid condition – Hypertension in India (ELSEVIER) Diabetes Research & Clinical Practice 83 (2009) 263-267.
  • Vijay V, Snehalatha C, Ramachandran A, Viswanathan M. Proteinuria in NIDDM in south India: analysis of predictive factors. Diabetes Research and Clinical Practice 1995; 28: 41 – 46.
  • Vijay V, Snehalatha C, Terin M, Ramachandran A. Does the presence of diabetic nephropathy in patients influence the metabolic response in the offspring? Diabetic Medicine 14: 854 – 857, 1997.
  • Vijay V, Snehalatha C, Terin M, Muthu J, Ramachandran A. Cardiovascular morbidity in proteinuric south Indian NIDDM patients. DRCP 39 (1998), 63 – 67.
  • Vijay V, Snehalatha C, Terin M, Muthu J, Ramachandran A. Serum sialic acid in south India type 2 diabetic patients with microvascular complication. Diabetic Medicine 1998; 15: 176.
  • Vijay v, Seena R, Lalitha S, Snehalatha C, Muthu J, Ramachandran A. Significance of Microalbuminuria at diagnosis of type 2 diabetes. Diabetes bulletin, International Journal of Diabetes in developing countries 1998; 18: 5 – 6.
  • Vijay V, Shina K, Lalitha S, Snehalatha C, Ramachandran A. Familial aggregation of diabetes kidney disease in south India. DRCP 1999; 43: 167 – 171.
  • Vijay Viswanathan. Type 2 diabetes and diabetic nephropathy in India – magnitude of the problem. Nephrol Dial Transplant (1999) 14: 2805 – 2807.
  • Vijay Viswanathan, Durga Prasad, Snehalatha C, A. Ramachandran. High prevalence and early onset of cardiac autonomic neuropathy among south Indian type 2 diabetic patients with nephropathy. DRCP 48 (2000); 211 – 216.
  • Vijay Viswanathan, Snehalatha C, Ramachandran A, Shina K. Evaluation of simple, random urine test for prospective analysis of proteinuria in type 2 diabetes six years follow up study. DRCP 49 (2000); 143 – 147.
  • Vijay Viswanathan, C Snehalatha, A Ramachandran. Diabetic nephropathy – strategy of management. Int. J. Diab. Dev. Countries 2000; 20.
  • Vijay Viswanathan, Yanqing Zhu, Karthik Bala, Stephen Dunn, C Snehalatha, A. Ramachandran, Muthu Jayaraman, Kumar Sharma. Association between ACE gene polymorphism and diabetic nephropathy in south Indian patients. JOP. J. Pancreas (Online) 2001; 2 (2): 83 – 87.
  • Vijay Viswanathan, C Snehalatha, R Suresh Mohan, B Mamtha Nair, A Ramachandran. Increased carotid intimal media thickness precedes albuminuria in south Indian type 2 diabetic subjects. The British Journal of Diabetes and vascular disease Vol 3, issue 2, March / April 2003, pg: 146 – 149.
  • Vijay Viswanatha, C Snehalatha, Mamtha B. Nair, A Ramachandra. Markers of endothelial dysfunction in hyperglycaemic Asian Indian subjects. Journal of Diabetes and its Complications 2004: 18 (1), 47 – 52.
  • B. Mamtha Nair, Vijay Viswanathan, C Snehalatha, R Suresh Mohan, A Ramachandran. Flow Mediated dilatation and carotid intimal media thickness in south Indian type 2 diabetic subjects. DRCP 2004; 25: 13 – 19.
  • Vijay Viswanathan, Mamtha B Nair, Sheethal Suresh, Snehalatha C, Ramachandran A. An inexpensive method to diagnose incipient diabetic nephropathy in developing countries. Diabetes Care 2005; 28: 1259 – 1260.
  • Vijay Viswanathan, C Snehalatha, Mamtha B Nair, R Kumutha, A Ramachandran. Levels of transforming growth factor beta 1 in south Indian type 2 diabetic subjects. Diabetes Metab Res Rev 2005; 21: 276 – 280.
  • Vijay V, Snehalatha C, Terin M, Ramachandran A. Socio – cultural practices that may affect the development of the diabetic foot. IDF Bulletin 1997: 42 ; 10 -12.
  • Vijay V, Seena R, Lalitha S, Snehalatha C, Ramachandran A. A simple device for foot pressure measurement: Evaluation in south Indian NIDDM subjects. Diabetes care 1998: 21; 1205 – 6.
  • Vijay Viswanathan, D.V.L. Narasimhan, R. Seena, C. Snehalatha and A. Ramachandran. Clinical profile of diabetic foot infection in south India – a restropective study. Diabetic Medicine 17 (5): 2000; 215 – 218.
  • Vijay V, Snehalatha C, Seena R, Ramachandran A. The Rydel Seiffer tuning fork: an inexpensive device for screening diabetic patients with high – risk foot – Practical Diabetes Int. 2001: 18 (5); 155 – 156.
  • Vijay Viswanathan, Seena Rajasekar, C. Snehalatha, A. Ramachandran. Routine foot examination: the first step towards prevention of diabetic foot amputation. Pract Diab Int June 2001. Vol 17, No.4.
  • Vijay Viswanathan, C. Snehalatha, M. Sivagami, R Seena, A. Ramachandran. Association of limited joint mobility and high plantar pressure in diabetic foot ulceration in Asian Indians. Diabetes research and clinical practice, April 2003; 60 (1), pg 57 – 61.
  • S. Morbach, J.K. Lutalet, Vijay Viswanathan, J. Mollenberg, H.R. Ochs, Seena Rajasekar, A. Ramachandran, Z.G. Abbas. Regional differences in risk factors and clinical presentation of diabetic foot lesions. Diabetic medicine 2003; 21: 91 – 95.
  • Vijay Viswanathan, Sivagami M, Saraswathy G, Gautham G, Das B N, Seena R, Ramachandran A. Effectiveness of different types of footwear insoles for the diabetic neuropathic foot. Diabetes care 2004; 27: 474 – 477.
  • Vijay Viswanathan, M. Sivagami, R Seena, C. Snehalatha, A Ramachandran and A Veves. Increased forefoot to rearfoot plantar pressure ratio in south Indian patients with diabetic foot ulceration. Diabetic medicine 2004; 21: 396 – 397.
  • Vijay Viswanathan, Sivagami M, Seena R, Snehalatha C, Ramachandran A. Amputation prevention initiative in south India : Positive impact of foot care education. Diabetes care 2005; 28: 1019 – 1021.
  • Vijay Viswanathan, Sivagami Madhavan, Seena Rajasekar, Snehalatha Chamukuttan, Ambady Ramachandran. Urban – Rural differences in the prevalence of foot complications in south Indian diabetic patients. Diabetes care 2006; 29: 701 – 703.
  • Vijay Viswanathan, Sharad Pendsey, N. Sekar, G.S.R Murthy. A phase III study to evaluate the safety and efficacy of recombinant human epidermal growth factor (REGEN – DTM 150) in healing diabetic foot ulcers. Wounds 2006; 18 (7): 186 – 196.
  • Vijay Viswanathan. The Diabetic Foot. International Journal of Lower Extermity Wounds, 2007; 6 : 34 – 36.


Patients with various diabetic complications are referred to our centre . Our centre is one of the largest diabetic centres in Asia. The foot care department of our centre is actively involved in the treatment and research of diagnostic foot problems. The services and facilities available are given in the following paragraphs.


The Diabetic Foot Clinic of M.V.Hospital for Diabetes, Royapuram called M.V.Centre for Diabetic Foot Care, Podiatry, Research and Management, provides routine integrated examination for diabetic patients. The services of the clinic include education of the patient in practical aspects of foot care, the early recognition of foot at risk, special advice on selection of footwear, and providing a comprehensive care for all diabetic foot complications
Staffing Pattern


The clinic has the required facilities and staff to provide the following services.

(a) Education of Patients & Carers,

(b) Timely detection of high risk foot through routine foot examination by specially trained staff capable of recognizing risk factors for ulceration and amputation,

(c) Measures to reduce risk, including Chiropody, appropriate footwear and vascular and orthopedic interventions,

(d) Prompt and effective treatment of active problems, including ulcers, infection and ischemia.

Scope and Activities

The Clinic emphasizes that most of the complications are preventable with adequate education, routine foot care and attention to footwear, early detection followed by specific advice and treatment. The services offered by the Clinic provide the best opportunity to prevent complications resulting in amputations. The Foot Clinic includes the following modern units with state of the art facilities.

1. Foot Laboratory

Foot Laboratory provides the following services.

(i) Doppler Studies – These non-invasive vascular tests can be used for:
(a) diagnosis and quantification of PVD (Peripheral Vascular Disease)
(b) predicting wound healing of a diabetic foot ulcer
(c) follow-up and control of treatment
(d) Colour Doppler (Duplex) scan to study the extent and severity of PVD and to aid the vascular surgeon to decide about management.

(ii) Biothesiometry Test (BT Test):
This study is done using a small electronic instrument to determine vibration perception. These tests have been shown to be a good indicator of diabetic neuropathy.


(iii) Monofilament Test:
10g monofilament is used for this test. Inability to perceive the 10g monofilament at the toes or dorsum of the foot predicts future occurrence of a diabetic foot ulcer.


This branded off the shelf footwear is the research product of M.V.Hospital for Diabetes and the Central Leather Research Institute, Chennai, supported by Novo Nordisk Educational Foundation. It is specially designed for diabetic patients who have neuropathy, minor foot deformation and have developed minor foot complications earlier.

Its special features are:

  • PU sole with extra depth for more effective pressure distribution
  • The extra depth sole has a special tread for better grip and traction
  • Specially designed insole bed and foam layer for added comfort
  • Rigid counter to ensure limited joint mobility
  • Specially designed upper with leather lining for comfortable wear
  • Adjustable Velcro fasteners to take care fluctuations in foot volume

Apart from these features, a specially derived angle of slant has been provided in the sole to give the “rocker” effect which is used to offload pressure from planter surface of the feet.

All these features incorporated after considerable research and after testing on people with Diabetes Mellitus at MV Hospital for Diabetes, Royapuram, Chennai make DIASTEPTM footwear an essential item for people with diabetes. Constant wear of this footwear will prevent foot ulcers and foot infection.

(iv) Nerve Conduction Studies:
Slowing of Nerve Conduction Velocity is one of the earliest neuropathic abnormalities in Diabetes Mellitus. Early diagnosis of Diabetic Peripheral Neuropathy is necessary to prevent fissure formation, infection and ulceration of the feet. In recent years, a number of Electro Physiological testing methods have been developed for early detection and diagnosis of Diabetic Neuropathies. These tests quantify nerve conduction and help to localize the lesions. These studies are carried out by this department.

(v) Tip Therm:
This instrument determines the thermal perception in the nerve endings, measuring warm and cold perception separately. This quantitative measurement helps an early diagnosis and staging of neuropathy.

2. Foot Care Education

All patients with foot complications are educated by the Foot Care Educator regarding:

(a) General principles of Foot Care like nail cutting, cleanliness of the foot, fungal infection between the toes and the heel fissures.

(b) Knowledge about the right type of footwear and also the importance of wearing them. Patients are also provided with books and pamphlets.

3. Pedicure Unit

Plantar aspect of the foot is examined by the Pedicurist for the presence of potential foot problems like heel fissures, in-growing toe nails, callus, dry skin, etc. Foot cleaning is taught along with nail filing.

4. In-house Footwear manufacturing unit

Proper footwear is one of the most important aspects of preventive foot care. New types of footwear are now being prepared at M.V. Hospital, Royapuram with technical assistance from Central Leather Research Institute, (CLRI) Chennai, for diabetic patients with foot complications. Patients in risk category 0,1 (low risk) are provided comfortable footwear made of good insole materials. These patterns are more attractive & acceptable to the patients, than the conventional MCR footwear. Patients in risk category 2, 3 (high risk) are given custom-made footwear. Those patients with previous ulceration, foot deformity are given custom made footwear with moulded insole.

New Equipment To Prepare Customised Insoles

Electronic Baropedometer

Foot ulceration in persons with diabetes is the frequent causes for amputation. Several studies have shown that the regular wear of therapeutic footwear, foot education, and diabetic foot care, prevents ulceration, reduces re-ulceration and amputation. Apart from these, Customized insoles are prescribed to offload high pressures from the metatarsal heads and from other areas, which helps in reducing the risk of plantar ulceration. The M.V. Hospital for Diabetes has introduced a new equipment, the ELECTRONIC BAROPEDOMETER to prepare customized therapeutic insoles.

Electronic podometer is used to evaluate in an accurate way the following parameters

Examination in standing position
  • Pressure distribution in orthostatic condition
  • Stabilometry of the patient in static position
  • Dynamic evolution of the pressure during the dynamic phase of step
  • Peaks of pressures and time of contact on the ground
  • Individualization of areas at risk for the foot
  • Comparison of the results of therapies adopted in time
  • Helps in the design of plantar orthesis.

Different steps in preparing customized insoles

  • Identify the pathology
  • Select treatment
  • Make a customized insoles
Luminoscope – Qualitative Analysis
Electronic platform or podoscope (footwork)-for static and dynamic analysis
Moulding Procedure
Samples of Modular insoles
A fully prepared customized insole

5. Surgical Care

A dedicated team of, general, podiatry, vascular, plastic and orthopedic surgeons provide surgical care for patients requiring operative care of their diabetic foot infection. Patients referred to our hospital are given prompt surgical care and measures are taken to ensure limb salvage to the extent possible.


The dont’s

  • Avoid walking bare-foot even inside the house.
  • Do not wear ill fitting shoes or open tight shoes particularly sandals with tongs between the toes.
    Don’t wear wet foot wear , it can be a source of infection like athletes foot.
  • Do not remove corns and callus by yourself. These tasks are better left to foot specialists to prevent accidental cuts.
  • Do not apply plasters, or corn remover or any type of adhesive tape.
  • Don’t apply cream or ointment between the toes. Dust a non-medicated powder between the toes after washing and drying.
  • Do not use hot water bottle or heating pads on your feet.
  • Avoid smoking . Smoking reduces the blood circulation to the legs leading to the loss of limb.
  • Never use scissors, blade , nail cutter or knife to cut the nails. Use of nail filer is safer.
  • Toe nails should not be cut too short, and the toe nail angles should not go deep in to the nail bed.


The do’s

  • Examine your feet daily for injury blisters , cracks , scratches , scaling and discolouration. Pay particular attention to the areas between the toes.
  • To avoid fissures in the heel soak your feet in warm water for 10mts. Test the water temperature with your elbow. Gently rub the hard areas with a pumice stone . Later wash both the feet with a mild soap. After completely drying apply a lubricating cream around the heels.
  • Avoid extremes of temperature whether hot or cold. Protect your feet from hot objects. (e.g. hot pavement in summer, silencer of motor bikes.)
  • If your feet get cold at night wear a pair of cotton or woolen socks. Ear properly fitting 100% cotton socks. Always wear leather shoes which are comfortable.
  • Check shoes and socks for any foreign objects daily and check your feet after you take them off at the
    end of the day.
  • While seated avoid crossing your legs, as this can cause pressure on the nerves and blood vessels.
  • Inform your doctor about any change in skin colour, pain or any abnormal sensation such as tingling, burning, pricking sensation.
  • Proper control of diabetes will reduce the risk of foot complication. Follow your doctor’s prescription.


This often triggers the train of events that lead to the diabetic foot. The trauma may be sufficiently mild to escape notice and may be of various types :

  • The use of chemical agents, e.g., strong antiseptic agents.
  • Thermal burns e.g. from hot soaks.
  • Damage by mechanical means , e.g., due to pressure from tight shoes, and / or friction through torn socks.
  • Cuts from pedicures, punctures from nails, prickles, etc. (This is particularly dangerous as it rapidly gives rise to deep sepsis and gangrene).


Fungal infection, when present , is invariably between the clefts or on the undersurface of the toes. This type of infection produces relatively slight discomfort , but its real importance lies in the fact that it paves the way for the entry of bacteria into the foot. More commonly, however, bacterial entry is via a traumatic lesion. The result of bacterial invasion into a foot already at risk by disease of both nerves and blood vessels, is usually severe.



Sensory peripheral neuropathy is present in at least 45% – 88% of people with diabetic foot. It may be symptomless or may produce symptoms which are so mild or vague that they are ignored. Sometimes a burning pain, often worse at night , may be present in the limb and this may lead to incorrect diagnosis and inappropriate local treatment.
Autonomic peripheral neuropathy can be likewise relatively symptomless. The foot is warm , and the pulse is easily felt , and the veins are easily distended in the lying position .

The interaction of PVD and peripheral neuroparthy entities coupled with negligence produce a variety of foot conditions , such as corns, calluses, ingrown toenails, skin lesions, foot ulcers and gangrene. Most foot infections leading to amputation can be traced to neglect or mismanagement of corns and calluses. Neuropathy of the diabetic foot is manifested by burning tingling , pins and needle sensation. Hammer toes and bunions are prone to ulceration from the shoe pressure. The calluses at the bottom of the foot are subject to constant shearing stress from improper shoe inserts and will eventually ulcerate . These ulcers are very frequently infected. The infection destroys tissue and clogs up the small blood vessels of the foot leading to gangrene and amputation. Blood vessel disease of a diabetic lower extremity involves most frequently the large arteries below the knee. In this process of blood vessel disease coupled with neuropathy danger of losing the leg is very high. In addition , cigarette smoking can lead to nerve damage and reduce blood flow to the feet.