Diabetic Foot Problems and Treatments
Foot problems are a leading cause of hospitalization for the twenty nine million people in the United States who have diabetes mellitus. Medical costs related to diabetic foot problems total hundreds of millions of dollars annually. It is estimated that 15% of all diabetics will develop a serious foot condition at some time in their lives and twenty percent of all hospital admission for people with diabetes are for a foot related complication.
Common problems include infection, ulceration, or gangrene that may lead to amputation of a toe, foot or leg. Most of these problems are preventable through proper care and regular visits to your Podiatrist. His office can provide information on foot inspection and foot care, proper footwear and early recognition and treatment of foot conditions.
Causes: Foot problems in people with diabetes are usually the result of a combination of three primary factors: neuropathy, poor circulation, and decreased resistance to infection. Also, foot deformities and trauma play major roles in causing ulcerations and infections in the presence of neuropathy and poor circulation.
Neuropathy (Nerve Damage): Ironically, neuropathy can be both painless and painful. Painless neuropathy is more common and often occurs without notice and causes your ability to feel sensations, pain or minor injury to be diminished or absent. With this, simple injuries can go unnoticed and untreated for a period of time, resulting in infection and worsening of the problem. The painful type of neuropathy may cause burning or sharp pains in feet and interfere with your sleep. The painful neuropathy may occur in combination with a loss of sensation. In addition to affecting sensation, neuropathy can also affect the nerves that control the muscles in your feet and legs. This “motor” or “muscle” neuropathy can cause muscle weakness or loss of muscle strength in the legs, and feet, leading to the development of hammertoes, bunions, and other foot deformities. In addition, neuropathy can affect your balance and result in an increase risk of falling.
Poor Circulation: Patients with diabetes often have a circulation disorder called peripheral arterial disease or PAD. Symptpoms of PAD can range from no symptoms at all to cramping in the calf or buttocks when walking. These symptoms can progress to severe cramping or pain at rest, with associated color and temperature changes (the feet may turn bright red or blue when hanging down and constantly feel cold). Also, the skin may become shiny, thinned and easily damaged. A reduction in hair growth and a thickening of the toenails might also be present. Poor circulation, resulting in reduced blood flow to the feet, restricts delivery of oxygen and nutrients that are required for normal maintenance and repair. Healing of foot injuries, cuts, scrapes, infection or ulcerations may be delayed or impaired by this reduction in circulation. In these cases peripheral arterial bypass operations may be needed to avoid an amputation.
Infection: Patients with diabetes are generally more prone to infections than those without diabetes. Due to deficiencies in the ability of white blood cells to defend against invading bacteria, diabetics have more difficulty in dealing with and mounting an immune response to the infection. Infections often worsen and may go undetected, especially in the presence of diabetic neuropathy or peripheral arterial disease. Often, the only sign of a developing infection is unexplained high blood sugar, even without fever. The combination of fever and high blood sugar often warns of a severe infection requiring hospitalization. Lesser degrees of infection are often treated on an outpatient basis, however serious or more complicated infections will require hospitalization.
Foot Deformities: Foot deformities such as hammertoes, bunions, and metatarsal disorders have special significance in the diabetic population. Neuropathy places the foot at increased risk for developing corns, calluses, blisters and ulcerations. If these are left untreated, serious infections may result. A particular deformity can occur in persons with neuropathy and good circulation, called Charcot joint. A Charcot joint, resulting from trauma to the foot with reduced sensation from neuropathy, causes the foot and arch to collapse and widen. This destructive condition is often first noted with persistent swelling and redness, mild to moderate aching, and an inability to fit into your usual shoes. If this occurs, it is important to stay off the foot and see your Podiatrist immediately.
Ulcers of the Foot: An ulceration or ulcer is usually a painless sore at the bottom of the foot or top of the toes, resulting from excessive pressure at that site. Ulcers frequently underlie a corn or callus that was allowed to build up too thick. Trauma from heat, cold, shoe pressure, or penetration by a sharp object are also potential causes. Neuropathy allows the lesions to develop because the normal warning sense of pain has been lost and these problems go unrecognized. Continued pressure or walking on the injured skin creates even further damage and the ulcer will worsen. The open sore will frequently become infected and may even penetrate to bone.
Treatment relies on early recognition of the ulceration, avoidance of weight bearing activities such as walking, avoidance of wearing “closed-in” shoes, and early intervention. Besides local wound care, dressings and antibiotics, other measures may be necessary to adequately relieve pressure on the area. When use of crutches, a wheelchair, or rest is not feasible, fiberglass casts, specialized boots, braces, healing sandals, or orthoses (special shoe inserts) can be used to protect the foot while it heals. If circulation is inadequate to allow healing, you may be referred to a vascular surgeon for appropriate evaluation and possible vascular surgery. Once an ulcer has healed, it is important to continue to see your Podiatrist regularly. Special footwear and inserts may be recommended to protect your feet and prevent new or recurrent lesions from developing.
Foot Surgery in the Diabetic Patient: Realizing the potential danger of foot deformities in the diabetic patient, corrective foot surgery is an option when you are in good health, maintain proper blood glucose and have appropriate circulation. Most foot deformities worsen over time as do the effects of neuropathy and vascular or circulatory disease. When foot deformities cannot be managed effectively with conservative care such as shoe modification, surgery may be indicated. Podiatric surgery is often “same day” surgery under local anesthesia to minimize potential complications. In some cases, such as in the presence of an active ulceration, hospitalization may be necessary to properly monitor your postoperative progress. Surgery may also be required to heal an ulceration or to treat an infection, especially if the infection involves bone. Your cooperation is an important part of your care. You must guard against injury and provide the daily care necessary to maintain the health of your feet.
Footwear Guidelines: Shoes must always fit comfortably and have adequate width and depth for the toes. Leather shoes easily adapt to the shape of your feet and allow them to “breathe.” Athletic shoes, jogging shoes and sneakers are usually excellent choices if they are well fitted and provide adequate cushioning. Your Podiatrist may recommend “extra depth” shoes or custom molded shoes to adapt to your particular needs, or diabetic orthotics to provide cushioning and support. Always check your shoes for foreign objects or torn linings before putting them on. You should wear two or three different pairs of shoes each day so that one pair is not worn for more than four to six hours. New shoes should be worn for only a few hours at a time and you should take care to inspect your feet for any points of irritation. Socks should be well fitted without seams or folds. They should not be so tight as to interfere with circulation. Well-padded socks can be very protective if there is an abundance of room in your shoes. Avoid wearing open-toe shoes or sandals until you have discussed this with your Podiatrist. Above all else, do not walk with bare feet.Foot Care Guidelines
- Inspect your feet daily for blisters, bleeding or lesions between your toes.
- Use a mirror to see the bottom of your feet and heels.
- Do not soak your feet unless the temperature of the water is lukewarm, not as hot as you can stand it. (95°-100° Fahrenheit).
- Avoid temperature extremes – do not use heating pads on your feet.
- Wash your feet daily with warm, soapy water and dry them well, especially between the toes.
- Use a moisturizer daily, but avoid getting it between the toes.
- Do not use acids or chemical corn removers.
- Do not perform “bathroom surgery”
- Have a podiatrist evaluate your feet for future care needs.
- Contact your podiatric surgeon immediately if your foot becomes swollen or is painful, or if redness occurs.
- Do not smoke.
- Learn all you can about diabetes and how it can affect your feet.
- Have regular foot examinations