Covington Foot and Ankle Clinic: Diabetes

DIABETES AND YOUR FEET

Currently, there are 21 million people with diabetes in America and the number grows by 500,000 annually. A person develops diabetes when their body is unable to maintain a normal level of sugar (glucose) in their blood.

Diabetes is a multi-system disease. It is the presence of elevated glucose in the body over a period of years that results in damage to the eyes, kidneys, heart, blood vessels, nerves, and feet. In the lower extremity, the most common effects of diabetes are peripheral neuropathy and early hardening of the arteries in the legs.

PERIPHERAL NEUROPATHY

Peripheral neuropathy is a reduced sensation that starts in the toes and can progress up the feet and legs. It can range from tingling and numbness in the toes, feet, or legs that is worse at night or sitting to severe aching burning pain to complete lack of sensation in the feet and legs. This is the most problematic consequence of diabetes on the feet. Without normal sensation, we lose an important warning sign that something is wrong, i.e. pain. As a result, a bony prominence on the foot rubbing on the ground or an ill-fitting shoe can create a pressure spot that is not felt. As pressure on the area continues, a blister develops which can turn into a callus and with continued pressure, can turn into an ulcer (a break in the skin). Skin is our first barrier to the environment, preventing bacteria, fungus, and other microorganisms from getting in. If there is a break in this barrier, these microorganisms can get into our bodies and cause infections in the skin, soft tissue structures, and bone. Ulcers develop over areas of pressure. Common areas in the feet that develop ulcers are the tips of the toes, over the top of a hammertoe, over a bunion, and on the ball of the foot. Poorly fitting shoes are responsible for up to 50% of the problems that lead to amputations. Diabetics who spend a lot of time in bed can develop ulcers on the backs of their heels due prolonged pressure from the mattress on these areas. Heel ulcers are very difficult to heal.

ARTERIOSCLEROSIS

People with diabetes can also have accelerated hardening of the arteries, especially to the blood vessels around the knee. This can lead to intermittent claudication, which is pain in the legs with activity that is alleviated by rest. Reduced blood flow to the feet can delay or prevent healing of cuts or ulcers. Also, medications, including antibiotics, have a hard time getting beyond the level of blockage and are, therefore, less effective in treating lower extremity infections. The combination of peripheral neuropathy and arteriosclerosis in a patient with diabetes puts them in a very high-risk category. Foot ulcers can develop quickly and painlessly over areas of pressure and can be very difficult to heal. This can lead to complicated infections requiring hospitalization, intravenous antibiotics, arterial bypass surgery, and possible amputation. Diabetes is the leading cause of non-traumatic amputations in the lower extremity and numbers about 70,000 per year.

OTHER FOOT COMPLICATIONS

People with diabetes also have a propensity for dry skin. Normally, skin is an elastic tissue, but when it dries out it, becomes brittle and splits when stretched. These cracks in the skin, also called fissures, provide openings for microorganisms to get in which can cause infection.

Diabetes can also cause muscle weakness in the feet resulting in deformities in the toes such as bunions and hammertoes. Toe deformities cause pressure points that can lead to blisters, calluses, and ulcers as these areas rub on ill-fitting shoes or the ground.

Repetitive stress on the joints in the foot from walking combined with neuropathy can cause a breakdown in the joints in the foot called Charcot neuroarthropathy. This usually occurs in the middle of the foot and results in a red swollen foot that eventually becomes flatter and misshapen.

Diabetics can also have impairment in their immune system due to elevated levels of sugar in the blood. The cardinal signs of infection (redness, swelling, and warmth) are less obvious in these patients due to their reduced immune response. Therefore, infections are harder to diagnose as well as harder to treat.

The management of diabetic foot problems often requires a team approach. The podiatrist, primary care physician, vascular surgeon, infectious disease specialist, nutritionist, and pedorthist are often involved in diabetic management.

One of the most important components in the care of the diabetic patient is PREVENTION of foot complications. By following the diabetic foot care guidelines, we can help prevent these complications from occurring.

DIABETIC FOOT CARE GUIDELINES

Inspect your feet daily for redness, swelling, blisters, openings in the skin, or changes in the shape of your foot. If necessary, use a mirror to see the bottom of the feet and heels.
Have a family member inspect your feet if you are unable to do so.
Wash your feet daily and dry well between the toes to help prevent fungal and bacterial infections. Use a skin cream after showering to moisturize the skin, but do not apply it between the toes.
Do not soak your feet unless prescribed by your doctor.
Always wear well-fitting shoes and socks.
Both feet should be properly measured when buying shoes and the shoes should be comfortable at the time of purchase. Have your podiatrist check your new shoes before you start wearing them to make sure they fit correctly. Proper shoe gear is key to reducing pressure on the feet and thus reducing the chance of ulceration.
Ask your podiatrist about the Medicare diabetic shoe program. You may be eligible for depth shoes and insoles.
Inspect the inside of your shoes for foreign objects before you put them on.
Change shoes two to three times per day because each shoe has different pressure points.
If you have neuropathy, NEVER go barefoot and do not use hot water bottles or heating pads to warm your feet. Protect your feet from cold and hot exposure such as hot pavement or at the beach. Use your elbow to test the temperature of the water before bathing.
Do not use chemical corn removers.
Keep your blood sugars under good control by checking them regularly and taking your prescribed medications. Eat a well-balance diet, avoid smoking, and get regular exercise. Keeping your blood sugar under good control helps delay or prevent diabetes-related foot problems as well as eye, kidney, and heart disease.
Schedule regular foot examinations with your podiatrist and always remove both shoes and socks.
Call your podiatrist immediately if you detect a new sore or if your foot becomes swollen, red, or painful. Early detection and prompt treatment are critical to achieving the best possible outcome.

RESOURCES

American Diabetes Association
1-800-232-3472
www.diabetes.org
The Joslin Diabetes Center
www.joslin.org
American Podiatric Medical Association
1-800-FOOTCARE
www.apma.org

To make an appointment, call (253) 631-4960