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Diabetic Foot Care
Why is foot care important for diabetics?
If you have diabetes, careful attention to the condition of your feet is an extremely important issue. Diabetes mellitus brings with it the risk of a number of significant medical problems for organs throughout the body, including the heart, eyes and kidneys. If you have diabetes, your feet are at substantial risk for several reasons.
- Neuropathy, or the impairment of nerves, can cause you to lose feeling in your feet, with the result that you may injure them without realizing it. A small injury - even a simple blister or minor cut or puncture - can become a serious problem in a short period, subject to infection.
- Impaired blood flow in your feet can slow down or even prevent healing of injuries.
- Your risk of developing an infection is increased significantly - an issue that can become life-threatening and could result in the need for amputation of the infected foot.
Diabetic foot problems can range in nature from ulcers (open sores that seem unable to heal) to Charcot foot, a condition in which the foot becomes warped in shape as the bones disintegrate and reknit.
For all these reasons, diligent foot care that prevents and detects foot injury is important, including attention to footwear, regular inspection and seeking prompt treatment from your healthcare providers.
The podiatrists of Connecticut Surgical Group have extensive experience in these problems, and are leaders in techniques of the care and treatment of diabetic feet.
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How common are diabetic foot problems?
Diabetes mellitus affects more than 15 million Americans, with more than 5 million unaware that they even have the disease.
It's estimated that foot problems affect as many as 70 percent of people with diabetes and that six percent of people with diabetic foot ulcers are hospitalized each year because of infections or other complications of diabetes. Each year more than 85,000 lower limbs are amputated because of complications from diabetes. In fact, diabetes is the leading cause in this country of lower limb amputations that are not necessitated by traumatic injury.
The good news is that by being diligent about inspecting and caring for your feet, many problems can be prevented, and significant medical assistance is available to you. Problems of neuropathy usually don't begin to develop until 10 years or more after diagnosis of diabetes, so monitoring from the beginning can be very beneficial.
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What causes diabetic foot problems?
In a real way, your feet are your connection to the world, and they are subject to great stress (you place 1½ times your weight on your feet when you just walk normally and it's estimated that the average person walks for approximately 1,000 miles each year).
Among the consequences of diabetes mellitus is neuropathy, or nerve damage that causes an inability to have feeling or sensation in a region of tissue. Another is vascular disease, in which narrowing and hardening of arteries result in inadequate circulation of blood to your extremities.
The loss of sensation in your feet, or neuropathy, exposes them to the development of serious injury without your even being aware of it. Neuropathy can cause paralysis of the small muscles in the feet, resulting in development of clawing in the toes - and both deformity of the metatarsal bones and development of corns and calluses that can lead to contamination and infection.
An "injury" can also start with a problem as seemingly minor as a blister from wearing an ill-fitting shoe or a tiny puncture wound or abrasion from walking barefoot on pavement.
Continuing to walk on an injury you can't feel and are unaware of can make it worse. And the impaired blood flow of vascular disease can seriously interfere with your body's ability to heal such a wound, or prevent it from healing altogether. At this point, the "minor" injury becomes a foot ulcer, an open sore that is difficult to heal.
A significant danger from such a wound is infection, which, in a blood-starved region of tissue, can be difficult to treat. An infection that grows in seriousness can place the preservation of the affected limb at risk and even be life-threatening. The American Podiatric Medical Association estimates that 14 to 24 percent of diabetics who develop a foot ulcer end up undergoing amputation of a lower limb. It's also estimated that 50 percent of diabetics who lose one foot to the disease will lose the other within five years.
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What is Charcot foot?
Charcot foot is a condition in which - as a consequence of nerve damage, the accompanying loss of sensation in the feet and continued walking on damaged feet - joints and bones in the feet experience microscopic trauma, fracture and fragmentation, leading to deformity (Jean Martin Charcot was a 19th century French physician who first described the problem).
Most Charcot foot patients had been experiencing nerve damage in their limbs for eight to 10 years before the Charcot problem develops. Initially, in a phase that can last as long as a year, Charcot foot involves fragmentation or destruction of joints and surrounding bones (accompanied by heat and significant, often painless swelling), leading to deformity of the affected foot as the bones shift. The results can be very flat feet that are wider at the arch where they should be narrower and boney prominences on the bottom surfaces of the foot.
In a second phase, the destruction diminishes and the affected bones begin to heal. Often, however, they heal in a deformed condition that can leave the foot unstable and difficult to fit. Prescription footwear and orthotics (inserts worn inside the shoes to correct imbalances) may be necessary to prevent development of foot ulcers.
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How are diabetic foot problems diagnosed?
Diabetes is a systemic disease that affects organs throughout your body, and it involves clinicians in many specialties of medicine. You'll most likely find out you have diabetes from an endocrinologist or diabetes specialist, very probably working in conjunction with your primary care physician.
Your podiatrist works closely with your other caregivers to help you manage your disease. The real issue isn't how your foot problem is diagnosed - it's that as soon as you are diagnosed with diabetes you should establish a relationship with your podiatrist so that he or she can monitor your foot health and intervene before any problems become serious issues.
Usually, neuropathy doesn't begin developing in diabetics for some 10 years of more after diagnosis of diabetes.
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What are the foot problems that I should be concerned about?
Tingling, pain or loss of feeling in the feet can all indicate developing foot problems caused by nerve damage related to your diabetes.
Stiff joints, calluses on the bottoms of your feet and corns on the sides, a history of open sores, and deformities such as hammertoes also represent foot problems, although these also can be caused by problems unrelated to diabetes.
Dry skin can become a problem, as the nerves that control oil and moisture in your feet cease to function. The resulting dryness can cause your skin to peel and crack - opening the risk of ulceration and infection.
The first sign to be concerned about is a diagnosis of diabetes, and the issue is that if you have such a diagnosis you should pay attention to their condition and maintain contact with a podiatrist so that any potential problems can be monitored and dealt with.
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How are foot ulcers treated?
The earlier a foot wound or injury such as a puncture can be treated, the better. For this reason, you should call your podiatrist as soon as you experience a cut, corn, callus or ingrown toenail so that you can receive timely treatment before a small problem becomes a big one.
Keeping in mind that since the underlying danger of untreated wounds is the risk of infection, it's essential that you have every ulcer monitored and treated. Your podiatrist may find it necessary or desirable to:
- Debride, or clean out, dead or infected tissue
- Apply medication and dressings to the ulcer
- Prescribe antibiotics to fight any infection that is identified
- Seek to take pressure off the ulcerous area by fitting you with a cast or special shoe to protect it while it heals or have you use a wheelchair or crutches
- Use a total contact cast that is molded very carefully to the bottom of the foot in order to spread weight and relieve pressure on the area of ulceration
If conventional dressings are used, you will likely be called on to clean the wound and change the bandage every day (total contact casts must be changed by trained personnel at regular, short intervals). You'll also be asked to pay close attention to your blood glucose levels, since they can affect the rate of healing. If it is determined that impaired circulation is an issue in your ability to heal, a referral to a vascular surgeon may be deemed appropriate.
In some cases, podiatric surgery may be necessary to correct bone and joint deformities that have developed, such as boney prominences on the bottom of the foot, bunions and hammertoes. The podiatrists of Connecticut Surgical Group have extensive experience in surgical management of diabetic feet.
And in the long run you may be fitted with special shoes, or with an orthotic - an insert worn inside the shoe - to correct the mechanical movement problems that led to development of the foot ulcer.
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How is Charcot foot treated?
As noted, Charcot foot develops in three stages - a period of six months to a year in which bones and joints fragment or disintegrate, a coalescence stage in which the body begins to heal, and a reconstruction stage.
Diagnosis usually is made during the first stage, and at this point treatment is focused on reducing heat and swelling and stabilizing the foot as a means of limiting deformity. A total contact cast - much more generously padded and more carefully molded to the contours of the foot than a conventional cast - may be used until the swelling and heat are reduced. Initially, this cast will have to be replaced at regular, short intervals. You may be asked to keep your weight off the foot through the use of a walker or crutches.
As the condition moves from the fragmentation stage to the coalescence stage, orthotics and braces can be developed.
For patients whose resulting deformities cannot be corrected with shoes, braces or orthotics, surgery to correct the abnormalities may be required. This is an area in which the podiatrists of the Connecticut Surgical Group have significant expertise. For some problems that remain intractable, amputation and use of a prosthetic may be considered as a possibility.
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How can I prevent foot problems from developing - or redeveloping?
If you have diabetes and especially loss of sensation in your feet, pay attention to these guidelines to keep your feet as healthy as possible:
- Wash them every day with mild soap and warm water and dry them carefully with a soft towel. Pay attention to drying between the toes. Talcum powder can help eliminate moisture.
- If your skin is dry, apply a skin cream to moisturize them and prevent cracking and peeling - and a risk of infection. Avoid putting cream between your toes, however - it increases the risk of infection there.
- Examine your feet every day for cuts, cracks, swelling, spots, blisters, redness, signs of developing corns or calluses or other abnormalities. If you can't see the bottoms of your feet, have someone assist you. This is especially important if you have diminished sensation in your feet, as you may not be able to feel a cut or other problem.
- Don't smoke. Smoking impairs your blood circulation and interferes with healing of wounds.
- Never walk barefoot and never wear sandals or thongs. The risk of injury to your feet is too strong.
- Don't try to shave or file down corns or calluses yourself. This should be done by your doctor or someone who works with your doctor.
- Cut your toenails straight across, without trying to round off the corners (use an emery board for them). If you have trouble cutting your toenails, have someone else help you with it. Have any ingrown toenails dealt with by your podiatrist.
- Don't use any antiseptic solutions, corn or callus removers or adhesive materials on your feet.
- Wear comfortable shoes that fit your feet well, and socks that cushion your feet. Check inside your shoes for pebbles or other objects before putting them on, and make sure your socks don't have seams that will rub against your feet.
- Avoid tight socks, stockings, garters and other apparel that may cut circulation or rub against your skin.
- Exercise regularly, since this improves circulation (and therefore healing). However, don't exercise if you have open sores on your feet.
- Make certain your shoes fit comfortably by comparing outlines of your feet and of your shoes.
- Ask your doctor about a possible need for orthotics or prescription shoes.
- Protect your feet from heat and cold, whether at the beach or on pavement, or in snow and slush. Don't use hot water bottles, heating pads of electric blankets.
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For additional information
You can find additional information about diabetic foot problems at web sites sponsored by government agencies, professional societies and healthcare institutions. It should perhaps be noted that the World Wide Web is open to many sources posting questionable information and promises, and you are encouraged to seek information from established, reputable organizations.
Likely sources include:
The American College of Foot and Ankle Surgeons
(www.acfas.org)
The American Diabetes Association
(www.diabetes.org)
The American Podiatric Medical Association
(www.apma.org)
The American Orthopaedic Foot and Ankle Society
(www.aofas.org)
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