the diabetic foot

The diabetic foot including diabetic neuropathy and peripheral vascular disease can be a very serious problem. Appropriate diabetic foot care is one of the most overlooked aspects of the diabetic’s daily regimen. The feet along with the eyes, heart, and kidneys all have the potential for serious consequences in a disease that many do not take seriously and choose to ignore until it is too late to reverse the devastation that the disease can create.

As the disease relates to the foot, two major events occur as the disease progresses. Many diabetics eventually lose sensation in their feet. This is known as diabetic neuropathy. Neuropathy can also present itself as relentless burning, tingling or numbness in the feet. The problem with neuropathy is multifaceted. With lack of sensation on the bottom of the diabetic foot, diabetics are at more risk for stepping on something, such as a broken piece of glass in the kitchen, and not even knowing it. The area then can become infected and at that point if the patient’s blood sugars are not under control and the circulation to the area is compromised, the body is unable to heal the infection and in many cases this scenario can lead to amputation. In fact, diabetes is the major factor in over 50 percent of amputations performed in the United States each year.

Another problem with neuropathy can be the relentless feeling of burning, tingling or numbness that is not alleviated by anything the diabetic does. It is the equivalent of tinnitus or constant ringing in the ears. Diabetic neuropathy usually occurs in both feet; neuropathic symptoms in only one foot is usually suggestive of a cause other than diabetes.

There are various prescription medications on the market for diabetic neuropathy all with varying degrees of success. Right now, Lyrica is probably the most popularly prescribed medication for diabetic neuropathy.

Recently, research has centered around a nutritional supplement which has been shown to be helpful in treating the pain of neuropathy without offering any of the side effects of prescription medication. Below is a blurb that appeared in the February 2007 issue of LifeExtension Magazine.

A further deterioration of the diabetic foot as a result of diabetic neuropathy is known as a Charcot foot. This basically is breakdown of the feet due to an inability of the patient feeling the ground that he or she walks on. For example, non diabetics walking on bumpy terrain will “feel” the uneven pressure on their feet and adjust their gait in order to compensate. A diabetic foot with diabetic neuropathy, on the other hand, will not be able to “perceive” the uneven terrain and instead the foot will experience abnormal pressure in certain areas. This abnormal stress to the feet eventually causes the joints of the feet to breakdown. This in turn creates an abnormal functioning foot and because of the change in architecture of the foot, creates abnormal bony pressure points against the ground and certain parts of the patient’s shoes. This abnormal pressure can lead to tissue breakdown and eventually ulceration.

Below is a picture of a diabetic foot ulcer

Because a diabetic foot ulcer is an “opening” in the skin, the diabetic foot is much more susceptible to infection, either infection in the soft tissue or because of the close proximity to the underlying bone, an infection directly into the bone. Bone infections are much more difficult to treat than soft tissue infections, many times requiring surgical intervention to remove the diseased portion of bone. Once the foot architecture has been changed due to surgery it can become much more difficult for the patient to walk. Of even more dire consequence is the fact that a diabetic foot ulcer in the presence of very poor circulation may lead to gangrene (death of the surrounding tissue) and in these instances many patients go on to amputation.

The other diabetic foot related factor to the feet is peripheral vascular disease. Over time, diabetes causes the arteries going into the feet to essentially become clogged and in doing so reduces the blood flow into the feet. This creates various problems, the most common being the inability of the tissue of the feet to get adequate nutrition. The skin becomes dry, thin, scaly; we lose the fat on the bottom of the feet, the bones become demineralized. This then makes the foot more susceptible to infection and difficulty in walking.

Adequate blood flow is necessary to the feet in order to help heal wounds. If a person cuts themselves or steps on a broken piece of glass, we need adequate blood flow to the area to bring nutrients to repair the wound. In a diabetic, this can be a problem due to lack of circulation.

No diabetic should take their disease for granted and should be proactive in their approach to their diabetes. The closer a person’s blood sugars are kept to normal on a daily basis, the less damage the disease can do. This is more the case in adult onset diabetes (Type II). So, managing one’s blood sugars is job number one.

Additionally, as far as the feet go, a diabetic should also do the following: inspect their feet daily, both visually and by rubbing their hands along the bottom of their feet, feeling for anything that may not feel normal. Anything questionable should be brought to the attention of their foot specialist, immediately. For older individuals who do not bend very well, placing a mirror on the floor and lifting your foot over the mirror is a good way to visually inspect your feet.

The feet should be hydrated daily to keep the skin soft. For most people, a good hand cream will work fine. As previously stated, diabetics tend to have drier skin then the general population and thus the skin is more prone to breaking down.

Proper daily hygiene includes washing the feet well with soap and water, including in between the toes, then drying them very well. Application of a good hydrating lotion is recommended immediately afterward. This is especially important in the winter months when skin in general gets dry due to low humidity in the air. Diabetics are affected even worse by the dry air. If the skin, particularly the heels get to dry, they may be prone to cracking and fissuring which once again opens the door for infection.

One point worth mentioning is that many of my patients tell me they soak their feet regularly, many using epsom salt. Unless there is an open wound of some sort with drainage, you should never routinely use epsom salt as it does nothing but dry out the skin. There are many good foot soak products on the market which will hydrate rather than dry. Additionally, a diabetic should never soak their feet in hot water especially when the circulation is compromised. The hot water will cause the skin to breakdown. Tepid water is a much better choice.

Proper fitting shoes are very important. Diabetics should wear non constricting shoes, as shoes that are too tight will cause unnecessary pressure points on the feet which can breakdown. In an effort to avoid pressure points many patients will go out and buy larger shoes. There is a fallacy with that logic. Shoes that are too big will cause the feet to have excessive motion within the shoe which will also create friction and eventually breakdown of the skin. For those diabetics on Medicare, the program offers what is known as the "Diabetic shoe program". Assuming there is documented evidence that the feet have undergone some changes due to diabetes, the patient is eligible for one pair of shoes and three pair of inserts each year. Your foot specialist will fit you for shoes and order the proper supports for your particular foot type.

Along with a good pair of shoes the diabetic should also have a good pair of orthotics to support the feet. When there is neurological diminishment to the foot and the patient cannot really "feel" the ground the bony architecture of the foot will begin to breakdown. A Charcot foot is a foot that has undergone a bony breakdown which then makes the diabetic even more susceptible to ulceration. An orthotic, therefore, supports the foot and fights the forces causing the foot to breakdown. See the diabetic foot and orthotics. {see my recommended orthotic}

Lastly, diabetics should never perform what we call “bathroom” surgery. If there is something on the foot that is of concern, it should immediately be brought to the attention of a foot specialist.

Earlier this year the American Diabetes Association in their Standards of Medical Care in Diabetes 2006 came out with new foot care recommendations. Basically it is a proactive approach in assessing the vascular and neurological status of diabetic patients. In my office we have begun doing COMPREHENSIVE DIABETIC FOOT EXAMS. This is a painless examination, which will be done on a yearly basis. In this exam we do a noninvasive vascular study and a standard neurological exam. In addition we do a review of what diabetic patients should do and not do to their feet. The total exam takes about 45 minutes.

When the test is repeated next year and every year thereafter we will be able to determine if there has been any worsening in the vascular or neurological status. If so, we can then refer the patient out for further workup. The idea behind this is to find potential problems before they manifest themselves as ulcers, non-healing infections or gangrene because in many instances the first time we realize there is a vascular or neurological problem is when the diabetic patient presents to the office with a severe foot problem.

I recently attended a diabetes symposium at the world renowned Joslin Clinic. Below are two handouts from that lecture that you may printout and use. Just click them for an enlargement in .pdf format.

The first is entitled "My Diabetes Care Plan" which allows you to keep track of your diabetes medication, your daily blood sugars, blood work and medical exams you should have on a regular basis and information on when you should call your healthcare provider.











The second handout is entitled "Making Healthy Food Choices" which gives you helpful hints on the right food types and amounts of food a diabetic should be eating along with when you should eat.











Lastly, if you are a diabetic I would strongly recommend you read the following news report on diabetic amputations.

Diabetes Foot Care/If your feet are constantly cold, your legs are sore when you walk, or your feet hurt in bed at night, you may be suffering from poor blood circulation.

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