Diabetic Foot

• With damage to the nervous system, a person with diabetes may not be able to feel his or her feet properly. Normal sweat secretion and oil production that lubricates the skin of the foot is impaired. These factors together can lead to abnormal pressure on the skin, bones, and joints of the foot during walking and can lead to breakdown of the skin of the foot. Sores may develop.
• Damage to blood vessels and impairment of the immune system from diabetes make it difficult to heal these wounds. Bacterial infection of the skin, connective tissues, muscles, and bones can then occur. These infections can develop into gangrene. Because of the poor blood flow, antibiotics cannot get to the site of the infection easily. Often, the only treatment for this is amputation of the foot or leg. If the infection spreads to the bloodstream, this process can be life-threatening.
• People with diabetes must be fully aware of how to prevent foot problems before they occur, to recognize problems early, and to seek the right treatment when problems do occur. Although treatment for diabetic foot problems has improved, prevention – including good control of blood sugar level – remains the best way to prevent diabetic complications.
  • People with diabetes should learn how to examine their own feet and how to recognize the early signs and symptoms of diabetic foot problems.
  • They should also learn what is reasonable to manage routine at home foot care, how to recognize when to call the doctor, and how to recognize when a problem has become serious enough to seek emergency treatment.

Several risk factors increase a person with diabetes chances of developing foot problems and diabetic infections in the legs and feet.

• Footwear:Poorly fitting shoes are a common cause of diabetic foot problems.
  • If the patient has red spots, sore spots, blisters, corns, calluses, or consistent pain associated with wearing shoes, new properly fitting footwear must be obtained as soon as possible.
  • If the patient has common foot abnormalities such as flat feet, bunions, or hammertoes, prescription shoes or shoe inserts may be necessary.
• Nerve damage:People with long-standing or poorly controlled diabetes are at risk for having damage to the nerves in their feet. The medical term for this is peripheral neuropathy.
  • Because of the nerve damage, the patient may be unable to feel their feet normally. Also, they may be unable to sense the position of their feet and toes while walking and balancing. With normal nerves, a person can usually sense if their shoes are rubbing on the feet or if one part of the foot is becoming strained while walking.
  • A person with diabetes may not properly sense minor injuries (such as cuts, scrapes, blisters), signs of abnormal wear and tear (that turn into calluses and corns), and foot strain. Normally, people can feel if there is a stone in their shoe, then remove it immediately. A person who has diabetes may not be able to perceive a stone. Its constant rubbing can easily create a sore.
• Poor circulation: Especially when poorly controlled, diabetes can lead to accelerated hardening of the arteries or atherosclerosis. When blood flow to injured tissues is poor, healing does not occur properly.
• Trauma to the foot: Any trauma to the foot can increase the risk for a more serious problem to develop.
• Infections
  • Athlete’s foot, a fungal infection of the skin or toenails, can lead to more serious bacterial infections and should be treated promptly.
  • Ingrown toenails should be handled right away by a foot specialist. Toenail fungus should also be treated.
• Smoking: Smoking any form of tobacco causes damage to the small blood vessels in the feet and legs. This damage can disrupt the healing process and is a major risk factor for infections and amputations. The importance of smoking cessation cannot be overemphasized.

• Persistent pain can be a symptom of sprain, strain, bruise, overuse, improperly fitting shoes, or underlying infection.
• Redness can be a sign of infection, especially when surrounding a wound, or of abnormal rubbing of shoes or socks.
• Swelling of the feet or legs can be a sign of underlying inflammation or infection, improperly fitting shoes, or poor venous circulation. Other signs of poor circulation include the following:
  • Pain in the legs or buttocks that increases with walking but improves with rest (claudication).
  • Hair no longer growing on the lower legs and feet.
  • Hard shiny skin on the legs.
• Localized warmth can be a sign of infection or inflammation, perhaps from wounds that won’t heal or that heal slowly.
• Any break in the skin is serious and can result from abnormal wear and tear, injury, or infection. Calluses and corns may be a sign of chronic trauma to the foot. Toenail fungus, athlete’s foot, and ingrown toenails may lead to more serious bacterial infections.
• Drainage of pus from a wound is usually a sign of infection. Persistent bloody drainage is also a sign of a potentially serious foot problem.
• A limp or difficulty walking can be sign of joint problems, serious infection, or improperly fitting shoes.
• Fever or chills in association with a wound on the foot can be a sign of a limb-threatening or life-threatening infection.
• Red streaking away from a wound or redness spreading out from a wound is a sign of a progressively worsening infection.
• New or lasting numbness in the feet or legs can be a sign of nerve damage from diabetes, which increases a persons risk for leg and foot problems.

A person with diabetes should do the following

• Foot examination: Examine your feet daily and also after any trauma, no matter how minor, to your feet. Report any abnormalities to your physician. Use a water-based moisturizer every day (but not between your toes) to prevent dry skin and cracking. Wear cotton or wool socks. Avoid elastic socks and hosiery because they may impair circulation.
• Eliminate obstacles: Move or remove any items you are likely to trip over or bump your feet on. Keep clutter on the floor picked up. Light the pathways used at night – indoors and outdoors.
• Toenail trimming: Always cut your nails with a safety clipper, never a scissors. Cut them straight across and leave plenty of room out from the nailbed or quick. If you have difficulty with your vision or using your hands, let your doctor do it for you or train a family member how to do it safely.
• Footwear: Wear sturdy, comfortable shoes whenever feasible to protect your feet. To be sure your shoes fit properly, see a podiatrist (foot doctor) for fitting recommendations or shop at shoe stores specializing in fitting people with diabetes. Your endocrinologist (diabetes specialist) can provide you with a referral to a podiatrist or orthopedist who may also be an excellent resource for finding local shoe stores. If you have flat feet, bunions, or hammertoes, you may need prescription shoes or shoe inserts.
• Exercise: Regular exercise will improve bone and joint health in your feet and legs, improve circulation to your legs, and will also help to stabilize your blood sugar levels. Consult your physician prior to beginning any exercise program.
• Smoking: If you smoke any form of tobacco, quitting can be one of the best things you can do to prevent problems with your feet. Smoking accelerates damage to blood vessels, especially small blood vessels leading to poor circulation, which is a major risk factor for foot infections and ultimately amputations.
• Diabetes control: Following a reasonable diet, taking your medications, checking your blood sugar regularly, exercising regularly, and maintaining good communication with your physician are essential in keeping your diabetes under control. Consistent long-term blood sugar control to near normal levels can greatly lower the risk of damage to your nerves, kidneys, eyes, and blood vessels.

• Antibiotics: If the doctor determines that a wound or ulcer on the patient’s feet or legs is infected, or if the wound has high a risk of becoming infected, such as a cat bite, antibiotics will be prescribed to treat the infection or the potential infection. It is very important that the patient take the entire course of antibiotics as prescribed. Generally, the patient should see some improvement in the wound in two to three days and may see improvement the first day. For limb-threatening or life-threatening infections, the patient will be admitted to the hospital and given IV antibiotics. Less serious infections may be treated with pills as an outpatient. The doctor may give a single dose of antibiotics as a shot or IV dose prior to starting pills in the clinic or emergency department.
• Referral to wound care center: Many of the larger community hospitals now have wound care centers specializing in the treatment of diabetic lower extremity wounds and ulcers along with other difficult-to-treat wounds. In these multidisciplinary centers, professionals of many specialties including doctors, nurses, and therapists work with the patient and their doctor in developing a treatment plan for the wound or leg ulcer. Treatment plans may include surgical debridement of the wound, improvement of circulation through surgery or therapy, special dressings, and antibiotics. The plan may include a combination of treatments.
• Referral to podiatrist or orthopedic surgeon: If the patient has bone-related problems, toenail problems, corns and calluses, hammertoes, bunions, flat feet, heel spurs, arthritis, or have difficulty with finding shoes that fit, a physician may refer you to one of these specialists. They create shoe inserts, prescribe shoes, remove calluses and have expertise in surgical solutions for bone problems. They can also be an excellent resource for how to care for the patient’s feet routinely.
• Home health care: The patient’s doctor may prescribe a home health nurse or aide to help with wound care and dressings, monitor blood sugar, and help the patient take antibiotics and other medications properly during the healing period.