The Diabetic Foot

diabetes and feetIntroduction

The diabetic foot is a complicated topic in podiatry. The reason being is that many risk factors and health problems can lead to severe problems for the diabetic foot. Common medical problems associated with diabetes include high blood pressure, high cholesterol, heart disease, neuropathy, poor vision, kidney problems, infection, and poor healing. Diabetes is a systemic disease and can create problems for several body systems. This is people with diabetes need specialists in almost every field to properly maintain a healthy lifestyle. The podiatrist is one of the most crucial components of the diabetic team of physicians since foot problems are very common. The primary care physician will refer the patient to a podiatrist if he/she does not currently have one. The primary care physician will be responsible for proper control of the patient’s diabetes by utilizing appropriate medications and giving guidance on proper diet. The patient will also have blood work performed for determining the average sugar levels. This three month sugar average is called the hemoglobin A1C. Patient’s should share their results with their foot doctor so that he/she can keep track of the diabetes. The diabetic team is focused on controlling the patient’s diabetes and having several doctors working towards a common goal.

What will happen at my first podiatry appointment?

The foot doctor will perform a comprehensive history and physical with a focus on the diabetic disease state. The doctor will test the patient’s lower extremity muscle strength and range of motion, nerve sensation, examination of the skin and nails, and will also check the circulation to of the feet and legs. All this can be completed in just a few minutes. X-rays of the foot will be taken if there is pain present or an open wound. The doctor will also forward any findings to the primary care physician so that there is constant communication throughout the diabetic team.

What is at risk foot care?

At risk foot care is an important treatment provided to patients with diabetes that have nail problems and calluses. The typical patient to receive at risk foot care has thickened, discolored, and fungal nails that they cannot trim themselves. Calluses are also trimmed with the at risk foot care treatment. Medicare patients with diabetes, and neuropathy and/or poor circulation, will be able to receive at risk foot care with minimal to no cost. At risk foot care is provided to diabetic patients to prevent future problems of the foot. Keeping nails thin and short can prevent unwanted infections, pain and suffering. Trimming of corns/calluses can prevent ulcerations and infections of the skin. Consider at risk foot care preventative maintenance so that the patient can lead a healthful lifestyle.

What is diabetic neuropathy?

Diabetic neuropathy is a condition due to poor sugar control in diabetic patients. Symptoms include paresthesias such as a feeling of pins and needles, numbness, dryness of skin, burning, and pain. The symptoms usually occur most frequently at night when the patient is laying in bed. The foot doctor can supply the patient with many options to decrease symptoms of neuropathy. The patient will also have to exercise proper blood sugar control so that their diabetes is under control. The higher the sugar levels the more symptoms of neuropathy can occur.

How do you treat diabetic neuropathy?

Diabetic neuropathy is treated by first exercising tight control of the diabetes. Normal HgbA1c range from 4% to 5.6%. The more controlled the diabetes the less symptoms occur. The podiatrist may diabetic footrecommend topical ointments (capsacin, biofreeze, cryoderm) that can create sensations of heat or cold in order to decrease symptoms of neuropathic pain. The body can only concentrate on so many stimuli and the cream/ointment provided can distract the patient’s brain from feeling pain. Vitamin B supplements may be provided if a B deficiency is found in the patient. Vitamin B complex vitamins help regenerate and heal damaged nerves. The nerves in a diabetic patient can be damaged by high levels of sugar in the blood. Another way to treat the neuropathy is through the use of a TENS unit. This machine is essentially a wearable device that distracts the brain from peripheral neuropathy pain by overstimulating major nerves with electric stimulation. The more the stimulation the greater the relief.

What is a diabetic foot ulcer?

Diabetic foot ulcer is an opening in the skin in a diabetic patient that is most likely caused by increased pressure or unknown trauma to the foot. A diabetic patient with neuropathy or loss of sensation is at a very high risk of developing an ulcer. This is because the patient loses feeling to the feet and as a result can cause increased pressures to certain parts of the foot resulting in an ulcer. The diabetic ulcer typically has a red circular base with a callus surrounding the wound. Neuropathy has a role in forming these ulcers because the lack of sensation to the foot results in increased pressure and friction areas. This is why the podiatrist will check the patient’s diabetic feet every few months so that the patient can discover any high pressure areas in its early stages. In many cases people are unaware that they even have an ulcer since they don’t feel it!

How do we treat diabetic foot ulcers?

There are three main treatments for diabetic foot ulcers. Offloading, which means staying off of the foot with the ulcers, increasing blood circulation to the ulcer site, and treating/preventing infection to the opening in the skin. The doctor will dispense a walking boot or will prescribe a walking cast in order to achieve proper offloading to the foot. If non weight bearing is required then the doctor will suggest rental of a knee scooter or some other walking device so that healing can occur efficiently. The blood flow to the foot is quite crucial in healing wounds. If there is no blood flow the skin is not able to migrate across the opening in the skin. Therefore, the doctor may refer the patient to a cardiovascular doctor that will attempt to improve circulation to the wound. The podiatrist may also send the patient to a wound care facility where skin grafts and hyperbaric chambers are readily accessible. Antibiotics may be prescribed if the doctor identifies any infection to the wound. A culture is taken of the wound in order to choose the appropriate antibiotic. Dressings may be dispensed to the patient if the wound has the appropriate characteristics. These dressings help to increase healing potential and also control any fluid leaking from the wound. Once the wounds are healed a diabetic shoe will be prescribed in order to prevent increased pressure areas. While the doctor has excellent treatment options and knowledge, the patient adhering to the treatment is equally as important to have excellent outcomes. This team approach is the best way to prevent loss of toes or the foot.

What is a diabetic shoe?

Diabetic shoes are specially designed shoe gear that have very soft insoles to allow for accommodation of the foot. If there are any lumps and bumps on the foot the soft plastazote insert will cushion these areas preventing any high pressure areas. The toe box (front of the shoe) is also higher so that the toes do not hit the top of the shoe. This prevents friction and pressure to the toes to decrease chance of ulceration. The inner lining of the shoes are also seamless in order to prevent any increased friction to the top and sides of the foot. The shoes work very well in preventing ulcerations and are recommended for every diabetic patient. In this modern age the shoes do not look undesirable. They come in a variety of styles such as athletic, dress, and casual styles. The podiatrist will send the patient to an orthotist who will take measurements of the patient’s foot and fabricate the shoe so that it is the perfect fit.

What is a Charcot Foot?diabetic patient

Charcot is a foot type that has a partial or complete collapse of the arch and foot. This is a result of neuropathy and repetitive micro trauma to the foot. The patient is unable to feel the trauma because the neuropathy causes pain sensation to be diminished. The patient will exhibit signs/symptoms of redness and swelling to the affected foot. The foot will also gradually change shape where a rounded bottom with loss of the arch will start to present itself on the bottom of the foot. X-rays will be taken of the foot in order to determine the severity of the Charcot foot.

How do we treat Charcot foot?

Conservatively we treat Charcot foot with offloading. The doctor will request that the patient remain off of the foot until the foot becomes more stable. Offloading can be achieved with crutches, knee scooter, scooter, wheel chairs, CROW walker, or a walking cast. These options will all be considered so that the patient can achieve the best possible outcome. Surgery is only necessary if there is a high risk of loss of limb or prolonged course of wounds to the Charcot foot. Surgery involves realigning the foot with pins and screws to correct any deformity thereby improving the overall shape of the foot. This is improved shape will lessen the chance of ulcerations and thus will result in less chance of infection.

Tips for treating your feet and avoiding complications:

  • Keep cream on your feet to avoid cracking skin
  • Don’t walk barefoot, as you can step on something without feeling it
  • Check your feet daily for unusual appearing blisters, redness or problems on the bottom of the feet or between the toes
  • Do not use hot water to soak your feet. You can burn your feet due to lack of feeling
  • Avoid pads with adhesive or acid such as acid plaster. These are very dangerous and can cause tearing of skin and burn damage resulting in ulcers.
  • Wear supportive shoes and avoid flip flops
  • Do not cut your own nails or calluses. This can result in broken skin which causes infections and ulcers. Also avoid pedicures.
  • Do not wear tight shoes, socks or stockings. These can cut off circulation or cause blisters.
  • Check your shoes to make sure there are no exposed seams rubbing or any objects like rocks, sharp plants, needles or nails.
  • DO NOT smoke. Contact your PCP t0 help you get on a smoking cessation program. Smoking causes poor circulation and many other medical conditions.
  • Keep your appointments with your PCP and podiatrist. If you have a problem and wait too long, your risk of limb loss is higher.
  • Call your podiatrist immediately with even minor foot problems. Early treatment is essential.