For a person with diabetes, seemingly minor foot problems can lead to severe infections, sometimes requiring amputation.
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Of all the treatments for the long-term management of diabetes, foot care is probably the simplest to do...and the easiest to ignore. The consequences can be enormous. Each year about 54,000 diabetics suffer amputations–usually as a result of a seemingly harmless skin sore.
Foot problems are recognized as one of the major long-term complications of diabetes, and they are intricately related to other complications such as diseased nerves and blood vessels. All are more common in patients who have had the disease for a number of years and are associated with poor control of blood sugar.
The most common diabetic complication is neuropathy, which is actually a group of diseases affecting the peripheral nerves of the legs, feet, arms and hands. It’s present in 12 percent of persons first diagnosed with diabetes and in 25 percent of those who have had the disease for 25 years or longer.
At first, the patient may feel a burning or pins and needles sensation in the limbs, particularly at night. Eventually, however, the pain or discomfort gives way to a reduction of feeling, making it more difficult to feel minor pain or take seriously cuts, scratches, blisters or other injuries to the foot.
Along with neuropathy, diabetics frequently suffer from peripheral vascular disease–blood vessel changes resulting in blockages or reduced blood flow to the legs, particularly in the area between the knee and the ankle.
Symptoms of peripheral vascular disease include cold feet, a dusky or bluish appearance of the skin, reduced or blotchy hair on the legs and feet and a cramping leg pain after walking a short distance.
Minor Nuisances Pose Hazard
Without normal flow of nerve messages and blood, muscles in the feet eventually tend to weaken and atrophy with loss of the protective pad of fat on the balls of the feet. A change in foot structure and gait increases the risk of bunions, hammer toes, corns, calluses and blisters. Minor nuisances for most individuals, these can pose a hazard for a person with diabetes.
Many diabetics also have poor temperature regulation and diminished sweating in the feet causing the skin to become dry and vulnerable to small breaks through which bacteria can enter.
An infection may develop under or around a callused area, for example, and quickly become severe before it is noticed. Even with a fairly severe infection, a patient with neuropathy may not have the tell-tale signs of redness and swelling. And reduced blood flow makes it more difficult for any wound to heal and for antibiotics to be delivered effectively to the diseased area.
An infection that reaches into the vicinity of bones is particularly dangerous, and the numerous small bones of the feet have relatively little skin and soft tissue covering them.
When an infection gets out of control, amputation may be the only solution. And patients who have had one limb removed have a higher than average risk of losing the other leg within five years.
Preventive Foot Care
If you’re diabetic, good preventive care requires being a little obsessive about taking care of your feet.
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Diabetic foot care requires that you be a little obsessive. That means inspecting your feet carefully every day, using a mirror if necessary to check every square inch–top, bottom, sides and between the toes–looking for cuts, blisters, bruises, red spots, swelling, infected toenails or any other injury. If you see anything out of the ordinary that does not go away in a day or so, you should see your doctor. You should also report any numbness, tingling or pain in your feet.
In addition to your self examination, the American Diabetes Association recommends a thorough foot examination by your doctor at least once a year (more frequently for individuals at high risk) and a visual inspection at every visit with a health care professional if you have any symptoms of neuropathy.
Patients who keep their blood sugar at or near normal levels have a reduced risk of major diabetic complications.
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Keeping your feet squeaky clean is essential. Wash them with soap and warm water every day, and dry them thoroughly with a soft towel.
Merely letting your feet get wet in the shower is not good enough if you have diabetes, but soaking your feet is not a good idea since it can cause your skin to dry and crack. Be aware that neuropathy may make your skin less sensitive to water that is too hot so test the water with your elbow or a thermometer before getting your feet wet.
Lotion or moisturizing cream will help keep your feet from getting too dry, but avoid the area between the toes since too much moisture there can lead to fungal infections. Change your socks frequently, and make sure they don’t have wrinkles or big seams that irritate your feet.
Trim your toenails at least once a week, and be on the lookout for ingrown toenails, fungal infections or other problems.
For a person with diabetes, walking barefoot is forbidden–even at the beach or in the water. Wear shoes and choose them carefully, making sure they are long enough, wide enough and deep enough so that they don’t rub or constrict any part of your foot. Shoes should feel comfortable when you first try them on and not require breaking in.
If you have bunions, hammer toes or any other kind of foot deformity, fit becomes even more important. You may require custom orthotics or footwear prescribed by your doctor or podiatrist.
Check your shoes for pebbles before putting them on and discard shoes when the inside lining becomes rough or frayed.
Be aware that your feet are vulnerable to damage from either heat or cold. Wear warm socks and shoes during the winter, but don’t use a hot water bottle or place your feet near a radiator or fire. In the summer, avoid sunburns on your feet by keeping them out of direct sunlight or protected with sunscreen.
Finally, good foot care requires diligent control of blood sugar. According to the Diabetes Control and Complications Trial, patients who kept their blood glucose at or near normal levels had a 69 percent reduced risk of developing neuropathy.
In the face of life-threatening complications such as heart disease and kidney failure, it’s easy to forget about the hazards of diabetic foot problems. It’s well worth taking a little extra care each day to avoid severe disabilities.
REFERENCES:
Annette Broersma, “Preventing Amputations in Patients with Diabetes and Chronic Kidney Disease,” Nephrology Nursing Journal, January-February, 2004.
Kelly James-Enger, “Focus on Feet: Here’s Why People with Diabetes Should Be Obsessed with Their Feet,” Diabetes Forecast, February, 2003.
Eric T. Fossel, “Improvement of Temperature and Flow in Feet of Subjects with Diabetes with Use of a Transdermal Preparation of L-Arginine: A Pilot Study,” Diabetes Care, January, 2004.
Adam Garrow, et al, “A Comparison of Regional Pain and Disabling Foot Pain in People with and without Diabetes–Results from a Population Survey,” Diabetes, June, 2003.
Edward Gregg, et al, “Prevalence of Lower Extremity Diseases in U.S. Adults with and without Diabetes, 1999-2000,” Diabetes, June, 2003.
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Johns Hopkins White Papers, “Diabetes, 2003.”
Terri Kordella, “The Foot Care Top Ten Tips! If You Have Diabetes, Your Feet Need Extra Tender, Loving Care,” Diabetes Forecast, May, 2003.
Heidrun H. Kramer, Martin Schmelz, Frank Birklein and Andreas Bickel, “Electically Stimulated Axon Reflexes Are Diminished in Diabetic Small Fiber Neuropathies,” Diabetes, March, 2004.
Lawrence Lavery and John D. Gazewood, “Assessing the Feet of Patients with Diabetes,” Journal of Family Practice, November, 2000.
Marie M. Lupo, “An Overview of Foot Disease Associated with Diabetes Mellitus,” MedSurg Nursing, August, 1997.
National Institute of Diabetes & Digestive & Kidney Diseases, “Prevent Diabetes Problems: Keep Your Feet and Skin Healthy,” pamphlet, May 3, 2000.
L. Selby-Silverstein, et al, “The Effects of Internal and External Shoe Cushioning on Plantar Pressure in Individuals with Diabetes Mellitus,” Physical Therapy, May, 1999.
James Wrobel, et al, “Do Clinical Exam Variables Predict High Plantar Pressures in the Diabetic Foot?” Diabetes, June, 2003.
