Diabetic Foot

Foot problems are common in people with diabetes. They might be afraid that they might lose a toe, foot or leg to diabetes, or know someone who has. But you can lower your chances of having diabetic-related foot problems by taking care of your feet every day. 

What do you look for when you check your feet every day?

Make it a habit to check your feet every evening while you take your shoes off. Also, remember to check between your toes. If you have trouble bending over to see your feet, try using a mirror to see them or ask someone else to look at your feet.

You look for problems such as cuts, soars or red spots, swelling or fluid-filled blisters, ingrown toenails, corns or calluses, plantar warts, athletes foot, warm or red areas or spots etc. 

How can diabetes affect your feet?

Prolonged diabetes may cause nerve damage also called diabetic neuropathy, that can cause tingling and pain in your feet and can make you lose feeling in your feet. When you lose sensation in your feet, you may overstep a hard or pointed object or even walk over a hot surface, which can lead to cuts, soars or boils. You may not be aware of this and may continue to walk or do your regular routines. This gradually gets infected. Diabetes can lower the amount of blood flow in your feet. This makes it hard for a wound or boil or an infection in the foot to heal. This infection can ultimately lead to gangrene. 

Peripheral neuropathy in diabetes causes foot ulcers by affecting the sensory, motor and autonomic pathways. Motor peripheral neuropathy or Charcot osteoarthropathy produces bone deformities. These deformities cause severe pressure in the skin which is increased by swelling caused by autonomic neuropathy. This results in tissue failure and skin ulcer ratio. Gangrene and foot ulcers that do not get better with treatment can lead to amputation of your toe, foot or part of your leg. Nerve damage from diabetes can lead to changes in the shape of your feet, such as Charcot’s feet. The bones in your feet and toes can shift or break which can cause your feet to have an odd shape such as rocker bottom. Diabetes can lead to changes in the blood vessels including arteries. In peripheral arterial, peripheral vascular disease, fatty deposits block blood vessels in hands and feet. It tends to affect blood vessels leading to and from the extremities such as hands and feet reducing blood flow to both.

What are the common symptoms that you see in a patient with a diabetic foot?

Symptoms in diabetic foot vary from person to person. It includes numbness or tingling sensation, loss of feeling, blisters or wounds without pain, skin discolouration and temperature changes, painful tingling, red streaks, wounds with or without drainage. If an infection dumbs a person may also experience fever, chills, uncontrollable blood sugar, redness and even shock. 

When should you see a doctor immediately?

When you notice changes in skin colour on foot, swelling in foot or angle, temperature changes in the feet, persistent sores on the feet, pain or tingling in the feet, ingrowing toenails, fungal infections of the feet, dry crack skin in heels or any signs of infection.

What are the tips you can give your patients for good diabetic foot care?

  • The most important thing is about maintaining good blood sugar control.
  • Follow your doctor’s advice regarding nutrition, exercise and medication.
  • Wash your feet in warm water every day using a mild soap. Nerve damage can affect temperature sensations in your hands and feet. So be careful to check the temperature of the water before you use it to avoid burn injuries. 
  • Check your feet every day for sores, blisters, redness, calluses etc. Keep your feet moist by applying lotion after you wash and dry your feet. 
  • Check your toenails once a week. Trim them with nail clippers straight across. Do not round off the corners of the toenails or cut down on the sides of the nail. 
  • Always wear close-toed shoes or slippers. Do not wear sandals and do not walk barefoot. Always wear socks or stockings. Always wear shoes that fit well. Check the inside of the shoes before your wear them and make sure that no objects are left inside. 
  • Protect your feet from heat and cold. Wear shoes on the beach or hot pavement and wear socks at night if your feet get cold. Keep exercising your legs lightly, regularly to improve blood supply to your feet. If you are a smoker, you must stop smoking. 
  • See your doctor or podiatrist every three months and get a thorough foot examination once a year. 

How do you evaluate and diagnose a foot problem?

Evaluation should include assessment of neurological status, vascular status and evaluation of the wound itself. A detailed history taken from the patient is very essential and useful in making a diagnosis. A careful inspection of the foot in a very well-lit room will be helpful in assessing any dermatological or muscular-skeletal problems of the patient. A good neurological assessment to identify loss of protective sensation should be carried out by assessing touch, pain, temperature and vibration senses using 10g monofilament, pinprick sensation test, 128-Hz tuning fork test, and biothesiometry respectively. 

The absence of anti-reflexes has also been associated with an increased risk of foot ulcer ratio. The peripheral arterial disease causes approximately 1/3rd of foot ulcers. Therefore assessment of peripheral arterial disease is important in assessing lower extremity risk. Apart from clinical examination of peripheral pulses, ankle-brachial index pressure is monitored by using an ultrasound flow Doppler study. 

How do you manage or treat a diabetic foot case?

Successful treatment of diabetic foot ulcers consists of a good debridement of the wound, offloading of the foot, and good control of the infection. Debridement consists of the removal of all necrotic tissue, peri-wound callus, and foreign bodies down to the viable tissue. After debridement, the wound should be irrigated well with saline. A dressing should be done such that it prevents tissue desiccation, absorbs excess fluid and protects the wound from contamination. If there is an abscess, immediate insession and drainage of the abscess is essential. Offloading of the foot is very important for wound healing. This is usually done by asking the patient to use a wheelchair or crutches to halt weight-bearing in the affected foot. Removable cast walkers may also be used. Limb threatening diabetic foot infections are usually polymicrobial. Hence antibiotics used to treat should include coverage of gram-positive and gram-negative organisms and provide both aerobic and anaerobic coverage. Such patients should be hospitalised and treated. 

Apart from debridement and cleaning of the wound, if the infection is severe, aggressive and radical surgical debridement is to be done to salvage the limbs. 

Surgical treatment of diabetic foot with osteomyelitis may lead to major recession of soft tissue and osseous defects, which may require reconstruction for proper wound closure. 

Various wound closure procedures include allogenic skin graphs, substitutes, autogenic skin grafting, free flap, NPWT etc. Treatment with growth factors and cellular therapy is also useful in non-healing wounds. In life-threatening diabetic foot infections with gangrene, amputation of the gangrenes toe or limb is the ultimate option. In patients with occlusive peripheral vascular disease, revascularisation can be achieved with traditional open surgery bypass using autologous vein or prosthetic graft or by endovascular techniques. Endovascular revascularization can be performed by Percutaneous transluminal angioplasty, Subintimal Angioplasty, intravascular stents or atherectomy devices.

Most of all and most important is good glycemic or blood sugar control.