Foot care in Diabetes - What you need to know about your feet!

Diabetic foot disease is a less concerned entity but, 5-15% of diabetics develop foot ulcers at some stage of their disease process, leading to amputation. It is said that 85% of non traumatic lower limb amputations follow diabetic foot ulcers and foot problems are responsible for nearly 50% of all diabetes-related hospital admissions.  Another important fact is that these ulcers take a long time to heal and 70% of healed diabetic ulcers are likely to recur within 5 years.

What are the causes of foot ulcers in diabetes?

There are various underlying mechanisms to cause ulcers; it can be divided into intrinsic and extrinsic causes. Extrinsic causes include diabetes related poor vision as a result of diabetic retinopathy, falls as a result of joint immobility or even oedema appearing in extremities, for example due to heart failure or renal failure. Intrinsic causes are the most important and those are direct complications of diabetes mellitus. Main causes are diabetic neuropathy, arterial disease causing Peripheral Arterial Disease (PVD) related with atherosclerosis, abnormal tissue response to trauma and sepsis.

How does diabetic neuropathy affect your feet?

In diabetic neuropathy there can be sensory involvement, motor involvement or autonomic involvement. Sensory involvement causes loss of pressure, pain, temperature and joint sense which will expose the patient into danger without being aware. Therefore the risk of trauma is high. When motor nerves get affected it causes weakness and atrophy of intrinsic muscles of foot, hence altered foot structure and leading to deformity and altered biomechanics. Also arterio-venous shunting which occurs due to autonomic neuropathy, affects maintenance of skin integrity and vascular tone so it causes a warm, dry, fissured foot.

A charcot foot is a condition which is seen in 0.2% of patients with long standing diabetic neuropathy. There are several features related with this i.e.

· Hyperaemic response

· Osteopenia

· Local fractures

· Inflammatory response

· Affected proprioception causing deformity

How can diabetic vascular disease affect your feet?

Arterial disease related with diabetes mellitus is of two types; either macrovascular or microvascular. Macrovascular disease which affects medium and large blood vessels with atherosclerosis leads to impaired blood supply to distal areas of lower limb. Here the risk of getting atherosclerotic plaques in blood vessels is 4 to 20 times high.

In Fontaine classification which describes the symptoms related to PVD; the grades are as follows;

Grade I- asymptomatic patient with absent pulse

Grade II- Symptomatic patients with intermittent claudication

Grade III- Critical ischemia with rest pain

Grade IV- Critical ischemia with tissue loss leading to ulceration, gangrene and amputation

There it shows that in greater degree of arterial insufficiency, ulceration is common. These ulcers may present as painful erosions between toes or as shallow, non-healing ulcers on the dorsum of the feet, on the shins and especially around the malleoli.

Microvascular disease causes microangiopathy affecting smaller blood vessels. Early onset of micro-vascular dysfunction affects arterioles and capillaries of several organs; here basement membrane thickening may impair oxygen diffusion which results in reduced tissue response to sepsis. The results are more serious in extremities.

What happens to your feet in daibetes?

Abnormal tissue response to healing occurs in a diabetic patient. It is due to a number of postulated theories; deficiency of growth factors, impaired fibroblast response and abnormalities of extracellular matrix are among the most appreciated theories up to date. It is also said that there are alterations in neuroinflammatory response, hyperaemic response and thermoregulatory response. Apart from that, the cell mediated immunity is depressed in long standing diabetics and the phagocytic function of multinuclear leukocytes affected with affected leucocyte migration at microcirculatory level. Since patients have hyperglycaemia associated with mycotic infections the end result may be secondary bacterial infections.

Infections causes large collections of pus since immunity is altered in these patients so they get very extended infections but with little pain if the patient has neuropathy or else severe pain if it is associated with ischemia. As there is poor ability of the body to fight against infection by the time patient comes to ward there can be tracking of pus along tendon sheaths which is difficult to cure.

Wargner 1-5 a Global Severity Score is based on the severity of the ulcer as mentioned below

1.       Superficial ulceration limited to dermis

2.       Ulceration down to fascia or bone without abscess or osteomyelitis

3.       Deep ulcers with abscess or osteomyelitis

4.       Localized gangrene confined to the toes or forefoot

5.       Gangrene requiring immediate major (above ankle) amputation

How to care for your feet!!

Most important part in management of diabetic foot is patient education on prevention. Many diabetic foot problems are avoidable, if patients know the principles of foot care. Following are some of the preventive measure in foot care which patients ought to practice

1. Ask not to walk barefoot

2. Inspect the feet daily

3. No hot fomentation

4. Wear correct footwear

5. Not to weight bear (unsupported) on the affected foot

6. Not to sit cross-legged

7. Not to remove footwear during traveling

8. Cut nails regularly (trim square) but they should not cut their own toe-nails

9. No home surgery

10. Clean the feet twice a day

Foot wear in diabetes.......

Patients are educated to wear mainly protective footwear which is specially designed for patients with diabetes mellitus. Features of protective footwear are

· There should be accommodation and cushioning in shoes

· Have wide toe box and extra depth

· Contain total contact insoles and rocker sole with wedging

· Heel to toe length, arch length, width measure both feet fit while weight bearing

· Check for the positioning of the first metatarsophalangeal joint

· Allow half a inch between end of the longest toe and the end of shoe

· Sniff fit around the heel

What to do if you get an ulcer!!

Proper wound care is very important to speed up the healing process. Manage the wound with deep swabbing; taking pus for culture and sensitivity test; blood transfusions if haemoglobin levels are low and expose to hyperbaric oxygen are some measures to be taken. Other measures are weight reduction; aggressive debridement and drainage of tissue space; give intravenous antibiotics like Penicillin, Co-amoxyclav , Metronidazole, Clindamycin  also leukocyte colony stimulating factors.

Also rest injured area with prophylactic surgery to correct Biomechanical damage can be performed. Revascularization with angioplasty and distal venous bypass are treatment modalities for PVD. If all the treatment modalities fail amputation is the last resort. Many diabetic limb amputations could be delayed or prevented by more effective patient education and medical supervision.

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Comments 16 comments

PETER LUMETTA profile image

PETER LUMETTA 5 years ago from KENAI, ALAKSA

A very good and comprhensive HUB but I'm afraid I only understood maybe 50% of it and the rest is to medical. you should dumb it down for non medically trained people. there is a lot I would like to know since I am diabetic. ai am a college graduate but not versed in medical terminology, Thanks, Peter


annaw profile image

annaw 5 years ago from North Texas

I completely agree with Peter's comments regarding the terminology,it is okay to use those terms but be prepared to define and put into layman's terms and where possible do not use acronyms e.g. PVD. You provided lots of information, but if what you have said is over the heads of those like myself or Peter for that matter then you have excluded many of your readers. I am more likely to read something that I understand, and less likely to search for the definition of those terms. I did vote this up and interesting and useful.


Nadeeshan301 profile image

Nadeeshan301 5 years ago from Kandy - Sri Lanka Author

Dear Peter and annaw,

I'm sorry for using too much medical terminology in the hub. I'm working on a more simplified hub on the same topic with the definitions and all. Will publish that soon.

Thank you for your interest on my hubs and your valuable constructive comments which I appreciate so much!


always exploring profile image

always exploring 5 years ago from Southern Illinois

Thank you for this very informative Hub. My Son is a diabetic and has problems with his feet. Happy you are on Hubpages.

Cheers


Nadeeshan301 profile image

Nadeeshan301 5 years ago from Kandy - Sri Lanka Author

Thank You always exploring! Cheers!!


Rob Jundt profile image

Rob Jundt 5 years ago from Midwest USA

Dear sir,

First of all. thank you for such an inclusive and educational hub. As the father of a young diabetic, our son has been type 1 since the age 6, I can understand the concerns and risks involved with diabetes. It is a daily task for us. And also, as a future member of the medical community soon to be working in the PT field, knowing how to adequately recognize and treat diabetic feet problems is crucial. We see them ALL the time! Your information is very helpful and fairly inclusive. Thanks again!

RJ


Nadeeshan301 profile image

Nadeeshan301 5 years ago from Kandy - Sri Lanka Author

Dear Rob,

I'm so glad to hear that you were helped by this hub and I also feel sorry for your son suffering from type I diabetes. We are planing to publish a few more hubs on diabetes with less medical jargon as we feel this is an area where the knowledge is deficient in the community.

Thank you for your encouraging and valuable comment!!


b. Malin profile image

b. Malin 5 years ago

Thanks Nadeeshan for a well written Hub on a subject that most of us know little about. Lots of good and useful information my friend. Thank you.


Nadeeshan301 profile image

Nadeeshan301 5 years ago from Kandy - Sri Lanka Author

Thank you b.Malin for your encouraging comment!! Glad that this was useful to you!


Sueswan 5 years ago

Hi Nadeeshan

Very useful information for diabetics.

Voted up and interesting.

Take Care


Nadeeshan301 profile image

Nadeeshan301 5 years ago from Kandy - Sri Lanka Author

Thank you Sueswan! Glad that this hub was interesting and useful to you!


vocalcoach profile image

vocalcoach 5 years ago from Nashville Tn.

This is a well written, excellent article on foot care for Diabetics. I appreciate it so much. My father developed ulcers and ended up with a leg amputation. I remember how I used to clean and massage his feet, taking care of his ulcers. That was years ago. I am bookmarking this and rating it Up. Eager to read more hubs of yours. Thanks!


Nadeeshan301 profile image

Nadeeshan301 5 years ago from Kandy - Sri Lanka Author

Thank you vocalcoach! So glad to hear your appreciation!


Glenn Stok profile image

Glenn Stok 5 years ago from Long Island, NY

I know someone who lost his foot due to diabetes. Terrible thing is that I predicted it 8 years before he lost it. He didn't listen to me when I told him he can get an infection and require amputation unless he takes care of his feet. I told him basically the same things you mentioned in this Hub. Major problems can possibly be avoided if one cares enough to follow this guidance. Voted up and useful.


Nadeeshan301 profile image

Nadeeshan301 5 years ago from Kandy - Sri Lanka Author

Thank you Glenn,

Increasing the awareness of diabetes and its complications is one important way to increase the control which would result in decreased complications. Two thumbs up for contributing to combat against diabetes!!


Peter Geekie profile image

Peter Geekie 3 years ago from Sittingbourne

Thank you for a well written and researched article. Most diabetics take insufficient care of their feet and the consequences can be catastrophic. I am a type 2 diabetic and suffered from a complication known as Charcot Foot. Luckily we caught the problem early and it is now under control. However it could very easily have resulted in the loss of my foot.

Voted up and useful

Kind regards Peter

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