The Diabetic Foot
Patients with diabetes must be made aware that their feet can be affected by the disease. The feet and lower extremities are examples of end organs that can develop complications from diabetes. Because of macro and microangiopathy, the feet may receive less blood flow. This ischemia puts the foot at risk, especially when stressed by extremes in temperature, breaks in skin integrity, and infection. Sensory, motor, and autonomic neuropathies may develop which can lead to a loss of sensation, muscle atrophy, and poor tissue quality. Neuroathropathy (Charcot Joint) may also occur, leading to subluxations (major joint dislocations and degeneration). Also, patients with diabetes have poor cellular response to bacterial infections, thus placing the diabetic foot at high risk for infection. Minor cuts, abrasions, or foot ulcerations can lead to concerning situations if infection is present.
A thorough lower extremity examination is necessary for patients with diabetes. In the initial evaluation, it is very important to obtain a detailed history and physical exam. A though vascular exam must be performed. If there are non-palpable or diminished pulses, further non-invasive vascular studies should be considered. A meticulous neurologic exam should be performed to establish the presence of neuropathy. Special attention is given to the sensory exam to ascertain the level of protective threshold (the ability for the patient to detect noxious stimuli).
Based on the clinical exam and risk category placement, a treatment protocol is established. Treatment of the diabetic foot focuses on prevention. A multidiscipline team approach is typical, including but not limited to the patient's internist or endocrinologist, foot specialist, vascular surgeon, and infectious disease specialist. The overall goal is to keep the patient ambulatory, out of the hospital, and ulcer and infection free.
Educating patients with diabetes regarding foot care is paramount to the overall treatment. They must be made aware of how their diabetes can affect their feet. The patients (and/or care takers) must recognize early warning signs of problems and inspect their feet everyday. Based on their foot risk category placement, patients with diabetes need to see their foot specialist on a regular prescribed basis.
The following list is an example of what patients need to know to prevent tissue breakdown and infection:
- Do not attempt to treat corns, calluses, toenails, or other foot problems oneself. No "bathroom surgery".
- Never use chemical agents or medicated pads (corn removers) as these agents contain acids that can erode the skin.
- Inspect the feet and legs daily for any unusual swelling, discolorations, areas of increased temperature, or breaks in the skin, paying particular attention to the areas between the toes and around the toe nails.
- Never go barefoot (including inside the house).
- Socks should be worn with shoes at all times to reduce friction, provide insulation, prevent soiling of the foot, and absorb perspiration. Socks should be made of cotton, wool, or a blend (not 100% synthetic) and preferable white, non-mended, and without holes.
- Shoe styles should be discussed with and inspected by one's foot specialist.
- Inspect the inside of shoes for any sharp or loose objects before placing on feet.
- Avoid exposing feet to temperature extremes. Bath water should be checked with a thermometer or hand (if good sensation in hands). Never warm cold feet with hot water bottles or heating pads.
- Do not apply creams or ointments between the toes.
- Be able to recognize early signs and symptoms of infection, including redness, swelling, and drainage. If any of these symptoms are noted please call your foot doctor immediately or go the nearest emergency room.
Many hospital admissions and non traumatic lower extremity amputations can be avoided with early recognition and treatment of diabetic foot problems. By providing foot health care, including prescribing oral and topical medications (i.e., for uncomfortable neuropathy, "burning feet"), accommodative orthoses, proper shoeing, and education, the foot care specialist can help the patient avoid the complications of infection and tissue loss. The goal of lower extremity care in patients with diabetes is to maintain ambulation with two full limbs and ten toes for the patient's entire life.
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