Health & Disease Info
All You Wanted to Know About ... Diabetic Foot

By the time diabetes has been present for 15 or 20 years, at least 50% of diabetics will have some evidence of vascular diseases. This increase to about 84% of patients with diabetes for longer than 20 years. Twenty-five percent of all diabetics will develop significant lower extremity occlusive diseases. Seventy-five percent of diabetics will die of vascular disease or its complications, primarily heart attach and stroke. Twenty percent of all hospitalizations of diabetics are for foot problems. One-third of diabetics requiring amputation of one leg, if they do not comply with instructions, will lose the other leg within three years, and 50% by 5 years. These results from a combination of phenomena associated with diabetes including ischemia (poor blood supply), neuropathy (changes in the nerves which results in loss of sensation for heat, pressure, pain and position as well as loss of some small muscle function), and infection. These effects are all interrelated.

Vascular Problems
The pattern of vascular involvement is different in the diabetics than in the nondiabetic. Diabetics patients have more involvement of the smaller, more distal vessels. The changes are seen primarily in the vessels below the knee and in the foot. Furthermore, the very small vessels in the foot become surrounded by a "thickened basement membrane" that interferes with the exchange of oxygen, nutrients, medications, and infection fight material and cells between the capillaries and the tissues.

Neuropathy
Peripheral neuropathy is extremely common in diabetics. These changes are caused by small blood vessel diseases interfering with the blood supply of the nerve trunk, accumulation of toxic by-products in the nerve cells, defects in the sheath-forming structures which surround the nerve fibers, and swelling of the nerve trunk due to the high sugar content of the body fluids. The earliest and most common indication of neuropathy is a diffuse loss of sensation in the feet in a stocking-type distribution. This can lead to damage due to stepping on foreign objects, irritation from poorly fitting shoes, or even burns or frost bite because of the loss of your ability to detect different temperatures. These are no satisfactory methods for relieving the symptoms of diabetic neuropathy.

Peripheral neuropathy also damages the nerves to the small muscles in the foot, upsetting the balance between different muscle groups and resulting in deformities such as bunion formation, hammer toes, and protrusion of the metatarsals heads (toe joints), causing excessive load and trauma on the soft tissues under the bones of the ball of the foot. Eventually, severe callus formation develops with injury and death of tissues below the callus. This tissue breakdown and ulcer formation is called a neurotrophic ulcer. these all become infected. If not treated promptly, this can lead to severed deep foot infections and, in extreme cases, amputation.

Finally, neuropathy affects the "sympathetic" nerve fibers which control sweating. This leads to a dry, non-sweating skin which cracks easily providing a portal of entry for infection to occur.

Infection
Infection is the final component of diabetic foot problems. It would seem that the portal of entry for infection is created by the changes caused by neuropathy. Vascular changes reduce the infection fighting capabilities of the local tissues, but there is also a general decrease in the infection fighting abilities of the whole body. Diabetics are much more vulnerable to infection than nondiabetics. The infection fighting blood cells are less active in moving to a site of infection and less able to kill the infective organism once they arrive when blood sugar levels are higher than normal. Small vessel disease magnifies these problems and also makes it more difficult to get satisfactory levels of antibiotics to the infected tissue. The bottom line of all this is that when an infection is caught early and treated vigorously it will usually respond, but once it becomes well established, it is rapidly invasive, spreading throughout the foot. When bacteria and fungi invade tissues, the body's defenses are unable to prevent the development of cellulitis (infection of the skin), abscesses (infection of soft tissue beneath the skin), or osteomyelitis (bone infection). The bacteria further destroy the blood supply to the foot causing death of infected tissues.

The Very Best Treatment is Prevention!!!

Prevention of Diabetic Foot Problems
Generally, the most effective means of preventing most of the problems of diabetes is the adoption of a healthy lifestyle. A healthy diet followed closely will help accomplish this. A regular exercise program will not only help control the disease, but will also help to establish collateral pathways in the heart and legs so that should blood vessels become blocked there are alternative pathways available to get the blood where it is needed. Diet and exercise will also help in weight control and will induce a feeling of well being. Cholesterol and lipid levels should be followed closely and treated when abnormal. High blood pressure must be controlled. The combination of diabetes and smoking is a lethal one.

There is No Choice. Don't Smoke!

Take Good Care of Your Feet

• Wash your feet with mild soap and warm (not hot) water at least once a day. Never put your feet in water without checking the temperature first. Pat your feet dry with a soft towel. Always dry well between the toes after bathing or swimming.
• If your skin is dry or cracked, use a moisturizing cream, but never put cream between the toes. Foot powders, particularly those with antifungal properties, may be used sparingly on both feet and in your shoes.
• Change your stockings daily. Never use old stockings that have been mended or which have prominent seams as these can injure the skin. Never wear shoes without stockings.
• Wear properly fitted shoes. Don't depend on the shoes to stretch or conform to your feet as you "break them in". If they are not comfortable when you buy them, they won't get comfortable by wearing them. Leather shoes are best because they allow your feet to "breathe". Always inspect the insides of your shoes
• Never go barefoot, even at home. Always wear shoes or slippers, especially in the dark.
• Do not do surgery at home. For some people the simple act of cutting toenails can become a surgical procedure. Be very careful to avoid injury to the skin while trimming the nails. Cut them straight across and not too short. Do not dig out the corners. Never try to remove ingrown toenails. This should be done only by a professional.
• Watch our for burns.
• Avoid foot swelling.

Specific Foot Problems

Corns and Calluses
Never let a callus build up. If you can't keep it down with a pumice stone, then see your doctor or podiatrist and have it trimmed. The heavy callus also indicates that the soft tissue under it is being damaged.

Neurotrophic Ulcer
This is caused by repeated trauma to the soft tissues of the foot. These are truly urgent problems. They are always infected and if left untreated the infection will penetrate deeper into the foot and even involve the bone.

Athlete's Foot
This is a common problem for a nondiabetics, but for a diabetics it is a serious problem that can be fatal.

Swelling and Redness of the Foot
Anytime these changes occur, a deep infection of the foot should be considered.

Ulcerated Heel and Ankle
The most common cause of ulceration on the heal or an ankle bone is pressure.

Gangrene
Gangrene means dead tissue. This is an end stage problem resulting from either severely impaired circulation, severe trauma, severe infection, or a combination of all. Don't wait until gangrene develops to seek medical attention.

Again, the very best treatment is prevention!