Diabetes Care: Down to the Feet
By John Lindsay, D.P.M.
Saint Anthony's Physician Group
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,” says John Lindsay, D.P.M., Podiatrist with Saint Anthony’s Physician Group. “All are more common in patients who have had diabetes 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. 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, neuropathy symptoms include a burning or pins and needles sensation in the limbs, particularly at night. “Eventually, 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,” Dr. Lindsay notes.
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.
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, according to Dr. Lindsay. “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.
“Diabetic foot care requires that you be a little obsessive,” he says. “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,” says Dr. Lindsay.
In addition to feet self-examination, the American Diabetes Association recommends a thorough foot examination by a 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 there are symptoms of neuropathy.
Keeping feet squeaky clean is essential. Wash them with soap and warm water every day, and dry them thoroughly with a soft towel.
Merely letting feet get wet in the shower is not good enough if someone has diabetes, but soaking their feet is not a good idea since it can cause skin to dry and crack. “Be aware that neuropathy may make skin less sensitive to water that is too hot so test the water with your elbow or a thermometer before getting your feet wet,” he says.
Lotion or moisturizing cream will help keep feet from getting too dry, but avoid the area between the toes since too much moisture there can lead to fungal infections. Change socks frequently, and make sure they don’t have wrinkles or big seams that irritate the feet.
Trim 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,” warns Dr. Lindsay. “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.”
For bunions, hammer toes or any other kind of foot deformity, fit becomes even more important. Custom orthotics or footwear prescribed by a doctor or podiatrist may be in order. He advises that individuals check their shoes for pebbles before putting them on and discard shoes when the inside lining becomes rough or frayed. “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,” he says.
Good foot care requires diligent control of blood sugar. According to the Diabetes Control and Complications Trial, individuals 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,” says Dr. Lindsay.
Dr. Lindsay specializes in the prevention, diagnosis and treatment of foot and ankle conditions, sports injuries, reconstructive foot and ankle surgery and plantar fasciitis. To make an appointment with Dr. Lindsay, call Saint Anthony’s Physician Group at 618/463-0227.