Diabetic Foot Care: Why It’s Important

What is Diabetic Foot Care and Why is it Important?

Diabetes is a condition that can cause a variety of health problems if it isn’t managed properly.
Multiple systems can be damaged if the glucose level in the bloodstream is not well regulated.
One of the most serious complications associated with diabetes is damage to the feet.
Some of the problems that Diabetes can cause in the feet are:

  • loss of sensation,
  • loss of circulation,
  • delayed healing,
  • joint damage,
  • Charcot foot,
  • Infected Ingrown Toenails,
  • foot and leg ulcers,
  • dangerous infections,
  • amputation.
If you like you can jump to a summary of things to do to keep your feet and yourself safe and healthy here.

That’s why it’s so important for people with diabetes to take good care of their feet.

With appropriate care, most of these problems can be prevented and you can have healthy feet for life.

A middle aged couple race each other over a hills in the countryside

How do Diabetic Foot Complications Occur?

Loss of Circulation (Blood Flow)

If blood glucose levels are allowed to be abnormally high for too long or uncontrolled for an extended period of time, they weaken the walls of the blood vessels that supply oxygen and nutrients to the feet.
This usually starts at the very smallest blood vessels called capillaries, in your toes and can move from there up the foot.
It’s the lack of circulation which is often the start of many of the other complications.

Loss of Sensation

The nerves of your feet are very important as a warning that something dangerous is happening e.g. you walk on something hot or sharp, the nerves tell you to get off it!
They also let us know if sores are developing when they are working well.
As the circulation to your feet decreases, the nerves don’t get enough of the nutrients they need to work properly.
This can often lead to tingling, burning, pins and needles, or pain for no reason in the early stages (neuropathic pain)
Then as it progresses it can lead to numbness in the toes and later, other parts of the feet.
This means that you lose that protective sensation and won’t know if something sharp, or hot has damaged your feet.
This will often mean that an open sore will go untreated, and as the feet are exposed to the elements, infections can take hold.
This can lead to very serious complications such as gangrene, which often means amputation is necessary, or blood poisoning (septicaemia) which can be life-threatening.

Delayed Healing

Healing of sores and cuts requires a good flow of blood to the area.
Blood carries the oxygen and the nutrients to help heal an area, as well as white blood cells which help to fight infection.
As the blood supply to the toes and feet diminishes, healing can take a lot longer, and in some instances, won’t happen at all.
This can leave you with a sore that needs to be cleaned and dressed several times a week to prevent infection from getting in and causing further damage or blood poisoning.

Joint Damage and Charcot Foot

Another complication of Diabetes that is not discussed very often, is damage to the joints of the feet and ankles.

This is called Charcot Joint or neuropathic arthropathy.

When nerves are damaged the joints aren’t as well protected and start to break down, particularly in the feet.

In severe cases, people will end up with a “Charcot Foot” where the arch totally collapse and the foot becomes like a rocker.
The problem with this is that rocker bottom feet are prone to developing ulcers beneath the bones that end up bearing weight they are not designed for.

Symptoms of a Charcot’s foot are heat, redness, and swelling. If you notice these symptoms, it is very important that you seek medical help immediately as they can be a sign of serious health conditions.

A Podiatrist can help with the management, treatment, and prevention of ulcers on the feet.

Charcot Foot showing that the bottom of the foot has become a rocker

Infected Ingrown Toenails

Ingrown toenails can happen to anyone, but they are a much higher risk factor in someone with poorly controlled Diabetes.

The body needs good blood supply to fight infections. Blood carries oxygen in its red cells but also carries infection fighting white cells. 

If there is a loss of circulation to the feet, the body will find it much harder to fight infections that occur in ingrown toenails. As mentioned earlier local infections can go further and cause a risk to life and limb (literally)!

 

An ingrown toenail showing pus, infection, redness, and swelling

Throw in a lack of sensation and you have a perfect storm. The person can’t feel any pain from the ingrown nail, and thus won’t be too worried about it, meanwhile the bacteria are multiplying and the body is poorly equipped to fight the infection.

Foot and Leg Ulcers

Ulcers on the feet and legs is a very serious condition that needs immediate attention from a podiatrist, doctor or nurse practitioner.

On the feet ulcers can form from a combination of factors including poor blood supply, slow healing, and poor nerve supply – all of which I’ve discussed above.

The great risk with neuropathic ulcers on the feet is that you may not know that they are even there! This is due to the damage to the nerves which would normally send pain messages from your feet to your brain when something is going wrong.

Most neuropathic ulcers are caused by repetitive stress. An area of skin which is under more than usual pressure, over time will cause callous.

Normally a person will seek help if the callous becomes sore, or the body may adjust the way you walk, sometimes without you even noticing.

A neuropathic ulcer on the bottom of the ball of a foot.

 

But when neuropathy (loss of sensation) is present a callous will get thicker and thicker until it causes the skin and the subcutaneous tissue (e.g. muscle, fascia) to break down.

This breakdown causes an ulcer which can then very easily become infected and can cause gangrene, and infection of the lymph or blood flow system. Unfortunately once things have got this bad, amputation is often required to save other parts of the body and ultimately, the patient.

Other wounds may start from direct damage to the tissue. I’ve heard of patients presenting to clinics with bottle caps, glass and other objects embedded in their feet cousin an ulcer.

I had a patient, who due to diabetic peripheral neuropathy, walked barefoot across a burning hot road and it stripped the skin right off the bottom of his feet!
This led him to have to endure many months of antibiotic treatment to avoid infection of the wounds and repeat dressings to keep them clean and dry.

Infections and Amputations

As I’ve mentioned in a couple of the sections above, infections are one of the greatest risks to diabetic foot health.

A study found that in two thirds of cases of amputations, infection was a major component.

One of the most dangerous types of infection is osteomyelitis or infection which has infiltrated the bone.

Unfortunately once the bone has become infected it is very hard to resolve the infection without amputation.

Amputation is only performed when the risk to the patient is high. By amputatin the surgeons are able to save the rest of the foot and leg, and prevent the patient from getting a blood borne infection.

Unfortunately once someone has had an amputation, they are at much greater risk of another amputation being required in the future.

Another reason for doing whatever we can to prevent someone from having an amputation is that studies have found that between 40-90% of people wil die within 5 years of having an amputation of any size due to diabetic neuropathy. (Thorud et. al. 2016).
One caveat that the researchers mentioned was that they couldn’t tell if people were dying due to the amputation, or because the disease was so advanced that amputation and death were incidental.

How to Prevent Diabetic Foot Problems from Developing

So it should now be clear why it’s so important for people with diabetes to take good care of their feet.

Luckily there are several steps that you can take to make sure that you avoid getting diabetic foot problems and have healthy feet for life!

Here are some tips for preventing foot problems:

  • Keep good blood glucose level control. This is the first thing to look at. If your blood sugars are well controlled, you are nowhere near as likely to develop diabetic foot complications.
    So whether your diabetes is controlled by diet and exercise alone, or you take oral medication or are injecting insulin, keep an eye on you levels.
    Keeping a diary is a great way to stay on top of this, that way you will notice changes and can bring them up with your doctor who may then adjust your treatment accordingly,
  • Exercise regularly to improve blood circulation.
    Exercise that involves using the calf muscles is best as the calf works like a pump to keep moving the blood around your body.
    So walking, running, or riding a bicycle are some of the best exercises.
    Tip: when sitting down for longer than 20 minutes, move your feet up and down for about a minute at regular intervals. This will help promote good circulation and also reduce swelling in the legs and ankles.
  • See a podiatrist at least once a year if you have good circulation and sensation. If you have any diabetic foot problems you may be asked to see your podiatrist at more regular intervals to make sure that things don’t get out of hand.
  • Check your feet every day for cuts, blisters, or other signs of injury.
    Detection is key to preventing problems from getting worse.
    As soon as you notice any redness, swelling, leakage of blood, pus or other fluid, or pain – seek medical help as soon as possible.
    Tip: If you have trouble seeing the bottom of your feet and no one else is able to help, place a small mirror on the floor and check them that way.
  • Keep your feet clean and dry. Sounds very simple but this one is very important. bacteria, funguses and yeast tend to like dirty, dark, moist and warm areas to grow in.
    The two we can control are moisture and cleanliness. Make sure you clean and dry between your toes every day.
    You can buy simple appliances to help you to get between the toes if you are unable to reach them easily and safely.
  • Wear shoes and socks as often as possible.
    I know that in hot climates like Queensland there is a great temptation to go either barefoot or to wear thongs (flip flops).
    But protecting your feet, especially if you have loss of sensation or circulation, is crucial to keeping your feet healthy and safe.
    Try to choose footwear that is breathable (mesh uppers are good) and also try to buy socks that are made of cotton or bamboo. Bamboo is claimed to be very good at wicking away the sweat from your feet.
  • Trim your nails regularly if you are able to do safely.
    If not, see a podiatrist on a regular basis to make sure that your toenails and any callouses or corns are kept well under control.
  • Don’t smoke. Smoking decreases blood flow to the feet and makes it more difficult for wounds to heal. If you have diabetes and smoke, you’re at especially high risk for developing foot problems.

How can a Podiatrist Help with Diabetic Foot Care?

Podiatrists are the primary care givers for the lower limb, so they are very important in preventing and managing diabetic foot problems.

Some of the things that Podiatrists can help you with are:

  •  Regular monitoring of your sensation perception and blood circulation.
    We use special tools including a doppler ultrasound to listen to your pulses for their strength, regularity and phases (in healthy arteries you will hear 3 phases or noises, in less healthy there are 2, and then only 1).
    At Dynamic Podiatry we also use a PPG (photoplethysmographer) which lets us hear the flow in the tiniest blood vessels in your toes.

We even do a blood pressure reading on your big toe! This helps us to see how strong the flow of blood is into your feet. If it’s getting to the end of your big toe, then it’s getting to the rest of your foot.
Studies have found that this is one of the most accurate methods of detecting circulation issues.

A podiatrist is performing a test of a patient's blood flow
  • Regular treatment of your nails and skin.
    As mentioned earlier, it is crucial that your nails are kept quite short, and that they don’t have any sharp edges. A podiatrist uses special clippers that can get through the toughest nails, and special burrs and files to round the edges.

A podiatrist works on an ingrown toenal.

We can also help to prevent ingrown toenails, another common cause of infection in people with diabetes.
The skin can develop callouses and corns over time if there is extra pressure or shearing on particular areas. We are able to debride (remove) any callouses and corns that are likely to cause a problem if left untreated.

  • Regular treatment of your nails and skin.
    As mentioned earlier, it is crucial that your nails are kept quite short, and that they don’t have any sharp edges. A podiatrist uses special clippers that can get through the toughest nails, and special burrs and files to round the edges.
    We can also help to prevent ingrown toenails, another common cause of infection in people with diabetes.
    The skin can develop callouses and corns over time if there is extra pressure or shearing on particular areas. We are able to debride (remove) any callouses and corns that are likely to cause a problem if left untreated.
  • Managing neuropathic foot ulcers.

    As I mentioned earlier, diabetic foot conditions including loss of protective sensation can lead to ulcers forming on the feet and toes.

    Podiatrist have the skills, tools, an dressing materials to manage foot ulcers.
    Sometimes it may be necessary to get treatment of ulcers every week, or even several times a week to get them under control.

     

  •  Offloading of pressure areas to prevent or manage ulcers.
    By using different materials such as felts, foams or even custom foot orthotics, Podiatrists can help to alleviate the pressure on certain areas of the feet.
    Typically it will be bony prominences that have the most amount of pressure and are at risk of ulceration. By cutting holes into materials we can allow the affected area to sit in a bit of an aperture so that the surrounding skin shares the load, making it much less likely to ulcerate.
  • Footwear advice.
    Podiatrists are able to give advice on what is the safest and most healthy footwear for your individual feet. Everyone is different, and that’s why footwear is never a “one fits all” situation. Some people will need extra width at the forefoot to prevent pressure on bunions, whereas others might need extra depth in the toe-box to accommodate clawed or hammer toes.
    Good footwear advice can help to prevent ulcers from developing, reduce the risk of falls, and reduce the chances of infection taking hold.

Summary of What You Can Do To Prevent Diabetic Foot Complications.

That’s been a lot of information!
So I’m going to give you a quick summary of the most important things you can do to keep you and your feet safe.

  1. Always wear enclosed shoes and socks,
  2. Wash and dry your feet thoroughly,
  3. Check your feet every day or get someone else to,
  4. If you see any problems or signs like – redness, swelling, pus, blood, smell – get to a doctor or podiatrist immediately! This is one of the biggest tips,
  5. See your Podiatrist regularly! They know the diabetic foot inside out and can keep you out of the surgeons office.
The Dynamic Podiatry Team. 3 ladies and 2 men.

We want to help you and your feet to stay active and healthy! If you have Diabetes and haven’t had your feet checked for more than 12 months, or if you are experiencing complications of Diabetes, give us a call on 3351 8878 or book online.

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