A Diabetes Health advisory board member offers advice on how to treat your feet well and avoid wounds and infections that could lead to amputation. 

The most frequent reason that people with diabetes are hospitalized is because of a serious foot problem, too often leading to amputation.  Each year more than 60,000 people in the United States require a lower-extremity amputation because of diabetes. But even Elliot Joslin, MD, recognized as early as the 1920s and 1930s, that amputation was not inevitable. With a team approach to diabetes care, amputation rates could be greatly reduced.

 
To decrease the possibility of an amputation, people with diabetes must understand the causes that lead to amputation. Once you understand the causes, a foot care program can help you to prevent them.

According to the International Diabetes Federation, a group of 200 diabetes associations from 158 countries, at least 246 million people worldwide have diabetes, and the number may, conservatively, grow to more than 380 million by 2025.  The complications of diabetes that may lead to amputation are: diabetic neuropathy (a decrease in sensation or numbness of the feet), peripheral vascular disease (poor circulation), ulceration (foot sores), deformities such as bunions or hammertoes, trauma and infections. Approximately 15 percent of people with diabetes develop foot ulcers, and these wounds precede 85 percent of amputations. Diabetic neuropathy is regarded as the most consistent complication leading to a foot ulcer.

You can see that preventing foot wounds, and healing them should they occur, are the two most important ways to avoid amputation. So what can you, as a person with diabetes, do to prevent a wound? A lot!

What You Can Do

First, decide to do whatever it takes to normalize your blood glucose levels. Tight glucose control decreases the incidence of diabetic neuropathy, a primary reason foot ulcers happen. Tell the doctor that helps you with your diabetes that you want tight control, and ask what you might need to change to achieve this goal. If you already have diabetic neuropathy your podiatrist should be your best friend.  Podiatrists have the training and tools to help keep numb feet intact. 

Ask your podiatrist if you are a candidate for preventive surgery.  If you have a foot deformity such as a bunion, hammertoe, Charcot foot, corns or calluses, seriously consider early surgery to have this irregularity fixed.  These deformities create pressure areas.  If your feet are numb, or if you have poor circulation, pressure spots can lead to a non-healing wound.  Removing the abnormality, while your circulation is still good, may ward off a future ulcer and amputation.

Surgery

Just the word surgery can be scary.  Understand, however, that most foot surgery is done on an outpatient basis, under local anesthesia or sedation.  Your foot surgeon will explain the procedure to you and should review the pros and cons of the surgery.  You should leave with an understanding of the risks of doing the procedure compared to the risks of living with the deformity and diabetes.

Ask if you need special shoes or insoles.  The Medicare system believes that foot protection with therapeutic shoes and custom shoe inserts are so important that it will pay for these devices on behalf of those who qualify. Even soft, supportive running or walking shoes have proven valuable for people with diabetes. Your foot specialist will be glad to advise you about appropriate foot protection.

And, while we are discussing shoes, wear them!  At the beach, at home, while in the locker room at the gym – wear foot protection at all times.  Many hospitalizations result from seemingly minor injuries such as a bump or a cut on a toe.  Fungal infections, viral infections and foreign bodies are lurking on all floor surfaces, just waiting for your bare feet. Also, wear good socks.  The concept that cotton socks are best is not true.  Look for socks made of a material such as acrylic or Cool Max™.  These materials wick perspiration away from the skin, keeping your feet drier.  Socks without bulky toe seams are especially helpful for those with numb feet due to neuropathy. Some socks even have silver or copper woven in to the material. These minerals help combat germs and fungi.

Your medical doctor and your podiatrist should check your circulation often.  There are pulses in your feet that your doctors should be able to feel.  If these pulses are absent or weak it may be a sign that blood is not flowing into your feet as well as it should be.  Other signs of peripheral vascular disease (PVD) include color changes (red or blue appearance), loss of hair on the toes, thick toenails, thin skin and a non-healing wound.  PVD has shown to not only double the risk for a foot infection, but also increases the severity of an infection if one occurs.  Testing for a decrease in blood flow may include a Doppler test and a comparison of the blood pressure in your arms and feet.  If the circulation is poor you should be referred to a vascular surgeon (circulation specialist) for care.  Want to prevent poor circulation before it’s too late?  Keep your glucose well controlled and exercise regularly.

Treating Foot Wounds

Since between 14 and 24 percent of people with a foot ulcer will require an amputation, it is clear that healing a foot wound will diminish the risk of having an amputation.  There are numerous treatment options that your doctor has available to treat a foot wound. Certainly before considering amputation, all other more conservative treatment modalities should be tried or considered.  According to an American Diabetes Association consensus report these may include offloading, debridement, dressings, management of infection, vascular surgery, good glucose control, improved nutrition and control of swelling.

Removing pressure from the wound, also called offloading, is crucial for wound healing.  This may be accomplished by using crutches, a wheelchair, shoe modifications, special pads or casting. Wounds heal faster if dead tissue and callus are removed from the area, this is called debridement. (Do not ever do this by yourself ! Consult a medical professional for this procedure.) There are many dressing materials available.  Any dressing used must keep the wound moist and should protect the area. Some materials also work to decrease the bacterial load of a wound and others add growth factors to speed wound closure. 

If a wound is infected, either oral or intravenous antibiotics will be necessary. If your blood circulation is poor your podiatrist will refer you to a vascular surgeon who may either bypass the clogged vessels or perform an angioplasty to open them up.  Of course your diabetes doctor should help in assuring that your diabetes is well controlled and that your nutrition is adequate to close the wound.

Finally, you must take responsibility for your own foot care.  You must wear the shoes and inserts provided to you.  You must keep your appointments for preventive foot care with your podiatrist.  You must examine your feet at least once a day and report changes to your health care team.  One study, in the Journal of Foot & Ankle Surgery, reported that noncompliant patients had “over a 50 times greater risk for ulceration and a 20 times greater risk for amputation than the most high-risk members of the compliant group.”  Keeping your feet healthy and preventing amputation requires daily vigilance. With good care your feet can last a lifetime.

Neil M. Scheffler, DPM, FACFAS, is co-author of the American Diabetes Association book “101 Tips on Foot Care For People With Diabetes”. He is board certified in foot and ankle surgery, and practices podiatry in Baltimore, MD. Dr. Scheffler is a past President, Health Care & Education, American Diabetes Association, Mid-Atlantic Region. He is also a member of the Diabetes Health advisory board. Possible Sidebar)

Tips For Home Care Of The Diabetic Foot
 

• Inspect your feet daily.  Let your podiatrist or diabetes doctor know of any problems. If necessary, use a mirror to see the bottoms. Poor vision?  Have a family member or friend help.
• Wash and dry feet carefully every day, but do not soak them.  Test water temperature with your hand, elbow or thermometer before immersing feet. Keep your feet clean and dry.
• Lubricate feet daily with a cream or lotion, but not between toes.
• Do not smoke.
• Never walk without shoes.  Always wear socks.
• Choose shoes and socks with care.  Ask your foot specialist for advice.
• Never use over-the-counter medications on your feet without asking your health care professional first.
• Make sure your doctor examines your feet at every visit.  Taking your shoes and socks off will help remind him/her to do this.
• Avoid excesses of heat on your feet.  Do not use hot water bottles or heating pads.
• Check inside your shoes daily for tears in the lining and foreign objects.
• Never treat corns or calluses yourself. See your podiatrist instead.
• Cut nails straight across and file to the shape of your toes.
• See a foot specialist at least once a year.  Tell the doctor that you have diabetes.