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 thatpeople with diabetes are hospitalized is because of a serious foot problem, toooften leading to amputation. Each yearmore than 60,000 people in the UnitedStates require a lower-extremity amputationbecause of diabetes. But even Elliot Joslin, MD, recognized as early as the1920s and 1930s, that amputation was not inevitable. With a team approach todiabetes care, amputation rates could be greatly reduced.
To decrease the possibilityof an amputation, people with diabetes must understand the causes that lead toamputation. Once you understand the causes, a foot care program can help you toprevent them.
According to theInternational Diabetes Federation, a group of 200 diabetes associations from158 countries, at least 246 millionpeople worldwide have diabetes, and the number may, conservatively, grow tomore than 380 million by 2025. Thecomplications 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 orhammertoes, trauma and infections. Approximately 15 percent of people withdiabetes develop foot ulcers, and these wounds precede 85 percent ofamputations. Diabetic neuropathy is regarded as the most consistentcomplication leading to a foot ulcer.
You can see that preventingfoot wounds, and healing them should they occur, are the two most importantways to avoid amputation. So what can you, as a person with diabetes, do toprevent a wound? A lot!
What You Can Do
First, decide to do whateverit takes to normalize your blood glucose levels. Tight glucose controldecreases the incidence of diabetic neuropathy, a primary reason foot ulcershappen. Tell the doctor that helps you with your diabetes that you want tightcontrol, and ask what you might need to change to achieve this goal. If youalready have diabetic neuropathy your podiatrist should be your bestfriend. Podiatrists have the trainingand tools to help keep numb feet intact.
Ask your podiatrist if youare 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 irregularityfixed. These deformities create pressureareas. If your feet are numb, or if youhave poor circulation, pressure spots can lead to a non-healing wound. Removing the abnormality, while yourcirculation is still good, may ward off a future ulcer and amputation.
Just the word surgery can bescary. Understand, however, that mostfoot surgery is done on an outpatient basis, under local anesthesia orsedation. Your foot surgeon will explainthe procedure to you and should review the pros and cons of the surgery. You should leave with an understanding of therisks of doing the procedure compared to the risks of living with the deformityand diabetes.
Ask if you need specialshoes or insoles. The Medicare systembelieves that foot protection with therapeutic shoes and custom shoe insertsare so important that it will pay for these devices on behalf of those whoqualify. Even soft, supportive running or walking shoes have proven valuablefor people with diabetes. Your foot specialist will be glad to advise you aboutappropriate foot protection.
And, while we are discussingshoes, 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 seeminglyminor injuries such as a bump or a cut on a toe. Fungal infections, viral infections andforeign bodies are lurking on all floor surfaces, just waiting for your barefeet. Also, wear good socks. The conceptthat 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 fromthe skin, keeping your feet drier. Sockswithout bulky toe seams are especially helpful for those with numb feet due toneuropathy. Some socks even have silver or copper woven in to the material.These minerals help combat germs and fungi.
Your medical doctor and yourpodiatrist should check your circulation often. There are pulses in your feet that your doctors should be able tofeel. If these pulses are absent or weakit may be a sign that blood is not flowing into your feet as well as it shouldbe. Other signs of peripheral vasculardisease (PVD) include color changes (red or blue appearance), loss of hair onthe toes, thick toenails, thin skin and a non-healing wound. PVD has shown to not only double the risk fora foot infection, but also increases the severity of an infection if oneoccurs. Testing for a decrease in bloodflow may include a Doppler test and a comparison of the blood pressure in yourarms and feet. If the circulation ispoor you should be referred to a vascular surgeon (circulation specialist) forcare. Want to prevent poor circulationbefore it’s too late? Keep your glucosewell controlled and exercise regularly.
Treating Foot Wounds
Since between 14 and 24percent of people with a foot ulcer will require an amputation, it is clearthat healing a foot wound will diminish the risk of having an amputation. There are numerous treatment options thatyour doctor has available to treat a foot wound. Certainly before considering amputation,all other more conservative treatment modalities should be tried orconsidered. According to an AmericanDiabetes Association consensus report these may include offloading,debridement, dressings, management of infection, vascular surgery, good glucosecontrol, improved nutrition and control of swelling.
Removing pressure from thewound, also called offloading, is crucial for wound healing. This may be accomplished by using crutches, awheelchair, shoe modifications, special pads or casting. Wounds heal faster ifdead tissue and callus are removed from the area, this is called debridement. (Do not ever do this by yourself ! Consult amedical professional for this procedure.) There are many dressing materialsavailable. Any dressing used must keepthe wound moist and should protect the area. Some materials also work todecrease the bacterial load of a wound and others add growth factors to speedwound closure.
If a wound is infected,either oral or intravenous antibiotics will be necessary. If your bloodcirculation is poor your podiatrist will refer you to a vascular surgeon whomay either bypass the clogged vessels or perform an angioplasty to open themup. Of course your diabetes doctorshould help in assuring that your diabetes is well controlled and that yournutrition is adequate to close the wound.
Finally, you must takeresponsibility for your own foot care. You must wear the shoes and inserts provided to you. You must keep your appointments forpreventive foot care with your podiatrist. You must examine your feet at least once a day and report changes toyour health care team. One study, in theJournal of Foot & Ankle Surgery,reported that noncompliant patients had “over a 50 times greater risk forulceration and a 20 times greater risk for amputation than the most high-riskmembers of the compliant group.” Keepingyour feet healthy and preventing amputation requires daily vigilance. With goodcare 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.