Foot Complications of Diabetes – Diabetes is a chronic disease, which can damage a whole range of body tissues and organs leading to increased morbidity. People with diabetes are prone to foot problems leading to formation of ulcers and amputations. Foot ulcers and amputations are the most common reasons for hospitalisation, disability, as well as emotional and physical costs among people with diabetes. While most people with diabetes take adequate care to protect eyes, kidneys and heart from the vulnerable effects of abnormal sugar levels, the foot is often neglected. Estimates suggest that more than 15% of people with diabetes develop foot problems. The Chennai Urban Population Study (CUPS) conducted by us at the Madras Diabetes Research Foundation and Dr. Mohan’s Diabetes Specialities Centre at Chennai revealed that nearly 25% of amputations were among people with diabetes. In fact 50% of the hospital admissions at our Centre are due to diabetes related foot problems.

RISK FACTORS FOR FOOT PROBLEMS:

Children or young adults (who usually have Type 1 diabetes) are not at great risk of diabetes related foot problems in the early years as their nerves and blood vessels will not have been severely affected by diabetes. They should be encouraged to play sports or undertake the activities they normally do. The risk of ulcers or amputations in individuals with diabetes is higher in males, in those with poorly regulated diabetes or in those who have eye, kidney or heart complications. In addition, as the duration of diabetes becomes longer (e.g. greater than 10-15 years) and the person becomes older (e.g. older than 40-50 years), progressively more care is required. People with Type 2 diabetes can get foot problems even soon after diagnosis because they might have had diabetes for a long time without their knowledge.

COMMON PROBLEMS IN DIABETIC FOOT:

Foot Complications of Diabetes due to:

• Neuropathy (nerve damage)
• Peripheral vascular disease (Poor blood circulation)
• Infections

Neuropathy

Neuropathy (nerve damage) is a common complication of diabetes, reducing the ability to detect sensations and predisposes an individual to injuries and trauma. Any weight bearing area without adequate protection tends to develop thickening of skin called a callus (“corn”). These can break down and lead to ulcers. The patient is usually unaware of this due to nerve damage.

Neuropathy may also affect the muscles of the foot causing clawing of the foot. Charcot foot is one of the deformities that result from trauma to the insensitive foot, due to which the arch of the foot collapses. Deformities make the feet more vulnerable to infection. The main symptoms of diabetic neuropathy are numbness and loss of sensation in the feet. The patient may feel that he is walking on cotton wool or on a mattress. Often the legs may feel like a “log of wood”. There are instances where footwear can fall off and yet the patient is unaware of this. Some have even had their toes nibbled off by rats while sleeping on the ground at night and they were unaware of it! Other patients complain of pins and needles, pricking sensation, burning of feet or even severe pain in both feet. These symptoms often begin gradually. In some cases the skin may become so sensitive that even the slightest touch is painful.

Peripheral vascular disease:

Diabetes can also affect blood circulation, which can affect the ability of the body to heal when damage occurs. Reduction in blood circulation to the feet restricts delivery of oxygen and nutrients that are required for normal maintenance and repair, which would result in slow healing of foot injuries, infection or ulcerations. Sometimes, poor circulation can result in ischemic foot and gangrene (cell death). It has been demonstrated that smoking decreases blood flow to the feet.

The symptoms include:

• Cramping pain in the foot muscles (usually at the calf) while walking, that improves on rest
• Cramping or pain at rest
• Absence of foot pulses
• Skin may become thin and shiny
• Loss of hair on the foot and ankle
• Colour and temperature changes
• Non healing ulcers
• Foot infection that is hard to heal

Infection:

Diabetes also alters the immune system, thus decreasing the body´s ability to fight infection. The body’s processes that normally fight infection respond slower and often have trouble getting to the site of infections due to poor circulation. Due to loss of sensation, infections often worsen and may go undetected. Infection to diabetic foot ulcers may be either superficial or deep and sometimes life threatening. Common symptoms of infection are fever, redness, swelling or pain. Pus may also be seen in the lesions.

Prevention from Foot Complications of Diabetes

To prevent diabetic foot problems, routine integrated examination of the feet is mandatory. Biothesiometry for detecting neuropathy, a diagnostic technique that is quick, simple to perform, and noninvasive help to detect and quantify early sensory loss in patients with diabetes. Peripheral Doppler assesses circulatory disorders and Foot Pressure Distribution Measurement measures the pressures in regions that are prone to get calluses and corns in the foot.

✓ DO’s AND ✗ DONT’S FOR FOOT CARE

• Examine your feet daily for blisters, bleeding, and lesions between your toes; use a mirror if it is difficult to see the entire foot
• Keep the feet clean by washing daily with lukewarm water and soap
• Avoid extreme temperatures
• Dry your feet carefully and pay special attention to the spaces between the toes to prevent athletes foot
• Nails should be trimmed straight across with nail clippers or nail scissors
• Use correct footwear
• Have regular foot examinations
• Do not walk barefoot
• Do not sit cross legged for long time
• Do not cut corns / calluses with blade or knife. Home surgery is dangerous
• Do not smoke
• Don’t use hot water bottles or heating pads, one can burn the feet without realizing it
• Don’t soak the feet since this dries out natural oils

In summary, although foot problems in diabetes cannot be eradicated completely, the opportunity exists to diagnose and manage them effectively by a multidisciplinary approach that focuses on prevention, education, regular foot examinations, aggressive intervention, and optimal use of therapeutic footwear to reduce the incidence of morbidity associated with foot complications.