Having Diabetes puts one at risk of potentially having foot problems. There are a collective number of reasons that attribute to these concerns. Numbness caused by nerve damage (diabetic neuropathy) this results in a decrease in sensation therefore damage to the foot can occur and not be detected. In addition, poor circulation to the legs and feet reduces the healing process when damage occurs. Wounds that do not heal ultimately become foot ulcers. Diabetic foot ulcers may become infected and can subsequently turn gangrenous because of poor circulation. Non-healing foot ulcers are the most likely cause of amputation in people with diabetes.
Why a Podiatrist?
Regular foot checks and routine foot care from a Podiatrist is vital in preventing symptoms from developing. Nail care, callous and corn management. Diabetic assessments are performed for neurological and vascular screening to monitor the effects of diabetes on your feet.
What is Diabetes?
Diabetes (mellitus) is a chronic disease that can affect people of any age. There are predisposing factors for the onset of diabetes such as genetic history, weight, regular exercise, diet and age. Insulin is a hormone that helps the body metabolise sugar in the diet. Depending on the type of diabetes (Type 1 or Type 2) the body either produces less or no insulin (Type 1), or the body tissues are resistant to the effects of insulin (Type 2). This results in elevated blood sugar levels which is the cause of Diabetes.
Podiatrists use a simple and painless method to check nerve function in the clinic. Neuropathy results in a decrease in sensation in the feet therefore the body’s nerves in the feet do not function properly. It can be due to poor glucose control or compromised blood flow to the nerves. There are three kinds of nerves: sensory, motor and autonomic, which will be explained below. Diabetic neuropathy is usually symmetrical and is progressive – it worsens with the duration of the disease. It is often not noticed as it progresses, and it is underestimated and underemphasized. It is one of the main causes of amputations.
The nerves that respond to touch, temperature, pressure and pain send messages to the brain. When the sensation is altered the message to the brain will indicate that. Sensory neuropathy may result in paraesthesia where the brain interprets ordinary sensations like touch as painful. This is worse at night and at rest and is relieved by movement. Standard tests for sensation will be nearly normal. Sensory neuropathy can also cause anaesthesia where sensations are dulled or not felt at all. This is obviously not painful but position sense and balance are affected. Sensory neuropathy can make injury more likely as your normal protective responses don’t occur (The response reflex is lost). It can lead to an injury not being noticed and therefore not cared for (You could stub your toe, breaking the skin and not feel it, you will only be aware of it when you see the blood). It can stop your immune and repair systems from detecting an injury and coming to fight infection or repair skin properly.
Neuropathy at the motor nerves (These allow movement) can cause muscles to become inactive and waste away. This causes muscle imbalances and bony joint deformities. Claw toes are so common in the diabetic foot as a result of this. Your Gait pattern will change and areas of excessive pressure will be found under the feet. Calluses and corns are the result.
The autonomic nerves control the actions that you are not in control of. For example, the beating of the heart. In the feet, they control sweating, blood flow, repair and healing. Loss of sweating leaves feet dry and cracked. This results in cracks in the skin which may become infected. When blood flow becomes impaired to the foot, the required amount of oxygen is not available for tissue repair, this will result in infection.
Peripheral Vascular Disease (PVD)
Your podiatrist or doctor should assess the arteries in the foot at regular intervals using a Doppler ultrasound machine. Physical inspection of the foot is as important. A foot with poor blood flow will have little hair growth. The skin is frail shiny, pale in color and thin with a loss of fatty tissue below the skin. The pulses are weak. The foot will be pale when elevated and mottled red / purple when hanging down.
Cholesterol plaques in arteries are more common in diabetics. This is as a result of fat and glucose being increased within the artery walls. The collagen within artery makes the walls stiffer. Arteries are then more likely to have the irregularities that first allow blood to clot within the vessel. Blood clots within vessels can come loose and cause the death of any tissue downstream of the blockage. Thickening of artery walls reduces blood flow to tissues, which results in a reduction of oxygen to the skin and flesh. This restriction limits antibiotic medicine and white blood cells from getting to the site of infection, therefore the delays in wound healing. This ultimately results in amputation.
Common structural problems in the feet are bunions, retracted or clawed toes, prominent metatarsal heads (the knuckles on the bottom of the ball of the foot) and areas of increased pressure that lead to corns, callus or ulceration. Those with diabetes can suffer from glycosylation of collagen. This means that the abnormally high blood sugar causes the soft tissue, muscles and like joint capsules, to stiffen up and contract. This results in pressure areas which ultimately ulcerate.
Charcot’s disease (Neuropathic arthropathy) is almost exclusively to diabetics. It occurs when the nerves that run into a joint lose the ability to report back to the brain and the brain is unable to sense when the joint is being used incorrectly. This can result in the joints, particularly one just below the ankle, being destroyed. There is a long build up to Charcot’s disease but the damage occurs very quickly. A joint can go from working fairly normally to being ruined in one day.
With the loss of motor and sensory nerve functions minor traumas such as sprains and stress fractures go undetected therefore untreated, leading to ligament laxity (slackness), joint dislocation, bone erosion, cartilage damage, and deformity of the foot. The bones most often affected make up the midfoot. If you suffer from neuropathy in the feet, you must see your podiatrist and have foot function monitored. If no damage has occurred yet, a foot support called an orthotic can dramatically reduce a Charcot’s episode from occurring. If it is too far advanced, an orthotic can help to make the position in which the foot will be permanently positioned a more functional position. If the foot is already trapped in a compromised position, parts of the foot will be bearing a lot of pressure. A different type of orthotic can be used to make these pressures more normal.
What Will the Podiatrist Assess?
- Foot Pulses – physically or by Doppler ultrasound.
- Skin – the texture, hair presence, and pressure marks corns & calluses, as well as temperature.
- Spaces between toes – Tinea (fungal infections) and skin splits.
- Nails – Ingrown, thickening, discoloration and fungal.
- Deformity – pressure areas.
- Footwear – Fitting and pressure.
- Neurological examination – monofilament assessment (for sensation) and vibration perception.
- Gait – altered walking patterns create an imbalance resulting in pressure areas.
- Range of motion – Are the joints in your feet restricted or at risk?
- Dry skin – leads to cracks and allows bacteria to enter through the skin resulting in infection.
Footwear can protect the foot against injury or cause the injury. Shoes should be comfortable straight away.
- Buy shoes later in the day when your feet are swollen and strained.
- Have shoes fitted. If sensation is affected, you may not be able to properly assess the fit.
- Stand when trying on shoes as feet are longer when standing.
- Expensive does not automatically mean good.
- Extra depth shoes are available at specialty shoe stores. They are higher in the toe box and heel allowing more
- room for your feet.
- Shoes will not stretch on a stitch line. Avoid stitch lines over any bony area, such as joints.
- Wear a good quality sock when going for long walks and long periods of standing.
- Do not buy off the shelf orthotics. Have the correct assessment done by your podiatrist.
- Wear new shoes in slowly. Examine your feet immediately after taking the shoes off for rubbed pressure areas.
- Feel inside shoes before putting them on. Items may have fallen into shoes (surprisingly common) or shoe nails or lining may be protruding or torn. Throw out socks with holes. Do not repair them.
- Throw out shoes with holes in the lining.
- Socks should not be too small or too big. Wrinkles cause blisters.
- Ill fitting footwear causes problems, too big are just as dangerous as too small.
- Shoes should allow your foot to move slightly in your shoes. Your toes must be allowed to move.
- There are various lacing technique to keep shoes snug on feet.
- Make sure the tongue of the shoe is in the correct position before tying the laces.
- Do not wear the same pair of shoes every day, alternate them.
- Thongs, if your foot is working to keep the thong in place, do not wear them.
The “to Do” and “Not to Do” for Diabetics
- Always know your blood glucose levels.
- Inspect your feet daily. If you are vision impaired try to feel your feet.
- Wash your feet daily and dry well between toes.
- Wear appropriate footwear.
- Have corns and callus regularly removed by your Podiatrist.
- Wear orthotics correctly if prescribed for you.
- Look after dry skin with an appropriate moisturizer. Do not use greasy preparations they do not penetrate dry skin.
- Do not cut your own toe nails if you do not have to. If your nails are not perfectly normal seek advice from your podiatrist. If there are no concerns with your nails, cut the nails following curve of toe, do not cut down the side of the nail.
- Have a plan of action should a problem develop with your feet.
- Always inform your carer and your podiatrist, that you have diabetes.
- Keep blood fats under control through diet, drugs and maintaining healthy weight.
- Exercise regularly to prevent weight gain and assist in improving circulation.
- See a podiatrist at least once a year for assessment.
- Have an eye and kidney examination as they can indicate problems in feet and vice versa.
- Drink alcohol to excess.
- Use any chemist preparation to treat corns and callus. They are chemicals that cause burns.
- Go barefoot.
- Cut skin on your feet, see your Podiatrist.
Do You Have Neuropathy?
- Beware of temperature extremes. Don’t use hot packs or cold packs, don’t put feet close to radiators or fires, don’t get sunburned and be aware of what surfaces might be hot. Remember how hot the sand used to get when you were a child? Concrete paths, balcony rails etc are still just as hot and can cause a severe burn, even if you can’t feel it.
- Don’t test water temperature with feet or soak in a hot foot bath.
- Don’t soak in any foot bath.
- Do not go barefoot inside or out.
- Don’t use pumice stones.
- Be wary of ripping skin with strong sticking plaster.
- Do not wear thongs.
- Don’t use garters or socks so tight that there is a visible mark on removal.
- Inspect shoes before putting on every time.
- Finally, remember that looking after your feet mostly involves looking after yourself as a whole. Controlling your blood sugar, cholesterol, blood pressure and body weight will have the biggest effect on how you fare in the long term.
Why Are Feet Important?
People with diabetes are at risk of foot problems due to numbness caused by nerve damage (diabetic neuropathy). With diabetic neuropathy, damage to the foot can occur and not be detected. In addition poor circulation to the legs and feet slows the healing process when damage does occur. Wounds that don’t heal may form foot ulcers (skin sores). Diabetic foot ulcers often become infected and can subsequently turn gangrenous because of poor circulation. Non-healing foot ulcers are a frequent cause of amputation in people with diabetes.
What Are the Risk Factors Which May Cause Foot Ulcers?
- Previous history of ulceration.
- Poor circulation.
- Poor foot care.
- Foot deformities e.g. claw toes, hammer toes which cause pressure lesions.
- Unsuitable footwear e.g. shoes that are too tight may rub or cut your feet.
How Can You Look After Your Feet Yourself?
- Wash your feet daily in luke warm water (not hot) with mild soap. Dry them well, especially between the toes.
- Check your feet daily for cuts, sores, blisters, redness, calluses, or other problems. You may need a mirror to look at the bottoms of your feet.
- If your skin is dry, rub lotion on your feet after you wash them. Do not put lotion between your toes.
- Cut your toenails when needed. Cut them to the shape of the toe and not too short. File the edges with an emery board. File corns and calluses gently with an emery board or pumice stone. If you are unable to reach your feet your podiatrist is happy to help.
- Always wear closed in shoes or slippers to protect your feet from injuries. Wear shoes that fit well and always wear socks or stockings to avoid blisters. Before putting your shoes on, feel the insides for things like gravel or torn linings. These things could rub against your feet and cause blisters or sores.
When You Need to See a Podiatrist?
- 6-12 monthly podiatry reviews are required for patients with no neuropathy.
- 6 month podiatry reviews are required for patients who have neuropathy but no foot deformities.
- 2-3 month podiatry reviews are required for patients with both neuropathy and foot deformities.
- 1-2 month podiatry reviews are required for patients with neuropathy, foot deformities and a history of ulceration.
Support and Assistance
For general information on understanding diabetes ‘click here’
Newly Diagnosed Type 1
Membership to Diabetes Australia can be helpful for support and information. Click here for their website.
Click here for The Queensland based diabetes association website.
Support for adults by other adults with type 1 diabetes can be found on the “reality check” website.
Newly Diagnosed Type 2
Membership to Diabetes Australia can be helpful for support and information.
The Queensland based diabetes association website.