Injury to the foot of a diabetic is the number one cause for amputation to occur and it is 15 times more likely for a diabetic patient to undergo an amputation then a non diabetic. The leading causes of foot disease associated with diabetes include ischemia, infection and sensory neuropathy. Approximately 80% of the patients with a diabetic foot ulcer have peripheral neuropathy. The chances for a foot injury increase due to the lack of ability to feel pain, heat and pressure on the feet. Wound healing is also slowed in the diabetic patient due to the impairment of blood flow.
Hammertoes are found with approximately 50% of those with diabetes; this is a deformity that is created due to motor neuropathy. Hyper-extension occurs in the toes increasing pressure to the metatarsal heads and causing ulceration. This is further complicated because the shifting and thinning of the fat pad beneath the metatarsal heads becomes thin and the cushion is lessened putting these areas at risk for ulceration. The patient is at risk for ulcers, infection and callus formation to occur. Hallux valgus, the abnormal turning of the big toe, also occurs with diabetic patients.
Yet another complication to the diabetic foot is the Charcot foot. This is a diabetic deformity. With Charcot foot the foot becomes painful, swollen and warm. If the foot is continued to be used for walking the result is a collapsed arch and the bottom of the foot becomes rocker shaped.
With sensory neuropathy the ability to regulate skin temperature and normal sweating is lost causing the skin to become dry and atrophic. When these abilities are lost cracks and fissures form putting the patient at risk for infections.
When the sensation is lost the diabetic patient is at risk for injury to the foot due to physical injury, chemical injury, and thermal injury. Without sensation often times these injuries are not treated. There are many things that a diabetic should be aware of that can cause foot injuries; walking bare foot, shoes that don’t fit properly, thermal burns from heaters, hot pads, and water, and caustics burns due to over the counter medication to treat corns. Amputation is often the result of these injuries due to poor circulation.
Ulcers result from continued pressure to an area. Most ulcers on the diabetic foot are found around or over the great toe, beneath the heads of the metatarsals and to the tops of claw toes. Planter ulcers located on the bottom of the foot are caused from walking and or standing. Ulcers located on the top or sides of the foot are often due to pressure from the shoe.
Any break in the skin is a source for infection but for the diabetic patient it could be the beginning of an amputation. Skin breakdown tends to happen with repetitive and excessive pressure. Infection in the diabetic foot is difficult to treat due to poor circulation and decreased immune function. With infection the glucose control is impaired causing higher blood sugar levels and reducing immune defense mechanisms.
All people with diabetes need to wear shoes that protect the foot from injury. The diabetic patient should have shoes fitted by certified podiatrist. Shoes should be one half to five eights inch longer then the patient’s longest toe. Heels should not be higher then 2 inches to keep the body weight from shifting and applying pressure to the metatarsal heads, increasing the risk of ulcers. Shoes that are too tight cause damage to the tissues if worn for more than 4 hours with out relief. Shoes should be changed mid day and evening. The patient with toe deformities will need to purchase custom shoes with wide and high toe boxes and extra depth. Those with Charcot foot will need molded shoes. All new shoes need to have a break in period where the patient periodically removes the shoes and visually inspects to feet for irritation and blisters.
Stocking and socks need to fit well and be appropriate for whatever activity is planned. Stockings should be free of seams, creases and holes to prevent irritation to the skin. Avoid stocking that are tight and have constricting bands.
The following is a list of foot care procedures all diabetics need to adhere to.
1. Feet should be inspected for dryness, cracking, lesions, corms, calluses, deformities and edema.
2. Shoes should be inspected for proper fit.
3. After bathing dry carefully between the toes.
4. Lotion feet
5. Keep nails clean
6. Use moister absorbing power as indicated
7. Have a usual foot care routine
8. Inspect inside of shoes for rough areas.
9. Monitor the temperature of the feet by using the back of hand.
10. Normal thickness nails can be cut when soft by using toenail clippers and the curve of the toe nail as a guide.
11. For thickened nails see a podiatrist for trimming.
Diabetic foot care is an important part of managing the effects of this disease. Failure to follow the proper foot care procedures can result in a variety of complications that can result in foot amputation.