Diabetes and your feetDiabetes, a disorder of high glucose levels, can harm various organs of the body if it is uncontrolled or there is a lack of proper care management. The long duration of uncontrolled glucose levels in the bloodstream damages the nerves. This is known as peripheral neuropathy. It affects the blood vessels resulting in decreased or complete obstruction of the blood flow towards the extremities (feet). This is called peripheral arterial disease. Neuropathy and peripheral arterial disease either individually or together result in serious problems like non-healing ulcer, infections and even amputation. People with Diabetes often don't realize or know that they have a problem until the resulting pain becomes apparent.There are many factors which contribute to the increasing incidence and severe Diabetes-related foot problems. The primary cause is a lack of proper annual foot assessment and foot examination. The foot is an often ignored organ in Diabetes management. Also generally, the foot does not have the care/attention as other organs like the heart, eyes and kidneys. Though feet are the second-most hard working organ after the heart, they often do not get that required attention. Diabetic foot complicationsThe gift of pain is extremely useful. People who have lost the gift of pain continue to walk on a fractured foot or they walk barefoot which could result in some foreign body or things lying on the floor penetrating the foot. This loss of sensation in the feet is due to diabetic peripheral neuropathy.Peripheral NeuropathyPeripheral Neuropathy is the most common problem among all long-term complications of Diabetes, affecting around half of the people with Diabetes. A longer duration of Diabetes and poor blood glucose control are major risk factors for the development of diabetic peripheral neuropathy. Peripheral neuropathy initiates a series of events which affect the sensory nerves responsible for the various types of sensation.Sensory NeuropathyPatient with sensory neuropathy either complain of pain or suffer a complete loss of sensation. Most of the people with peripheral neuropathy show symptoms of numbness or a 'cotton and wool' sensation in the feet. Some individuals display painful symptoms like burning, pricking, discomfort and electric shock-like pain often accompanied by disturbed sleep. Symptoms of neuropathy vary among individuals.Foot DeformitySevere neuropathy not only affects sensation but also affects muscle function- resulting in a foot deformity, inability to grip, walking disturbance and weakness.Structural deformity can result in high- pressure points over certain areas of the feet. When the foot structure is normal, the foot has the ability to distribute the pressure or load equally over the entire surface of the foot. However people with foot or toe deformity often have some areas of the feet which are subjected to very high pressures when standing on the ground - these points on the sole of the feet are referred to as 'high-pressure points or peak plantar pressures'.CallusesPeople with high-pressure points are at risk of developing foot problems like extreme thickening of certain areas of the sole, called calluses, mainly observed over the weight-bearing areas. These calluses can break due to repeated injuries. If ignored, this can lead to infection which can spread to the underlying tissue and cartilage including the bone.Other common problems seen in people with Diabetes include Athlete's foot or fungal infections which are most commonly seen in between the toes. Also common are ingrown toenails because of incorrect nail trimming techniques. These become a pathway for infection to spread and are often not taken care of or noticed because of a loss of sensation.Note: If you have lost the gift of pain, you have neuropathy. Therefore you need to take care every day. Like you use a mirror while you shave, use a mirror to look under your feet. Wear sensible shoes. Do not walk barefoot. Don't get into the bath without testing the temperature of the water..Lifestyle modification for foot healthWalking barefoot is not advisable especially if you have lost the gift of pain. People think it is okay to walk barefoot at home but the level of activity of people with neuropathy and foot problems is far greater at home than outdoors. It is advisable to wear a cast or a protective shoe gear when they are out and wear simple footwear to protect insensitive feet indoors. The carpet or flooring may contain some foreign body which may penetrate the foot and lead to a non-healing wound..Charcot neuroarthropathy (CN)The Charcot foot is a condition affecting the bones, joints, and soft tissues of the foot and ankle. Charcot Foot occurs due to nerve damage, most common is diabetic neuropathy. In the early stages, the foot is swollen, red in appearance and hot while palpation and later on the bones of the foot literally begin to 'fragmented' resulting in a very deformed foot. The prevalence of diagnosed CN in patients with Diabetes has been reported to be 0.08 to 7.5 per cent.The acute stage of Charcot foot presents with a markedly swollen, warm and often redness on the skin (often a sign of inflammation or infection) of the foot, with only mild to moderate pain, in some case- patient may not complain of pain because of complete loss of sensation. These symptoms lead to a diagnosis of Acute Charcot Foot which may also be identified if the temperature difference between both feet is 2o Celsius or more. This is usually measured using a special device called laser infrared thermometer. They also require other higher levels test such as a series of X-ray, Nuclear scan or MRI.The most important aspect in the medical treatment of Charcot foot is to offload the foot and prevent additional foot and ankle fractures and deformities.• A medicine called Bisphosphonates is administered in oral and intravenous form.• Surgical treatment of Charcot is generally advised to remove infected bone (osteomyelitis), and correct deformities that cannot be successfully accommodated with therapeutic footwear.• To prevent recurrence, the individual is prescribed diabetic footwear with a custom moulded insole or a Charcot restraint orthotic walker. Offloading techniquesIt is important - for any person with a foot wound - to follow good wound care practice like offloading - relieving weight from the wound site and wound care with advanced dressing products is also helpful.It is well known that patients with diabetic foot ulcers need to rest their feet. This is because putting pressure on the foot by walking can cause ulcers to deepen, be infected and further complicated. However, patients often refuse to offload, citing personal reasons, like the feeling of being bed-bound. As a result, they are prescribed special shoe gears and removable casts till the ulcer heals.Preventive measuresPrevention is better than cure. People with Diabetes must undergo foot examination on an annual basis as chronic wounds require specialized podiatry care. Exposure of pre-existing calluses, corns, bruises, cuts and wounds to the advent of fungus, bacteria and other infections, increases the risk of infection.The foremost thing to prevent diabetic foot problems is to stop smoking and manage cholesterol levels. We know that hypercholesterolemia and hyperlipidaemia are two contributing factors to vascular disease and therefore good lipid control and glycaemic control are important..Dr Andrew Boulton is a Professor of Medicine at Manchester University. He has authored more than 500 peer- reviewed manuscripts and book chapters, mainly on a diabetic lower limb and renal complications. Among his many awards, he has received the ADA's Roger Pecoraro Lectureship, theEuropean Association for the Study of Diabetes (EASD) Camillo Golgi prize and was the first recipient of the international award on diabetic foot research. He was the 2008 winner of the ADA's Harold Rifkin award for distinguished international service in diabetes. He is a previous Editor of Diabetic Medicine and is currently an Associate Editor of Diabetes Care. He was the founding Chairman of the Diabetic Foot Study Group. Until recently he was President of the EASD and International Diabetes Federation (IDF).
Diabetes and your feetDiabetes, a disorder of high glucose levels, can harm various organs of the body if it is uncontrolled or there is a lack of proper care management. The long duration of uncontrolled glucose levels in the bloodstream damages the nerves. This is known as peripheral neuropathy. It affects the blood vessels resulting in decreased or complete obstruction of the blood flow towards the extremities (feet). This is called peripheral arterial disease. Neuropathy and peripheral arterial disease either individually or together result in serious problems like non-healing ulcer, infections and even amputation. People with Diabetes often don't realize or know that they have a problem until the resulting pain becomes apparent.There are many factors which contribute to the increasing incidence and severe Diabetes-related foot problems. The primary cause is a lack of proper annual foot assessment and foot examination. The foot is an often ignored organ in Diabetes management. Also generally, the foot does not have the care/attention as other organs like the heart, eyes and kidneys. Though feet are the second-most hard working organ after the heart, they often do not get that required attention. Diabetic foot complicationsThe gift of pain is extremely useful. People who have lost the gift of pain continue to walk on a fractured foot or they walk barefoot which could result in some foreign body or things lying on the floor penetrating the foot. This loss of sensation in the feet is due to diabetic peripheral neuropathy.Peripheral NeuropathyPeripheral Neuropathy is the most common problem among all long-term complications of Diabetes, affecting around half of the people with Diabetes. A longer duration of Diabetes and poor blood glucose control are major risk factors for the development of diabetic peripheral neuropathy. Peripheral neuropathy initiates a series of events which affect the sensory nerves responsible for the various types of sensation.Sensory NeuropathyPatient with sensory neuropathy either complain of pain or suffer a complete loss of sensation. Most of the people with peripheral neuropathy show symptoms of numbness or a 'cotton and wool' sensation in the feet. Some individuals display painful symptoms like burning, pricking, discomfort and electric shock-like pain often accompanied by disturbed sleep. Symptoms of neuropathy vary among individuals.Foot DeformitySevere neuropathy not only affects sensation but also affects muscle function- resulting in a foot deformity, inability to grip, walking disturbance and weakness.Structural deformity can result in high- pressure points over certain areas of the feet. When the foot structure is normal, the foot has the ability to distribute the pressure or load equally over the entire surface of the foot. However people with foot or toe deformity often have some areas of the feet which are subjected to very high pressures when standing on the ground - these points on the sole of the feet are referred to as 'high-pressure points or peak plantar pressures'.CallusesPeople with high-pressure points are at risk of developing foot problems like extreme thickening of certain areas of the sole, called calluses, mainly observed over the weight-bearing areas. These calluses can break due to repeated injuries. If ignored, this can lead to infection which can spread to the underlying tissue and cartilage including the bone.Other common problems seen in people with Diabetes include Athlete's foot or fungal infections which are most commonly seen in between the toes. Also common are ingrown toenails because of incorrect nail trimming techniques. These become a pathway for infection to spread and are often not taken care of or noticed because of a loss of sensation.Note: If you have lost the gift of pain, you have neuropathy. Therefore you need to take care every day. Like you use a mirror while you shave, use a mirror to look under your feet. Wear sensible shoes. Do not walk barefoot. Don't get into the bath without testing the temperature of the water..Lifestyle modification for foot healthWalking barefoot is not advisable especially if you have lost the gift of pain. People think it is okay to walk barefoot at home but the level of activity of people with neuropathy and foot problems is far greater at home than outdoors. It is advisable to wear a cast or a protective shoe gear when they are out and wear simple footwear to protect insensitive feet indoors. The carpet or flooring may contain some foreign body which may penetrate the foot and lead to a non-healing wound..Charcot neuroarthropathy (CN)The Charcot foot is a condition affecting the bones, joints, and soft tissues of the foot and ankle. Charcot Foot occurs due to nerve damage, most common is diabetic neuropathy. In the early stages, the foot is swollen, red in appearance and hot while palpation and later on the bones of the foot literally begin to 'fragmented' resulting in a very deformed foot. The prevalence of diagnosed CN in patients with Diabetes has been reported to be 0.08 to 7.5 per cent.The acute stage of Charcot foot presents with a markedly swollen, warm and often redness on the skin (often a sign of inflammation or infection) of the foot, with only mild to moderate pain, in some case- patient may not complain of pain because of complete loss of sensation. These symptoms lead to a diagnosis of Acute Charcot Foot which may also be identified if the temperature difference between both feet is 2o Celsius or more. This is usually measured using a special device called laser infrared thermometer. They also require other higher levels test such as a series of X-ray, Nuclear scan or MRI.The most important aspect in the medical treatment of Charcot foot is to offload the foot and prevent additional foot and ankle fractures and deformities.• A medicine called Bisphosphonates is administered in oral and intravenous form.• Surgical treatment of Charcot is generally advised to remove infected bone (osteomyelitis), and correct deformities that cannot be successfully accommodated with therapeutic footwear.• To prevent recurrence, the individual is prescribed diabetic footwear with a custom moulded insole or a Charcot restraint orthotic walker. Offloading techniquesIt is important - for any person with a foot wound - to follow good wound care practice like offloading - relieving weight from the wound site and wound care with advanced dressing products is also helpful.It is well known that patients with diabetic foot ulcers need to rest their feet. This is because putting pressure on the foot by walking can cause ulcers to deepen, be infected and further complicated. However, patients often refuse to offload, citing personal reasons, like the feeling of being bed-bound. As a result, they are prescribed special shoe gears and removable casts till the ulcer heals.Preventive measuresPrevention is better than cure. People with Diabetes must undergo foot examination on an annual basis as chronic wounds require specialized podiatry care. Exposure of pre-existing calluses, corns, bruises, cuts and wounds to the advent of fungus, bacteria and other infections, increases the risk of infection.The foremost thing to prevent diabetic foot problems is to stop smoking and manage cholesterol levels. We know that hypercholesterolemia and hyperlipidaemia are two contributing factors to vascular disease and therefore good lipid control and glycaemic control are important..Dr Andrew Boulton is a Professor of Medicine at Manchester University. He has authored more than 500 peer- reviewed manuscripts and book chapters, mainly on a diabetic lower limb and renal complications. Among his many awards, he has received the ADA's Roger Pecoraro Lectureship, theEuropean Association for the Study of Diabetes (EASD) Camillo Golgi prize and was the first recipient of the international award on diabetic foot research. He was the 2008 winner of the ADA's Harold Rifkin award for distinguished international service in diabetes. He is a previous Editor of Diabetic Medicine and is currently an Associate Editor of Diabetes Care. He was the founding Chairman of the Diabetic Foot Study Group. Until recently he was President of the EASD and International Diabetes Federation (IDF).
