A case study
Mr Roy (Name changed) is 72 years old and he retired as a manager at an Insurance firm. He is quite active and healthy and loves travelling to see different cultures and destinations. He leads a healthy lifestyle. He walks daily for three hours and plays table tennis. He neither smokes nor does he consume alcohol. He eats a balanced diet. He has had Diabetes for the past 40 years and has controlled it with oral pills.
One night his leg started hurting and he found the pain to be intolerable. His family was shocked when he described how unbearable the pain was as he had never complained of foot pain before. The diagnosis at the hospital suggested some blockage. His blood sugar level when checked displayed a reading of 500 mg/dL and he was administered insulin . An Arterial Doppler examination which detected blockages in his legs. An Angiogram also confirmed the blockage of two main arteries of the leg. The recommended course of action was implanting a stent to improve blood flow. The successful stent implantation helped relieve the pain.
However three days later he discovered a discoloration on the upper part of his foot and toes. A visit to a Diabetes specialty centre ensued and the doctor's diagnosis indicated gangrene. Gangrene is a blackish discolouration of the foot/ toes due to local death of the tissues therein, and results from a lack of proper blood flow to the area.
The doctor advised conservative management with wound care, relieving weight from the wound site and intravenous antibiotics. This led to demarcation (the gangrenous toes started separating from the healthy part). Mr Roy was advised on his choices which included 'auto amputation' [where the toe fell off by itself, time consuming process] or surgical operation to remove the gangrenous toe.
Mr Roy opted for the surgery which led to a speedier recovery. The wound healed completely after two weeks but Mr Roy lost three toes. He was able to eventually resume his prior life and take up routine including playing table tennis. Though Mr Roy led a healthy life and controlled his Diabetes, he had never undergone a foot examination or visited a foot care specialist or diabetic foot surgeon to understand the health status of his nerves and blood flow.
Key Messages: It is imperative to have your nerves and blood flow tested on an annual basis. This simple checking helps avoid major problems which may lead to amputation.
Diabetes and your feet
Diabetes, 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. Long duration of uncontrolled glucose levels in the blood stream 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 problem until the resulting pain becomes apparent.
There are many factors which contribute to the increasing incidence and severe Diabetes related foot problems. Primary cause is lack of proper annual foot assessment and foot examination. "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" says Dr Arun Bal.
Diabetic Peripheral Neuropathy
Peripheral 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 various type of sensation.
Patient 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. Sometimes these symptoms are also seen in those with impaired fasting glucose (IFG) or impaired glucose tolerance (IGT), deteriorating one's quality of life. Severe 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 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'.
People with high pressure points are at risk for 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 toe nails because of incorrect nail trimming techniques. These become a pathway for infection to spread and are often not taken care or noticed because of a loss of sensation.
Peripheral arterial disease (PAD):
Diabetes, one of the main predictor for arterial disease, is also one of the major causes for feet amputation. Patients with PAD may complain of pain like cramps, ache, numbness or a sense of fatigue feeling in the calf muscle which occurs during exercise and is relieved by rest. Also, people with Diabetes may have PAD without any symptoms which is seen typically in the presence of neuropathy and can be diagnosed through clinical examination and screening.
All patients coming to a hospital or clinic are routinely checked for pulse rate on the wrists, which is considered to be very important part of examination. In the same way all people with Diabetes should be examined for the presence and absence of foot pulses not for calculating the pulse rate but for the diagnosis of an arterial problem. Absent or weak pedal pulse can be a clue for early or more severe block which need investigations and aggressive treatment.
Diabetic foot ulcer (DFU)
Diabetic foot ulcer or infection (DFU or DFI) is one of the most common, serious and costly complications of Diabetes affecting 15 per cent of all people with Diabetes. The onset of DFU is not sudden, it usually occurs due to some intrinsic or extrinsic injuries like abrasions, foreign body, thermal injury, repeated rubbing or high pressure points due to structural deformities over the weight bearing area, alternation in walking cycle and the most commonly seen injury is due to ill-fitting footwear. Once the skin breaks down it is exposed to a bacterial load resulting in more serious infections and poor glycaemic control which can delay the healing process. Indeed, an ulcer is defined by a loss of continuity of the skin surface. When the protective skin covering is lost, the foot tissue below becomes an easy target for the bacteria. Pus and infection may sometime spread upwards from the feet. Spread of infection to tissues like lungs and brain may prove fatal. DFU management requires proper antibiotic therapy to control the infection, wound care management via dressing of the wound and rest to the affected limb.
Diabetic foot problems are associated with long term Diabetes. Good blood glucose control along with preventive management helps to prevent foot problems. Diabetic foot problems should not be neglected. All patients with Diabetes must have their feet checked at least yearly once for the presence of predisposing factors for ulceration and amputation.
"The occurrence of foot ulcers is an economic burden on the family as well as the society. On an average, diabetic foot infection patients spend 50 per cent of their annual income on medical treatment. Death due to diabetic foot infection ranks third in list of diseases of high mortality after Lung and Pancreatic Cancer" says Dr Vijay Viswanathan.
Take the pressure off, literally!
It is important – for any patients 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 offloading, citing personal reasons, like the feeling of being bedbound. As a result, they are prescribed special shoe gears and removable casts till the ulcer heals. However, the latest guideline from the Journal of the American Podiatric Association strongly emphasizes the importance of offloading- or rest, in healing diabetic foot ulcers. The guideline also suggests that for offloading, certain plaster-like casts of the foot- called total contact casts, which can be removed only under medical supervision, are ideal. Taking the pressure away from the feet, using these offloading techniques, can result in more rapid ulcer healing.
Prevention 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.
It is important to:
Rest your feet.
Invest in appropriate footwear to prevent wounds.
Wearing only clean, dry socks and shoes.
Thoroughly wash with soap and dry your feet, especially between the toes.
Apply moisturizer except between the toes.
Cut nails straight across (not too close to the skin).
Poor foot care results in nerve and blood vessel damage, foot deformity and non-healing wounds that may even lead to amputation. In case of infection, consult a doctor as treatment may require oral antibiotics or intravenous injections. People with Diabetes can have healthy feet with good glucose control and by taking habitual good care of their feet.