Overview of Diabetic Foot Care
Diabetes is a condition where the amount of sugar in your blood is too high. It’s estimated that around 451 million people around the world have diabetes and there were about 5 million diabetes-related deaths globally in 2017.
If you have diabetes, you’re more likely to get a foot ulcer. This is because diabetes can cause changes in the small blood vessels in your feet, alter the nerves in your feet, and affect the way your foot moves and copes with pressure. This combination can lead to a lower sensation in your feet making them more likely to get pressure sores or wounds from minor injuries. It can also mean you have less blood flow in your lower leg and foot, which makes it harder for any sores or wounds to heal.
There’s a test for diabetes that measures your average blood sugar levels over the past two to three months. It’s called the hemoglobin A1c test. The American Diabetes Association and an international group of experts agree that if the results of your test are 6.5% or higher, it means you have diabetes. It’s worth knowing that for every 1% increase in your HgA1c level, your risk of problems with the blood vessels in your legs increases by 25 to 28%.
People with diabetes are at a high risk of needing a part of their lower leg or foot amputated, spending more on health care and experiencing a lower quality of life. One review of the research found that among people with diabetes and problems with the blood vessels in their legs, between 40 and 82% died within five years of having an amputation below the knee, and between 40 and 90% died within five years of having an amputation above the knee. Importantly, many of these complications can actually be avoided. Regular foot checks and taking good care of your feet can help.
This article aims to explain more about the structure of the foot, when and why foot checks might be needed for people with diabetes, what equipment and people are required for these checks, how to prepare for and carry out these checks, any complications that might arise, and the importance of foot checks in managing diabetes.
Anatomy and Physiology of Diabetic Foot Care
The foot of a person with diabetes is different from a normal foot in several ways. This could include changes to the muscles and joints, skin, nerves, and blood vessels.
Talking about muscles and joints, people with diabetes may lose some muscle strength in their foot or have stiff joints. Some people can even have a thickening in their Achilles tendon and on the bottom of their foot. This thickening can lead to a stiff foot, flat foot issues, and even difficulty in walking. There can also be changes in the foot shape, leading to conditions like “hammertoes” or “claw toe” where the toes look like they are curling downwards. These kinds of changes can even contribute to the increased risk of skin ulcers.
When it comes to skin changes, dry skin or skin cracks can be more common in people with diabetes. This can increase the risk of skin ulcers. The layer of skin on the bottom of the foot can also become thinner in people with diabetes, especially if they also have neuropathy, or nerve damage. Once an ulcer heals, the skin around it may break down faster and the ulcer could reappear.
In terms of blood flow, there are three main arteries that supply blood to the foot and ankle. People with diabetes have a higher risk of developing a condition called peripheral arterial disease (PAD), which is where the arteries in the legs become narrower. Symptoms can include leg pain during activity that stops when resting, and in severe cases, tissue loss and gangrene (where tissue dies due to lack of blood supply).
We have five main nerves that supply our foot, originating from different parts of the leg and spine. They provide control and sensation to various parts of our leg and foot. However, one of the complications of diabetes is diabetic neuropathy – nerve damage. This most often affects the nerves farthest from the heart, like those in the feet. This nerve damage could cause different sensations ranging from numbness to burning pain. The damage usually starts in the toes and gradually moves upward, and could also affect the upper parts of the body like the hands. Muscle weakness can also develop. Uncontrolled diabetes and neuropathy can lead to a serious condition called Charcot foot which affects the shape of the foot.
A Charcot foot, where the joints collapse and deform, can greatly increase the risk of getting a foot ulcer. If a person with Charcot foot also has an ulcer, they have a higher risk of needing an amputation. Therefore, it is very important to catch and treat Charcot foot early. If a person with diabetes has a warm, red, swollen foot, it could be a sign of Charcot foot and should not be ignored.
Why do People Need Diabetic Foot Care
If you have diabetes, it’s important to take special care of your feet. This can help prevent problems from diabetes affecting your feet. Steps to do this include identifying if your feet are at risk, examining and looking at your feet every day, learning about foot care for diabetes, wearing suitable shoes and treating any foot skin problems quickly.
People with diabetes that have a higher risk of foot problems should see a foot doctor (podiatrist) for regular check-ups and treatment. The International Working Group on Diabetic Foot (a group of experts on this problem) suggest these routine check-ups:
* Once a year for people with diabetes who don’t have a condition called peripheral neuropathy (damage to nerve cells outside the brain and spinal cord, which can cause weakness, numbness and pain in hands and feet).
* Every six months for people with diabetes who have peripheral neuropathy.
* Every 3 to 6 months for people with diabetes who have peripheral neuropathy, peripheral arterial disease (a circulatory condition where narrowed blood vessels reduce blood flow to the limbs) and/or a deformed foot.
* Every 1 to 3 months for people with diabetes who have peripheral neuropathy and a history of foot ulcers (open sores) or lower limb amputation.
When a Person Should Avoid Diabetic Foot Care
There are no reasons why a person with diabetes should not take proper care of their feet.
Equipment used for Diabetic Foot Care
Conducting a basic check-up for a person with diabetes-related foot problems doesn’t need many specialized tools and can be carried out by most general physicians as well as foot specialists.
For the nerve assessment, a tool called a Semmes-Weinstein monofilament is used. This tool is used to help doctors test if you’re able to feel light touches on your skin. A 128Hz-tuning fork is used to check if you can feel vibrations and cotton wool is used to check your sense of touch.
To check the blood flow in your foot, a doctor may use a device called a Doppler ultrasound.
If foot sores or ulcers are found during the check-up, it might need to be cleaned out, a process called debridement, or pressure might need to be relieved from the sore, also called offloading. Tools like scalpels, tissue cutters, and specially designed padding like felt pads, foam pads or cushions may be used.
In situations where the condition of the foot is severe, a variety of different materials may be needed. This can include: bandages; cleaning fluids like saline, hydrogen peroxide, and weak solutions of acetic acid; creams that can fight infection like povidone-iodine, cadexomer iodine, silver, or medical-grade honey; bandages that hold in moisture like films, foams, alginates, hydrogels, or hydrocolloids; vacuum-assisted closure devices, which help wounds heal faster by creating a vacuum that removes air pressure and drains excess fluids; and bioengineered bandages, which are synthetic or natural materials that help to enhance healing and protect your wound.
Who is needed to perform Diabetic Foot Care?
When dealing with diabetes and foot complications that it can cause, taking a team approach can dramatically lower the chances of needing an amputation by up to 85%. This team is made up of different healthcare professionals who each have their own crucial role to play in caring for a person’s feet when they have diabetes. This may include, but isn’t limited to, experts in diabetes (endocrinologists and diabetologists), foot specialists (podiatrists), surgeons who specialize in blood vessels (vascular surgeons), and specialists who design supports (orthotists) and false limbs (prosthetists). There are also nurses who focus on treating wounds, and educators who teach about how to look after your feet and manage diabetes.
There could be other specialists involved too, depending on the person’s individual health needs and whether they have an infection. These might include infection disease specialists, kidney doctors (nephrologists), heart doctors (cardiologists), skin doctors (dermatologists), among others.
The team will work together on several goals. This includes treating any medical conditions the person has alongside their diabetes, preventing problems with the feet, and dealing with any foot complications that might develop.
Preparing for Diabetic Foot Care
People with diabetes should take off both their shoes and socks before the examination. Feet should be washed and dried well. If there is a need to change the bandage on a diabetic foot wound, always wash your hands before and after changing the bandage. It’s important to keep the area where you’re carrying out these procedures clean and germ-free, as this will help lower the risk of infection.
How is Diabetic Foot Care performed
The foot check-up for patients with diabetes involves looking at four main areas: skin, blood flow, nerve function, and the shape and movement of the foot.
During the skin check, doctors look closely at the foot and ankle, including the spaces between the toes and nails. Any hard skin needs to be removed. If there are any wounds or pre-wound areas, it’s important the details like their size, depth, appearance, surrounding skin, any drainages, and signs of infection, be noted. A temperature that is higher by 3 to 4 degrees compared to the other foot could indicate an infection or a serious condition called Charcot foot, which affects the bones, joints, and soft tissues of the foot. Doctors also need to know any past history of wounds, how they were treated, and how they were prevented. If there’s a new wound, a foot X-ray is needed to monitor the health of the bones.
Blood flow to the foot is evaluated by a careful review of health history and risk factors for peripheral artery disease (PAD), which is a common condition in people with diabetes. By feeling the dorsalis pedis (the artery on the top of the foot) and the posterior tibial (at the ankle) arteries, doctors can assess the blood flow in the foot. If there’s a drop in the pulse felt in these arteries, doctors may use a Doppler ultrasound or other tests to further assess PAD. If there are signs of PAD, referral to a vascular surgeon is advised.
The nerve function in the foot is checked by testing the Achilles reflex, using a tool called Semmes-Weinstein monofilament to gauge the sense of touch, performing vibration testing using a tuning fork, and assessing the ability to distinguish between a sharp and dull pinprick.
The shape and movement of the foot are assessed to check muscle strength and any foot or ankle deformities. The flexibility and stiffness of the foot joints guide the treatment options. People with diabetes are at a higher risk of having foot deformities such as toe contractions and stiff ankle, which increase the risk of wounds. Depending on the type of foot deformity, referral to a foot doctor or surgeon may be needed.
During the visit, doctors need to emphasize to patients and their family members the importance of proper foot care. Patients should know to wear protective footwear to prevent wounds. Footwear needs to fit correctly. Feet with foot deformities may need special shoes, and the patient’s need for these should be assessed during the check-up. Modifications to shoes, temporary footwear, toe spacers, arch supports, and padding to relieve pressure points may all help protect the foot.
Possible Complications of Diabetic Foot Care
If you have diabetes and don’t take good care of your feet, you could develop sores (ulcers), infections, and in severe cases, you might even lose a limb. Research shows that patients who miss more than half of their scheduled appointments within a year are 54 times more likely to develop foot sores and 20 times more likely to need an amputation, compared to those who keep their appointments.
Interestingly, one study found that many patients with diabetes fear the need for a large-scale leg amputation more than they fear death, foot infection, or having an extreme kidney disease. Another study found that amputation had the most significant impact on people’s quality of life when compared to other complications of diabetes like stroke, blindness, kidney failure, heart failure, or heart attacks.
Therefore, if you have diabetes and a high risk of foot problems, it’s essential to have your feet regularly checked and cared for by a foot specialist (podiatrist).
What Else Should I Know About Diabetic Foot Care?
Taking good care of your feet is a very important part of managing diabetes, as it can prevent serious problems like the loss of a leg. One of the main reasons why people with diabetes end up in the hospital or have to have a limb removed is because of sores or infections on their feet. Most issues with diabetic feet are due to poor blood flow (ischemia), nerve damage (neuropathy), or infections.
If you have diabetes and also suffer from neuropathy, you may have about a 7 to 10% chance of getting a foot sore each year. If you have additional risk factors like poor blood flow to your legs (peripheral arterial disease), abnormal foot shapes, or a history of amputations or ulcers, your chances can rise to 25 to 30%. In fact, 85% of amputations in people with diabetes happen because of complications from foot sores.
As you age, the risk of amputation due to diabetes also increases. People with diabetes who are over 45 years old are eight times more likely to have an amputation, while those who are over 65 are 12 times more likely. This risk increases to 23 times more likely for those aged 65 to 74. That’s why it’s so essential for people with diabetes to keep checking their feet and take good care of them.
