Amputation is a common consequence of uncontrolled diabetes. — Photos: Filepic
Take care of your feet like your face – this advice is always told to diabetic patients to emphasise the importance of caring for their feet in order to avoid serious complications from the non-communicable disease.
Complications like ulceration, infection, tissue destruction and gangrene, can potentially result in loss of the affected limb, or even life, as well as affect the patient’s quality of life and livelihood.
Globally, an estimated half a billion people are living with diabetes.
A person with diabetes has a 25% risk of developing a foot ulcer within their lifetime.
Foot complications are the most frequent reason for hospitalisation of patients with diabetes.
Treating a diabetic foot ulcer is costly, accounting for one-fifth of the total healthcare cost of diabetes – the highest compared to the cost of any other diabetic complication.
It is a real challenge to national health systems and healthcare providers in general.
Nerve and blood issues
So, how exactly does diabetes affect the feet?
One of the first symptoms of diabetic neuropathy is reduced sensation due to the damaged nerves.
Uncontrolled blood glucose (sugar) levels contribute to the development of peripheral neuropathy and peripheral arterial disease via complex metabolic pathways.
Neuropathy leads to loss of sensation and arterial disease results in reduced blood flow to the tissues.
Both these factors, either alone or in combination, lead to foot ulcers.
Neuropathic lesions account for four in five foot ulcers and the remaining one in five is due to neuro-ischaemia.
In diabetic neuropathy, the soles and feet of diabetic patients will become numb (diminished sensation) over time due to nerve damage.
They may not be able to feel the usual soreness or pain if any blisters or minor cuts should develop due to ill-fitting shoes or stepping on sharp objects or hot surfaces when walking barefooted, among others.
These minor injuries go unnoticed, get infected and eventually progress to deep ulcers, destroyed tissue, and even gangrene.
Once gangrene develops, the toe or limb cannot be saved and requires amputation to save the life of the patient.
Diabetic neuropathy also causes weakness of the muscles and loss of joint position sensation, resulting in toe deformities and Charcot’s foot.
The normal shape of the foot gets altered, thus disturbing the weight-bearing alignment of the foot.
When the patient walks, there will be abnormal loading and pressure concentration on certain areas of the foot.
Callosities, cracks and fissures will develop in these areas, which serve as entry points for infection to develop, leading to ulcers and other serious complications.
In diabetic angiopathy, the small and medium-sized blood vessels become narrow, resulting in reduced blood flow to the affected areas and tissues.
This ischaemia (diminished blood supply) causes skin dryness, nail changes, ulcers and gangrene of the toe or limb.
Infection may also set in, leading to its associated complications.
Prevention and treatment
Diabetic neuropathy can result in complications like gangrene and ulcers, as seen in this model of a diabetic foot.
Diabetic foot management is focused on both prevention and treatment.
Awareness and active participation of the patient in the identification of pre-ulcerous conditions and implementation of early interventions to prevent ulcers is crucial.
If the development of a diabetic foot lesion is halted at the pre-ulcer stage, it will be easier to treat.
The patient’s quality of life will be improved and loss of limb or life can be prevented.
The disease burden on the healthcare system will also be reduced.
The following are signs of a foot at risk of developing ulcers and infections:
- Loss of feeling, tingling and/or numbness
- Skin discoloration, dryness and change in temperature
- Cracks, fissures, corns and/or callosities
- Minor injuries like red streaks, abrasions and bruises
- Changes and/or abnormalities in the nails
- Deformity of the toes
- Charcot foot (abnormal shape of the foot)
- Signs of peripheral neuropathy and peripheral arterial disease
Any pre-ulcerous condition needs to be attended to by appropriately-trained healthcare providers, as well as allied health personnel who can help provide proper foot wear and orthotics, and help prevent infection and ulcers.
Unfortunately, most of the time, patients only seek treatment after ulcers have already formed and serious infection has set in.
Post-ulcer management needs a multidisciplinary team approach for wound care; infection control; various surgical treatments, including amputation and revascularisation; and rehabilitation.
Teams such as these can only usually be found in tertiary healthcare facilities that have specialised diabetic foot care services.
Regular foot examination
Diabetics should get their feet assessed regularly by trained healthcare providers, like this diabetes nurse.Along with monitoring blood glucose levels regularly, diabetic patients need to be examine their feet daily.
They should also ensure that their feet are assessed by a healthcare professional regularly to help identify lesions of potential risk.
Those with normal or low-risk feet can be assessed during their usual follow-up consultations, while those with moderate- and high-risk feet need more frequent visits and clinical examination.
Patients are also advised to seek immediate help if they notice any abnormalities in between clinic visits.
Here are some tips on foot care for people with diabetes:
Look at your feet daily, especially the soles and in between the toes for any early changes or injuries.
A mirror can be used to help with this examination or you can ask someone to help you do the check.
Wash your feet every day with room temperature water.
Ensure that you carefully and thoroughly dry your feet, especially in between your toes.
Toe nails should be trimmed straight across without any rounding to prevent ingrown toe nails.
This is to help maintain adequate skin moisture.
However, avoid applying these creams or oils in between your toes.
Do not try to remove or excise these by yourself at home.
They need to be managed by trained personnel.
Periodic gentle toe and foot exercises can help to improve tissue perfusion and blood flow in the feet.
Avoid exposing your feet to extreme heat or cold.
Never walk with bare feet; even at home, you should wear indoor slippers.
Avoid tight and compressive foot wear.
Always wear socks with shoes and check for any sharp objects inside your shoes before putting them on.
It would be best if you could use non-occlusive, custom-made diabetic foot wear.
Make sure your feet are regularly checked by qualified healthcare professionals.
Notify and consult your healthcare provider once a blister, cut, sore or ulcer develops in your feet – do not ignore or treat the problem yourself.
Most diabetic foot problems can be managed well and serious complications avoided, provided patients understand the principles of prevention and take proper precautions and care of their feet.
Dr Neelakanta Reddy is an associate professor in the Orthopaedics department at the Perdana University Graduate School of Medicine. This article is courtesy of Perdana University. For more information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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