The Diabetic Foot

Diabetes is not just an isolated problem effecting the pancreas’s inability to produce enough insulin or even any insulin. The longer a person has diabetes and/or the more uncontrolled their glucose regulation is, the more likely other complications will develop.

These complications include retinopathy (damage to the retina of the eye), nephropathy (damage to the kidney), neuropathy (damage to the nerve), atherosclerosis (hardening of the arteries), heart disease, and immunopathy (absent or deficient immune response).

The two major complication which can gravely affect the foot are neuropathy and atherosclerosis. Arteries carry oxygenated blood from the heart to the rest of the body. The blood carries oxygen, nutrients, building blocks to help healing, and white blood cells (WBC) to fight infection. When atherosclerosis develops, the blood flow in the artery gets blocked by cholesterol plaques deposited inside the blood vessel wall. This process can unfortunately reduce the amount of blood, delivered by the lower extremity arteries, getting down to the feet to a trickle. As such, a wound on a diabetic’s foot will often heal slower than a non-diabetic or in some cases not heal at all. The wound is also more likely to become infected as a result of less available white blood cells getting to the wound. The white blood cells are not only delivered to the wound by the arteries but also migrate to the wound. When the blood sugar goes over 180 mg/dl, this WBC migration process is impeded, further compromising the body’s ability to fight infection.

The nerves have a multiplicity of functions. There are sensory nerves, which provide a person the ability to feel sensations such as light touch, sharp, dull, vibration, pain, temperature and where a body part is in space (up/down etc.) There are also motor nerves, which activate muscles in order to move body parts. There are also autonomic nerves, which regulate functions such as how fast our heart beats, dilation and constriction of blood vessels, or sweating. I like to think of these as automatic nerves because they just happen without us thinking about it.

When a person develops neuropathy any or all of these nerve functions can be affected. It is typically a slow and insidious process that a diabetic is completely unaware of. When it happens the muscles can become weaker, the skin can become dry, and numbness as well as pain can develop. The numbness can become so profound that a diabetic could step on a pin and have no idea the pin was lodged in their foot. Imagine stepping on a pin and having no idea you’ve done so. Bacteria have entered the foot with the pin and are multiplying unchecked. Several weeks later you notice something wet inside your shoe looking like blood or pus. Essentially an infection has developed which you had no idea was present. Even a non-diabetic would have a serious infection by that time, let alone a diabetic whose circulation and immune response are compromised. This scenario may sound farfetched, however, it happens quite frequently. Instead of getting immediate care the infection spreads, sometimes up the leg, and perhaps into the rest of the body making the diabetic septic. The hospital is loaded with such patients who unfortunately require surgery including amputation in order to quell the infection. A far better scenario starts with early recognition of the problem, prompting early diagnosis and rapid treatment. The treatment probably would consist of pin removal, some local wound care and antibiotics all done on an outpatient basis. This scenario would, in all medical probability, have resulted in a resolution of the infection without the need for a lengthy hospitalization or loss of part of your body.

So how does a diabetic protect themselves from infection, gangrene, and amputations? Remember the skin is our barrier to the outside world. Any break in the skin could allow bacteria to enter and cause an infection. Therefore any break in the skin or impending break, such as a blister or red mark, warrants immediate attention. A visit to your primary care physician or podiatrist should not be delayed. The best thing you could hear is “Don’t worry, it’s nothing” as opposed to “Why did you wait so long? You need to be immediately hospitalized.” So PROTECT YOUR SKIN! Never, not even in your house, should you walk without shoes and socks. Don’t self-treat any corns, calluses or toenails without your podiatrist’s permission. Wear shoes and socks that fit properly. Replace shoes which are worn out. Inspect your skin when you start your day and when you retire to your bed at night. Use a mirror if necessary to check the soles or have a loved one check for you. Get into good habits early on when you are first diagnosed with diabetes.  Have your circulation and nerve status checked by your podiatrist every six months. BE PROACTIVE, NOT REACTIVE! Be in the center of the room with lots of choices, not stuck in the corner with no choice but going to the hospital.

I have put together what we call in our office ‘The Diabetic Bible‘. It includes the dos and don’ts relative to diabetic foot care to increase the probability of enjoying the mobility your feet afford you. Mobility is the key to an active rich life!