Zeehan S. Husain, DPM
Charles G. Kissel, DPM
Michael S. Schey, DPM
Angela
Stoutenburg, DPM
Board
certified by the
American Board of
Podiatric Surgery.
Foot problems are a leading
cause of hospitalization for the 25 million Americans who have been
identified as having diabetes mellitus.
Expenditures related to diabetic foot problems currently cost $30
billion annually on diabetic foot problems alone as of 2007.
It is estimated that 25% of all diabetics will develop a serious
foot condition at some time in their lives with 20% ultimately requiring
an amputation. Common
problems include infection, ulceration, or gangrene that may lead, in
severe cases, to amputation of a toe, foot, or leg.
Most of these problems are
preventable through proper care and regular visits to your podiatric
surgeon. Your podiatric
surgeons at the Rochester Center for Foot and Ankle Surgery can provide
information on foot inspection and care, proper footwear, and early
recognition and treatment of foot conditions.
We strongly believe in networking with primary care physicians,
endocrinologists, cardiologists, and vascular surgeons to coordinate your
overall medical care.
Subtopics
Contributing
Factors
Foot problems in persons with
diabetes are usually the result of three primary factors: neuropathy, poor
circulation, and decreased resistance to infection. Also, foot deformities and trauma play major roles in causing
ulcerations and infections in the presence of neuropathy or poor
circulation.
 | Neuropathy— The ability
to detect sensations or vibration may be diminished. Neuropathy allows injuries to remain unnoticed and untreated
for lengthy periods of time. It
may cause burning or sharp pains in feet and interfere with your
sleep. Ironically,
painful neuropathy may occur in combination with a loss of sensation.
Neuropathy can also affect the nerves that supply the muscles
in your feet and legs. This
‘motor neuropathy’ can cause muscle weakness or loss of tone in
the thighs, legs, and feet, and the development of hammertoes,
bunions, and other foot deformities. |
| Poor Circulation— Persons with diabetes often have circulation disorders (peripheral vascular disease) that can cause cramping in the calf or buttocks when walking. The symptoms can progress to severe cramping or pain at rest, with associated color and temperature changes (the feet may turn bright red when hanging down and constantly feel cold). Also, the skin may become shiny, thinned, and easily damaged. A reduction in hair growth and a thickening of the toenails might also be present. |
| Poor circulation, resulting
in reduced blood flow to the feet, restricts delivery of oxygen and
nutrients that are required for normal maintenance and repair. Healing of foot injuries, infection, or ulceration is
affected. Peripheral
revascularization techniques may avert lower extremity amputation. |
| Infection— Persons with
diabetes are generally more prone to infections than non-diabetic
people. Due to
deficiencies in the ability of white blood cells to defend against
invading bacteria, diabetics have more difficulty in dealing with and
mounting an immune response to the infection.
Infections often worsen and may go undetected, especially in
the presence of diabetic neuropathy or vascular disease.
Often, the only sign of a developing infection is unexplained
high blood sugar, even without fever.
The combination of fever and high blood sugar often warns of a
severe infection requiring hospitalization.
Lesser degrees of infection are often treated on an outpatient
basis. |
Footwear
Guidelines
Shoes must always fit
comfortably and have adequate width and depth for the toes. Leather shoes easily adapt to the shape of your feet and
allow them to “breathe”. Athletic
shoes, jogging shoes and sneakers are usually excellent choices if they
are well fitted and provide adequate cushioning.
Your podiatric surgeon may recommend “extra depth” shoes,
custom molded shoes to adapt to your particular needs, or orthotics to
provide cushioning and support.
Always check your shoes for
foreign objects or torn linings before putting them on.
You should wear two or three pairs of shoes each week so that one
pair is not excessively worn. New shoes should be worn for only a few hours at a time and
you should take care to inspect your feet for any points of irritation.
Socks should be well fitted
without seams or folds. White
socks will make it easier to spot any problems with bleeding or open
wounds. They should not be so
tight as to interfere with circulation.
Well-padded socks can be very protective if there is an abundance
of room in your shoes. Avoid
wearing open-toed shoes or sandals until you have discussed this with your
podiatric surgeon. Above all
else, do not walk with bare feet.
1.
Diabetic Foot Care Guidelines
(top)
Diabetes
can be dangerous to your feet. Even
a small cut could have serious consequences.
Diabetes may cause nerve damage that takes away the feeling in your
feet. Diabetes may also
reduce blood flow to the feet, making it harder to heal an injury or
resist infection. Because of
these problems, you might not notice a pebble in your shoe.
So you could develop a blister, then a sore, then a stubborn
infection that might cause amputation of your foot or leg.
To avoid serious foot problems that could result in losing a toe,
foot, or leg, be sure to follow these guidelines.
|
Inspect
your feet daily—
Check
for cuts, blisters, redness, swelling, or nail problems.
Use a magnifying hand mirror to look at the bottom of your
feet. Call your doctor if
you notice anything. |
|
Wash
your feet in lukewarm (not hot!) water—
Keep
your feet clean by washing them daily. But only use lukewarm
water
or the temperature you would use on a newborn baby. |
|
Be
gentle when bathing your feet—
Wash
them using a soft washcloth or sponge.
Dry by blotting or patting and make sure to carefully dry
between the toes. |
|
Moisturize
your feet, but not between your toes—
Use
a moisturizer daily to keep dry skin from itching or cracking.
But DO NOT moisturize between the toes.
This could encourage a fungal infection. |
|
Cut
nails carefully and straight across—
Also,
file the edges. Do not
cut them too short or round the edges to avoid developing ingrown toe
nails. |
|
Never
trim corns or calluses—
No
“bathroom surgery”—let your doctor do the job. |
|
Wear
clean, dry socks—
Change
them daily. |
|
Avoid
the wrong type of socks—
Avoid
tight elastic bands (they reduce circulation).
Do not wear thick or bulky socks (they can fit poorly and
irritate the skin). |
|
Wear
socks to bed—
If
your feet get cold at night, wear socks.
NEVER use a heating pad or hot water bottle. |
|
Shake
out your shoes and inspect the inside before wearing—
Remember,
you may not feel a pebble. So
always shake out your shoes before putting them on. |
|
Keep
your feet warm and dry—
Do
not get your feet wet in snow or rain.
Wear warm socks and shoes in winter. |
|
Never
walk barefoot—
Not
even at home! You could
step on something and get a scratch or cut. |
|
Take
care of your diabetes—
Keep
your blood sugar levels under control. |
|
Do
not smoke—
Smoking
restricts blood flow in your feet. |
|
Get
periodic foot exams (at least annually)—
See
your podiatric foot and ankle surgeon on a regular basis for an
examination to help prevent the foot complications of diabetes.
Get annual examinations just like you would get annual physical
examinations. |
2.
Diabetic Peripheral
Neuropathy (top)
Diabetic
neuropathy is nerve damage caused by diabetes.
The type of neuropathy occurring in the arms, hands, legs and feet
is known as diabetic peripheral neuropathy.
Diabetic peripheral neuropathy is different from peripheral
arterial disease (poor circulation) which affects the blood vessels rather
than the nerves.
Three
different groups of nerves can be affected by diabetic neuropathy:
|
Sensory
nerves—
enable people to feel pain, temperature, and other sensations |
|
Motor
nerves—
control the muscles and give them their strength and tone |
|
Autonomic
nerves—
allow the body to perform certain involuntary functions, such as
sweating |
Diabetic
peripheral neuropathy does not emerge overnight.
It usually develops slowly and worsens over time.
Some patients have this condition long before they are diagnosed
with diabetes. Having
diabetes for several years may increase the likelihood of having diabetic
neuropathy. The loss of
sensation and other problems associated with nerve damage make a patient
prone to developing skin ulcers (open sores) that can become infected and
may not heal. This serious
complication of diabetes can lead to loss of a foot, a leg, or even a
life.
Signs
and Symptoms
Depending
on the type(s) of nerves involved, one or more signs and symptoms may be
present in diabetic peripheral neuropathy.
For
sensory neuropathy:
|
Numbness
or tingling in the feet |
|
Pain
or discomfort in the feet or legs including prickly, sharp pain, or
burning feet |
For
motor neuropathy:
|
Muscle
weakness and loss of muscle tone in the feet and lower legs |
|
Loss
of balance |
|
Changes
in foot shape that can lead to areas of increased pressure |
For
autonomic neuropathy:
|
Dry
feet |
|
Cracked
skin |
What
Causes Diabetic Peripheral Neuropathy?
The
nerve damage that characterizes diabetic peripheral neuropathy is more
common in patients with poorly managed diabetes.
However, even diabetic patients who have excellent blood sugar
(glucose) control can develop diabetic neuropathy.
There are several theories as to why this occurs, including the
possibilities that high blood glucose or constricted blood vessels produce
damage to the nerves. As
diabetic peripheral neuropathy progresses, various nerves are affected and
these damaged nerves can cause problems that encourage development of
ulcers. For example:
|
Deformities
(such as bunions or hammertoes) resulting from motor neuropathy may
cause shoes to rub against toes, creating a sore.
The numbness caused by sensory neuropathy can make the patient
unaware that this is happening. |
|
Because
of numbness, a patient may not realize that he or she has stepped on a
small object and cut the skin. |
|
Cracked
skin caused by autonomic neuropathy, combined with sensory
neuropathy’s numbness and problems associated with motor neuropathy
can lead to developing a sore. |
Diagnosis
To
diagnose diabetic peripheral neuropathy, the foot and ankle surgeon will
obtain the patient’s history of symptoms and will perform simple
in-office tests on the feet and legs.
This evaluation may include assessment of the patient’s reflexes,
ability to feel light touch, and ability to feel vibration.
In some cases, additional neurologic tests may be ordered.
Treatment
First
and foremost, treatment of diabetic peripheral neuropathy centers on
control of the patient’s blood sugar level.
In addition, various options are used to treat the symptoms.
Medications are available to help relieve specific symptoms, such
as tingling or burning. Sometimes
a combination of different medications is used.
In some cases, the patient may also undergo physical therapy to
help reduce balance problems or other symptoms.
Prevention
The
patient plays a vital role in minimizing the risk of developing diabetic
peripheral neuropathy and in preventing its possible consequences.
Some important preventive measures include:
|
Keep
blood sugar levels under control. |
|
Wear
well-fitting shoes to avoid getting sores. |
|
Inspect
your feet every day. If
you notice any cuts, redness, blisters, or swelling, see your foot and
ankle surgeon right away. This
can prevent problems from becoming worse. |
|
Visit
your foot and ankle surgeon on a regular basis for an examination to
help prevent the foot complications of diabetes. |
|
Have
periodic visits with your primary care physician or endocrinologist.
The foot and ankle surgeon works together with these and other
providers to prevent and treat complications from diabetes. |
3.
Diabetic
Complications and Amputation Prevention (top)
People
with diabetes are prone to many foot problems, often because of two
complications of diabetes: nerve damage (neuropathy) and poor blood
circulation. Neuropathy
causes loss of feeling in your feet, taking away your ability to feel pain
and discomfort, so you may not detect an injury or irritation.
Poor circulation in your feet reduces your ability to heal, making
it hard for even a tiny cut to resist infection.
When
you have diabetes, you need to be aware of how foot problems can arise
from disturbances in the skin, nails, nerves, bones, muscles, and blood
vessels. Furthermore, in
diabetes, small foot problems can turn into serious complications.
You can do much to prevent amputation by taking two important
steps: follow the proactive measures discussed below and see your
foot and ankle surgeon regularly.
Diabetes-Related
Foot and Leg Problems
Having
diabetes puts you at risk for developing a wide range of foot problems:
|
Infections
and ulcers (sores) that do not heal— Because
of poor circulation in the feet, cuts or blisters can easily turn into
ulcers that become infected and will not heal.
This is a common and serious complication of diabetes and can
lead to a loss of your foot, your leg, or your life.
An ulcer is a sore in the skin that may go all the way to the
bone. |
|
Corns
and calluses— When
neuropathy is present, you can not tell if your shoes are causing
pressure and producing corns or calluses.
Corns and calluses must be properly treated or they can develop
into ulcers. |
|
Dry,
cracked skin— Poor
circulation can make your skin dry.
This may seem harmless, but dry skin can result in cracks that
may become sores. |
|
Nail
disorders— Ingrown
toenails (which curve into the skin on the sides of the nail) and
fungal infections can go unnoticed because of loss of feeling.
If they are not professionally treated, they can lead to
ulcers. |
|
Hammertoes
and bunions— Motor
neuropathy (nerve damage affecting muscles) can cause muscle weakness
and loss of tone in the feet, resulting in hammertoes and bunions.
If left untreated, these deformities can cause ulcers. |
|
Brittle
bones— Neuropathy and circulation changes may lead to brittle bones
(osteoporosis). This
makes you susceptible to breaking a bone, even without a major blow or
injury occurring. |
|
Charcot
foot— This is a complex foot deformity.
It develops as a result of loss of sensation and an undetected
broken bone that leads to destruction of the soft tissue of the foot.
Because of neuropathy, the pain of the fracture goes unnoticed
and the patient continues to walk on the broken bone, making it worse.
This disabling complication is so severe that amputation may
become necessary. |
|
Blocked
artery in the calf— In
diabetics, the blood vessels below the knee often become narrow and
restrict blood flow. A severely blocked artery is a serious condition that may
require intervention. If
revascularization surgery fails and the wound does not heal,
amputation may be necessary. |
What
Your Foot and Ankle Surgeon Can Do
A
major goal of the foot and ankle surgeon is to prevent amputation.
There are many new surgical techniques available to save feet and
legs, including joint reconstruction and wound healing technologies. Getting regular foot checkups and seeking immediate help when
you notice something can keep small problems from worsening.
Your foot and ankle surgeon works together with other health care
providers to prevent and treat complications from diabetes.
When
Is Amputation Necessary?
The
goals of treatment of diabetic foot problems are not only to save the life
and limb, but also to get the patient healed and moving about as soon as
possible. If
revascularization surgery cannot improve blood flow and podiatric surgery
cannot restore function, amputation may be the only solution that gets the
patient walking again. Amputation
may involve one or two toes, part of the foot, or part of the leg.
The level of amputation is selected on the basis of the patient’s
condition and level of predicted healing.
A return to normal life is especially possible today because of
advances in prosthetics.
Your
Proactive Measures
You
play a vital role in reducing complications.
Follow these guidelines and contact your foot and ankle surgeon if
you notice any problems:
|
Inspect
your feet daily—
If your eyesight is poor, have someone else do it for you.
Inspect for: |
|
Observe
for changes in circulation— Pay attention to the color of your toes. If they turn red, pink, or purplish when your legs hang down
while sitting, poor circulation may be a problem. |
|
Do
not ignore leg pain—
Pain in the leg that occurs at night or with a little activity could
mean you have a blocked artery. Seek
care immediately. |
|
Nail
cutting—
If you have any nail problems, hard nails, or reduced feeling in your
feet, your toenails should be trimmed professionally. |
|
No
“bathroom surgery”—
Never trim calluses or corns yourself, and do not use over-the-counter
medicated pads. |
|
Keep
floors free of sharp objects— Make sure there are no needles, insulin syringes, or other sharp
objects on the floor. |
|
Do
not go barefoot—
Wear shoes, indoors and outdoors. |
|
Check
shoes and socks—
Shake out your shoes before putting them on.
Make sure your socks are not bunched up. |
|
Have
your sense of feeling tested— Your foot and ankle surgeon will perform various
tests to see if you have lost any feeling. |
4.
Charcot
Foot (top)
Charcot
foot is a sudden softening of the bones in the foot that can occur in
people who have significant nerve damage (neuropathy).
The bones are weakened enough to fracture, and with continued
walking the foot eventually changes shape.
As the disorder progresses, the arch collapses and the foot takes
on a convex shape, giving it a rocker-bottom appearance, making it very
difficult to walk.
Charcot foot is a very serious condition that can lead to severe deformity, disability, and even amputation. Because of its seriousness, it is important that patients with diabetes, a disease often associated with neuropathy, take preventive measures and seek immediate care if signs or symptoms appear.
Symptoms
The
symptoms of Charcot foot can appear after a sudden trauma or even a minor
repetitive trauma (such as a long walk).
A sudden trauma includes such mishaps as dropping something on the
foot, or a sprain or fracture of the foot.
The symptoms of Charcot foot are similar to those of infection.
Although Charcot foot and infection are different conditions, both
are serious problems requiring medical treatment.
Charcot foot symptoms may include:
|
Warmth to the touch (the foot feels warmer than the other) |
|
Redness in the foot |
|
Swelling in the area |
|
Pain or soreness |
What
Causes Charcot Foot?
Charcot
foot develops as a result of neuropathy, which decreases sensation and the
ability to feel temperature, pain, or trauma.
When neuropathy is severe, there is a total lack of feeling in the
feet. Because of neuropathy,
the pain of an injury goes unnoticed and the patient continues to walk
which makes the injury worse. People
with neuropathy (especially those who have had it for a long time) are at
risk for developing Charcot foot. In
addition, neuropathic patients with a tight Achilles tendon have been
shown to have a tendency to develop Charcot foot.
Diagnosis
Early
diagnosis of Charcot foot is extremely important for successful treatment.
To arrive at a diagnosis, the surgeon will examine the foot and
ankle and ask about events that may have occurred prior to the symptoms.
X-rays are also essential for diagnosis.
In some cases, other imaging studies and lab tests may be ordered.
Once treatment begins, x-rays are taken periodically to aid in
evaluating the status of the condition.
Treatment
It
is extremely important to follow the surgeon’s treatment plan for
Charcot foot. Failure to do
so can lead to the loss of a toe, foot, leg, or life.
Treatment for Charcot foot consists of:
|
Immobilization— Because
the foot and ankle are so fragile during the early stage of Charcot,
they must be protected so the soft bones can repair themselves.
Complete non-weightbearing is necessary to keep the foot from
further collapsing. The
patient will not be able to walk on the affected foot until the
surgeon determines it is safe to do so.
During this period, the patient may be fitted with a cast,
removable boot, or brace, and may be required to use crutches or a
wheelchair. It
may take the bones several months to heal, although it can take
considerably longer in some patients. |
|
Custom shoes and bracing—
Shoes
with special inserts may be needed after the bones have healed to
enable the patient to return to daily activities as well as help
prevent recurrence of Charcot foot, development of ulcers, and
possibly amputation. In cases with significant deformity, bracing is also
required. |
|
Activity modification— A
modification in activity level may be needed to avoid repetitive
trauma to both feet. A
patient with Charcot in one foot is more likely to develop it in the
other foot, so measures must be taken to protect both feet. |
|
Surgery— In
some cases, surgery may be required.
The foot and ankle surgeon will determine the surgical
procedure best suited for the patient based on the severity of the
deformity and the patient’s physical condition. |
Preventive
Care
The
patient can play a vital role in preventing Charcot foot and its
complications by following these measures:
|
Diabetes patients should keep blood sugar levels under control.
This has been shown to reduce the progression of nerve damage
in the feet. |
|
Get regular check-ups from a foot and ankle surgeon. |
|
Check both feet every day and see a surgeon immediately if
there are signs of Charcot foot. |
|
Be careful to avoid injury, such as bumping the foot or overdoing
an exercise program. |
|
Follow the surgeon’s instructions for long-term treatment to prevent recurrences, ulcers, and amputation. |
5.
Peripheral Arterial Disease
(top)
Commonly referred to as “poor circulation,” peripheral arterial
disease (PAD) is the restriction of blood flow in the arteries of the leg.
When arteries become narrowed by plaque, accumulation of
cholesterol and other materials on the walls of the arteries, the
oxygen-rich blood flowing through the arteries cannot reach the legs and
feet. The presence of PAD may
be an indication of more widespread arterial disease in the body that can
affect the brain causing stroke or the heart causing a heart attack.
Signs
and Symptoms
Most
people have no symptoms during the early stages of PAD.
Often, by the time symptoms are noticed, the arteries are already
significantly blocked. Common
symptoms of PAD include:
|
Leg
pain (cramping) that occurs while walking (intermittent claudication) |
|
Leg
pain (cramping) that occurs while lying down (rest pain) |
|
Leg
numbness or weakness |
|
Cold
legs or feet |
|
Sores
that will not heal on toes, feet, or legs |
|
A
change in leg color |
|
Loss
of hair on the feet and legs |
|
Changes
in toenail color and thickness |
If
any of these symptoms are present, it is important to discuss them with a
foot and ankle surgeon. Left
untreated, PAD can lead to debilitating and limb-threatening consequences.
Risk
Factors of PAD
Because
only half of those with PAD actually experience symptoms, it is important
that people with known risk factors be screened or tested for PAD.
The risk factors include:
|
Being
over age 50 |
|
Smoking
(currently or previously) |
|
Diabetes |
|
High
blood pressure |
|
High
cholesterol |
|
Personal
or family history of PAD, heart disease, heart attack, or stroke |
|
Sedentary
lifestyle (infrequent or no exercise) |
Diagnosis
of PAD
To
diagnose PAD, the foot and ankle surgeon obtains a comprehensive medical
history of the patient. The
surgeon performs a lower extremity physical examination that includes
evaluation of pulses, skin condition, and foot deformities to determine
the patient’s risk for PAD. If
risk factors are present, the foot and ankle surgeon may order further
tests.
Several
non-invasive tests are available to assess PAD.
The ankle-brachial index (ABI) is a simple test in which blood
pressure is measured and compared at the arm and ankle levels.
An abnormal ABI is a reliable indicator of underlying PAD and may
prompt the foot and ankle surgeon to refer the patient to a vascular
specialist for additional testing and treatment as necessary.
General
Treatment of PAD
Treatment
for PAD involves lifestyle changes, medication and, in some cases,
surgery.
|
Lifestyle
changes— Include
smoking cessation, regular exercise, and eating a heart-healthy diet. |
|
Medications— Medicines
may be used to improve blood flow, help prevent blood clots, or to
control blood pressure, cholesterol, and blood glucose levels. |
|
Surgery— In
some patients, small incision (endovascular) procedures or open
(bypass) surgery of the leg is needed to improve blood flow. Your podiatric surgeon can help direct the proper referral. |
PAD
and Foot Problems
Simple
foot deformities (hammertoes, bunions, bony prominences) or dermatologic
conditions such as ingrown or thickened nails often become more serious
concerns when PAD is present. Because
the legs and feet of someone with PAD do not have normal blood flow and
because blood is necessary for healing seemingly small problems such as
cuts, blisters, or sores can result in serious complications.
Having
both diabetes and PAD further increases the potential for foot
complications. People with diabetes often have neuropathy (nerve damage that
can cause numbness in the feet), so they do not feel pain when foot
problems occur. When
neuropathy occurs in people with PAD, ulcers can develop over foot
deformities and may never heal. For
this reason, PAD and diabetes are common causes of foot or leg amputations
in the United States.
Once
detected, PAD may be corrected or at least improved.
The foot and ankle surgeon can then correct the underlying foot
deformity to prevent future problems should the circulation become
seriously restricted again.
Avoiding
PAD Complications
Getting
regular foot exams, as well as seeking immediate help when you notice
changes in the feet, can keep small problems from worsening.
PAD requires ongoing attention.
To avoid complications, people with this disease should follow
these precautions:
|
Wash
your feet daily— Use
warm (not hot) water and a mild soap.
Dry your feet especially between the toes, gently and well. |
|
Keep
the skin soft— For
dry skin, apply a thin coat of lotion that does not contain alcohol.
Apply over the top and bottom of your feet, but not between the
toes. |
|
Trim
toenails straight across and file the edges— Keep
edges rounded to avoid ingrown toenails, which can cause infections. |
|
Always
wear shoes and socks— To
avoid cuts and abrasions, never go barefoot even indoors. |
|
Choose
the right shoes and socks— When
buying new shoes, have an expert make sure they fit well.
At first, wear them just for a few hours daily to help prevent
blisters and examine the feet afterward to check for areas of
irritation. Wear seamless
socks to avoid getting sores. |
|
Check
your feet every day— Check
all over for sores, cuts, bruises, breaks in the skin, rashes, corns,
calluses, blisters, red spots, swelling, ingrown toenails, toenail
infections, or pain. |
|
Call
your foot and ankle surgeon— If
you develop any of the above problems, seek professional help
immediately. Do not try
to take care of cuts, sores, or infections yourself. |
