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Zeehan S. Husain, DPM

Charles G. Kissel, DPM

Michael S. Schey, DPM

Angela Stoutenburg, DPM

Board certified by the 
American Board of 
Podiatric Surgery.


Diabetic Problems

Diabetic Foot Issues

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

  1. Diabetic Foot Care Guidelines

  2. Diabetic Peripheral Neuropathy

  3. Diabetic Complications and Amputation Prevention

  4. Charcot Foot

  5. Peripheral Arterial Disease

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.

bulletNeuropathy— 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.
bulletPoor 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. 
bulletPoor 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.
bulletInfection— 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.

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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.

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Wash your feet in lukewarm (not hot!) waterKeep your feet clean by washing them daily. But only use lukewarm water or the temperature you would use on a newborn baby.

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Be gentle when bathing your feetWash them using a soft washcloth or sponge.  Dry by blotting or patting and make sure to carefully dry between the toes.

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Moisturize your feet, but not between your toesUse a moisturizer daily to keep dry skin from itching or cracking.  But DO NOT moisturize between the toes.  This could encourage a fungal infection.

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Cut nails carefully and straight acrossAlso, file the edges.  Do not cut them too short or round the edges to avoid developing ingrown toe nails.

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Never trim corns or callusesNo “bathroom surgery”—let your doctor do the job.

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Wear clean, dry socksChange them daily.

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Avoid the wrong type of socksAvoid tight elastic bands (they reduce circulation).  Do not wear thick or bulky socks (they can fit poorly and irritate the skin).

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Wear socks to bedIf your feet get cold at night, wear socks.  NEVER use a heating pad or hot water bottle.

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Shake out your shoes and inspect the inside before wearingRemember, you may not feel a pebble.  So always shake out your shoes before putting them on.

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Keep your feet warm and dryDo not get your feet wet in snow or rain.  Wear warm socks and shoes in winter.

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Never walk barefootNot even at home!  You could step on something and get a scratch or cut.

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Take care of your diabetesKeep your blood sugar levels under control.

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Do not smokeSmoking restricts blood flow in your feet.

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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:

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Sensory nerves— enable people to feel pain, temperature, and other sensations

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Motor nerves— control the muscles and give them their strength and tone

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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:

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Numbness or tingling in the feet

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Pain or discomfort in the feet or legs including prickly, sharp pain, or burning feet

For motor neuropathy:

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Muscle weakness and loss of muscle tone in the feet and lower legs

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Loss of balance

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Changes in foot shape that can lead to areas of increased pressure

For autonomic neuropathy:

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Dry feet

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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:

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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.

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Because of numbness, a patient may not realize that he or she has stepped on a small object and cut the skin.

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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:

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Keep blood sugar levels under control.

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Wear well-fitting shoes to avoid getting sores.

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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.

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Visit your foot and ankle surgeon on a regular basis for an examination to help prevent the foot complications of diabetes.

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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:

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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.

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Corns and callusesWhen 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.

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Dry, cracked skinPoor circulation can make your skin dry.  This may seem harmless, but dry skin can result in cracks that may become sores.

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Nail disordersIngrown 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.

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Hammertoes and bunionsMotor 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.

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Brittle bonesNeuropathy 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.

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Charcot footThis 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.

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Blocked artery in the calfIn 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:

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Inspect your feet daily— If your eyesight is poor, have someone else do it for you.  Inspect for:
Skin or nail problems— Look for cuts, scrapes, redness, drainage, swelling, bad odor, rash, discoloration, loss of hair on toes, injuries, or nail changes (deformed, striped, yellowed or discolored, thickened, or not growing).
Signs of fracture— If your foot is swollen, red, hot, or has changed in size, shape, or direction, see your foot and ankle surgeon immediately.

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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.

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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.

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Nail cutting— If you have any nail problems, hard nails, or reduced feeling in your feet, your toenails should be trimmed professionally.

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No “bathroom surgery”— Never trim calluses or corns yourself, and do not use over-the-counter medicated pads.

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Keep floors free of sharp objects— Make sure there are no needles, insulin syringes, or other sharp objects on the floor.

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Do not go barefoot— Wear shoes, indoors and outdoors.

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Check shoes and socks— Shake out your shoes before putting them on.  Make sure your socks are not bunched up.

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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:

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Warmth to the touch (the foot feels warmer than the other)

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Redness in the foot

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Swelling in the area

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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:

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ImmobilizationBecause 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.

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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.

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Activity modificationA 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.

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SurgeryIn 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:

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Diabetes patients should keep blood sugar levels under control.  This has been shown to reduce the progression of nerve damage in the feet.

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Get regular check-ups from a foot and ankle surgeon.

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Check both feet every day and see a surgeon immediately if there are signs of Charcot foot.

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Be careful to avoid injury, such as bumping the foot or overdoing an exercise program.

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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:

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Leg pain (cramping) that occurs while walking (intermittent claudication)

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Leg pain (cramping) that occurs while lying down (rest pain)

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Leg numbness or weakness

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Cold legs or feet

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Sores that will not heal on toes, feet, or legs

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A change in leg color

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Loss of hair on the feet and legs

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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:

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Being over age 50

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Smoking (currently or previously)

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Diabetes

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High blood pressure

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High cholesterol

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Personal or family history of PAD, heart disease, heart attack, or stroke

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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.

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Lifestyle changes— Include smoking cessation, regular exercise, and eating a heart-healthy diet.

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MedicationsMedicines may be used to improve blood flow, help prevent blood clots, or to control blood pressure, cholesterol, and blood glucose levels.

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SurgeryIn 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:

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Wash your feet dailyUse warm (not hot) water and a mild soap.  Dry your feet especially between the toes, gently and well.

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Keep the skin softFor 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.

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Trim toenails straight across and file the edgesKeep edges rounded to avoid ingrown toenails, which can cause infections.

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Always wear shoes and socksTo avoid cuts and abrasions, never go barefoot even indoors.

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Choose the right shoes and socksWhen 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.

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Check your feet every dayCheck all over for sores, cuts, bruises, breaks in the skin, rashes, corns, calluses, blisters, red spots, swelling, ingrown toenails, toenail infections, or pain.

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Call your foot and ankle surgeonIf you develop any of the above problems, seek professional help immediately.  Do not try to take care of cuts, sores, or infections yourself.

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Rochester Center For Foot & Ankle Surgery
248-651-0162
Crittenton Medical Building
1135 West University Drive, Suite 235
Rochester, Michigan 48307

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