Foot problems in Diabetes

Dr. M.K. Mam
Diabetes is the most common non-communicable disease globally and is rapidly increasing at an alarming rate that too in developing countries. It is reported that India harbors the majority of diabetic people and by the year 2030 AD India will have the largest number of diabetic patients.
Patients with diabetes are prone to multiple complications and one of them is diabetic foot. Foot the organ of support and locomotion is worst affected in diabetes and somehow or other has not received much attention. Foot problems are very commonly seen in the diabetics and certainly represent the most common complications and the hospitalization in diabetics. It is a well know fact that the foot problems in diabetic’s cause considerable suffering, disability, frequent hospitalization and lot of expenses to the patient, family and the community. It is responsible for substantial emotional and physical distress as well as productivity and financial losses that lower the quality of life. It has been reported that gangrene, a dreadful complication is 15 times more common in diabetics as compared to non diabetics and most often it is preceded by an ulcer in the foot. Apparently the socioeconomic burden of the diabetic foot on the country`s resources is tremendous
The foot in diabetic is affected primarily due to nerve damage – neuropathy, blood vessel damage- angiopathy and the infection. Nerves in feet are affected in more than 50 % patients and in almost all the patients having diabetes for more than 20 years. There occurs blunting or total loss of sensation in foot especially the sole with the result person is incapable of feeling pain, touch and temperature. The person is unaware of any injury, which could be mechanical, thermal or chemical. Very often minor injury like a shoe bite caused by wearing badly fitting footwear or walking bare foot or any foreign body inside shoes or any minor injury because of a fall or accident goes unnoticed by the person and he continues walking leading to formation of an ulcer. The fact is that the person is unaware of it until it has progressed to a severe stage or is pointed out by a relative or a doctor. Small sores or breaks in the skin may turn into larger and deep skin ulcers which get infected and when these are not treated properly, it can end up in an amputation of the affected toe, foot or the limb.The good thing is that these complications are preventable. It is therefore quite rational to prevent these devastating consequences. Prevention certainly is better than cure. All people with diabetes should be examined by a doctor regularly at least once in six months to a year for potential foot problems. Patients with demonstrated risk factor(s) should be examined more often. We need to understand that the absence of symptoms does not mean that the feet are healthy; a patient might have involvement of nerves, blood vessels, or even an ulcer without any complaints.
Screening of diabetics for feet with risk factors is somehow not routinely done in our country. We have to identify the patients whose feet are at risk. Any foot with i) nerve damage i.e. blunting or loss of sensation ii) blood vessels damage iii) deformities iv) a callus v) previous ulcer or vi) amputation is certainly at risk. Patients having other co-morbidities like blindness partial or total, or kidney involvement and the elderly ones especially those living alone and when the duration of diabetes is longer than 10 years are also at risk. Recent studies have indicated multiple risk factors are associated with the development of diabetic foot problems. All such cases need a special attention.
Education of patient regarding foot hygiene, nail care and proper footwear is crucial to reducing the risk of an injury that can lead to ulcer formation. Patients with diabetes should be educated about risk factors and the importance of foot care, including the need for self-inspection, monitoring foot temperature, appropriate daily foot hygiene, use of proper footwear, and blood sugar control. A religiously under -taken foot care, which is quite simple and does not need much of expenses but the will and the motivation of the person, helps a lot in reducing the foot problems in the diabetics. Feet should be checked at least once daily by the diabetic himself for any minor trauma, which may go unnoticed in the beginning. We need to look for minor injury ,blister , crack or a fissure in skin, corn or a callus, puncture , swelling or redness at the pressure points or in between the toes One should ask his relation to have a look at his feet if he is unable to do it , may be because of vision problem . One can also use a mirror to have a look at his feet. Feet have to be washed twice a day with mild soap and warm water and carefully dried especially in-between the toes with soft towel. One must check the temperature of water to be used for washing the feet or taking a bath, obviously it has to be warm not hot i.e. below 37degree. Feet should not be allowed to remain too wet or too dry so that it cracks. Feet should not be exposed to extremes of temperature, never apply hot fomentation, cold compresses or heating pads. Again, we should not use a heater or a hot-water bottle to warm the feet. Proximity to fire, heating devices or the hot water bottles is certainly dangerous. Nails should be cut transversely. Corns and callosities should not be taken lightly and should be treated by a doctor. A diabetic must never use chemical agents or plasters to remove corns and calluses and should never walk bare footed. Barefoot walking whether indoors or outdoors must never be done. Shoes have to be of right size, never wear tight or too loose shoes and should never be worn without socks. We must regularly inspect and check the inside of the shoes for any small pebble etc. Socks must be changed daily and should be clean and dry with loose elastic. Never wear tight or knee high socks. One should never use pumis stones. Lubricating oils or creams should be used for dry skin – but not between the toes. Nails should be cut straight across. A diabetic must consult the doctor at once if a blister, cut, scratch or sore has developed.
Smoking we all know, causes narrowing of blood vessels, has to be stopped at all costs. Alcohol aggravates diabetes, has to be avoided. Blood sugar has to be kept under control, and then only the incidence of complications will reduce. It is also essential to screen all diabetics to detect those at high risk of getting foot ulceration.
It has been shown that up to 50% of diabetic foot problem can be prevented by effective education. In fact, educating patients about self foot care is considered the cornerstone to prevent diabetic foot problem. A diabetic, who does not take care of his feet, certainly has the highest chances of landing in devastating complications of losing the foot or leg. In addition to an intensive patient education and religiously under-taken foot care, a good control of diabetes, screening of diabetics for early detection of feet at risk, and the establishment of diabetic foot clinics with a multidisciplinary team approach involving a general practitioner, a nurse, an educator, an orthotic specialist, a podiatrist, endocrinologists- diabetologist, orthopedic specialists and consultations with other specialists such as vascular surgeons, infectious disease specialists and dermatologists will certainly go a long way in not only saving the feet and legs in the diabetics, but will also decrease the agony of morbidity and the financial drain. Many studies have shown that proper management of diabetic foot can greatly reduce, delay, or prevent complications such as infection, gangrene, amputation, and even death.
(The author is formely- Vice Principal ,Professor & Head Deptt Of Orthopaedics ,CMC,Ludhiana)