Foot Maintenance for Patients with Diabetes

Foot Maintenance For Patients With Diabetes

Diabetes mellitus afflicts more than 23 million Americans, an astounding fifteen percent of the population of the United States. Most people know that diabetes results from the body’s inability to either produce sufficient insulin or to make proper use of the insulin that it does produce. What many do not realize is the devastating impact that diabetes can have on general health, particularly when diabetic symptoms are not properly treated or the diabetic’s blood glucose levels are not adequately controlled. Over time, diabetes can affect all organ systems in the body, resulting in heart and kidney disease and blindness, among other complications. One of the most serious health risks associated with diabetes is posed by foot infections and other foot problems, which, in some cases, can lead to disability and even amputation of the toes, feet, or legs. 

Foot problems are particularly dangerous to diabetics because of two conditions commonly associated with diabetes: diabetic neuropathy and peripheral artery disease. Sixty to seventy percent of people suffering from diabetes also suffer from neuropathy, an impairment of the nervous system that causes a loss of sensation in the extremities, including the fingers, toes, hands, and feet. When individuals with diabetic neuropathy experience an injury, they may not realize immediately that they have been hurt, or, even if they do, they may underestimate the severity of their wounds because they are incapable of feeling pain to the extent that a normal person does. 

In addition to diabetic neuropathy, diabetics typically suffer from peripheral artery disease which reduces the blood flow to the feet, making it harder for wounds in the feet to heal. Peripheral artery disease is a narrowing of the blood vessels in the extremities. Diabetics who suffer from peripheral artery disease have decreased blood flow to the legs, feet, and toes, which makes it difficult for injuries in those areas to heal and renders the diabetic susceptible to infection. Thus, diabetics who suffer even small injuries to the feet may be at risk of complications because the delay in healing invites infection which may, in some cases, penetrate to the bone or escalate to a gangrenous state.

Individuals who lose feeling in their feet are at greater risk for developing deformities of the feet as well as open sores known as ulcers. Because one of the effects of diabetics is a difficulty in healing, it is often challenging to treat and eliminate these ulcers. A dangerous situation can arise when these ulcers become infected. It is very easy for a diabetic to develop infections, and once an infection has developed, it generally spreads quickly.

Because of the grave consequences that can result from foot infections in diabetics, diabetics should carefully and routinely monitor and examine their feet. A diabetic should perform a self-foot-exam on a daily basis, checking for cuts, bruises, swelling, red spots, ulcers, blisters, and areas that feel warm or appear red, dark, or otherwise discolored. The exam should be thorough and include the bottom of the foot, as well as the top, and the areas between the toes. Even a small injury to the foot, one which would be of little consequence to a healthy individual, such as a blister, can result in serious complications for a diabetic. If any wounds or suspicious spots are detected, the diabetic should consult his physician immediately. Since diabetics can injure themselves without realizing it, they should avoid walking around barefoot, whether indoors or outdoors. Thorough foot exams should be performed on a routine basis by a medical professional, such as a podiatrist who specializes in diabetic foot care. Medical foot exams should be scheduled annually, or more frequently if a diabetic exhibits certain risk factors, particularly advanced neuropathy or peripherally artery disease, or has a history of foot problems and symptoms.

In addition to performing daily foot exams, the diabetic should wash his or her feet every day with a mild soap in luke-warm water. Lotion should be applied to the tough skin on the bottom of the foot to keep it soft, but areas between the toes, where fungal infections can arise, should be avoided. Toe nails should be kept trimmed. Because of the potential consequences of an accidental wound, it is best for nail trimmings to be performed by a doctor or other health care professional. In-grown toenails in diabetics should receive prompt medical attention. An individual with diabetes should never attempt to remove calluses or corns from his own feet; such procedures should be left to a health professional because of the risk of injury to the surface of the skin.

Shoes and socks should be chosen carefully, preferably from a medical supply store that sells shoes and socks specially designed for diabetic feet. Bulky socks or socks with tight elastic bands should be avoided as they can irritate the skin and reduce circulation in the feet. Socks should be clean and dry and changed on a daily basis. Diabetics should keep their feet warm by wearing loose socks to bed and keeping their feet well protected if they venture out in the snow or rain. In addition, when at rest, diabetics should elevate their feet whenever possible. Crossing of the feet and legs should be avoided when possible, since this could restrict circulation. However, they should resist the temptation to prop their feet up on a radiator or other potentially hot spot, since they could sustain burn injuries without realizing due to the effects of neuropathy. Diabetics should also resist the temptation to use a heating pad or hot water bottle in bed. Smoking is strongly discouraged as it constricts the blood vessels and contributes to the effects of peripheral artery disease and further impedes healing. 

In extreme cases, diabetics with foot injuries and infections can eventually suffer amputation of one or more toes, part or all of a foot, or part of the leg. The path toward amputation generally begins with a foot ulcer that emerges and persists as a result of a combination of neuropathy and peripheral artery disease. It is estimated that somewhere between 40 and 70 percent of all leg, foot, and toe amputations are directly related to diabetic foot infections or ulcers. However, amputations can be prevented by proper foot care and prompt medical attention in the event that foot problems and complications arise. Perhaps the most important thing a diabetic can do to limit the possibility of amputation is to keep his or her blood sugar levels under control. Although it may initially seem counterintuitive, exercise is actually helpful in staving off the worst diabetic foot problems because activity increases the flow of blood to the extremities.

All diabetics are at risk of developing serious foot conditions and should always follow a careful foot care regimen. However, some diabetics are at even greater risk for developing the gravest foot problems associated with their disease, including diabetics who are male, have had diabetes for more than ten years, have poor glucose control, or are already suffering from diabetes-related cardiovascular, retinal or kidney disease. 

In a worst-case scenario, a minor foot injury could lead to an infection, which, if it were left untreated or proved resistant to treatment, could develop into a serious infection such as osteomyelitis (infection of the bone) or cellulitis (infection of the connective tissue) and, eventually the tissue death known as gangrene. When gangrene occurs, the afflicted area must generally be amputated to avoid spread of tissue death to other parts of the body. Untreated gangrene is potentially fatal.

When a surgeon deems that an infection has progressed to the point where the tissue cannot be salvaged or life-threatening gangrene has set in, amputation may be the recommended course. Surgeons will generally remove only as much tissue as necessary, so it is common to amputate only a toe or toes in an effort to salvage the rest of the foot and leg. Rehabilitation from a toe amputation is much easier than rehabilitation from the amputation of a foot or leg, as most patients can learn to walk again using a shoe equipped with a prosthetic toe. Because of the slow healing time that is typical of diabetes, a diabetic may need up to eight weeks to recover from a toe amputation, during which time no weight should be placed on the injured foot. Even if amputation of the toes or foot on one side becomes necessary, a careful regimen of diabetic foot care should be maintained in order to preserve the remaining healthy tissue on both feet.

Diabetics and those who care for them will find many helpful resources on the web related to foot care and other health matters of particular relevance to diabetes. Many diabetes advocacy and research organizations maintain a strong presence on the internet, and, because diabetes has become such a serious and prevalent health care issue in the United States, many of the nation’s premier hospitals and medical institutions offer online information concerning diabetic care. What follows is a collection of links to some of the most useful and information web pages regarding diabetic foot maintenance and the prevention and treatment of serious foot infections and other complications.

American Diabetes Association, Living With Diabetes, Foot Care: The American Diabetes Association is a research and advocacy organization devoted to curing, preventing, and education the public about diabetes and its effects. In addition, the American Diabetes Association provides educational resources and funds to improve the quality of life of individuals suffering from diabetes. This page provides information about concrete steps diabetes patients can take to prevent the onset of foot problems that can be a frequent complication of diabetic illness.

Diabetes Care: Preventive Foot Care in Diabetics: This article from the journal Diabetes Care, published by the American Diabetes Association, includes detailed information on identifying risk factors for foot complications in diabetics, the importance of foot exams, and the prevention and management of high-risk foot problems.

Diabetic Foot Infections: This article, available on the WebMD web site, provides detailed clinical information about the foot infections to which diabetic patients are vulnerable, including osteomyelitis and cellulitis.

American College of Foot and Ankle Surgeons, Diabetic Foot Care Guidelines: The American College of Foot and Ankle Surgeons (ACFAS) is a professional medical society whose membership includes over 6,000 foot and ankle surgeons who practice in the United States. In extreme cases, the complications of diabetes may lead to foot problems that require surgical intervention, particularly when bone infections and gangrene set in. This page explains why the feet of diabetics are so vulnerable to complications and provides clear instructions for foot care and for other steps that can preserve diabetics’ health and possibly forestall the necessity of toe and foot amputations.

Medline Plus Interactive Tutorial on Diabetic Foot Care: Medline Plus, a project sponsored by the National Library of Medicine of the National Institutes of Health, provides an interactive tutorial on foot care for diabetic patients.

American Academy of Orthopaedic Surgeons, Diabetic Foot: This page on the website of the American Academy of Orthopaedic Surgeons (AAOS) provides diabetic patients with invaluable tips for preventing infections, ulcers, and foot deformities.

International Diabetic Foundation: Position Statement--The Diabetic Foot: This page from the web site of the International Diabetic Foundation (IDF) argues that many foot amputations suffered by diabetics are preventable and provides treatment and educational goals for reducing the incidence of this radical form of surgical treatment of foot complications.

The International Working Group on the Diabetic Foot: The International Working Group on the Diabetic Foot is a project sponsored by the International Diabetes Foundation.

World Diabetes Day 2005: The theme of World Diabetes Day 2005, an event celebrated and remarked worldwide and sponsored by the International Diabetes Foundation, was diabetic foot health and care.

Dermatology Information System (DermIS): This page provides a collection of images showing the effects of gangrenous infections on the feet of diabetic patients.

Mayo Clinic: Amputation and Diabetes: This page from the website of the Mayo Clinic provides information about preventing amputation and coping when amputation is the only option for treating diabetic foot problems.

A Practical Manual of Diabetic Foot Care: This page from provides information about the book A Practical Manual of Diabetic Foot Care, authored by medical experts in the field of foot complications in diabetics. The book is a clinical manual for diagnosis and treatment of diabetic foot problems for physicians and health care professionals and covers foot ulcers and infections as well as conditions necessitating surgical amputations.

Des Moines University Clinic Diabetic Foot Care: This page from the website of the Des Moines University Clinic provides specific information about preventing foot complications and recognizing the signs of dangerous foot problems in diabetic patients.

Diabetes: Peripheral Artery Disease (PAD) and Limb Loss: This page from the dLife web site, which collects resources for those living with diabetes, engages in an in-depth discussion of peripheral artery disease, one of the greatest risk factors and causes of foot and leg amputations in diabetic individuals.

inMotion: Keeping the Sound Limb Sound: Foot Issues for Amputees with Diabetes: This article from inMotion magazine, a publication of the Amputee Coalition of America, addresses issues that arise in terms of rehabilitation and limb preservation that are unique to diabetic amputees.