Foot Complications

The following are the major Foot Complication for people with diabetes

• Skin Changes
• Calluses
• Foot Ulcers
• Poor Circulation
• Amputation

Skin Changes

Diabetes can cause feet to be very dry at times. This is because the nerves that control the oil and moisture in the foot are no longer working. After bathing, feet need to be dried well. Use petroleum jelly, unscented hand cream, or a similar product to seal in extra moisture. It is important not to put oils or creams between toes, since extra moisture can lead to infection.

Calluses

Calluses occur more often and build up faster in the diabetic. Too much callus build up may mean that therapeutic shoes and inserts are required. Calluses, if not trimmed, get very thick and can break down and turn into ulcers (open sores). It is important not to self treat calluses. This can lead to infection. Your healthcare provider should do this for you.


Treatment

Assess the shoes of patients who have calluses. Teach patients to manage calluses with an emery board, callus file, or pumice stone--but strongly caution patients against trying to perform "home surgery" on calluses.

Foot Ulcers

Even though some ulcers do not hurt, every ulcer should be seen by the health care provider immediately. Neglecting ulcers can result in infections, which can lead to potential loss of a limb. Keeping off the feet, when there are problems, is very important. Walking on an ulcer can make it get larger and force the infection deeper into the foot.

Treatment of foot ulcers

Carefully evaluate and vigorously debride foot ulcers to establish the depth of the ulcer. Use X-ray studies to help exclude the possibility of imbedded foreign objects or osteomyelitis. If osteomyelitis is suspected, use follow-up radiographs and appropriate scans to help establish the diagnosis. Where there is significant infection, use parenteral antibiotics. Since anaerobes frequently occur in the foot ulcers of diabetic patients, take both aerobic and anaerobic bacterial cultures to help select antibiotics.

Ulcers that occur in areas other than the usual plantar area, that cannot be explained by previous trauma or ill-fitting shoes, or that do not respond to aggressive treatment should be biopsied.

Ensure that patients do not put weight on the affected foot. Patients who do not feel pain will likely continue to walk; the resulting pressure on the foot will prevent healing. Total bed rest or the use of crutches may be required. Total-contact casts have been shown to help patients with foot ulcers ambulate while ulcers heal; the casts redistribute pressure so that the area of the ulcer bears much less weight than it would otherwise.

Good glycemic control also may help the patient's foot to heal. Topical use of hyperbaric oxygen, however, is not effective.

If foot ulcers do not respond to therapy, vascular surgery must be considered.


Prevention of recurrence of foot ulcers

Without special post- ulcer care, recurrence of the ulcer is almost certain. Such care may entail a change in job, a change in walking habits, and most importantly, special shoes. Extra-depth shoes with molded plastic insoles help redistribute weight and may prevent recurrent ulcers. In one study, ulcers recurred in only about 20% of patients who wore these special shoes, whereas ulcers recurred in 80% of patients who resumed wearing ordinary shoes.

If ulcers recur despite protective shoes, the most likely cause is a bony deformity. If the patient's circulation is good, orthopedic procedures to repair such deformities may help prevent recurrence of the ulcer

Poor Circulation

Poor blood flow can make the foot less able to fight infection and heal. There are things that can be done to improve circulation: stop smoking, keep blood pressure and cholesterol in check. Also, exercise is good for poor circulation because it stimulates blood flow in the legs and feet. Exercise is a good idea for individuals who currently do not have any open sores on the foot. Proper shoes are essential.

Amputation

People with diabetes are far more likely to have a foot or leg amputated than anyone else. This is because many people with diabetes have artery disease, which reduces blood flow to the feet. Also, individuals with diabetes usually have nerve damage, which reduces sensation. These two problems combined make an individual much more likely to get ulcers and infection that may potentially lead to amputation. Luckily, most amputations are preventable with regular and proper footwear. Two of the most important factors in reducing the likelihood of amputation is to always follow your health care provider’s advice when caring for foot problems and to stop smoking! Smoking affects small blood vessels by decreasing their blood flow to the feet and delays the healing of wounds.

Complete Foot Exam

Early detection and management of diabetic neurovascular foot complications have been shown to decrease the incidence of diabetic foot ulcers and lower limb amputations.

Category of Patient	Recommended Procedure	Schedule
0 No loss of protective sensation (LOPS)	Visual exam with shoes and socks off by MD, RN, or trained personnel. Complete exam including visual inspection, neurovascular examination, and risk categorization. Discuss appropriate footwear.	At all regularly scheduled diabetes visits. Annually and with each new abnormality.
1 LOPS	Complete exam as above. Soft insoles. Discuss appropriate footwear.	At all regularly scheduled diabetes visits.
2 LOPS Pressure (callus/ deformity) or decreased circulation	Complete exam as above. Speciality care by podiatrist, orthopedic surgeon, vascular surgeon, or physiatrist experienced in the management of diabetes. Custom insoles. Prescription footwear.	At all scheduled diabetes visits. Every 3 - 4 months.
3 LOPS Plantar ulcer (or history), or neuropathic fracture	Same as Risk Category 2	As above. More frequent specialty care plan.

Methods to Care your Foot

Wash your feet daily : Dry them carefully, especially between the toes. Don't soak your feet (unless instructed to do so by your health care provider). If your feet are dry, apply a very thin coat of lubricant (oil or cream) to them after bathing and drying them. Don't put oil or cream between your toes.

Inspect your feet daily : Use an unbreakable mirror to help see the bottom of your feet. If your vision is impaired, ask someone to check your feet for you. Check for scratches, cuts, or blisters. Always check between your toes.

Cut your toenails by following the contour of the nail. Smooth the corners with an emery board. Don't trim into the corners of your toenails or cut ingrown toenails. If redness appears around your toenails, see your health care provider immediately.

Don't cut corns or calluses. Don't use corn plasters or chemicals for removing corns or calluses. Don't use strong antiseptic solutions or adhesive tape on your feet.

Avoid extreme temperatures. Test water with your hand or elbow before bathing. Don't walk on hot surfaces, such as sand at the beach or cement around swimming pools. In winter, wear wool socks and protective foot gear, such as fleece-lined boots. Don't apply hot water bottles or heating pads to your feet. If your feet are cold at night, wear socks.

Don't walk barefooted--even indoors. Don't wear sandals with thongs between your toes. Don't wear shoes without stockings or socks. Inspect the inside of your shoes every day for foreign objects, nail points, torn linings, and rough areas. Shoes should be comfortable at the time of purchase. Don't buy shoes that are too tight and depend on them to stretch out. Break in new shoes before wearing them regularly. Ask your health care provider or podiatrist about the types of shoes most appropriate for you.

Don't wear restrictive clothing (such as leg garters). Avoid crossing your legs; doing so can cause pressure on the nerves and blood vessels in the legs.

Don't smoke.

Don't drink alcohol excessively.

Tell your health care provider or podiatrist at once if you develop a blister or sore on your foot. Be sure to tell your podiatrist that you have diabetes.