Diabetic Complications and Amputation Prevention

What is diabetes?
It’s true that many medical conditions have absolutely nothing to do with the foot. Colds, for instance, are not particularly related to podiatric care. (Unless, of course, you’re sneezing so hard that you accidentally stumble into the corner of the table and break your toe.) However, some diseases or medical conditions are linked closely with the feet, and diabetes is most definitely one of these conditions.

Diabetes is a disease in which your body is either (in the case of Type I diabetes) unable to produce insulin (a hormone that helps the body process sugar), or your tissues don’t respond to the insulin that’s produced (in the case of Type II diabetes). This leads to too much sugar in the blood, which, in turn, can damage blood vessels, nerves, kidneys, the heart, the eyes, and the feet. It’s estimated that about 24 million people in the U.S. alone suffer from diabetes, and up to a quarter of that number may be unaware that they have it.

Because diabetes can be so damaging to your overall health, you should talk with your doctor right away if you start to experience any symptoms. Common signs of diabetes include an increase in thirst, urination, extreme hunger, fatigue, unexplained loss of weight (although often a cause to celebrate, this weight loss is not normal and may be dangerous), a tingling sensation or loss of feeling (numbness) in your extremities (hands and feet), blurry vision, or wounds that are slow to heal.

If you have diabetes, don’t deny it. Ignoring the problem can lead to your health spiraling completely out of control. Whereas being aware of your diabetes, keeping close tabs on your blood sugar level, and managing any problems that arise can prevent severe complications and extend your life. However, acknowledging you have diabetes doesn’t mean you have to resign yourself to losing limbs or having a huge host of problems. There are many things you can do to prevent complications from developing, and thus protect the health of your foot, and your life.

Possible foot complications
Diabetes can cause two serious problems that are closely linked to foot health: nerve damage and damage to the blood vessels. Nerve damage (also known as diabetic peripheral neuropathy) might mean that you won’t notice when your foot becomes injured, so you continue to walk on it or fail to get it treated, which will cause further damage. Circulation problems mean that diabetics will be slow to heal from injuries or infections. Feet are particularly susceptible to circulation issues, since they’re about as far from the heart as your body gets, and blood coming from your feet has to fight against gravity to get back up to the heart. So, in short, if you get even a small cut or irritation on your foot, it can develop into serious trouble. In fact, it can even lead to infection and eventual tissue death.

Some possible complications that can arise from diabetes are listed below. Please remember: this information isn’t intended to terrify you and make you retreat into a dark room where you never put your feet on the ground again. However, it’s very, very important to understand the seriousness of diabetic complications so that you take the time and effort to resolve problems early before they become life-threatening.

• Ulcers – This is a particularly common complication from diabetes. Basically, ulcers form from areas of the skin that are under pressure, injured (such as with a small cut) or otherwise irritated. Because of nerve damage, people with diabetes can’t always feel this irritation developing. Without any changes made to protect this irritated skin, (such as switching shoes, padding the area, etc.), it may eventually break down completely, leaving an open sore: an ulcer. Unfortunately, because people with diabetes also have trouble healing (due to circulation issues), these ulcers are slow to heal and can easily become infected. They may eventually become so bad that it’s necessary to remove a portion of the foot, the entire foot, or even your leg. In some very serious circumstances, ulcers can even become life- threatening.
• Corns and Calluses – Corns and calluses aren’t experienced by diabetics alone. They form when skin is under unusual pressure from shoes, or may form as a result of a deformity in the foot. However, diabetics may be particularly susceptible to these foot problems, since (again, because of nerve damage) noticing when shoes or other things are irritating the foot is somewhat difficult. Without proper treatment, it’s easy for corns and calluses to turn into ulcers, so getting these problems treated early is essential.
• Hammertoes and Bunions – Neuropathy (nerve damage) doesn’t just affect your ability to feel things through your skin. Remember that it’s nerves (transmitting signals from your brain) that causes your muscles to move. So, damage to these nerves can also cause your muscles to get weaker or have a change in tone. Hammertoes or bunions may result, which, in turn, can lead to ulcers as your foot begins to experience pressure in unusual areas.
• Dry Skin – Oddly enough, both a lack of proper circulation and nerve damage can make the skin of your feet dry and cracked. Now, dry feet may not seem like a particularly serious condition, but left untreated, the skin can crack, which can lead to infection and… you guessed it… possible amputation.
• Nail Problems – Ingrown toenails and fungal infections of the nail are, again, not restricted to those with diabetes. Unfortunately, people with diabetes may not notice these problems (yup-once again due to nerve damage) and so infection may follow.
• Charcot Foot – Charcot foot is a very serious diabetic complication. Imagine breaking a bone in your foot (sometimes only a very small fracture) and then continuing to walk on it. For a long time. That’s a really ugly image, right? This is what happens with Charcot foot. Because of nerve damage (that ever-present diabetic threat), someone with diabetes may not be aware that they’ve developed a fracture. Where someone with fully operational nerves may be moaning and crying and staying off the foot, a diabetic might blithely walk along, not noticing the damage they’re continuing to cause by putting weight on it. Eventually, the soft tissue of the foot are destroyed, bones are seriously damaged, and surgery or even amputation may become the only option.

What you can do
Now, lest you think life with diabetes is all doom and gloom and foot problems, please remember that it’s entirely possible to take good care of yourself, your diabetes, and your feet. Catching problems early (and preventing problems entirely where possible) are crucial in preventing future complications. So, here are a few things you can do:

• Keep blood sugar level in target range – Your primary care physician can assist you with this, but it’s vital that you monitor your blood sugar level closely between visits. Remember that it’s problems with your blood sugar level that can cause the damage to blood vessels and nerves that can be so detrimental to your overall health (and your feet in particular). Keeping that level in check can prevent a whole host of other problems.
• Daily foot inspections – Inspecting your foot daily may not sound like the most exciting use of your time, but such inspections are essential in finding problems to your foot early on, particularly if you have nerve damage. (If it helps to make it seem less boring, you can begin your inspections by donning a Sherlock Holmes type of cap, putting a pipe (an unlit one, of course) firmly between your teeth and using a wonderfully large magnifying glass.) If you can’t see your foot well, or if you have trouble reaching it, have a friend or family member assist you, or use a mirror (the magnifying ones are best) to check those hard-to-see places (like the bottom of your foot). (You can also use the mirror to tell yourself what a wonderful person you are, and compliment yourself on your excellent self-care of your feet.)
  • Pay particular attention to the soles of your foot and between your toes, since this is where problems can often crop up.
  • Check your skin for any sign of irritation or injury. Look for scrapes or cuts (however small), blisters, rashes, signs of infection like redness, swelling, drainage, or a bad smell, or possibly changes in skin color, or loss of hair on your foot or toes.
  • Check your nails for problems. Do they look yellowed or have other changes in color? Are they thickened, deformed, striped, or just not growing?
  • Look for signs that you may have fractured your foot. Check your foot overall for redness, see if it’s warm or hot to the touch, swollen, or has changed in size, shape or direction.
  • If you notice any of the above on your feet, see your podiatristas soon as possible. Don’t assume that the problem will go away on its own, and don’t try to just wait it out. Getting problems treated early is a MUST in diabetic foot care. Doing so can significantly reduce your chance of developing a severe complication.
  • Set a specific time for your foot inspection every day, just to be sure you don’t forget.
• Clean your feet – Wash your feet every day with lukewarm water and mild soap. (You can even make this part of your foot inspection regimen, if you like.) Be sure to test the water temperature with your hand (or elbow if your hand doesn’t have great sensation either) just to make sure it isn’t too hot, or have someone test the water for you. Dry your feet thoroughly but gently using a soft towel, paying particular attention to the skin between your toes. You can use talcum powder (aka baby powder) to wick moisture away from your skin, but be sure to get rid of any residue, particularly between your toes. Don’t soak your feet unless your podiatrist advises you to do so.
• Use proper shoes – Because they may expose your feet to harm, cause significant pressure, or may position your foot unnaturally, it’s important to avoid wearing certain types of shoes, such as sandals (especially those with a thong between the toes), slippers, and shoes with high heels. Instead, wear comfortable, well-fitting shoes with soft leather uppers that can mold to the shape of your feet. (Running or walking shoes may fit the bill nicely.) Wear socks with your shoes, but avoid socks or stockings with seams in them, since this can cause irritation (and potentially an ulcer). (You can ask your podiatrist about special shoes and socks designed for diabetic patients.) Always check the insides of your shoes before wearing them and after taking them off, making sure that the lining of the shoe is smooth and that there are no foreign objects (like rocks or (shudder) spiders) inside.
• Lubricate dry skin – Apply a thin film of moisturizer (Cetaphil cream is recommended) to the soles of your feet while they’re still wet. Avoid getting the cream between your toes, since this can foster a fungal infection.
• Trim nails – Cut your nails straight across. Rounding corners down can lead to ingrown toenails, which can become infected. Keeping your nails properly trimmed can also reduce pressure within your shoe and help you avoid other complications.
• Lose weight – This one may make you groan a bit. And you may not be overweight. But the truth is that an overwhelming majority of diabetic patients are also not at a healthy weight. While improving your health in general, weight loss can also take pressure off your feet, thus preventing future problems. Weight loss plans should always be discussed with your doctor, particularly if you are diabetic.
• Exercise – Along with reducing weight, exercise can help improve circulation and condition your feet. Walking is often the best exercise for diabetics. However, you should consult with your primary care physician as well as your podiatrist before adopting an exercise regimen. (Also, be sure to ask your podiatrist about the best kind of shoes to wear while exercising. He or she is sure to have some good ideas.)
• Promote circulation to your foot – You can help blood flow more easily to your foot by putting up your feet while sitting. (Putting up your feet while standing isn’t likely to work well.) You can also try little foot exercises like wiggling your toes and moving your foot up and down at the ankle for five minutes at a time. Try doing this about two or three times a day.
• See your podiatrist – See your podiatrist at least twice a year, and be sure to tell him or her that you have diabetes. See your podiatrist immediately if you notice any blisters, punctures, pain in your feet or legs (leg pain may be a sign of a blocked artery), change in skin or nail color, loss of sensation, or if there’s an area of your foot with increased or decreased temperature.

What you should NOT do
Just as you should do certain things when you have diabetes, there’s also a list of things you should avoid.

• DON’T go barefoot – Whether in your house or out of it, your feet may encounter things on the ground that cause damage, like small plastic toys, bits of glass, nails, or very sharp rocks. (Although you should also keep your floors free of these potentially dangerous bits of things.) Because you may not notice when you step on something like this, (and thus damage your foot as you continue to walk on your injury), you can avoid the problem entirely by wearing shoes (WITH socks) pretty much all the time. Except in bed. Your feet are usually pretty safe there. (Although you can wear socks in bed for warmth.)
• DON’T put tight things around your legs – Foot or leg-wear like garters or knee-high stockings (or elastics to hold UP the stockings) can reduce circulation to your foot, thus exacerbating your bloodflow problems. Panty girdles, thigh highs, and even sometimes men’s socks can also be problematic if the elastic is too tight.
• DON’T expose feet to extreme heat/cold – Again, because of nerve problems, you may not be able to feel when the skin of your foot is too hot or too cold, and thus be unaware when extreme heat or cold causes damage. In order to avoid problems, don’t walk on hot pavement, never use a hot water bottle or heating pad on your feet (wear socks instead if your feet are cold), be careful of car heaters on road trips, and don’t put ice on your feet if they feel hot. Also, apply sunscreen to your feet to avoid sunburn.
• DON’T cut corns or calluses yourself – If you try to perform “bathroom surgery” on your corns or calluses, you run the risk of cutting too much off, or getting an infection. If you need them removed, your podiatrist is very skilled at taking corns and calluses off. He or she can also instruct you how to work on calluses (the ones that aren’t too thick) using pumice stones or emery boards, but only if you promise to follow their instructions carefully. NEVER use medicated callus or corn removers, since these can eat into healthy skin and cause infections.
• DON’T use commercial foot supports – Your podiatrist may wish to prescribe orthotics for your use, but avoid over-the-counter arch supports or foot pads.
• DON’T smoke – Smoking can further reduce your circulation, causing even more complications with healing. Quit smoking as soon as possible to avoid these complications.
• DON’T drink excessively – Just as smoking can further damage your circulation, so alcohol can speed up the damage to your nerves already caused by neuropathy. This increases the likelihood that you’ll be unable to detect injury or other problems with your foot. Avoid drinking in excess.
• DON’T cross your legs – Crossing your legs while sitting (or even lying down) can compromise the circulation in your legs and feet. You may look great while doing it, but remember that it’s your health that’s most important, not your appearance. (Yes. Despite what the fashion industry may tell you.)

What your doctor can do
If you have diabetes, you need an entire team of specially trained physicians to assist you in caring for your body. Your primary care physician is one team member, and can help you to manage your blood sugar levels, among other things. Ophthalmologists will help you manage your eyesight, and your podiatrist will help you with your ever-important foot care.

Seeing your podiatrist regularly (again, at least twice a year) for foot inspections will help prevent foot problems from turning into disasters. Your podiatrist is trained to detect issues in their beginning stages. However, you can help him or her out by performing daily checkups. Again, it’s essential that you see your podiatrist immediately if you notice any blisters, bruising or bleeding around your calluses, puncture wounds, sores, ingrown nails, ulcers (especially when there’s redness around the ulcer), loss of sensation or an area of increased or decreased temperature.

No one is happy about an amputation. In fact, your podiatrist will do everything possible to prevent it. Fortunately, many techniques have been developed to aid diabetics in the healing process. Your podiatrist is an expert in healing wounds, and will use all the tools at his or her disposal to assist in the healing process. Surgery may also be an option, depending on your overall condition, and the condition of your foot.

Sometimes Amputation is necessary
Unfortunately, despite your best efforts and the best efforts of your podiatrist, amputation is sometimes necessary in order to curb infection before it spreads to the rest of the limb, or to the body as a whole. Such amputations might be the best way to save your limb or your life. Your podiatrist will discuss your options with you if this step becomes necessary.

Always remember though: amputation is a last-step resort. In most cases, it can be prevented by regular screenings with your doctor, proper management of your diabetes, and daily self-checks. Early recognition of problems and immediate treatment are essential in preventing serious complications. So, in short, stay on top of your diabetes, and it’s much less likely to bowl you over.