DIABETIC COMPLICATIONS AND AMPUTATION PREVENTION
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
- 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:
- Infections and ulcers (sores) that don't heal. Because of poor circulation in the feet, cuts or blisters can easily turn into ulcers that become infected and won't 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.
- Corns and calluses. When neuropathy is present, you can't 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.
- Dry, cracked skin. Poor circulation can make your skin dry. This may seem harmless, but dry skin can result in cracks that may become sores.
- Nail disorders. Ingrown 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're not professionally treated, they can lead to ulcers.
- Hammertoes and bunions. Motor 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. Brittle bones. Neuropathy 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.
- Charcot foot. This 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.
- Blocked artery in the calf. In diabetes, 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 from a vascular surgeon. If vascular 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 vascular 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. It 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:
- Inspect your feet daily. 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. (If your eyesight is poor, have someone else do it for you.)
- 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.
- Don't 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.
- Nail cutting. If you have any nail problems, hard nails, or reduced feeling in your feet, your toenails should be trimmed professionally.
- No bathroom surgery. Never trim calluses or corns yourself, and don't use over-the-counter medicated pads.
- Keep floors free of sharp objects. Make sure there are no needles, insulin syringes, or other sharp objects on the floor.
- Don't go barefoot. Wear shoes, indoors and outdoors.
- Check shoes and socks. Shake out your shoes before putting them on. Make sure your socks aren't bunched up.
- Have your sense of feeling tested. Your foot and ankle surgeon will perform various tests to see if you've lost any feeling.
Diabetic Foot Care Guidelines
As a diabetic, many times a patient can have a loss of sensation or poor circulation. Some patients are not even aware of these issues. For this reason it is important the patient follows some simple foot care prevention. Below are suggestions for preventive diabetic foot care.
- Take care of your diabetes.
- Work with your healthcare team to keep your blood sugar within a good range.
- Check your feet every day.
- Look at your bare feet every day for cuts, blisters, red spots and swelling.
- Use a mirror to check the bottoms of your feet or ask a family member for help if you have trouble seeing.
- Wash your feet every day.
- Wash your feet in warm, not hot, water every day.
- Dry your feet well. Be sure to dry between the toes.
- Keep the skin soft and smooth.
- Rub a thin coat of skin lotion over the tops and bottoms of your feet, but not between your toes.
- Smooth corns and callouses gently.
- If your feet are at low risk for problems, use a pumice stone to smooth corns and callouses. Do not rub the skin too vigorously.
- Don't use over-the-counter products or sharp objects on corns and callouses.
- If you can see and reach your toenails, trim them each week or when needed.
- Trim you toenails straight across.
- Do not dig into the corners of your toenails.
- Wear protective footwear at all times.
- Never go barefoot.
- Wear comfortable shoes that fit well and protect your feet. Walking or running shoes may be helpful for some diabetics.
- Feel inside your shoes before putting them on each time to make sure the lining is smooth and there are no objects inside.
- Wear socks at night if your feet get cold.
- Wear protective footwear at the beach, swimming pool or on hot pavement.
- Keep the blood flowing to your feet.
- Wiggle your toes and move your ankles up and down for 5 minutes, 2-3 times per day.
- Don't smoke.
- Don't cross your legs for long periods of time.
- Finally, have a podiatrist at Weil Foot & Ankle Institute check your bare feet and find out whether you are likely to have serious foot problems. Remember that you may not feel the pain of an injury.
What is Diabetic Peripheral Neuropathy?
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:
- Sensory nerves, which enable people to feel pain, temperature, and other sensations
- Motor nerves, which control the muscles and give them their strength and tone
- Autonomic nerves, which allow the body to perform certain involuntary functions, such as sweating.
Diabetic peripheral neuropathy doesn't emerge overnight-instead, 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:
- Numbness or tingling in the feet
- Pain or discomfort in the feet or legs-including prickly, sharp pain or burning feet
For motor neuropathy:
- Muscle weakness and loss of muscle tone in the feet and lower legs
- Loss of balance
- Changes in foot shape that can lead to areas of increased pressure
For autonomic neuropathy:
- Dry feet
- 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:
- 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.
- Because of numbness, a patient may not realize that he or she has stepped on a small object and cut the skin.
- Cracked skin caused by autonomic neuropathy, combined with sensory neuropathy's numbness and problems associated with motor neuropathy can lead to developing a sore.
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.
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.
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:
- Keep blood sugar levels under control.
- Wear well-fitting shoes to avoid getting sores.
- 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.
- Visit your foot and ankle surgeon on a regular basis for an examination to help prevent the foot complications of diabetes.
- 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.