The Diabetic Foot

Overview

Contributing Factors

Prevention and Management

Overview

Approximately two million peoples in Canada have diabetes. It is estimated that 4-10% of those with diabetes will develop a foot ulcer.
In other words, 80,000-200,000 Canadians with diabetes will be affected in their lifetime.

The numbers get even worse because statistics show that 14-24% of those persons with diabetes and foot ulcers will require amputation (either a partial foot amputation or a leg amputation) because the ulcer won't heal. Quality of life is another big concern because persons suffering from a foot ulcer are often reluctant to go out for fear of offending others with the odor. Routines are interrupted by the need for daily dressing changes, a situation that may mean waiting around for the visiting nurse. It is not surprising that foot ulcers are one of the biggest fears shared by persons with diabetes.

Foot Ulcer
A foot ulcer is a defect or break in the skin which provides a doorway for harmful germs known as bacteria to enter. Once a break occurs, the foot is prone to invasion from harmful bacteria that can cause infection. The longer an ulcer remains open and untreated, the greater the risk of infection.

Foot ulcers are caused by excessive pressure or rubbing against the skin from things like poor-fitting shoes, walking barefoot or stepping on a sharp object. The first sign of an ulcer may be a blister. Harmful pressure or motion against the skin will set off a pain alarm to protect against further injury. For instance, if you step on a sharp object, the pain (alarm) will cause you to lift up your foot, and thus protect you from further injury.

Why People with Diabetes are Prone to Foot Ulcers.
Some persons with diabetes develop neuropathy or loss of feeling in the feet. If excessive pressure on the foot or stepping on a sharp object goes undetected, it can cause serious injury. If you have neuropathy, you may not realize that your shoes are too small until an ulcer has formed.

Contributing factors in developing a foot ulcer.
Individuals with diabetes share a common disorder that results in elevated blood sugars. Elevated blood sugars can cause many different problems including neuropathy or loss of feeling in the feet. The effects of the elevated blood sugars will vary from individual to individual. There are four major risk factors for developing a foot ulcer:

(1) Neuropathy or loss of feeling is the single biggest risk factor for developing a foot ulcer. Remember this resembles having broken detectors on the skin alarm. Your health care provider can test you for neuropathy, but chances are you will recognize the signs of neuropathy, signs that include burning, tingling and numbness in the feet.

(2) Foot deformity

(3) Prior history of foot ulcers

(4) Loss of circulation. The risk for developing a foot ulcer increases with the number of risk factors. Those persons with high-risk feet should receive risk-lowering treatments like regular foot care, professionally fitted shoes, and custom shoe inserts. It is important to remember that all persons with diabetes, even those without any risk factors, must be careful with their feet. You should be aware of your individual risk status.

Infected  foot ulcers.
It is important to treat foot ulcers as soon as possible, because the longer an ulcer remains open, the greater the chance of developing an infection. Ulcers become infected when bacteria enter the foot through the break in the skin, and start to grow and spread. In severe cases the infection can spread into the leg. The signs that an ulcer is infected include redness, swelling, increased drainage, sudden elevations in blood sugar, fever, chills and fatigue. Pain may be lacking because of neuropathy.

Ulcer treatment
The first thing to do is to recognize and eliminate the cause of the ulcer. Often the cause is harmful pressure or rubbing against the skin that goes unnoticed because of loss of feeling in the feet. Pressure reduction may be as simple as switching shoes, or it may be more involved and require orthotics, braces or casts. Antibiotics and possibly even surgery may be necessary for infected ulcers. Antibiotics will not help ulcers that are not infected. Dressings and care for the wound or ulcer are also important. Some persons will be able to do their own wound care and dressing changes; others will need the help of nurses. The types of dressings and care are dependent upon the complexity of the ulcer. The majority of foot ulcers will respond to pressure reduction and dressings.

Regardless of the treatment there are some foot ulcers that just don't heal. Persons with diabetes are often slow healers, and one of the reasons for this may be that their wound healing proteins or growth factors are defective. Growth factors are proteins that play an important role in the wound healing process. Without functional growth factors, an ulcer can get stuck in a non-healing phase.

Caring for your feet.

For people with diabetes, complications such as infection or injury can be particularly serious when they affect the feet. The good news is that by following these simple steps for taking care of your feet, you can greatly reduce the risk of incurring problems.

1. Check your feet. Look for any changes and/or breaks in the skin, such as redness, swelling, broken skin, sores, bleeding, or any unusual feelings such as tingling or numbness. A hand mirror can be useful here, or if that is difficult, another person can check for you. Any such changes can be the early stages of a potentially serious complication, and if noticed, you should make an appointment to see your diabetes health care provider as soon as possible.
   
   
2. Keep your feet clean. It is important to wash your feet with soap and warm water every day; prolonged soaking should be avoided. It is also important to make sure the water is warm - not hot - by checking it with your elbow. Don't check it with your hands and feet because you may not feel the temperature differences accurately enough.
   
   
3. Go soft on your skin. As much as one third of the diabetic population suffers from dry skin on their legs and especially their feet. You may need to apply a moisturizer to your feet every day to prevent them from becoming dry and cracked. Damaged skin can lead to serious problems. If your skin is extremely dry, you may require more specialized treatment.
   
   
4. Avoid the heat. Do not use a heating pad or hot water bottle on your legs or feet for any reason.
   
   
5. Listen to your health care experts. Be sure to stay in contact with the health professionals who make up your health care team. Never use any medication on your feet unless you talk to your health care team first.
   
   
6. Let your clothes stay loose. If you have problems with your blood circulation (ask your doctor if you're not sure), avoid crossing your legs, and stay away from garters, girdles, or other clothing that might restrict blood flow to your feet.
   
   
7. Be careful with sharp instruments. Do not cut corns or calluses off your feet. This invites infection, and people with diabetes need to avoid infections even more that the rest of the population. In addition, when cutting toenails, cut straight across to avoid ingrown toenails.
   
   
8. Maintain a proper weight. Lose weight if you need to, because not only will it help you control your diabetes, but it will also mean less pressure on your feet.
   
   
9. Be kind to your feet. Never go barefoot. And before you put on your shoes, examine them to make sure there are no pebbles or rough surfaces inside. Check your socks to avoid rough seams or mended areas - everything should fit smoothly and comfortably.
   
   
10. Kick the smoking habit. This is easier said than done, but people with diabetes already face blood circulation problems, and smoking makes things even worse.

These guidelines are not a substitute for seeing your doctor on a regular basis, but diligently following these steps will be a big help to you and your doctor.