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Diabetic Foot

An estimated 15% of diabetics experience serious foot problems and they are the leading cause of hospitalizations for these patients. A preventive program can significantly reduce serious complications, including amputations.

Infections and Ulcers. People with diabetes are at risk for multiple problems, especially infections, resulting from blood vessel injury, which may be severe enough to cause ulcers in the legs and feet. Numbness from nerve damage, which is common in diabetes, makes this a significant problem, since the patient may not be aware of injuries.

Amputations. Extensive surgery may be required, and, in extreme cases, amputation may be necessary. Diabetes is responsible for more than half of all the lower limb amputations performed in the US each year and every year there are over 86,000 foot amputations due to this disease.

Charcot Foot. Charcot foot or Charcot joint is of particular note. Between 1% and 2.5% of people with diabetes have this condition, which is caused by abnormalities in the nerves in the feet. This condition can numb the feet so that the sufferer does not feel pain at first and is not aware of injury. Instead of resting an injured foot or seeking medical help, the patient often continues to walk, causing further damage. Early changes appear like an infection, with the foot becoming swollen, red, and warm. A seriously affected foot can become deformed. The bones may crack, splinter, and erode, and the joints may shift, change shape, and become unstable.

Preventive foot care can reduce the risk of amputation in people with diabetes by nearly 85%. Some tips for preventing problems include the following:

• Inspect feet daily and watch for changes in color or texture, odor, and firm or hardened areas, which may indicate infection and potential ulcers.
• When washing the feet, the water should be warm (not hot) and the feet and areas between the toes should be thoroughly dried afterward.
• Moisturizers should be applied, but not between the toes.
• Corns and calluses should be gently pumiced and toenails trimmed short and the edges filed to avoid cutting adjacent toes.
• Patients should not use medicated pads or try to shave the corns or calluses themselves.
• Well-fitting footwear is very important. High heels, sandals, thongs, and going barefoot should be avoided.
• Shoes should be changed often during the day.
• Wear socks, particularly with extra padding.
• Choose footwear that reduces foot pressure and stress on the ulcers, allowing them to heal. For example, custom-molded boots (e.g., Conformer Diabetic Boot) are designed to increase the surface area over which foot pressure is distributed. Special insoles (e.g., the Rocker insole) have also been designed to reduce pressure on the front of the foot.
• Avoid tight stockings or any clothing that constricts the legs and feet.
• Foot pain, numbness, or tingling is worse at night; Benadryl may help.
• A specialist in foot care should be consulted for any problems.

If the foot ulcers are present, about one-third of them will heal within 20 weeks with good wound care. Some treatments are as follows:

• In virtually all cases, wound care requires debridement, which is the removal of injured tissue until only healthy tissue remains. Debridement may be accomplished using chemical (enzymes), surgical, or mechanical (e.g. irrigation) means. Hospitalization and intravenous antibiotics for up to one month may be needed for severe foot ulcers.
• Charcot foot is initially treated with strict immobilization of the foot and ankle; some centers use a cast that allows the patient to move and still protects the foot. Patients usually need lifelong protection of the foot using a brace and custom footwear.

There are a number of new treatments that are emerging in diabetic foot care:

• Some treatments use human skin equivalent (HSE) (Dermagraft, Apligraf, Regranex) They stimulate new cell growth and help heal skin ulcers. Studies are showing that HSE promotes healing and the risk for rejection of such grafts is low. Adverse effects include infections at other sites.
• Administering oxygen given at high pressure is showing promise in promoting healing and preventing amputation.
• Total-contact casting (TCC). This approach uses a cast that is designed to contact the exact contour of the foot and distribute weight along the entire length of the foot. It is usually changed weekly. In one trial, it healed ulcers in nearly 90% of selected patients. It is also useful for Charcot foot.
• A device that compresses the foot (NuPulse) appears to increase the circulation, reduces edema (swelling), and improves wound healing.