Diabetic Foot Afflictions - Causes, Symptoms, Diagnosis, Prevention & Treatment

Diabetic Foot Afflictions: How They Affect You

Dr.Purushottam Reddy Padala profile Authored by Dr.Purushottam Reddy Padala on 27 May 2014 - 12:28.

A majority of foot disorders are related to diabetes and related diseases. Every minute a toe or foot is lost to amputation or infection or the consequences of poorly managed diabetes somewhere in India.

More diabetics have foot complications than any other diabetic complications like retinopathy (diabetic eye complications) and nephropathy (diabetic kidney complications). Lack of awareness about foot care is one of the main reasons for foot afflictions, especially in the case of diabetes.

Foot deformities and trauma play major roles in causing ulcerations and infections due to poor circulation or nerve damage. Common problems include infection, ulceration, or gangrene that may lead to amputation of a toe, foot or leg in severe cases.

With diabetes, the ability to detect sensations or vibrations in the feet is diminished. With neuropathy or damaged nerves injuries remain unnoticed and therefore untreated for lengthy periods of time. Ironically, painful neuropathy may occur in combination with a loss of sensation and can also affect the nerves that supply the feet and leg muscles. Thus causing muscle weakness or loss of tone in the thighs, legs, and feet, and the development of hammertoes, bunions, and other foot deformities.

Following are the conditions that affect the foot:

Ingrown toe nail: The nail normally grows out and is flat in a cross section on both sides of the nail bed. But in growing toe nail, it curves in and grows into the tissue, giving rise to pain.

Cellulitis: The superficial skin infection due to bacterial infection, causing redness of skin appearing like a rash is called cellulitis. If neglected deep infection can ensure.         

Paronychia: Infections of tissue around the nail fold is called paronychia. It can occur in an acute setting causing pain and redness, getting worse in a day or two. However chronic occurring over weeks or months causing periodic flare ups is also common especially in those who keep their feet wet often.

Progressive Necrotizing Fascitis: Infection of the deep tissues and muscles can occur in diabetes. This can very rapidly, cause necrosis and death of muscles and fascia. It is then called necrotizing fasciitis. It has the potential to cause limb loss or loss of life.

Osteomyelitis: Infections of bones can often occur especially of the toe bones. This gives rise to pus exuding from a wound if acute, and a festering wound with periodic flare ups in a chronic osteomyelitis. A chronic situation is also seen when antibiotics are used indiscriminately. This is why, surgical drainage is more important when there is infection, than taking an antibiotic. Remember, osteomyelitis is more often than not a diagnosis made on x-ray.

Gangrene:  Death of tissue is called gangrene. That means blood supply is completely stalled to that part of the body. The tissue is charcoal black and there is no sensation in the toe. Left alone it gets infected and can threaten the upper part of that part of the body, above the gangrene. Eg: If the tip of toe is gangrenous, the more upper part of toe or foot can get involved.

Diabetic Ulcer: An ulcer is a defect in the skin covering due to trauma or due lack of sensation (anesthesia) or lack of blood supply(vascular disease)-both of which occur in diabetics. These are usually located on weight bearing surface of the foot and because of constant pressure, and infection they do not heal.

Charcot’s Arthropathy: Like the skin, joints too have receptors which help us have orientation and balance (called proprioception). In late stages of diabetic neuropathy, proprioception is lost in addition to loss of pain sensation resulting in damaged joints. This combination of loss of pain and joint sensation with destroyed foot joints is called Charcot’s Arthropathy. It can result in devastating deformities.                               

Diabetic neuropathy: Diabetes causes narrowing of blood vessels which is called peripheral vascular disease (PVD). PVD occurs due to deposits of fatty material which builds up on the walls of blood vessels deposits. Fatty deposits are formed from excess unused sugars in the diabetic. As blood flow becomes a trickle, nerves become dysfunctional and patient presents with tingling, numbness, burning and pins and needles sensation.

Gout: Gout is a disorder of protein metabolism. Protein is usually excreted by the body through the kidney. Sometimes, either there is normal production of uric acid, but the body is unable to rid itself of the excess acid, or at other times there is excess production and the body simply cannot get rid of it. These excesses are deposited usually near the big toe and causes intense inflammation which can mimic infection with intense pain swelling and redness. It occurs in both diabetics and non-diabetics but more common in meat eaters and alcoholics.

Redness pain and swelling are common ways in which a diabetic foot can present itself. Additionally pus and exudates are expelled from the wound. In neuropathy sensation of pins and needles, burning, numbness, dry legs, cramps in feet and legs are the usual symptoms. Gout presents with acute swelling, intense pain and redness of the foot.

Diagnosis is paramount to treatment, as wrong treatment can result in devastation of a toe, foot, leg or even a life.

Blood tests: Simple blood tests can often clinch the diagnosis in addition to an astute examination of the foot and leg.

1) White cell counts, ESR, CRP: All these tests indicate an inflammatory response by the body and are usually elevated when there is inflammation or infection.

2) Pus swab for culture and sensitivity: any pus exuding from the wound should be sent for bacterial examination and only then an antibiotic is started. Bacteria are present even on normal skin. Infection is caused by an aggressive bacteria causing damage to tissue. Since a non-specific antibiotic does not eradicate infection, and resistance to antibiotics is common, indiscriminate use of antibiotics is to be condemned.

3) Uric acid levels: Although high uric acid indicates gout, a normal or sub-normal can also be associated with gout. Hence to start treatment in gout, clinical skill and experience is all that is required.

4) ABPI and Doppler studies: One way of knowing if the foot is receiving enough blood or not is to put blood pressure cuff around the ankle first and then the same side arm, and compare the measured pressure with a ratio. If the ratio is less than one, then there is blood flow impediment in the foot and means the toe or foot, are at risk for gangrene.   

5) Bioethsiometry: Since vibration and touch and pressure sensation goes early in diabetes, testing these is imperative in diagnosing diabetic neuropathy. Manual and semi-automatic are available and give an idea of the extent and severity of nerve involvement.             

Broad principles of treatment in diabetic foot are:

1)     Blood sugars should be optimized with medication and insulin.

2)     Consumption of low carbohydrate diet for maintaining optimal sugars levels.

3)     Only in cellulitis or superficial skin infection, paronychia and ingrown toe nail,is antibiotic given before any surgical treatment.

4)     In diabetic foot infections where there is pus and deep seated infection in the fascia, Liberal Surgery is done to remove all dead and necrotic tissue, and let out pus.

5)     Ozone: Oxygen with an additional molecule is called ozone. Ozone has powerful anti-infective action and can abort early infection or fairly superficial infection.

6)     Hyperbaric oxygen: Oxygen used at a concentration greater than normal is called hyperbaric oxygen. At these concentrations it is toxic to bacteria. There is a lot of media hype surrounding hyperbaric oxygen for its purported non-surgical treatment of foot infections. Public are cautioned that it is used selectively in anaerobic infections (where bacteria thrive in non-oxygen atmosphere) only and is not a panacea for severe infections, where surgical cleaning and letting out infection (debridement) can save a life and is still the gold standard.

7)     Treatment of gout with anti-gout and anti-edema measures suffices. Recurrences might require anti-gout medication on a chronic basis.

 

Most of these problems can be prevented through proper care and regular visits to your podiatric surgeon. (Podiatry is the study of disorder of the feet of which a major bulk is related to diabetes and related diseases based on vascular disease.) Visiting a podiatric surgeon can help you get some guidelines and the do’s and don’ts of foot care for early recognition and treatment of foot conditions.

Foot care guidelines

Preventing foot ulcers:

Here are some things which all diabetics should follow to avoid foot ulcers:

Dont’s:

  • Do not cut your nails curved at the edges. Curved nail cutting at the edges causes in-growing toe nails. It can lead to infection, and before one realizes, loss of a toe!
  • Using excessive soap on the feet can cause dryness and cracking leading to infection.
  • Never be barefoot at home ever! Because diabetic patients have lessened sensation on their feet, they are more prone for ulceration.                                                      
  • If you wear shoes, use only cotton socks, as it allows the feet to breathe.
  • Repeatedly washing your feet several times a day can lead to drying and cracking, leading to infection.
  • Do not use hot water to wash or immerse feet in.
  • Using narrow fronted shoes can give rise to a variety of problems like fungal infections between toes, and corns and ulcers on adjacent toes.

Do’s:

  • Consult your doctor if you have a cut or redness or boil on your foot.
  • Inspect your feet and toes at least once a day, preferably at bedtime. Look for corns, reddish areas, ulcers and deep cracks.
  • Use a mild soap and water at room temperature for cleaning your feet.
  • Use moisturizing cream (not oil or ointment) after bath in the morning and at bedtime.
  • A clean soft cloth should be used to remove excessive water between toes.
  • Soft footwear made of special microcellular polymer (MCP) is recommended for use.
  • Use cotton or silicone socks if you wear shoes.
*Disclaimer This is not medical advice. The content is for educational purposes only. Please contact your doctor for any health care issues.