Put your Best Foot Forward

Foot-related complications in diabetic patients require utmost care. The patient should inspect his feet daily and seek care early if he gets a foot injury
By Dr Vipra Mangla/Dr M. Meghachandra Singh/ Dr Suneela Garg

People with diabetes can develop many different foot problems. Even ordinary problems can get worse and lead to serious complications. Foot problems in diabetics most often happen when there is nerve damage, which is also termed as neuropathy.
Neuropathy can cause tingling, pain burning or stinging sensation or weakness in the foot. It can also cause loss of sensation in the foot, so that the diabetic patient does not feel any pain during injury, which further aggravates the injury. Poor blood flow or changes in the shape of feet or toes may also cause problems.
The foot complications in diabetic patients include neuropathy, skin changes, calluses, foot ulcers, intermittent claudication and can finally result in amputation.

Neuropathy
Diabetic nerve damage lessens the ability in the patient to feel pain, heat and cold. Loss of feeling means that the patient may not feel the sensation. For instance, the patient may have a tack or stone in his shoe and walk on it all day without knowing; or the patient can get a blister and not feel it. Also, the patient may not notice a foot injury until the skin breaks down and becomes infected.
Nerve damage can also lead to changes in the shape of feet and toes. The diabetic patient should be provided with special therapeutic shoes and should not force deformed feet and toes into regular and tight shoes.

Skin Changes
Diabetes can cause changes in the skin of foot. The foot may become very dry and the skin may peel and crack. This happens because the nerves that control the oil and moisture in foot get damaged.After bathing, the feet should be dried and the remaining moisture should be sealed with a thin coat of plain petroleum jelly or an unscented hand cream. Oils or creams should not be put between toes as the extra moisture can lead to infection.

Calluses
Calluses occur more often and build up faster on the feet of people with diabetes. This is because of high-pressure areas under the foot. For callus, therapeutic shoes and soft pad inserts are required.
Calluses, if not trimmed get very thick, break down and turn into ulcers or open sores. The diabetic patient should not try to cut calluses or corns on their own with sharp materials such as razor blade as this can lead to ulcers and infection. The calluses should be cut by the health care provider only. The calluses and corns should not be removed with chemical agents as these products can burn the skin of the diabetic patients.
Using a pumice stone every day helps keep calluses under control. It is best to use the pumice stone on wet skin. Lotion should be used immediately after using the pumice stone.

Foot Ulcers
Ulcers occur most often on the ball of the foot or on the bottom of the big toe. Ulcers on the sides of the foot are usually due to poorly fitting shoes. Though some ulcers do not hurt, but every ulcer should be seen by healthcare provider immediately since neglecting ulcers can result in infections which in turn can lead to loss of a limb.
The healthcare provider should take X-rays of foot to make sure that the bone is not infected or clean out the dead and infected tissue around the ulcer. The culture of the wound should be taken to find out the type of infection and to find out the antibiotic which works best.
Walking on the ulcer can make it get larger and force the infection deeper into the foot. To protect the ulcer, special shoe, brace or cast on foot is required.
Good diabetes control is important as high blood glucose levels make it difficult to fight infection. After the foot ulcer heals, the foot should be treated carefully as the scarred tissue under the healed wound breaks down easily. Special shoes should be worn after the ulcer is healed to protect the affected area and to prevent the ulcer from recurrence.

Intermittent Claudication
Some people feel pain in their calves when walking fast up a hill or on a hard surface. This condition is called intermittent claudication. Stopping to rest for a few moments ends the pain. The diabetic patient with iintermittent claudication should stop smoking, work with healthcare provider to get started on a walking program and use medication to improve circulation to the foot. Exercise is good for poor circulation. It stimulates blood flow in the legs and feet. Walking in sturdy, good-fitting, comfortable shoes is helpful but the patient should not walk with open sores.

Amputation
People with diabetes are more likely to have a foot or leg amputated than other people. This occurs bacause many diabetics have peripheral arterial disease (PAD), which reduces blood flow to the feet. Also, many diabetics have nerve disease, which reduces sensation of the foot. These problems in combination, predisposes the diabetic patient to ulcers and infections of the foot that may lead to amputation. Most amputations are preventable with regular care and proper footwear.

Foot Care in Diabetes
The healthcare provider should check the feet of the diabetic patient at least once a year and more often if the patient has foot problems.
The foot care in diabetes includes the following steps which should be followed for keeping the feet in the patients healthy.
1: The healthcare provider should be contacted if the diabetic patient has cuts or breaks in the skin or has an ingrown nail. The health care provider should also be contacted if the diabetic patient develops foot changes such as change in colour, shape or just feels different i.e. foot becomes less sensitive or hurts.
2: The trimming of corns, calluses and also toenails should be done by the healthcare provider if the diabetic patient is not able to do so safely himself.
3: The patient should take care of diabetes and blood glucose level should be kept in the target range.
4: The patient should check the feet every day and set a time every day to check them. The bare feet of the patient should be looked for red spots, cuts, swelling and blisters. If the patient cannot see the bottoms of his feet, then he should use a mirror or ask someone for help.
5: The patient should be more active and plan out a physical activity programme. The patient should wash his feet every day and dry them carefully especially between the toes. The skin should be kept soft and smooth. A thin coat of skin lotion should be rubbed over the tops and bottoms of patient’s feet but not between the toes. If the patient can see and reach his toenails, then he should trim them when needed. The toenails of the patient should be trimmed straight across and the edges should be filed with a nail file.
6: The diabetic patient should wear shoes and socks at all times and should never walk barefoot. The patient should wear comfortable shoes that fit well and protect his feet. The patient should check inside his shoes before wearing them and make sure that the lining inside the shoes is smooth and there are no objects inside.
7: The patient should protect his feet from hot and cold and should wear shoes while walking at the beach or on hot pavement. He should wear socks in winter even while sleeping. The patient should not put his feet into hot water and test water temperature before putting his feet in water. Diabetic patients should never use hot water bottles, heating pads or electric blankets as they can burn their feet without their realizing it.
8: The patient should keep the blood flowing to his feet and should put up his feet while sitting. The patient should wiggle his toes and move his ankles up and down for 5 minutes, two to three times a day and should not cross his legs for long periods of time. Also, diabetic patients should not smoke.
9: If the feet of the patient are cold, then they should not be warmed because the feet in diabetics cannot feel heat and they can easily be burned with hot water, hot water bottles or heating pads. The best way to help cold feet in the patient is to wear warm socks.

Prevention of foot related complications in diabetics
A) Poor circulation in the foot of the diabetic patient can make the foot less able to fight infection and to heal properly. Diabetes cause narrowing and hardening of blood vessels of the foot and leg. As a result, poor blood flow should be controlled.
B) Smoking should be avoided as it makes arteries harden faster. Smoking affects small blood vessels, causes decreased blood flow to the feet and makes wounds heal slowly.
C) Also, blood pressure and cholesterol should be kept under control by the patient.

(The authors are PhD Scholar; Director Professor; Director Professor & Head, Department of Community Medicine, Maulana Azad Medical College, New Delhi)