Diabetes Foot Care Health Education: Guidelines, Prevention

diabetes foot care health education

Guest post by Dr. Mark Hinkes, DPM

The lives of nearly one billion people worldwide are affected or are about to become affected by diabetes. There are about 500 million people with diabetes and another 500 million people with pre-diabetes. 

China, India, and the United States lead the world in the sheer numbers of people affected by the condition. Every one of these people are vulnerable to problems with their foot health that could lead to foot ulcers, infections, hospitalizations, amputations, and premature death -all due to their diabetes.

How are the Feet Affected by Diabetes?

Chronically elevated blood sugar levels cause vascular and neurological disease along with impairment of the immune system. The smallest blood vessels become narrowed or totally clogged when blood sugars are not controlled, and this results in pathology to the feet, eyes, kidneys and cardiovascular systems.

The blood vessels provide oxygen and nutrients to the nerves. When the nerves are deprived of these two essential components of nerve health, the nerve malfunctions.

As a result, in the feet, many people feel the sensations of burning, tingling or shooting pain which eventually progresses into total numbness of the foot and an inability to sense pain, which is called Diabetic Sensory Neuropathy.

Three Other Comorbidities of Diabetes

There are three other comorbidities of diabetes.

  • In the eyes, diabetes can affect the retina and blindness can result.
  • When the kidneys are affected the result is the need for renal dialysis.
  • Finally, when the cardiovascular system is affected the result can be heart attacks, strokes and decreased or lack of adequate blood flow to the extremities and organs.

Focus on the Foot – The Gift of Pain

In his 1979 book titled, Pain, the Gift Nobody Wants, Dr. Paul Brand documented his life working with lepers in India who suffered with neuropathy (inability to sense pain).

With this knowledge and while working at the Carville Leprosy Center is Louisiana, he was the first physician to realize that the numbness that those who suffered with diabetes experienced was the same as the numbness of those with leprosy. 

In his book, Dr, Brand tells us that the benefit of pain is that it is the body’s burglar alarm, it helps protect us from injury. 

The Three Traumas

With a numb foot, that has poor circulation combined with an immune system that is unable to properly respond to an infection, people with diabetes are vulnerable to mechanical, chemical or thermal trauma that can result in an ulcer that can lead to an amputation. 

Mechanical Trauma

Is any trauma that breaks the skin of the foot. It can be caused by an improperly fitted shoe or improperly applied sock. Another common cause of mechanical trauma is walking barefooted to the bathroom at night and the foot hits a door frame or by dropping an object on the foot like a ketchup bottle. 

Thermal Trauma

Can be the result of either heat or cold, but it is usually caused by heat. People with diabetes tend to either objectively or subjectively feel that their feet are cold. In an effort to warm them they use artificial heat sources like heating pads, hot water bottles or expose their foot to open fires, radiators, or heat registers. In most cases the foot never warms up, but the result is that the foot is burned due to the exposure to the heat. Thermal trauma can also be the result of walking barefooted directly on concrete or blacktop asphalt. 

Chemical Trauma

Results from application of topical medications that contain salicylic acid, a common ingredient in over-the-counter medications used to treat warts, corns, callouses and ingrown toenails.

Acid has no brains; it destroys everything it touches and that includes normal tissue which can result in an ulcer.

A Look at the Numbers – Why You Should Check Your Feet

The incidence of ulcers and amputation is rising. Worldwide, a diabetic foot ulcer happens every 1.2 seconds and a lower extremity amputation is done every 20 seconds.

There are nearly 1 million diabetes related lower extremity amputations done every year. There is a high percentage (> 50%) of recurrent foot ulcers and amputations that follow the initial pathology. 

The cost of treating ulcers and amputations is also rising. The average cost of hospitalization to treat an infected diabetic foot ulcer can be as high as $15,000. An amputation may cost near $100,000 and the lifetime cost of rehabilitation can cost near $150,000. 

In 2018, in the US there were 179,000 Lower Extremity Amputations due to the complications of diabetes. To protect yourself from having an amputation, you should have a yearly comprehensive diabetic foot examination/screening to identify your unique risk factors for developing a foot ulcer and seek cost effective, preventive, proactive care. Prevent the ulcer and the accompanying hospitalization, and you can prevent the amputation. 

In their lifetime, people with diabetes have a twenty five percent chance of developing a foot ulcer. Eighty five percent of all diabetes related lower extremity amputations are preceded by a foot ulcer.

While these numbers are bad there are even worse things to fear. Thirty Seven percent of those patients who undergo an amputation will lose the other leg in three years and seventy-five per cent of those who undergo an amputation will not survive five years.

The mortality of a lower extremity amputation is greater than all forms of cancer combined excluding lung and pancreatic cancers. This is why people with diabetes need to be aware of their foot health and be proactive in managing it.

Diabetic Neuropathy – The Signs of Diabetic Feet

The ultimate result of chronically elevated blood sugars is nerve damage called diabetic neuropathy. Most people fail to realize there are three types of neuropathy and each has a unique presentation and treatment. 

Diabetic Sensory Neuropathy

Occurs when the foot becomes numb and is unable to sense pain. This complication of diabetes can be identified by the monofilament test which is accomplished by touching the foot in specific locations with a tool composed of a specially calibrated piece of plastic wire attached to a holder to see the patient can feel it.

If the patient cannot feel the wire, diabetic, extra depth or custom molded shoes and diabetic socks should be used to protect the foot. The feet should be visually inspected every day.

The inside of the shoes should also be inspected for foreign bodies like keys, and coins daily. I once had a patient who walked on her glasses that were inside her shoes for a full day and she never felt them.

Diabetic Autonomic Neuropathy

Occurs with the “automatic functions” such as sweating, and production of normal skin moisture is affected. If there is cracking or fissures of the skin under the toes or the heels or if there is very dry skin to the feet or legs, it is likely the result of autonomic neuropathy. 

Treatment for this problem is to use a urea-based lotion to the feet and legs and if necessary professional debridement of the fissures by a Podiatrist.

Diabetic Motor Neuropathy

Occurs when the 13 small muscles in the front of the foot called the Lumbricales and Interossei muscles lose their mass due to diabetes.

These muscles are responsible for maintaining the position of the toes and when they malfunction, the normally straight toes become deformed resulting in hammer toes that and can rub against the shoes, causing soft tissue problems like blisters or corns that can lead to ulcers.

Since deformed feet have difficulty fitting into shoes, diabetic, extra depth or custom molded shoes should be worn to prevent mechanical trauma to the foot.

The Keys to the Diabetic Foot Health Education and Prevention

Education is the keystone to prevention. Every person with diabetes should use the services of a diabetes educator.

These specially trained professionals are excellent resources for information on blood glucose control, nutrition and in the management of various aspects of the condition.

Their help can make the difference between living a relatively normal life instead of one of suffering and high medical costs.

Prevention is the key to limiting the complications of diabetes to the feet. Here are the 5 things that every person with diabetes should do to prevent diabetic foot complications:

  1. Control Blood Glucose
  2. Control Blood Lipids
  3. Exercise
  4. Avoid smoking or vaping
  5. Practice preventive foot health behaviors

While the feet of people with diabetes are vulnerable to a variety of problems, adopting a strategy of prevention will limit the likelihood of developing a foot ulcer that can lead to an amputation. 

For further in depth knowledge on keeping your feet healthy see 2 of Dr. Hinkes’ Books he has published available on Amazon here for more info: Healthy Feet For People With Diabetes and Keep the Legs You Stand On.

Diabetic Foot Case Study

Mr. CG came to my clinic as a result of a referral from the hospital Diabetes Educator, Maggy who was my coworker in the “At Risk” Foot Clinic. In the past several years, working together, we had evaluated close to 250 patients a year and we had seen pathology that most healthcare providers only hear stories about or see pictures of in books. Maggy had a vast knowledge of diabetes and had authored several book chapters on the subject of diabetes and patient education. Every time we discussed a case or evaluated a patient, I learned something new about diabetes and management of its comorbidities.

One Wednesday morning she stopped by my clinic, poked her head in the door and with a sly smile on her face asked if I had time to see a patient that she felt needed a debridement of a foot wound. On most days my clinic was booked solid. Nevertheless, usually I ended up seeing a few more patients than were scheduled in the clinic because the demand for Podiatry services far exceeded my ability to provide the care. I knew that Maggy would not ask me to see a patient on a same day basis unless it was truly medically necessary. Without hesitation I told her to bring the patient to the clinic and I would be happy to see him. This is an example of how our interdisciplinary team works for the benefit of quality patient care; all the providers that were needed were in one location and accessible in a timely fashion.

One Wednesday morning she stopped by my clinic, poked her head in the door and with a sly smile on her face asked if I had time to see a patient that she felt needed a debridement of a foot wound. On most days my clinic was booked solid. Nevertheless, usually I ended up seeing a few more patients than were scheduled in the clinic because the demand for Podiatry services far exceeded my ability to provide the care. I knew that Maggy would not ask me to see a patient on a same day basis unless it was truly medically necessary. Without hesitation I told her to bring the patient to the clinic and I would be happy to see him. This is an example of how our interdisciplinary team works for the benefit of quality patient care; all the providers that were needed were in one location and accessible in a timely fashion.

During her evaluation of CG, Maggy noted he was recently admitted to the hospital because of a serious infection to his right great toe. Although he was receiving intravenous antibiotics his foot wound had not yet been debrided. She thought the patient would benefit from a debridement and also pointed out that he needed to have his nails trimmed because they were long and thick. She was concerned that he might lacerate one of his toes with his own nails and inadvertently cause an ulcer on the toe. CG was a 57-year-old black male who had type 1 diabetes. His blood sugar levels ranged from the low 200’s all the way to the low 500’’s. It was clear to me that he was in a select group of the most non-compliant patients I had ever encountered. When CG arrived for treatment, I knew right away that he had a terrible infection. I could smell it as I entered the treatment room and approached him to introduce myself. Doctors are typically taught that from the moment they start the patient visit it is important to use all of our senses when evaluating the patient. For instance, we look at how a patient walks, if their balance is disturbed, what type of gait do they have, and are they alert and oriented?

If there is a wound present to the feet or legs, we use all of our senses to measure and document its condition and to especially note if infection is present. There are several unique systems that can be used to categorize foot ulcers. The most commonly utilized is the Wagner System. Another wound classification system is the University of Texas Wound Classification System. These wound classification systems provide a basis for practitioners to communicate precise information about the wound by understanding its dimensions of width and depth, and its infection status which all combine to document the severity of the wound. CGs wound was a Wagner Grade 3, and a University of Texas Grade B-3.

CG was wearing a surgical shoe and there was a loosely applied dressing on his foot wound. His nails were thick and discolored; they were definitely in need of debridement. My concern was that the infected wound on his great toe was in greater need of debridement than the nails. The skin of the 1st toe was thickened in some places and flaking in others. A portion of the toenail remained attached but was lifted up from the nail bed and the tissue underneath was whitish in color and the source of the foul odor from the wound. This indicated to me that this wound had been festering for more than a few days. There was a hole in the tip of his toe the size of a nickel and the ulcer site had gummy yellow to grayish black infected tissue present.

I reviewed CG’s x-ray and noted the classic moth-eaten appearance of the distal phalanx that helped confirm my suspicion that he had a bone infection or osteomyelitis. CG told me that the cause of his problem was that he tried to trim his toenail with a razor blade, the most convenient instrument he had in his bathroom. Instead of trimming the toenail he cut the end of his toe off and felt nothing. CG was legally blind and had a history of non-compliance concerning control of his blood sugars and diet. I guessed that he may not have been educated about his diabetes, or either he did not understand his diabetes condition or just did not care about the long-term complications of his condition that had remained uncontrolled for so many years.

Debriding the toenails was a straightforward procedure but debriding the infected ulcer was a bit trickier. After removing the remaining portion of the toenail, I then started debriding the ulcer, aiming to harvest a bit of tissue for culture and sensitivity. At first there was significant calloused tissue at the end of the toe that surrounded the ulcer, and that came off with ease, but the gummy tissue on the ulcer bed was different. The tissues had become a mass of fibrinous tissue that could not be trimmed with conventional tissue forceps. I switched tactics and used a # 15 scalpel blade to remove as much of the fibrinous infected tissue until I got to normal tissue that bled when I trimmed it. Probing the wound with a sterile instrument I was able to touch the bone. This probing to bone test confirmed that the infection had unfortunately reached the bone as I surmised by looking at the x-ray in combination with my clinical evaluation.

It was clear that the infection had devastated the bone in the toe and there was no choice except to remove the infected bone, fearing that if the infection spread, he might lose his leg or worse. CG underwent a successful digital amputation of the distal phalanx of his great toe. After the procedure we provided CG with nutritional counseling, and consultations with an endocrinologist, and a prosthetist. Being cognizant of the other problems that may be brewing due to pathology we noted in his foot, we also referred him to a cardiologist, vascular surgeon, ophthalmologist, and nephrologist to evaluate other comorbidities of diabetes. Understanding that one comorbidity of diabetes can portend other pathology in other body systems is a proactive method to prevent more suffering and costly care.

Once CG had healed, we fabricated custom molded bio-mechanical orthotics with a plug for the missing toe and provided him with diabetic shoes. He was seen for ongoing foot care and has not had another significant incident to his feet since he was able to better control his blood sugars.

What can we learn from CG’s case?

Foremost, educating patients with diabetes about the risks of their condition and the benefits controlling it would permit them to live a relatively normal life. The following are the five areas that need to be addressed for patients with diabetes to preserve their foot health.

1. Control blood sugars

2. Control lipids

3. Control blood pressure

4. Abstain from tobacco or vaping

5. Practice prevention in foot health

The most important lesson that was demonstrated from CG’s case was that controlling blood sugars is critical for patients with diabetes to prevent its comorbidities. We questioned why, when this patient ignored taking has medications and ran chronically elevated blood sugars, no one kept an eye on him? This case confirmed that following up with continuing diabetes education is critical. We questioned why a legally blind patient had not been previously been referred for ongoing foot care by his Primary Care Provider?

The lesson to be learned concerning foot health for CG’s case is that “at risk” patients with diabetes need to have ongoing professional foot care. Had this patient been able to access professional foot care, the safety net of seeing a foot care specialist for his nails would have prevented him from performing “bathroom surgery” and would have prevented the infection, hospitalization and amputation

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