General Information

Not all people with diabetes develop foot problems. In many cases serious problems can be prevented by an understanding of what can happen to feet and how to take care of them. What are the types of diabetic foot problems? People with diabetes are more prone to infection. They can also develop neuropathy (damaged nerves) or peripheral vascular disease (blocked arteries) of the legs and either can lead to foot ulceration. Infection and foot ulceration, alone or in combination, often lead to amputation. This happens to about 3000 people in Australia each year. Neuropathy and peripheral vascular disease can also cause distressing pain in the lower limbs. Can diabetic foot problems be prevented? Theoretically, if diabetes is well controlled it should be possible to avoid these foot problems. However, as it is not always possible to achieve good diabetic control and as severe neuropathy and peripheral vascular disease cannot be easily reversed, many people with diabetes are at risk of developing foot problems. Therefore it is important to know how best to minimize the risk of foot problems and how best to treat them. What are the steps that can be taken to prevent or treat foot problems? Good diabetic control is always helpful. However, by itself, it is often not enough. For people with diabetes who have not yet developed active infection or ulceration, the important thing is to grade the degree of risk and then to provide them with appropriate foot care education to minimize the risk of developing active foot problems. For people already with infection or ulceration, the important thing is to urgently treat the infection and heal the ulcer. The treatment required for ulceration due to neuropathy or peripheral vascular disease may be quite different. Therefore it is necessary to distinguish the different types. For people with pain, the important thing is to determine whether it is due to neuropathy or vascular disease because the treatment is again quite different.

Infection of the Foot

People with diabetes, especially those with very high blood glucose levels, have poorer defence against infection. Minor cuts and abrasions to the foot that we all get from time to time can turn into infection. So protect the feet with appropriate footwear. If there is a foot ulcer, the break in skin would also make infection much more likely to occur. It is essential to distinguish between localized versus generalized foot infection because they require different intensity of treatment. Localized foot infection is recognized by redness, heat and swelling confined to an area. Note the foot as a whole is not swollen. Oral antibiotics for a few days can usually eliminate the infection. Localized foot infection associated with a neuropathic ulcer. Due to the neuropathy, the patient may not feel any pain or discomfort. Oral antibiotics are usually satisfactory but may need to be continued until the ulcer has healed. Generalized foot infection. Note the whole foot is red and swollen. Oral antibiotics in higher dosage can be tried but if there is no rapid response (eg. within 24 hours), intravenous antibiotics and sometimes surgical intervention are urgently required because there is likely to be infected tissue deep inside the foot. Foot infection complicated by osteomyelitis. In the presence of a foot ulcer there is a risk of the underlying bones being involved. X-ray may show bone destruction. Once there is osteomyelitis, a much higher dose of antibiotics and for a longer period (eg. several months) is often required to eradicate the infection. Quite often, intravenous antibiotic therapy is required. Sometimes the infected bones need to be surgically removed to help the foot heal. Osteomyelitis in the early phase does not show up on X-ray but can be detected as a hot spot on a technetium bone scan, confirmed by a similar uptake in a white cell bone scan. MRI scan has emerged as the most sensitive and specific test for osteomyelitis and should be performed if the diagnosis is in doubt. If an ulcer is big (> 2cm) or so deep that bone can be probed at the bottom of the ulcer, one should suspect that osteomyelitis is present. Many patients are hesitant to take antibiotics and many doctors are hesitant to prescribe antibiotics. However, when infection is present in the foot of a person with diabetes, antibiotic treatment is required. Many feet are lost unnecessarily due to failure to treat the infection.

Diabetic Neuropathy

What is diabetic neuropathy ? What is a neuropathic ulcer and how do you treat it ? What is diabetic neuropathy ? Diabetic neuropathy means damage of nerve fibres in people with diabetes. How the nerves are injured is not entirely clear but research suggests that high blood glucose changes the metabolism of nerve cells and causes reduced blood flow to the nerve. There are different types of nerves in the body. These can be grouped as :

sensory (detect sensation such as heat, cold, pain) motor (contract muscles to control movement) autonomic (regulate functions we cannot control directly, such as heart rate and digestion)

The most common type of diabetic neuropathy affects the nerves in the legs and is usually known as peripheral neuropathy. This is the type of neuropathy that causes foot problems. It affects mainly the sensory nerves although the motor and autonomic nerves can also be involved with important consequences. What problems can be caused by diabetic neuropathy ? Neuropathy can result in two sets of what superficially appear to be contradictory problems. Most patients who have neuropathy have one of these problems but some can be affected by both. 1. loss of ability to feel pain and other sensation which leads to neuropathic ulceration. 2. symptoms of pain, burning, pins and needles or numbness which lead to discomfort (see section on Painful Neuropathy). A typical neuropathic ulcer is shown in the figure below. Patients with neuropathy lose their sensation of pain. As a result, they exert a lot of pressure at one spot under the foot when they walk, building up a callus at that site without causing discomfort. The pressure becomes so high that eventually it causes breakdown of tissues and ulceration. The patient hardly notices any pain. Therefore a typical neuropathic ulcer is :

painless surrounded by callus associated with good foot pulses (because the circulation is normal)

at the bottom of the foot and tips of toes

Please note if neuropathic ulcers occur elsewhere in the foot, it is usually due to footwear that is too tight. This image is of a neuropathic ulcer caused by shoe straps that were too tight Are you at high risk of developing a neuropathic ulcer? This will be dealt with more thoroughly in the section on "Foot examinationChecking your risk of developing a diabetic foot ulcer". Briefly, you are at risk if :

you have had a foot ulcer before you have lost a lot of sensation in the feet when your doctor tested it you do not follow advice to protect your feet with good footwear and hygiene

Remember that even if you have no pain in the feet, it does not mean you are not at risk. On the other hand, just because you have pain in the feet does not necessarily mean you are facing ulceration and amputation. What sort of treatment is required for a neuropathic ulcer ? This is dealt with in greater detail under the technical info button at the bottom of this page. In principle, these are the important measures: Remove the precipitating cause eg. replace shoes that are too tight. Remove the callus regularly to relieve pressure. This usually needs to be done every week. It is best carried out by a podiatrist accustomed to treating diabetic foot ulcers because experience is important to ensure adequate removal of callus. See image below which shows adequate removal of callus. It is better for healing if the wound is kept moist under a foam dressing which protects the ulcer from further trauma and yet allows oxygen to get through. The old edict of keeping a wound dry and painting it with antiseptics is no longer thought to be the treatment of choice. Do not clean the ulcer with anything that is too caustic (eg strong Eusol or hydrogen peroxide) because this can damage the tissue further. A good rule of thumb is not to put anything on the ulcer that you wouldn't put in your eye.

Taking antibiotics if the ulcer is infected. Remember, most foot ulcers are infected. Many weeks of antibiotics may be required if the ulcer is not completely healed or if there is underlying osteomyelitis. Rest the feet as much as possible because this helps to reduce pressure on the ulcer. Walking is not a good exercise for someone who has a neuropathic ulcer (or someone who is at great risk of developing one). Wearing an Orthowedge If a neuropathic ulcer does not heal with the above conservative measures, more specialised methods of relieving the pressure may be needed. These may include wearing an Orthowedge designed to reduce pressure at the front of the foot where most of the neuropathic ulcers are situated. Sometimes application of contact casting (a special form of cast not unlike what is used to treat a fracture, except it is better padded inside) can promote ulcer healing, again by reducing pressure on the ulcer. Sometimes when all the above measures have been tried but the ulcer still does not heal, it may be necessary to ask a surgeon to correct some foot deformities which are causing too much pressure. Examples of this include removal of a clawed toe or a prominent metatarsal head Although blood supply is normal in a purely neuropathic ulcer, in real life many ulcers are neuro-ischaemic. In other words, there is a combination of impaired nerve function and poor blood supply. Therefore it would also be wise to check that blood supply is normal. Sometimes a neuropathic ulcer will only heal when blood supply is improved.