Diabetes is a serious disease that affects millions of Americans, and that number is going to astronomically grow as the baby boomer generation ages further. Complications associated with diabetes can be devastating, and can lead to organ failure and even death. Foot-related complications in particular are very common in diabetes, and unfortunately cause the majority of leg amputations performed by surgeons. Comprehensive care by a podiatrist can identify foot problems early before they lead to leg loss, and in many cases can prevent those problems in the first place. This article will discuss the ways a podiatrist can protect diabetic feet, and ultimately save a diabetic’s limb and life.
Diabetes is a disease in which glucose, the body’s main source of ‘fuel’, is not properly absorbed into the body’s tissues and remains stuck in the bloodstream. Glucose is a type of ‘sugar’ derived from the body’s digestion of carbohydrates (grains, breads, pastas, sugary food, fruits, starches, and dairy) The body needs a hormone called insulin, which is produced in the pancreas, to coax the glucose into body tissue to fuel it. Some diabetics are born with or develop at a young age an inability to produce insulin, resulting in type 1 diabetes. The majority of diabetics develop their disease as they become much older, and the ability of insulin to coax glucose into tissue wanes due to a sort of resistance to or an ineffectiveness of the action of insulin. This is called type 2 diabetes. Diabetes can also develop from high dose steroid use, during pregnancy (where it is temporary), or after pancreas disease or certain infections. The high concentration of glucose in the blood that remains out of the body tissue in diabetes can cause damage to parts all over the body. Organs and tissue that slowly are damaged by high concentrations of glucose stuck in the blood include the heart, the kidneys, blood vessels, the brain, the nerve tissue, skin, and the immune and injury repair cells. The higher the concentration of glucose in the blood, and the longer this glucose is present in the blood in an elevated state, the more damage will occur. Death can occur with severe levels of glucose in the blood stream, although this is not the case in most diabetics. Most diabetics who do not control their blood glucose well develop tissue damage over a long period of time, and serious disease, organ failure, and the potential for leg loss does eventually arrive, although not right away.
Foot disease in diabetes is common, and one of the more devastating and taxing complications associated directly and indirectly with high blood sugar. Foot disease takes the form of decreased sensation, poor circulation, a higher likelihood of developing skin wounds and infections, and a decreased ability to heal those skin wounds and infections. Key to this entire spectrum of foot complications is the presence of poor sensation. Most diabetics have less feeling in their feet than non-diabetics, due to the indirect action increased glucose has on nerve tissue. This decreased sensation can be a significant numbness, or it can be a mere subtle numbness that makes sharp objects seem smooth, or erases the irritation of a tight shoe. Advanced cases can actually have phantom pains of burning or tingling in addition to the numbness. With decreased sensation comes a much greater risk for skin wounds, mostly due to the inability to feel pain from thick calluses, sharp objects on the ground, and poorly fitting shoes. When a wound has formed as a result of skin dying under the strain of a thick corn or callus, from a needle or splinter driven into the foot, or from a tight shoe rubbing a friction burn on the skin, the diabetic foot has great difficulty starting and completing the healing process. Untreated skin wounds will break down further, and the wound can extend to deeper tissue, including muscle and bone. Bacteria will enter the body through these wounds, and can potentially cause an infection that can spread beyond the foot itself. A diabetic’s body has a particularly difficult time defending itself from bacteria due to the way high glucose affects the very cells that eat bacteria, and diabetics tend to get infected by multiple species of bacteria as well. Combine all this with decreased circulation (and therefore decreased distribution of nutrients and chemicals to preserve foot tissue and help it thrive), and one has all the components in place for a potential amputation. Amputations are performed when bacteria spreads along the body and threatens death, when wounds and foot tissue will not heal as a result of gangrene from advancing tissue death and infection, and when poor circulation will not allow the tissue to thrive ever again. The statistics following a leg amputation are grim: about half of diabetics who undergo one amputation will require an amputation of the other foot or leg, and about that same number in five years will be dead from the heart strain endured when one’s body has to expend energy to use a prosthetic limb.
A podiatrist can ensure that all the above complications are significantly limited, and in some cases prevented all together. Podiatrists are physicians who specialize solely in the care of foot and ankle disease, through medicine and surgery. The attend a four year podiatric medical school following college, and enter into a two or three year of hospital-based residency program after that to hone their advanced reconstructive surgical skills, and to study advanced medical. Podiatrists are generally considered the experts on all things involving the foot and ankle, and their unique understanding amongst other medical specialties of how the foot functions in relationship to the leg and ground (biomechanics) allows them to target therapy towards controlling or changing that function in addition to treating tissue disease. A great majority of the problems that lead to diabetic amputations start off as problems related to the structure of the foot and how it relates to the ground and to the shoe worn above. Controlling or repairing these structural problems will often result in prevention of wounds, which in turn will prevent infection, gangrene, and amputation.
To start with, a podiatrist will provide a diabetic patient with a complete foot exam that takes into account circulation, sensation, bone deformities, and skin issues, and pressures generated by walking and standing. From this initial assessment, a protection and treatment course can be created specific to the individual needs of the diabetic for maintenance, protection, and active treatment of problems that do develop. Commonly performed maintenance services include regular examinations several times a year to identify developing problems, care of toe nails to prevent a diabetic with poor sensation from accidentally cutting themselves when attempting to trim their nails, regular thinning of calluses to prevent wounds from developing, and repetitive education on diabetic foot problems to ensure proper habits are followed. Preventative services include using special deep shoes with protective inserts in diabetics at-risk for developing wounds from regular shoes, assessment of potential circulation problems with prompt referral to vascular specialists if needed, and possible surgery to reduce the potential of wounds to develop over areas of bony prominences. Active treatment of foot problems performed by a podiatrist involves the care and healing of wounds, the treatment of diabetic infections, and surgery to address serious foot injury, deep infections, gangrene, and other urgent problems. Because of a podiatrist’s unique understanding of the way the foot structure affects disease and injury, all treatment will be centered around the principles of how the foot realistically functions in conjunction with the leg and the ground. This becomes invaluable in the struggle to prevent diabetic wounds and infections, while allowing one to remain mobile and active at the same time.
The essential goal of a podiatrist in caring for a diabetic patient is to prevent wounds, infections, and the amputations that result. This philosophy is called limb salvage, and it is accomplished through the above listed methods. Because of the severity of foot disease as a complication of diabetes, a podiatrist is an integral part of a diabetic’s care, and sometimes can even be the physician that diagnoses diabetes in the first place if foot disease appears as an early symptom of undiagnosed diabetes. For these reasons, all diabetics should be assessed by a podiatrist for potential problems, and those at-risk for foot wounds and infections should have regular foot examinations and preventative treatment. As a final note, online resources by podiatrists discussing diabetic foot issues abound, including a regular blog by this author ( thediabeticfoot.blogspot.com ). While these resources do not replace a diabetic foot exam, they do help educate diabetics on how best to care for their feet, and what to do if problems develop. This can lead to better knowledge and understanding of foot issues when diabetics begin to see a podiatrist regularly, and can help prevent early foot complications from developing.