Diabetic Foot

What is Diabetic Foot?

Several characteristic Diabetic Foot pathologies like infection, diabetic foot ulcer, diabetic neuropathy, diabetic arthropathy are collectively called Diabetic Foot syndrome.

What is diabetic neuropathy?

High blood sugar can injure the nerve fibers throughout the body but in diabetics mainly legs and feet are involved. The patient presents with pain and numbness in the extremities. The patient may have pain, disability or the condition may be fatal due to sepsis. It can be prevented by lifestyle changes and blood-sugar control.

Can diabetes affect other organs of the body?

Diabetes involves almost every organ of the body through more commonly it involves the digestive, urinary tract, blood vessels, and the heart.

    How does Diabetic Foot patient present?

    This is called peripheral neuropathy.

  • Feet and legs are involved before hands and arms

  • Symptoms are worse at night

  • There is numbness

  • Reduced ability to feel pain and temperature

  • Tingling or burning sensation

  • Cramps or sharp pain off and on

  • Increased sensitivity to touch – a weight of bed-sheet may be agonizing

  • Muscle weakness

  • Loss of balance and coordination

  • Serious foot problems – ulcers, infections, deformities

    How do I know other organs are involved?

  • This is called autonomic neuropathy because the autonomic nerves control the heart, lungs, intestines, sex organs and eyes. They present as:

  • Lack of awareness that the blood sugar levels are low.

  • Urinary problems like urinary tract infection, retention of urine or urinary incontinence.

  • Constipation, uncontrolled diarrhea or a combination.

  • Show stomach emptying causing nausea, vomiting, and lack of appetite.

  • Difficulty in swallowing

  • Erectile dysfunction in men

  • Increased or decreased sweating.

  • Inability to adjust blood pressure and heart rate with a sharp fall on standing or sitting making one feel light headed or faint.

  • Problems regulating your body temperature

  • Changes in the adjustment of eyes from light to dark

  • Increased heart rate at rest.

    • Diabetes and muscle involvement.

  • This is called Rediculoplexus Neuropathy (Diabetic amyotrophy) It involves nerves of the hips, buttock, and legs. It presents as:

  • Elderly patients with type 2 diabetes

  • Generally unilateral but may be bilateral

  • Sudden severe pain in hips and thigh

  • Weakness due to atrophy of the thigh muscles

  • Difficulty to rise from the sitting position

  • Weight loss

  • Abdominal swelling if abdominal muscles are involved

    • Can there be a single nerve involvement?

  • This is called mononeuropathy.

  • Severe pain sudden in onset affecting specific nerves and takes a few weeks to disappear.

  • Difficult to focus eyes, double vision or aching eyes

  • Paralysis of one side of the face (Bell’s palsy)

  • Pain in any part of the leg

  • Pain lower back or pelvis

  • Carpel tunnel syndrome – tingling in the fingers, weakness in the hands and tendency to drop things

      • When do I need to see a doctor?

    • If there is a sore on the foot which is not healing or getting infected and red
    • Burning, numbness of hands and feet interfering with sleep or routine activities
    • Dizziness
    • Changes in urination, digestion or sexual function

    Why does Diabetic Foot take place?

  • Exposure to high sugar levels damages the delicate nerves leading to neuropathy. High blood sugars interfere with the ability of the nerves to transmit signals. It also weakens the capillary walls that supply the nerves with oxygen and nutrients.

  • There is also inflammation of the nerves caused by an autoimmune response which means that the immune system mistakes its own part as foreign and attacks it.

  • Then there are genetic factors making people more susceptible to nerve damage. Smoking and alcohol damage both nerve and blood vessels.

    • Who is more prone to Diabetic Foot?

  • People with poorly controlled blood sugars – it is vital that diabetes is kept under control

  • The length of time since the patient has had diabetes – the longer the time the more the damage.

  • Kidney disease – diabetes damages the kidneys and the increased blood toxins because of renal failure contribute to the nerve damage.

  • Overweight – Body Mass Index (BMI) over 24 increases the risk of diabetic neuropathy.

  • Smoking – damages the blood vessels reducing the blood flow to the legs and feet. This promotes nerve damage and delays wound healing.

Problems

    What major problems can diabetes create?


    Limb loss –

  • due to lack of sensation cuts, bruises and infection go unnoticed and lead to infected ulcers. To make matters worse the blood supply may be compromised and may lead to gangrene which is responsible for a loss of limb.

    • Charcot joint –

  • it is the deterioration of the joint due to nerve damage leading to swelling, sensory loss, joint instability, and deformity.

    • Urinary tract infection and urinary incontinence –

  • due to damage to the nerves controlling the bladder preventing it from emptying completely which leads to bacteria multiplying and causing urinary tract infection. The damage of the nerves also leads to reduced ability to know when to pass urine with loss of control leading to incontinence.

    • Unaware of hypoglycemia –

  • normally if the blood sugar falls below 70 mg% you develop sweating, rapid heartbeat, and dizziness.

    • Low blood pressure –

  • damage to the nerves causes this and when you stand or sit there is a sudden fall of blood pressure which could lead to fainting.

    • Digestive problems –

  • may cause constipation or diarrhea along with bloating, nausea, vomiting, and loss of appetite. It is due to slow emptying of the stomach. It may severely affect blood sugar levels and nutrition.

    • Sexual dysfunction –

  • it is due to the damaged nerves leading to loss of erectile function in men and arousal in women.

    • Increased and decreased sweating –

  • If the sweat glands not functioning properly the body temperature cannot be regulated properly. Reduction or total lack of sweating (anhydrosis) can be life-threatening.

Diagnosis

    How is diabetic neuropathy diagnosed?
  • Good history and examination
  • Examine muscle strength and reflexes
  • Examine temperature and vibration
  • Filament test where we test for sensitivity using a soft nylon fiber called monofilament.
    Nerve conducting studies –

  • Electromyography (EMG) measures the electrical discharges produced in the muscles.

  • Quantitative sensory testing – tests how your nerves respond to vibration and temperature changes

  • Autonomic testing – here your blood pressure is tested in various postures and your ability to sweat

    • Comprehensive foot examination –done every year and at every visit feet checked for cracks, sores, calluses, bone, and joint abnormalities

    How is it treated?

    Diabetic neuropathy has no cure. The treatment focuses on:

  • Slowing the disease

  • Relieving pain

  • Managing complications and restoring function

    How can one slow the progression of the disease?

  • Keep blood sugars under check to slow the progression of diabetic neuropathy and perhaps improve symptoms

  • The target sugar levels recommended are:

  • 80 – 120 mg% for patients below 60 years

  • 100 – 140 mg% for patients over 60 years or those with other medical ailments like heart, lung or kidney problems.

  • For slowing nerve damage the following is recommended:

  • Regular foot care

  • The target sugar levels recommended are:

  • Control BP

  • Healthy diet

  • Regular Physical activity

  • Maintain recommended weight

  • Stop smoking

  • Avoid alcohol or drink in moderation

    • How does one relieve the pain?

  • Most pain-killers are not helpful or have unacceptable side effects. The recommended
    plan is:

  • Capsaicin cream (from chili pepper)

  • Acupuncture or physiotherapy

    • Anti-seizure drugs –

  • gabapentin (Neurontin, grabilase) pregabalin (Lyrica), carbamazepine (Carbatrol, Tegretol).

    • These are used for epilepsy and also nerve pain. Side effects are drowsiness, dizziness, and swelling.

    Antidepressants –

  • tricyclic antidepressant medicines like amitriptyline, desipramine (Norpramin), imipramine (Tofranil) help relieve mild to moderate symptoms but have many side effects like dry mouth, sweating, weight gain, constipation, and dizziness. Serotonin or nor-epinephrine reuptake inhibitors (SNRIs) like duloxetine may relieve pain with a few side effects like reduced appetite, nausea, sleepiness, dizziness, and constipation.

Complications

How can one manage complication and restore function?
    Urinary tract problems –

  • They generally have urinary incontinence due to lack of bladder control. It is treated by antispasmodic medication (anticholergenic) drugs, behavioral techniques, devices like pessaries (ring inserted into the vagina to prevent a urinary leak.

    • Digestive problems –

  • It is due to slow stomach emptying leading to indigestion, belching, nausea vomiting. It is treated by eating smaller frequent meals, reducing fiber and fat in the diet and taking soups and mashed food. Nausea, vomiting, diarrhea, and constipation are treated by drugs.

    • Low blood pressure on standing (orthostatic hypotension) –

  • avoid alcohol, drink a lot or water and sit or stand slowly. Abdominal binder and compression stockings may help. Several medicines could be given.

    • Sexual dysfunction –

  • Sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) could improve sexual function in men but are not safe drugs. Mechanical vacuum devices may improve the penile blood supply in men. Women could get relief with vaginal creams.

Remedies

Are there any lifestyle remedies?

These reduce the risk of diabetic neuropathy

    Keep your blood pressure under control –

  • High blood pressure damages your blood vessels.

    • Eat healthy food –

  • Fruits, green vegetables, whole grain in limited portions to maintain a healthy weight.

    • Active life –

  • Protects your heart and improves blood flow. Keeps your blood pressure and blood sugar under control. Exercise 30 minutes 5 times a week. If the patient has severe neuropathy and reduced sensations in legs one must do non-weight bearing exercises like swimming and cycling.

    • Stop smoking –

  • Smoking with diabetes markedly increases chances of death due to heart attack or stroke. Besides, you could lose your legs due to choking of the blood vessels of the legs.

      • Is alternative medicine effective?

      Capsaicin -

    • Cream that can reduce the pain sensation in some but could produce skin burns and irritation

      • Alpha-Lipoic Acid -

    • is a powerful antioxidant found in some foods and may relieve symptoms of peripheral neuropathy.

      • Transcutaneous electrical nerve stimulation (TENS) -

    • prevents pain signal from reaching the brain by delivering tiny electrical impulses. Though safe it does not work for everyone.

      • Acupuncture -

    • It could relieve the pain of diabetic neuropathy and has no known side-effects. Multiple settings may be needed.

    • Counseling may be needed

    Prevention

    Can diabetic neuropathy be prevented?
    Blood sugar control –

  • This is important to prevent or delay neuropathy or other diabetic complications. Variations in the blood sugar levels accelerate nerve damage. All diabetics must have A1c done every 6 months to see an average blood sugar level in the past 2-3 months. If not well-controlled change medication or get more tests done.

    • Foot care –

  • Non-healing ulcers and amputations are common in diabetic neuropathy. Your doctor should see your feet at every visit and you must inspect them daily.

    • What do we mean by foot care?

  • Check your feet daily for cuts, bruises, peeling skin, redness, and swelling. Use a handle mirror to see the sole of the foot.

    • Keep the feet clean and dry –

  • wash with lukewarm water and mild soap. Do not soak your feet for over a few minutes. Dry between the toes with a soft towel. Moisturize your feet to prevent cracks especially heels but avoid it in between the toes as it leads to fungal growth.

    • Trim toenails carefully –

  • cut your toenails straight across and file them to prevent sharp edges.

    • Wear clean dry sox –

  • cotton without tight bands.

    • Wear padded shoes that fit well –

  • always wear shoes or slippers to protect your feet from injury. Your shoes must fit your feet properly and allow your toes to move.

  • Even tiny sores can get infected and create a major problem. So be careful