THE DIABETIC FOOT

DAILY FOOT CARE

Washing of Feet. Wash, but do not soak, your feet in warm, soapy water each day. Soaking softens the skin and makes it more susceptible to infection. Never use hot water.

You are diabetic. This disease is common and, if properly managed, you will be able to enjoy a normal life. However, diabetes offers potential problems. This is written with you, the diabetic, in mind. We will discuss the importantce of good foot care, because you, in particular, must pay special attention to the health of your feet.

There are two main contributing factors to foot problems in diabetes. There are neuropathy and poor circulation.

Noeuropathy is best described as a loss of lessening of feeling. For exampl,e if you should step on a shpar object and not experience the pain, you most likely have diabetic neuropathy. There are varying degrees of loss of feeling. Many of you may be aware of excruciating pain but many ignore simpole injuries such as the stubbing of a toe or overexposure to sunlight. You may not feel the pain byt may notice the damage at a later date.

Poor circulation is also a factor. This is most common in people who have had diabetes for a long time. This problem usually gets worse with age, even with people who are not diabetic. The blood vessels age more rapidly in the diabetic and become "clogged" so that they are no longer able to transport enough blood to the lower extremtiies. Blood is necessary for maintenance of normal blood tissue. When your circulation is inadequate your feet and legs are adversely affected. An early indication that this is happenining is the cramp-like pain you experience upon walking. Another early sign is poor healing of an abrasion or cut. When sitting you may notice that your feet appear red. This is a later indication of poor circulation. Please pay attention to all these signs!

Be sure your physician or pediatricts knows you are a diabetic to help you avoid problems with your feet. Maintain a daily routine of general foot care, hygienem, and inspection.

Many of you who are reading this sheet for the first time are not aware of the fact that diabetic feet are any different from anybody else's feet. Nothing could be further from the truth however, because the person who has diabetes stands a strong chance of getting some of the problems that are associated with this disease. One of the first things that we pedorthists and orthopaedic surgeons notice about the diabetic foot is that the toes start clawing somewhat and that the shoes start getting smaller. Of course, that's not really true. The shoes don't shrink; its the feet that get a little bit larger, but this happens so slowly that the patient doesn't even realize that this is occurring. Another thing that will occur is that the patient will start getting callouses here and there that they weren't even aware they had and then "lo and behold" one morning they may wake up and have an ulcer on their foot or may even have some blood in a sock as the first clue of a blister or an ulcer on the foot where they put too much pressure.

What causes all of this trouble in a diabetic? We have some answers to the problem, but we don't now all of the answers yet. The two most common causes of foot problems for people with diabetes are neuropathy and poor circulation in the blood vessels. Neuropathy is a loss or lessening of feeling in the feet. If, for example, you step on a sharp object such as tack and do not experience pain, you probably have neuropathy. There are varying degress of loss of feeling. You might be aware of stepping on a tack but totally unaware of stubbing your toe or of a severe subnurn on your feet.

Poor circulation in the blood vessels is most common with people who have had diabetes for a long peiod of time. Circulation usually deteriorates with age, even in people who do not have diabetes. The blood vessels age and become clogged so that they are unable to carry enough blood to the lower extremities. Blood is necessary, of course, fo rmaintaining your normal body tissue. It carries nourishment to the tissues and carriers normal waste products away. When you circulation is poor, your legs and feet are the first to be adversely affected.

Cramps in the legs while walking are an early symptom of poor circulation. Another symptom is the slow healing of cuts and scratches. Still other symptoms are redness of the feet when you are sitting or whiteness or the feet whne they are propped up on a chair or table. A lack of normal hair growth on the legs and feet may also occur.

To help yourself avoid foot problems, it is important to develop a daily routine of foot care.

To give you the few answers that we do have available to us, we know that the person with diabetes loses the feeling in the feet. That's the first place for the feeling to start leaving and sometimes they'll even get loss of sensation to the fingers and hands, but that occurs at a later time. It seems that neuropathy (deterioration of the nerves) occurs more readily in the diabetic in the feet. The reason for this is probably because that's the farthest part of the body from the heart and the blood supply to the body. After the neuropathy occurs, other things start occurring that make the feet susceptible to infection. Of course, you may know that diabetic patients have more problems with infections than other people. They can't fight infections quite as well and these callouses and corns will form blisters and sores and these will get infected readily and sometimes an infection can be pretty far along before the diabetic patient will even realize that they have an infection.

Besides the clawing of the toes and the callouses and corns and then ulcers that develop in these areas, the diabetic is also susceptible to getting small micro fractures that eventually lead to a major collapse in the foot and ankle area. The bones deteriorate, but it seems to be a slow fatiguing process where they sort of crumble rather than just a straight break across the bone. This type of problem is called a Charcot joint, and it can occur in the ankle or any joints in the foot. In cases like this the patient is put in a cast or a brace. The patient also might eventually need a plastic type of brace made for the foot and ankle and this is call a foot/ankle orthosis. This helps in preserving the joints in the foot in fairly norma position while they are healing. These braces and casts sometimes have to be worn up to six months or even longer.

The ulcers and infections have to be treated rather vigorously with debridement (that is, a surgical removal of dead necrotic tissue). They also need whirlpool and antibiotics if the infection becomes severe. Weight bearing is usually forbidden, at least initially, to get the ulcers to heal! This is extremely important.

If abscesses or osteomyelitis (infection of the bone) occur, these must be dealt with, quickly, surgically, and usually with intravenous antibiotics, to try to avoid amputation.

If the blood supply is severely diminished, a vascular surgeon may be needed to revascularize (increase the blood supply through surgery) the foot.

Footwear

Shoes and Slippers. Wear shoes that protect and cover the feet. Do not wear sandals, clogs, or flip- flops. Make certain your shoes allow room for your toes to rest in their natural position. Avoid pointed shoes that sqwueeze the toes together. Breack new shoes in gradually: this will prevent blisters from forming. When you wear slippers around your home, make certain they have sturdy toes in order to prevent stubbing the toes. Do not go barefoot!

Socks and Stockings. Cotton and wool socks and stockings are preferable, but any machine- washable hosiery is satisfactory. Wear a clean pair each day. Socks and stockings should be the correct size and free of seams and darns. Never wear socks or stockings with constricting tops. Constricting garters and girdles shoudl also be avoided.

Always test the temperature of the water with your wrist. This will prevent burning your feet if you have neuropathy. Ue a mild hand soap. Rinse your feet well after washing and dry them carefully, especially between the toes. Washing your feet daily while taking a bath or shower is an important procedure in foot care.

Daily Examination of Feet. After you have washed and dried your feet, examine them closely in a good light. If you cannot bend over to see the bottom of your feet, place a hand mirror on bottom of your feet, place a hand mirror on the floor and hold each foot, in turn, over it so you can see the reflection in the mirror. If your eyesight is poor, have someone examine your feet for you. Look for areas of dryness or breaks in the skin, especially around the toenails and between the toes. Notify your physician immediately about sores or infections that do not seem to be healing properly.

Daily Skin Care. Lubricate your feet to prevent dryness by using a moisture-restoring lotion such as Nivea, Dermassage, Alpha-Keri, Polusorbhydrate, or lanolin. Do not use perfumed lotions; they contain alchohol. Do not put lotions or creams between your toes.

If your feet perspire, use talcum, baby powder, or a mild foot powder to absorb the moisture. Do not allow the powder to cake between the toes.

Care of Toenails. File your toenails with an emery board or nail file. Never use scissors or clippers since any isntrument that will cut your nails could also cut your skin. Never file your nails shorts than the ends of your toes. Shape them according to the contours of your toes and the toes next to them, as nearly straight across as possible. If your nails are thick or tend to split, have a pedorthist or pedorthis assistant trim them for you. If you have poor vision, have a pedorthist or pedorthist's assisant trim your nails when needed.

Care of Corns and Calluses. After washing your feet, rub any corns or calluses hard with a towel. Use a mosture-restoring lotion to soften them. Do not tear off loose skin and never use corn or calluse remover products. NEVER cut corns or calluses -no bathroom surgery!

FIRST AID TREATMENT

Cuts and Scratches. Prompt treatment should be given to cuts and scratches. Wash the affected area with warm water and soap. Do not soak. Apply a mild antiseptic such as S.T. 37, Bactine, or Johnson's First Aid Cream. Never use strong antiseptics such as iodine, Betadine, mercurochrome, boric acid, Epsom salts, cresol, or carboic acid. Cover the affected area with a dry sterile dressing and paper tape or a Telfa bandage. Do not use adhesive tape on your skin. Do not use Band-Aids. Do not apply heat treatments such as a hot water bottle or heating pad to the cut or sratch. Stay off your feet as much as possible and call your physician if the affected areas do not improve wiuthin 24 to 30 hours. If red swollen areas develop or a yellowish drainage occurs, contact your physician immediately. Do not assume the condition is improved jut because there is no pain.

Athlete's Foot. Athlete's foot is caused by a fungus that grows in a warm, moist setting. Symptoms are itching, tiny blisters, and scaling of skin between the toes and/or on the soles of the feet. If these symptoms appears, consult your physician to make certain it is athlete's foot rather than some other skin problem.

Since athlete's foot occurs in a warm, moist setting, it may be neessary to wash your feet and cahnge your soks or stockings more than once a day. Treat the affected areas with Tinactin, Halotex, or Lotrimin. Do not use any other remedies without first asking your physician or poditrist.

All of this may seem "over-kill" to the diabetic, but there are many diabetics waling around with amputations of toes and feet or even legs that are living examples of the need to be more vigorous in the treatment of these problems.

SUMMARY: TEN TULES FOR FOOT CARE

1.Never soak the feet.

2.Never apply heat of any kind to the feet.

3.Never cut your toenails; file them.

4.Never wear shoes that do not fit.

5.Never go barefoot.

6.Never assume that sensation or circulation in your feet is normal.

7.Never use strong medicines on the feet.

8.Never allow corns or calluses to go untreated.

9.Never perform bathroom surgery on your feet.

10.Never keep the feet too moist or too dry.

Avoidance of Athlete's Foot

1. Athlete's foot, caused by a type of fungus, thrives in a warm moist setting. Therefore, it may be necessary for you to wash your feet and change your socks or stockings more frequently than once a day.

2.Never use over-the-counter remedies without first obtaining an OK from your podiatrist or physcian. Often these solutions are harmful.

3.At the first sign of athelte's foot (itching, tiny blister formation, scaling of skin between toes and/or on soles of feet) seek the advice of your physcian or pediatrist.

Exercise

1.Walking is the best exercie for your feet, provided that your shoes fit properly.

The health of your feet depends on your understanding of these principles and giudelines.

REFERENCES

1.Cataland, S., O'Dorisio, T.M.: Diabetic Nephropathy. JAMA, April 15, 1983, Vol. 249, No. 15.

2.Barrett, J.P., Mooney, V.: Neuropathy and diabetic pressure lesions. Orthop Clin North Amer 4:43, 1973.

3.Bordelon, R.L.: Surgical and Conservative Foot Care. Slack, Inc, Thorofare, N.J., 1988.

4.Carter, S. A.: The relationship of distal systolic pressure to healing of skin lesions in limbs with arterial occlusive disease with special reference to diabetes mellitus. Scan J. Clin Labor Quest 31 (Suppl 128) 239, 1973.

5.Douglas, D. M., et al: Late results of autogenous vein grafting and lumbar sympathectomy in ischemic limbs. Lancet 1:459-461, 1973.

6.Ellenberg, M., Rifkin, H.: Diabetes mellitus. New York:McGraw-Hill, p. 1031, 1970.

7.Johnson, K.A.: Surgery of the Foot and Ankle. Raven Press, N.Y., 1989.

8.Joslin Clinic and New England Deaconess Hospital Diabetic Testing Guide, Management of Diabetic Foot Probelms, W.B. Saunders Co., 1984, Philadelphia

8.Kane, W.J.,: Diabetic foot problems - Pathogenesis. Minn Med 56:396-473, 1973.

9.Ritter, A.E.: A technique for salvage of the infected diabetic gangrenous foot. Orthop Clin North Amer 4:21, 1973.

10.Wagner, F.W., Jr.: Orthopedic rehabilitation of dysvascular lower limbs. Orthop Clin North Amer 9:2, 325, 1978

11.Wagner, F.W., Jr.: The diabetic foot and amputation of the foot. In DuVries' Surgery of the Foot, R.A. Mann, Ed., 4th Ed. St. Louis: C.V. Mosby Co., 1978.

12.Wagner, F.W., Jr.: Use of transcutaneous Doppler ultrasound in prediction of healing potential and selection of surgical level in dysvascular lower limbs. West J Med 130:59, 1979.

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