Diabetes is a serious disease that affects millions of Americans, and that number will grow astronomically as the baby boomer generation ages. Complications associated with diabetes can be devastating and can lead to organ failure and even death. Complications related to the foot in particular are very common in diabetes and sadly cause the majority of leg amputations performed by surgeons. Comprehensive care from a podiatrist can identify foot problems 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, pasta, sugary foods, fruits, starches, and dairy products) The body needs a hormone called insulin, which is made in the pancreas, to persuade glucose in body tissue to feed it. Some diabetics are born or develop at a young age an inability to produce insulin, resulting in type 1 diabetes. Most diabetics develop their disease as they age, and the ability of insulin to induce glucose in the tissues decreases due to a kind of resistance or ineffectiveness of insulin action. This is called type 2 diabetes. Diabetes can also develop from the use of high doses of steroids, during pregnancy (when it is temporary) or after a disease of the pancreas or certain infections. The high concentration of glucose in the blood that remains outside the body tissue in diabetes can damage parts of the entire body. Organs and tissues that are slowly damaged by high concentrations of stuck glucose in the blood include the heart, kidneys, blood vessels, brain, nerve tissue, skin, and injury repair and immune 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 bloodstream, 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, eventually leading to serious illness, organ failure, and the possibility of leg loss, although not immediately.
Foot disease in diabetes is common and one of the most devastating and overwhelming complications directly and indirectly associated with high blood sugar. Foot disease takes the form of decreased sensation, poor circulation, an increased chance of developing skin wounds and infections, and a decreased ability to heal those skin wounds and infections. The key to this entire spectrum of foot complications is the presence of bad feeling. Most diabetics have less sensitivity in their feet than non-diabetics, due to the indirect action of increased glucose in nervous tissue. This decreased sensation can be a significant numbness, or it can be a simple subtle numbness that makes sharp objects appear soft or erases the irritation of a tight shoe. Advanced cases may have phantom burning or tingling pains in addition to numbness. Decreased sensitivity carries a much higher risk of skin wounds, primarily due to the inability to feel pain from thick calluses, sharp objects on the floor, and ill-fitting shoes. When a wound has formed as a result of the death of the skin under the tension of a thick corn or callus, a needle or splinter stuck in the foot, or a tight shoe rubbing a friction burn on the skin, the diabetic foot has great difficulty. initiate and complete the healing process. Untreated skin wounds will break further and the wound can spread to deeper tissues, including muscles and bones. Bacteria will enter the body through these wounds and can potentially cause an infection that can spread beyond the foot. A diabetic’s body has a hard time defending itself against bacteria due to the way that high glucose affects the same cells that eat bacteria, and diabetics also tend to become infected with multiple species of bacteria. Combine all of this with decreased circulation (and therefore decreased distribution of nutrients and chemicals to preserve foot tissue and help it thrive), and you have all the components in place for a possible amputation. Amputations are performed when bacteria spread through the body and threaten death, when foot wounds and tissue do not heal as a result of gangrene from tissue death and infection, and when poor circulation prevents the tissue flourish never again. The statistics that follow a leg amputation are grim: about half of diabetics who undergo an amputation will require an amputation of the other foot or leg, and roughly that number will die in five years from the stress of the heart. when the body has to spend. energy to wear a prosthesis.
A podiatrist can make sure that all of the above complications are significantly limited, and in some cases completely prevented. Podiatrists are physicians who specialize solely in the care of diseases of the foot and ankle, through medicine and surgery. They attend a four-year podiatric medical school after college, then enter a two- or three-year inpatient residency program to hone their advanced reconstructive surgical skills and study advanced medicine. Podiatrists are generally considered experts in all things related to the foot and ankle, and their unique knowledge, among other medical specialties, of how the foot works in relation to the leg and the ground (biomechanics) allows them to orient therapy towards the control or change of that function in addition to treating tissue disease. A large majority of the problems that lead to diabetic amputations begin as problems related to the structure of the foot and its relationship to the ground and the shoe that is worn on it. Controlling or repairing these structural problems will often result in wound prevention, which in turn will prevent infection, gangrene, and amputations.
To begin, a podiatrist will provide the diabetic patient with a comprehensive foot exam that takes into account circulation, tenderness, bone deformities and skin problems, and the pressures generated by walking and standing. From this initial evaluation, a specific protection and treatment course can be created for the individual needs of the diabetic for the maintenance, protection and active treatment of the problems that develop. Commonly performed maintenance services include regular exams several times a year to identify developing problems, toenail care to prevent a diabetic with poor sensitivity from accidentally cutting while trying to cut their nails, regular thinning of calluses to avoid the development of wounds and repeated education on diabetic foot problems to ensure proper habits are followed. Preventive services include the use of special deep shoes with protective inserts in diabetics at risk of developing injuries from normal footwear, evaluation of possible circulation problems with immediate referral to vascular specialists if necessary, and possible surgery to reduce the potential for development of wounds in areas of bony prominences. Active treatment of foot problems by a podiatrist involves wound care and healing, treatment of diabetic infections, and surgery to address serious foot injuries, deep infections, gangrene, and other urgent problems. . Due to a podiatrist’s unique understanding of how the structure of the foot affects disease and injury, all treatment will focus on the principles of how the foot realistically functions in conjunction with the leg and the ground. This becomes invaluable in the fight to prevent diabetic injuries 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 injuries, infections, and the resulting amputations. This philosophy is called limb rescue and is accomplished through the methods listed above. Due to the severity of foot disease as a complication of diabetes, a podiatrist is an integral part of a diabetic’s care and can sometimes even be the doctor who diagnoses diabetes in the first place if foot disease appears as an early symptom of undiagnosed diabetes. For these reasons, all diabetics should be evaluated by a podiatrist for potential problems, and those at risk for foot injuries and infections should undergo regular foot exams and preventive treatment. As a final note, online resources for podiatrists discussing diabetic foot problems abound, including a regular blog by this author (thediabeticfoot.blogspot.com). While these resources are not a substitute for a diabetic foot exam, they do help educate diabetics on the best way to care for their feet and what to do if problems arise. This can lead to a better knowledge and understanding of foot problems when diabetics begin to see a podiatrist regularly and can help prevent the development of early foot complications.