Welcome, Guest    Sign in to Windows Live ID | Register  

  Industry Medical Portal |  Student Centre |  Sitemap |  Help 
FAQAbout Us |  Disclaimer & Legal |  Contact Us 
Expert Speak

Footcare in Diabetics

Dr G Sivakumar M.S., FICS, FAIS

 

Why is the foot at risk in a patient with diabetes?

The long - term effect of diabetes is wide spread and affects almost every structure of the foot. The nerves are predominantly affected and this leads to loss of protective sensation. The small muscles are also affected. This leads to structural changes in the foot (arch collapse). The blood vessels are clogged by macrangiopathy and this results in ischaemia (diminished blood supply). The depressed immunolgical status leads to increased susceptibility to infection. This ravages the already dilapidated foot.

Can a diabetic avoid foot complications?

All diabetic foot ulcers are predictable and preventable. The insensitive foot of the diabetic patient is an important indicator. Preventive screening of the diabetic foot requires less than two minutes per patient. This simple screening can identify the patients in whom major amputations can be prevented, simply by education and attention to footwear. Physicians should never forget routine foot screening and patients should seek periodic foot evaluation.

Who is at risk to developing foot ulcers?

Diabetes by itself does not cause major foot problems. The most common event that may lead to amputation is an "ulcer". This occurs because a person cannot feel injury to the foot due to nerve damage caused by prolonged diabetes. This is called "neuropathy". Patients with loss of protective sensation or with poor circulation in the feet need extra efforts towards prevention. The deformed foot in diabetics alters the foot contact to the surface during walking. This altered foot pressure creates pressure-points which ulcerate.

Who manages these foot complications in the diabetics?

The diabetologist primarily manages the holistic care of the diabetes. Once he identifies the foot at risk he evaluates the foot with the help of a broad array of consulting specialists. The team members who implement preventive and therapeutic strategies are foot surgeons, vascular surgeons, plastic & reconstructive surgeons, and orthopaedic surgeons, podiatrists, physiotherapists, and rehabilitation specialists.

How does a diabetic develop foot ischaemia?

Diabetes mellitus along with cigarette smoking, hypertension, and hyperlipidemia (raised level of lipids), is a major risk factor for the development of arterial disease in the lower extremity. 15 to 20 % of diabetics have reduced blood flow to the limb. Bedside assessment depends on symptoms of claudication (severe pain in the legs) and the palpation of peripheral pulses. A common misconception is that in diabetes the small vessels are at fault. Micro angiopathy of the small arteries is common in diabetes but does not cause clinically significant foot ischemia. The arterial disease often manifests when there is a block in one of the major blood vessels in the abdomen or lower limbs.

How is the foot ischaemia assessed?

The diagnosis is made with history and bedside examination. Swelling in the foot (Pedal Oedema) prevents assessment of the pulse. Doppler measurement of the ratio of the ankle blood pressure to the brachial blood pressure is useful. Lower limb BP may be falsely elevated due to calcified arteries, (Monckeberg’s medial calcinosis). Non-invasive arterial duplex ultrasound scanning is done when symptoms and physical findings suggest a vascular occlusion. When occlusion warrants reconstructive surgery arteriography is done. (This includes a careful evaluation of the pedal (foot) vessels by injecting dye in the vessels and taking X-rays. This test is the gold standard for evaluation of the extent of arterial disease. Easily palpable foot pulses exclude clinically significant vascular disease in the majority.

How is ‘neuropathy’ assessed?

Most of the foot problems are primarily a consequence of neuropathy due to loss of protective sensation. A quick & effective method of screening for neuropathy is the Semmes-Weinstein monofilament. The bedside tests of neurologic function like the vibration and thermal sensation are less efficient for screening. Electrophysiological nerve conduction tests are not needed for screening.

Does it also affect the joints in the limb?

Neuropathy produces joint destruction and this is termed Charcot’s joint. The first symptoms of the Charcot foot are swelling and warmth of the foot and ankle. These signs may be mistaken for infection. Most patients do not feel pain .Any of these symptoms in a person with diabetes warrants surgical opinion. X-ray may be normal, but in a diabetic patient with a warm swollen red foot , a Charcot foot must always be considered.

Are ‘corns’ in the sole dangerous?

Corn like callosities in the foot of diabetics are mainly trophic in nature and they should not be mistaken for ‘corns’. The callus itself causes further increase in pressure during walking. Small amounts of haemorrhage into the callus results in ulcer formation. Patients with significant foot deformities have elevated plantar pressures. This requires carefully designed shoes by an experienced professional for prevention of complications. All patients with loss of sensation must have protective and correct footwear. Bare foot walking is dangerous and leads to foot sepsis.

Why do foot infections and ulcers take many days to heal?

Every foot needs to be assessed individually. When treated appropriately the foot infection gets controlled and amputations can be averted. The mainstay in therapy is adequate rest to the foot so that the insensitive foot heals. If major vascular occlusion is identified and reconstructable, prompt vascular surgery heals the ulcer in the foot.

How should the diabetics take care of the foot?

Foot care needs to be an important daily routine in the diabetics. This involves:

  • Foot and footwear inspection,
  • Avoiding bare foot walking and ‘bath room’ surgery for the corns
  • Wearing the right footwear and the socks.

People with history of previous foot ulcers need to be doubly careful.

 

Dr G Sivakumar M.S., FICS, FAIS

Dr.G.Sivakumar MS.,FICS.,FAIS, is a Senior General and Vascular Surgeon. He has been in the Tamil Nadu Medical Service in the surgical faculty for the last 20 years. He is a consultant at BSS Hospital, Chennai Kaliappa Hospital and Priya Nursing Home, Chennai.

He has launched a movement called ‘PADHAM’ (acronym of Prevention of Amputation in Diabetics, Health Awareness and Management), to avert amputations in diabetics. The aim of the movement is to spread the message of foot care to the masses through lectures, seminar and health camps. He is the co-author of the paper titled ‘Phenytoin Sodium powder in the healing of Diabetic Foot ulcers’, in Diabetes Care of the American Medical Association. He has conducted many health camps and has a keen interest in the salvage of the foot in the diabetics.

Advertisement
Tell us what you think about Web Health Centre - Send us your feedback
Copyright © 2015 WebHealthCentre. All rights reserved. Brought to you by