Diabetic Foot: Charting the Course of the Effect on Feet

Diabetic foot, a condition of foot problems linked to diabetes mellitus, is common among people with diabetes. These problems can occur in one or both feet due to type 1 or type 2 diabetes.

Symptoms associated with diabetic foot can occur over time. They can be linked to nerve damage or blood flow problems common with this disease.

Diabetic foot problems can affect your skin or the structure of your foot. Foot ulcers (open sores), infections, and changes in the shape of your foot can develop.

This article describes the causes and signs of diabetic foot problems, the need for treatment, and ways to support foot health. It also details types of treatments and how to support proper healing.

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Why Does Diabetes Cause Foot Problems?

Insulin is a hormone produced in the pancreas that controls sugar, or glucose, levels in the bloodstream. In diabetes, either the body can't make insulin, which is the case in type 1 diabetes, or the body can't respond to insulin properly, which occurs in type 2. Insufficient amounts of insulin can allow glucose to build up in the blood and remain at unsafe levels.

Over time, too much blood sugar can damage your nerves, which results in peripheral neuropathy (nerve damage in your feet). It can also cause peripheral artery disease (PAD) (poor blood circulation to your feet and leg), affecting the lining of your blood vessels. Peripheral neuropathy occurs in about 33% to 50% of people with diabetes.

Diabetic Foot

Symptoms of peripheral neuropathy include numbness, tingling, and a loss of feeling in your feet. As a result, you likely wouldn't realize you had an ulcer (open sore), cut, or another type of wound on your foot until it becomes severe.

As the wound remains untreated, an infection can develop. However, blood vessels damaged by diabetes can interfere with normal blood flow, which could help heal the wound. An untreated infection and poor blood flow can lead to a major health problem called gangrene, resulting in the death of skin, muscle, and other tissues in your foot.

Early Stages of Diabetic Foot

The early stages of diabetic foot problems often go unnoticed since they are not specific to diabetic foot. Learning how to identify these changes can help you prevent serious complications.

Visit your healthcare provider if you develop any of the following problems that could indicate early stages of diabetic foot problems or diabetic toes:

• Pain or cramps in your legs, calves, thighs, or buttocks, especially during physical activity
• Numbness (loss of sensation) or the ability to feel heat or cold in your feet
• Burning, tingling, or pain in your feet
• Dry, cracked skin on your feet
• Loss of hair on your feet, toes, and lower legs
  
• Athlete's foot (tinea pedis) or other fungal infections between your toes
• Thickened, yellow toenails
• A sore, blister, ulcer, infected corn, or ingrown toenail
• Edema (swelling)
• Redness or warmth on your feet
• Changes in the shape of your feet, possibly leading to a "rocker bottom," which is a sign of a rare form of diabetic foot called Charcot foot neuropathy, in which the bones in your feet and toes shift or break
  

Signs Diabetic Foot Is Progressing 

Diabetic foot problems progress at different rates depending on your condition. However, diabetic foot ulcers typically progress so that the wound worsens until it eventually involves your entire foot. The traits of the wound at a given time are used to classify the wound.

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There are several classification systems for diabetic wounds. Wagner's classification system is widely accepted for the proper diagnosis and treatment of diabetic foot wounds.

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Wager's classification system of diabetic foot wounds includes the following levels of wound severity:

• Grade 0: Intact, normal-looking skin with bony deformities that indicate a foot at risk
• Grade 1: A superficial (surface) foot ulcer on the outer layers of your skin
• Grade 2: A deeper, thicker ulcer that may involve ligaments, tendons, bones, or joints of your foot
• Grade 3: An ulcer with an abscess or osteomyelitis (bone infection)
• Grade 4: Gangrenous (dead, or necrotic) tissue in the front of your foot
• Grade 5: Gangrene that has spread to your entire foot
  

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Risks of Untreated Diabetes Foot Problems

The risks of untreated diabetes foot problems can include the following complications:

• Ulcers and infections that do not heal, resulting in the loss of a foot, your leg, or your life
• Corns and calluses that can develop into ulcers
• Dry, cracked skin that can lead to sores and infections
• Muscle weakness and loss of tone in your feet, resulting in deformities like hammertoes and bunions
• Charcot foot
• Poor blood flow that prevents wounds from healing leading to tissue death
  

Shoes and Accessories to Support Diabetic Feet

You can help prevent diabetic foot complications by choosing the right shoes and accessories to support diabetic feet. Follow these tips to choose the right products:

• Wear well-fitting cotton socks without seams to reduce friction, and change them daily.
• Select shoes that have a wide toe box.
• Have your foot measured every time you purchase shoes. Purchase shoes late in the day when your feet are larger.
• Avoid pointed-toe shoes and high heels that exert extra pressure on your toes.
• If possible, rotate among several pairs of comfortable, well-fitting shoes to avoid pressure on the same part of your foot.
• Ask your healthcare provider about customized shoes that can reduce your chances of developing foot ulcers.
• Talk to your healthcare provider about being fitted for customized orthotic shoe inserts or wearing braces to cushion your steps and redistribute your body's weight across your foot's bones and joints to improve your gait (walking pattern).

At-Home Monitoring and Foot Care

At-home monitoring and foot care can help you catch symptoms of diabetic foot early. This can facilitate faster treatment and reduce your risk of amputation due to complications.

Controlling your blood sugar levels so they remain in your target range is the best way to protect your feet from nerve and blood vessel damage. Taking the following steps to ensure foot care can also help keep your feet healthy:

• Examine the tops and bottoms of your feet for changes such as cuts, redness, sores, blisters, or other changes to the skin or nails on your feet. Use a mirror to help you examine the bottoms of your feet.
• Wash your feet with warm water and soap daily. Avoid soaking your feet, which could dry them out. After washing your feet, dry them completely and apply moisturizer to the tops and bottoms, avoiding between your toes.
• Wear shoes and socks that fit properly to avoid causing irritation or sores from friction.
• Never walk barefoot, even indoors, to avoid injury. Check that small pebbles or other materials do not become stuck inside your shoe, which can irritate your skin.
• Do not attempt to remove calluses or corns yourself with scissors, clippers, or over-the-counter products. Consult a podiatrist to address these problems.
• Trim your toenails straight across using a clipper. If you can't accomplish this, ask your podiatrist to do it for you.
• Protect your feet from extreme temperatures. During warmer weather, use sunscreen and resist the urge to walk barefoot. In the colder months, wear socks rather than placing your feet near a heater to stay warm.
• Keep the blood flowing in your feet by keeping them elevated when you're sitting. Wiggle your toes and circle your feet for a few minutes several times during the day.
• Stay active with movements such as walking, riding a bicycle, or swimming, which are less likely to damage your feet.
• Get regular foot checks that involve a physical examination of your feet and a test of their flood flow at your healthcare visits, even if you don't notice a problem.
  

How a Provider Treats Diabetic Foot

The way your provider treats a diabetic foot depends on the location and extent of damage present as well as other factors such as your overall health and underlying conditions. While there is no cure for diabetic foot, treatment can slow its progression and manage complications before they become serious.

With early diagnosis, your provider may be able to treat your diabetic foot with one of the following nonsurgical treatments:

• Wound dressings: Specialized wound dressings and topical creams can protect a diabetic foot ulcer from infection and promote healing.
• Antibiotics: These drugs are given orally or intravenously (through an IV within a vein) therapy to treat an infection and prevent it from spreading.
• Off-loading: Devices like special casts, shoes, or braces can be used to remove pressure from a diabetic foot ulcer, a process known as off-loading, and promote healing. Methods can include bed rest, wheelchair use, crutch walking, and removable cast walkers. The gold standard for offloading is the total contact cast.
• Debridement: This involves the removal of contamination (foreign matter) and necrotic (dead or dying) tissue from a diabetic foot ulcer to promote healing and infection. Debridement can be achieved either surgically or with non-surgical methods that involve the use of special dressings and gels.
• Relieve limb ischemia (restricted blood flow): Nonsurgical interventions such as balloon angioplasty and stenting may be appropriate if your diabetic foot ulcer is linked to vascular disease such as peripheral artery disease (PAD).
• Hyperbaric oxygen therapy: This therapy involves sitting in an enclosed space filled with high-pressure oxygen and breathing so you can increase the oxygen in your bloodstream. The effect stimulates the repair of damaged tissue.
  

When Would Someone Need Surgery?

You may need surgery for a diabetic foot when evidence of a nonhealing, deep, infected wound or gangrene is present. Without prompt treatment, gangrene can lead to sepsis (a blood infection), resulting in the loss of the affected body part. As gangrene spreads, it can become life-threatening.

The type of surgery you'll need depends on whether the treatment is used to treat a foot wound, correct the underlying cause for the foot wound, or correct the foot to improve the chances of healing.

When surgery is necessary, your provider may recommend one of the following procedures to treat a diabetic foot:

• Vascular surgery: When nonsurgical approaches are not appropriate, vascular surgery techniques such as an atherectomy (opening of a clogged artery by shaving tiny amounts of a blockage) can promote healing by restoring proper blood flow to the wound site.
• Skin grafts: These treatments can restore proper blood flow, reduce the risk of infection, and promote healing by reconstructing weakened or missing skin. The replacement skin can be taken from another part of your body or a donor.
• Deformity correction: These surgeries can correct a surface deformity such as a hammertoe or bunion or a structural deformity like high-arched feet, which can cause areas of high pressure on your foot.
• Fusing or realigning joints: This treatment can address biomechanical defects that increase pressure on your foot, making it more vulnerable to a diabetic foot.
• Achilles tendon lengthening: If your Achilles tendon pulls or exerts unnatural pressure on the front part of your foot, it can interfere with the healing of a diabetic foot ulcer. Achilles tendon lengthening can release the tension in the tendon and relieve excess pressure from an ulcer.
• Amputation: The surgical removal of a diabetic toe or foot may be necessary if your diabetic foot involves severely damaged tissue or a severe infection that can't be stopped from spreading. This is a last resort when other options have been exhausted.

Road to Healing: Ongoing Foot Maintenance With Diabetes

After treatment, your rate of healing will depend on the type of treatment you receive. Healing times depend on various factors like wound size, location, pressure being exerted on the wound, blood glucose levels, wound care, and wound dressing. Wound healing can take from weeks to several months.

The following strategies are key to healing and maintaining foot health with diabetes:

• Closely monitor blood sugar levels so they remain in your target ranges.
• Learn how to check your feet to identify potential problems as early as possible.
• Change your wound dressing daily and keep it covered and moist.
• Get regular foot checks from your healthcare provider.
• Treat any infections as directed.
• Reduce friction and pressure on your feet.
• Work to reach and maintain a healthy weight if you are overweight.
• Reduce risk factors for diabetic foot such as smoking, drinking alcohol, and high cholesterol.
  

Summary

Diabetic foot problems are among the most common complications of this disease. They often involve open sores called ulcers that form when you get a minor cut or scrape that goes without treatment. These wounds can also occur when excess pressure is placed on one part of your foot and a blister forms.

Diabetic foot often occurs over time due to nerve damage or problems with blood flow to your feet. These issues can prevent sores from healing, leading to the loss of tissue and bone. In severe cases, the problem can result in losing your toe or foot.

You can reduce your risk of diabetic foot by keeping your blood sugar levels under control. Looking at your feet daily can help you find problems before they worsen. This can help you get the right treatment early and avoid severe issues.