While "One Foot, Two Foot, Red Foot, Blue Foot" may be the opening line of a humorous children's book by Dr. Seuss, foot complications are no laughing matter to the 20 million Americans with diabetes. According to the American Orthopaedic Foot & Ankle Society (AOFAS), ulceration, infection, and gangrene are the most common foot and ankle problems of the diabetic patient. Approximately 60,000 lower extremity amputations are performed annually, in the US alone, in patients with diabetes. However, with ongoing, diligent and proper foot care, many of these amputations are preventable.
The AOFAS recommends diabetic individuals check their feet daily by inspecting all sides including the bottom; any changes in shape or color, sense of feeling/sensation, painful areas or skin integrity need to be evaluated by an orthopaedic foot and ankle surgeon. There are two major causes of foot complications in diabetic patients: nerve damage (neuropathy) and loss of circulation (ischemia). Neuropathy or loss of feeling in feet affects 60-70% of diabetics. With a diabetic foot, a wound as small as a blister from wearing a shoe that is too tight can lead to a major emergency if undetected. Many diabetics experience a decrease in blood flow; therefore injuries are often slow to heal. If a blister is not healing it's at risk for infection. As a diabetic, an infection may spread quickly with little warning.
AOFAS member Michael S. Pinzur, MD, Professor, Orthopaedic Surgery, Loyola University Medical Center, Maywood, IL, former chair of the AOFAS Diabetes Committee, and assistant editor of the FootForum which appears monthly in the Society's scientific journal, "Foot & Ankle International (FAI)," provides the following advice: "It is imperative that diabetics inspect their feet daily, as foot infection is the leading cause of hospitalization for diabetic individuals in the US. Foot ulcers, blisters and infections are often difficult for diabetic individuals to discover, as many have impaired vision or limited ability to examine the bottoms of their feet. Often a spouse or caregiver needs to participate in the daily evaluation. Mirrors and magnifying glasses are helpful aids in inspecting difficult to access areas of the feet. This becomes crucial, as many diabetics have impaired immune systems and have a lowered resistance to infection. The ability to spike a fever or develop an elevated white blood cell count is often impaired. Often times, the first signs of a developing infection are a rising blood sugar level or a need for increased doses of insulin."
The AOFAS suggests the following daily foot care routine and infection prevention tips for individuals with diabetes:
-- Use gentle cleaning routines. Wash feet (do not soak them) in lukewarm water, never hot. Wash with soft cloth and mild soap. -- Dry thoroughly but gently between the toes. Use a moisturizing lotion for dry skin, but do not use in between the toes. Keep dry skin soft and pliable. -- Trim nails straight across with a nail clipper. Do not round the corners. -- Reduce calluses with gentle daily rubbing with a foot file or pumice stone. Rub in one direction to avoid tearing the skin. Never trim with a sharp razor blade or apply liquid callus removers. -- Choose good footwear with cushioned soles and uppers made of soft, breathable material such as leather, not plastic. -- Avoid wearing sandals and never walk barefoot. -- Wear cotton or natural fiber socks for the best padding. Avoid synthetic materials. Don't wear socks with holes. Do not wear socks with elastic tops that can cut off circulation. -- Break in new shoes gradually. Wear them one or two hours at a time. -- Patients with neuropathy should use custom-molded insoles to help cushion the foot.
"Patients should urgently be examined by an orthopaedic foot and ankle surgeon whenever they develop a new ulcer, redness or acute onset of pain and swelling. Based on the AOFAS 'Guidelines for Diabetic Foot Care,' published in FAI in 2005, patients should have an ongoing program of evaluation by a healthcare professional," says Pinzur.
The good news is the care of the lower extremities in diabetic individuals has improved in the last several years. But the key to success is prevention. Taking responsibility for good foot hygiene, wearing sensible footwear, and careful daily inspection of feet are life-long steps to help prevent and avoid future foot complications.
Public education resources on the care and treatment of the diabetic foot may be found on the AOFAS website www.aofas.org by clicking on Patient Education & Resources, then Ailments and Conditions. The site also features a surgeon referral service; making it easy for diabetic patients to find a local orthopaedic surgeon specializing in foot and ankle care.
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