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Contents
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Foot Information
Foot Problems
Normal Foot
Diabetic Foot
Heel Pain
Bunions
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Foot Surgery
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Orthotics
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Contents
(click on a topic hyperlink to go directly to it)
Material from common foot problems page
Diabetes
Nerve Problems (Peripheral Neuropathy)
Deep Space
Infections
Circulation Problems
(Peripheral Vascular Disease, PVD)
Charcot
Joint ( Charcot Foot, Diabetic Neurotrophic Osteoarthropathy)
Ulcers
Neuropathic ulcers
Ischemic ulcers
Additional material
Mechanisms of Ulcer Formation in the
Diabetic
Managing Foot
Ulcers
Photos of ulcers healing with
proper treatment:
Tips for proper foot care
by the diabetic
The text in bold print also appears in
the Common Foot Problems page. To skip the redundant portion and go
directly to Additional Material, Click Here  .
Diabetes
Diabetes is a disease in which either not enough Insulin is produced by the
pancreas (Type 1) or the insulin that is produced is not recognized by the cells of the
body (Type 2). As a result, both types of diabetes lead to abnormally high blood sugar
concentrations. High blood sugar (glucose) levels can lead to coma and death. In addition,
chronic diabetes, through mechanisms that are still not completely understood, often
results in complications involving many of the organ systems throughout the body. Some
commonly affected organs are the kidneys (nephropathy), the eyes (retinopathy), the
nerves (neuropathy) and the blood vessels( vascular disease). It is the neuropathy and
vascular disease that may have a devastating effect on the feet. Both of these conditions
can lead to amputation, particularly if the feet are neglected.
Nerve Problems (Peripheral Neuropathy)
Neuropathy, the nerve disease associated with diabetes, often results in
numbness and loss of protective sensation of the feet. Neuropathy can be the first
manifestation of undiagnosed diabetes that prompts the patient to seek medical attention.
Although pain is by definition an unpleasant experience, it is nonetheless a very
important mechanism to alert us to danger. Without the ability to detect pain, one could
walk around all day with a pebble in one's shoe and not know it. This could result in the
development of an ulcer. Also, an infection could go unnoticed, until
irreversible damage has already occurred. Neuropathy is probably responsible for more
cases of ulcers, infections and amputations than vascular disease. There are several
tests that can be utilized to determine the presence of peripheral neuropathy. The
Semmes-Weinstein monofilament test is a simple way of determining whether neuropathy has
advanced to the stage at which there is a loss of protective sensation.This is a simple
test in which a small filament of plastic, similar to bristle on a hair brush, which has
been calibrated to bend at a specific amount of force is touched to the skin. If it can be
felt, there is adequate sensation to protect against the development of ulcers. If not,
there is a loss of protective sensation and the person is at risk for ulceration.
In addition to the loss of the ability to detect painful stimuli, some cases of
neuropathy also result in a chronic, burning pain in the absence of any harmful
stimulation. This neuropathic pain is often most severe at night, when resting and the
person is not focusing on other things.
There is no effective treatment to reverse the loss of protective
sensation in the person with neuropathy once it has developed. But tight sugar control has
been shown to reduce the risk of developing neuropathy in the first place. There are
several treatments that may be used to try to reduce the discomfort associated with
neuropathic pain but they are often ineffective. Mild neuropathic pain sometimes responds
to capsacin cream applied 4 times daily. Sometimes Elavil is effective. Electrical
stimulators have also been used to try to reduce neuropathic pain.
Neuropathy may also be seen in some people without diabetes. Alcohol abuse is
another leading cause of neuropathy. It may also be caused by certain drugs used to
treat cancer and AIDS. Much of the early neuropathy research was related to the
study and treatment of Hanson's disease (leprosy). Fortunately, Hanson's disease is now
very rare.
Deep Space Infections
Those with neuropathy are susceptible to the development of deep space
infections in the foot. Deep space infections have a high morbidity and may lead to
amputation if not identified early . There are several compartments in the foot surrounded
by various layers of muscle and connective tissue. The compartments in the foot
communicate with compartments of the leg through tunnel-like spaces around the tendons
that travel through both the leg and the foot. This allows for easy spread of the
infection from the foot to the leg. Frequently, there is no pain in the foot due to
neuropathy. A deep space infection is a surgical emergency requiring hospitalization,
immediate incision and drainage, and intravenous antibiotics. This type of infection can
also easily cause blood poisoning (sepsis). Surgery involves creating a large incision,
usually on the bottom of the foot, to completely drain all pus. Otherwise, an abscess may
persist which is often resistant to antibiotic treatment alone. The wound that is created
by opening the abscess is often packed open to allow for additional drainage.
Circulation Problems
(Peripheral Vascular Disease, PVD)
Diabetics are more prone to the development of peripheral vascular disease than
the non-diabetic. However, one certainly does not have to be diabetic to develop vascular
disease. With peripheral vascular disease, arteries in the leg that carry blood to the
foot become clogged. The earliest sign of PVD may be intermittent claudication which is a
severe cramping of the leg or thigh that occurs while walking, usually at a predictable
distance measured in blocks, and which may resolve after a period of rest. As the vascular
disease worsens with time, the distance one can walk prior to feeling claudication pain
becomes shorter.
A later sign of PVD is rest pain. This is pain that is often felt at rest when
laying in bed. Typically, the pain is relieved by putting the feet down on the floor which
allows the blood to flow down to the feet more easily.
PVD may also result in ischemic ulcers or gangrene. These develop when the
tissues of the feet do not get enough blood flow. Without enough blood, the tissues do not
get enough oxygen and they die.Once gangrene develops, the tissue death is not reversible
and an amputation is often required.
Many limbs can be saved with procedures to restore blood flow to the feet. This
may be accomplished in some cases with angioplasty, where a balloon is fed through the
arteries and used to open the blockage. Sometimes a stent, a cylindrical piece of metal,
is used to keep the area open. Other cases may benefit from the performance of a bypass
procedure by a vascular surgeon. In a bypass, a vein or synthetic tube is used to bring
blood around the blockage. A "Fem-Pop" bypass refers to a bypass connection the
Femoral Artery in the thigh to the Popliteal artery near the knee. Blockages in diabetics
may occur further down the leg and may require a bypass to an artery such as the posterior
tibial or dorsalis pedis.
Charcot Joint ( Charcot
Foot, Diabetic Neurotrophic Osteoarthropathy)
It has been estimated that 2% of people with diabetes develop Charcot Joint.
This is a condition in which certain joints, most commonly the midfoot, collapse and
degenerate. This occurs only in people who have peripheral neuropathy. The earliest stage
consists of a red, hot, swollen foot. This is often mistaken for an infection. X-rays will
often show severe destruction and erosions of the involved joints. Later stages are
without the inflammation but may show either a completely flattened arch or the
classical "rocker-bottom " foot. This can be a big problem since ulcers often
develop beneath the collapsed bone.
Treatment for a Charcot joint is aimed at reducing weightbearing pressure. This
may be accomplished by using a wheelchair, complete bed rest or a contact cast. The
treatment is usually continued until the inflammation has subsided and the bones have
begun to fuse together. This may take 3 months or longer.Once the inflammation has
subsided, treatment is aimed at preventing the development of ulcers and further
breakdown. This is often accomplished with molded shoes and/or braces. Sometimes surgery
may be needed to reconstruct the foot or to eliminate a prominent deformity.
Surgery for the Charcot joint has traditionally been performed in the chronic
stage, after all of the inflammation has resolved. Some podiatric surgeons have advocated
a more controversial approach during the acute stages. Reconstruction of the Charcot joint
may be extremely difficult due to the severity of the deformity and the condition of the
bone. Reconstruction often involves cutting and fusing all of the metatarsal cuneiform and
metatarsal cuboid joints in the midfoot. These bones are then held together with special
metal screws and/or pins and plates. Casting is then usually required for two or three
months. Other, less complex procedures may also be performed on the Charcot foot, such as
the shaving or removal of isolated bony prominence. These types of procedures are most
commonly utilized to help to eliminate an ulcer that has developed beneath such a
prominence.
Ulcers
An ulcer is a condition in which there is death of skin tissue (necrosis)
resulting in an opening in the skin. (Similarly, a gastric or peptic ulcer is a break in
the integrity of the lining of the stomach or gastrointestinal lining.) The skin serves an
important role as a barrier to germs. When an ulcer develops in the skin, bacteria can
enter the body and cause an infection. A variety of different disease processes are
responsible for ulcerations of the foot. Effective treatment depends on correctly
diagnosing the cause of the ulcer. A description of the most common ulcers follows:
Neuropathic ulcers occur when there is
a nerve disease that results in numbness or the inability to feel pain. Although none of
us likes to experience pain, it is an important warning sign and lets us know there is a
problem that needs to be addressed. This type of ulcer is frequently associated with diabetics, who often develop a nerve condition known as peripheral
neuropathy. Chronic abuse of alcohol may also result in neuropathy. Neuropathic
ulcers are most commonly seen on the bottom of the foot. These ulcers may often
start as a callus and may be hidden by a callus. These ulcers often occur in the presence
of good blood circulation and will often heal well once weightbearing pressure is removed
from them. The frequency of these ulcerations may be reduced by performing
daily foot inspections, wearing properly fitting shoes and seeing a podiatrist regularly.
Deep depth or custom molded shoes with special inlays or orthoses may also be required.
Ischemic ulcers are caused by poor
blood circulation (peripheral vascular disease or atherosclerosis.) The arteries, which
carry blood from the heart to the rest of the body, become clogged. When this happens, not
enough blood reaches the feet and tissue in the feet die and ulcerate due to lack of
oxygen. These ulcers are often associated with diabetes
since diabetics have an increased prevalence of vascular disease. They may also be seen in
patients who are not diabetic but who have peripheral vascular disease. These ulcers most
commonly involve the toes rather than the bottom of the foot. These ulcers often
lead to gangrene. These ulcers may also be painful although some people such as diabetics
may have both neuropathy and vascular disease in which case they could have ischemic
ulcers that are also painless.
Additional
Material:
Foot surgery in the person
with diabetes
Elective foot surgery may be performed safely in most diabetics, provided certain
criteria have been met. The most important factors to be considered are vascular status,
the level of blood sugar control and other metabolic factors. If the pulses of the foot
are palpable, the blood sugar is under good control and there is no significant anemia or
other metabolic problems, the same elective procedures performed in the non-diabetic can
usually be performed safely in the diabetic patient.
Vascular Considerations
If the pulses of the foot (dorsalis pedis and posterior tibial) are palpable, there is
usually adequate blood flow to permit healing.Other clues that suggest good vascular
status are warm, pink skin, the presence of hair on the toes and quick refill of the blood
in the toes after they are squeezed. Elective foot surgery is usually not performed
when the pedal pulses are not palpable. If the vascular status is questionable after the
physical evaluation, other tests may be utilized. Doppler ultrasound and ankle pressures
are non-invasive ways to check the circulation status. Ankle pressure tests may not be
reliable since many diabetics have calcified arteries which lead to artificially high
readings. Sometimes non-elective surgery must be performed even in the patient with
questionable vascular status. This may be the case when there is an infection or wound
that needs to be treated. These cases may require an arteriogram to determine healing
potential. An arteriogram is an invasive test where radiographic dye is injected into the
body and x-rays are taken to determine if there are any blockages in the arteries. If
blockages exist, a vascular surgeon may be able to perform a bypass procedure to restore
blood flow.
Glucose control
High blood sugar levels increase the risk of infection and other complications. Therefore,
good glucose control should be attained prior to undergoing any elective surgical
procedures. (On the other hand, when it comes to non-elective surgery such as incision and
drainage of an abscess, the infection often contributes to the high blood sugar levels and
surgery must often be performed immediately to treat the infection. Once the infection is
better controlled, the blood glucose is more easily controlled.)
Anemia
Diabetics, particularly those with diabetic kidney disease(nephropathy), are prone to
chronic anemia. A reduction in red blood cells and hemoglobin elevates the risk of
infection and delayed healing.
Mechanisms of Ulcer
Formation in the Diabetic
 | A. Ischemic Ulcers
Poor blood flow prevents an adequate amount of oxygen to reach the tissue. As a result of
poor nutrition, the skin and tissue beneath it either die directly or do not heal after an
injury.
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| B. Neuropathic Ulcers
1. Large amount of pressure in a Short time
e.g. an acute traumatic injury
This mechanism of injury produces an immediate ulceration when a sharp object such as a
nail or a piece of glass pierces the skin. This may go unnoticed for some time due to the
lack of sensation. For example, the injury may occur early in the day an may not be
noticed until undressing in the evening and noticing blood on the socks. Therefore, it is
important to avoid going barefoot and to check the insides of the shoes before putting
them on.
2. Small amount of pressure over a long time(several hours)
e.g. a tight shoe
This injury occurs as a result of a constant pressure on the skin over a period of time,
e.g. 2 or 3 hours or more. If a shoe is worn that is too tight, the shoe squeezes the skin
on certain areas of the foot. This causes the skin in those areas to blanche or turn
white. Blanching occurs when the blood is squeezed out of a certain area due to pressure.
You can demonstrate this yourself by pressing your finger against a window. Notice how the
part of your finger that touches the window turns white. If you kept it there for several
hours, that part of your finger would die and ulcerate.The same damage could occur with a
tight pair of shoes . This is unlikely to happen in someone with normal nerve function
because pain would soon develop and cause that person to remove the shoe. Someone with
neuropathy, not sensing any pain, would continue to wear the shoe and develop an ulcer.
3. Moderate pressure that is repeated over a longer time.
e.g. a callous that turns into an ulcer
This is the most common cause of ulcers on the bottom of the foot. To understand this
mechanism, let us first look at the example of someone without neuropathy. During the
course of walking, particular spots beneath the foot may be subjected to an increased
amount of pressure. The person with normal nerve function either consciously or
subconsciously changes the way they walk to transfer weight to another area of the foot
thereby reducing pressure to that area. In the person who has neuropathy, there is no
conscious or subconscious change in gait and as walking is continued, the area continues
to be subjected to a repetitive, moderate amount of pressure. This leads to a localized
area of inflammation which results in tissue breakdown and eventually ulceration. The
potential location of a plantar ulcer can often be predicted based on the shape of
one’s foot and the presence of calluses.Calluses usually develop beneath parts of the
foot that bear an excessive amount of weight or are subjected to a lot of friction.
Accommodative orthoses can help to prevent ulceration by protecting the foot and
dispersing weight more evenly.
4. Infection
An infection can develop if there is a break in the skin which allows
bacteria to enter. To the sensate person, infections are usually very painful, causing the
person to seek treatment. With neuropathy, the infection could go unnoticed for several
days or longer resulting in severe tissue damage.
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Managing Foot Ulcers
Identify the cause of the ulcer
If there is vascular disease, have a vascular surgeon
determine if a bypass or angioplasty is possible to increase blood flow
If the ulcer is neuropathic (or a combination of
neuropathic and ischemic), try to determine the cause. E.g. repetitive weightbearing over
a bony prominence, tight shoe, burn etc.
Determine if there is an infection
This is usually done by clinical evaluation. E.g. redness, swelling,
pain, pus all point to infection. Keep in mind that all ulcers will have some drainage.
Since the skin, which is ordinarily a barrier to prevent dehydration, is disrupted,
drainage which is usually watery or blood tinged will be present. (This is in distinction
to drainage that is thick, white and creamy which usually indicates pus and an
infection) Also, culture swabs should not be used alone as an indication of infection
since most diabetic ulcers will have bacterial colonization on the surface of the ulcer
but which do not represent a true infection. Culture swabs are most useful as a means of
determining which bacterial organisms are causing an infection once a diagnosis of
infection has been made from clinical findings. Once a diagnosis of an infection has been
made, antibiotics should be initiated. If there is an abscess, the wound should be incised
and drained immediately. The podiatrist may do this in either the office or the
hospital, depending on the extent and depth of the abscess.
Debridement
Ulcers should be trimmed of all dead, infected, fibrous and/or callus
tissue. If not debrided, these things can significantly slow down or prevent wound
healing. In the case of infection, bacteria release enzymes which prevent healing. In the
case of callus tissue, the thickened callus tissue causes pressure over or around the
ulcer which prevents wound healing. Debridement may need to be done weekly by the
podiatrist. Debridement of the ulcer often produces bleeding as the dead tissue is removed
and healthy bleeding tissue is exposed. The bleeding is beneficial since it delivers
platelets and growth factors to the ulcer bed. If bone is exposed, it may need to be
debrided to remove infected tissue.
Off loading
The lack of effective off-loading is
perhaps the single most important factor contributing to non-healing neuropathic
ulcers. All the antibiotics in the world will not heal an ulcer if weight is
not taken off the ulcer. Off-loading is best accomplished by complete bed rest. However,
this is usually not practical. Wheelchairs are often effective as well. However, in order
to keep the person with the ulcer walking and working, other measures are usually
necessary. Sometimes, total contact casts(TCC) are utilized. These are special
leg casts which take weight off the ulcer and allow ambulation. Another effective means of
permitting ambulation and off-loading an ulcer is a healing sandal. These are specially
made shoes with insoles that help to take weight off the ulcer site. Other devices used to
off-load ulcers are Cam Walkers, removable walking casts as well as special leg
braces such as a patellar tendon-bearing brace (PTB Brace) which transmits weight
off the foot and onto the knee. Sometimes surgery is utilized to off-load an ulcer. This
can sometimes be done by simply shaving off a prominent piece of bone. Other cases may
involve reconstructive surgery where bones are repositioned to provide more balanced
weightbearing.
Dressings
There are many products that are used to treat ulcers. Some are
designed to keep the ulcer free from infection (antibiotics), others are designed to
assist with debridement (enzymes) and others are designed to promote wound healing. The
type of ulcer and status of the ulcer may help to determine which of these products the
treating doctor may select. Common dressing include saline(salt water) and Silvadene
cream, an antibiotic cream. Certain products such as full-strength Betadine (povidone
iodine) have fallen out of favor among many members of the wound care community because of
its reported toxicity to healing (granulation) tissue. Also, keeping the wound moist,
rather than allowing it to dry out, appears to help wound healing. Newer products, growth
factors such as Regranex, are also gaining acceptance.
Maintenance and prevention of recurrence
Once an ulcer is closed, it is important to take the proper steps to
prevent recurrences. This involves reassessing shoe gear. Deep depth or custom molded
shoes with accommodative orthotic insoles are often required. Sometimes a rocker placed in
the sole of the shoe is necessary. Sometimes a double upright leg brace or patellar
tendon-bearing brace is necessary. Daily inspection of the feet is required as are regular
trips to the podiatrist.
Photos
of ulcers healing with proper treatment:
Patient "H.B." Diabetic with
neuropathic ulcer
Patient "K.F." Diabetic with
Neuropathic ulcer
Patient "H.H." Diabetic with
Neuropathic ulcer
Patient "L.G." Diabetic with
Neuropathic Ulcer
Tips
for proper foot care by the diabetic
Do's and Don'ts
Do
| Wash feet daily with warm water and mild soap
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| Inspect your feet daily. Look for any areas of discoloration, scratches,
blisters or changes of any kind. A small hand mirror is often useful to help see the
bottom of the feet. This can be placed on the floor with the foot held over it. If it is
difficult to see the bottom of the feet, have a family member check your feet for you each
day.
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| Check inside shoes before putting them on.
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| Use a lotion or cream daily on your feet (but not between the toes) to
keep them soft. The best time to do this is after bathing. There are a wide variety of
creams. You do not have to use the most expensive items which often cost more because of
perfumes and marketing expenses. Something as simple as vegetable shortening or Vaseline
may be adequate.
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| Wear soft, protective, roomy shoes that have good support. Diabetics
with neuropathy and/or peripheral vascular disease may require deep-depth or custom molded
shoes. (These are often covered by Medicare).
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| Keep your blood sugar level well controlled. Studies have shown that
tight sugar control lowers the occurrence of peripheral neuropathy as well as kidney
disease and eye disease.
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| See your podiatrist regularly
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Don't
| Do not go barefoot
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| Do not use heating pads. These can cause burns and ulcers.
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| Do not soak your feet, unless prescribed for a specific purpose by your
doctor. Soaking can dry your feet by removing its natural oils. This could lead to
cracking.
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| If you have neuropathy or peripheral vascular disease do not trim your
toenails yourself. If you do care for your nails yourself, use an emery board or nail file
rather than scissors or a curved nail clipper. Trim nails straight across and do not make
them too short.
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| Do not try to cut corns or calluses yourself. see your podiatrist for
this.
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| Do not use "Corn Removers' or medicated pads. These contain acid
that can burn a hole in your skin. It is usually o.k. to use simple non-medicated corn
cushions.
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