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©2012 by the American Diabetes Association, Inc.® All Rights Reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including duplication, recording, or any information storage and retrieval system, without the prior written permission of the American Diabetes Association.
Printed in the United States of America
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The suggestions and information contained in this publication are generally consistent with the Clinical Practice Recommendations and other policies of the American Diabetes Association, but they do not represent the policy or position of the Association or any of its boards or committees. Reasonable steps have been taken to ensure the accuracy of the information presented. However, the American Diabetes Association cannot ensure the safety or efficacy of any product or service described in this publication. Individuals are advised to consult a physician or other appropriate health care professional before undertaking any diet or exercise program or taking any medication referred to in this publication. Professionals must use and apply their own professional judgment, experience, and training and should not rely solely on the information contained in this publication before prescribing any diet, exercise, or medication. The American Diabetes Association—its officers, directors, employees, volunteers, and members—assumes no responsibility or liability for personal or other injury, loss, or damage that may result from the suggestions or information in this publication.
The paper in this publication meets the requirements of the ANSI Standard Z39.48-1992 (permanence of paper).
ADA titles may be purchased for business or promotional use or for special sales. To purchase more than 50 copies of this book at a discount, or for custom editions of this book with your logo, contact the American Diabetes Association at the address below, at booksales@diabetes.org, or by calling 703-299-2046.
American Diabetes Association
1701 North Beauregard Street
Alexandria, Virginia 22311
DOI: 10.2337/9781580404778
Library of Congress Cataloging-in-Publication Data
Scheffler, Neil M.
21 things you need to know about diabetes and your feet / by Neil M. Scheffler, DPM, FACFAS.
pages cm
Includes bibliographical references and index.
ISBN 978-1-58040-477-8 (alk. paper)
1. Foot--Diseases--Popular works. 2. Diabetes--Complications--Popular works. 3. Foot--Care and hygiene--Popular works. I. American Diabetes Association. II. Title. III. Title: Twenty-one things you need to know about diabetes and your feet.
RC951.S34 2012
616.4’62--dc23
2012036748
eISBN: 9781580405324
“This book is dedicated to my wife, Eleanor,
who puts up with all the time I spend on my computer.
Thanks also to those podiatrists
who helped train me during my residency:
Drs. Irvin Donick, Larry Block, Steven Berlin and Lanny Rubin.
I can never thank you enough.”
Table of Contents
6 Foot Ulcers
7 Infection
8 Nail Problems
9 Shoes and Socks
10 Additional Risk Factors
11 Skin Care
12 Melanoma
13 The Aging Foot
14 Arthritis
15 Surgery
16 Other Foot Problems
17 Over-the-Counter Products
18 Exercise
19 Emergencies
20 Seasonal Foot Care
21 Prevention
Resources
Diabetes has become an epidemic in this country. This epidemic is costing hundreds of billions of dollars each year in direct and indirect costs while destroying the lives of those with this disease, as well as those of their friends and families. The personal costs to patients include financial as well as non-economic, emotional, social, and psychological burdens. The risk for death among people with diabetes is about twice that of people of similar age without diabetes.
According to data from the 2011 National Diabetes Fact Sheet, 25.8 million children and adults in the United States—8.3% of the population—have diabetes. 79 million people have prediabetes. 1.9 million new cases of diabetes were diagnosed in people aged 20 years and older in 2010, and there is no end in sight. Diabetes rates in adults ages 65 and up may surge in the next 20 years as the population of senior adults is expected to double to more than 71 million by 2030.
Lower extremity complications of diabetes account for more in-patient hospital days than any other complication of the disease. More than 60% of lower-limb amputations due to causes other than trauma occur annually in people with diabetes; this number is more than 65,000.
If you want to be active and independent all of your life—whether or not you have diabetes—you need to have healthy feet. Most people take their feet for granted, but people with diabetes do not have that luxury. You are challenged by complications of diabetes that can make it easier for you to develop a foot ulcer that may not heal. Nonhealing ulcers often lead to amputation, which will severely limit what you can do for yourself.
The good news is that by taking good care of your feet, you can often prevent diabetic foot complications. If you take care of your feet every day and get good medical care as soon as you suspect you might need it, you’re much more likely to avoid getting the infections that make amputation necessary. According to the Center for Disease Control (CDC), “comprehensive foot care programs, i.e., those that include risk assessment, foot-care education, and preventive therapy, treatment of foot problems, and referral to specialists, can reduce amputation rates by 45% to 85%.”
This book will help you protect your feet. You will learn about the major lower extremity complications of diabetes: vascular disease (circulation problems), diabetic neuropathy (nerve problems), and foot deformities (such as bunions and hammertoes). You will see how these can affect your feet, how to prevent them, or, if they do happen, what you can do about it. Reading this book is the first step in preventing amputations and keeping your feet happy and healthy. Let’s get started!!
Perhaps you have heard about the “team approach” to treating diabetes. You may be interested in putting together a team for your foot care. Who should be on this team? How often should you see them and what should you expect?
The most important member of the team is YOU. You need to practice good foot hygiene, wear your prescribed shoes and inserts, and in general take charge of your own foot health. You need to assemble your team and help them to help you.
A podiatrist is a foot and ankle specialist who you should see at least once a year. If you have foot problems, such as poor circulation, nerve problems, wounds, or deformities you will need more frequent visits. You can see a podiatrist for routine foot care if you are unable to reach or see your feet. Podiatrists are doctors of podiatric medicine (DPM) and, in most states, diagnose and treat conditions of the feet and ankles. They perform routine foot care, such as toenail trimming, callus removal, and treatment of ingrown toenails, and they perform foot surgery on bones and soft tissue, such as bunion or hammertoe surgery. If necessary, a podiatrist can operate on infected bones and do amputations (some orthopedists do foot surgery as well). Podiatrists study how your feet and legs work when you move and walk (biomechanics). Podiatrists can identify bone and joint deformities that put unusual pressure on the skin of your feet. They can design insoles or braces to help your feet work normally and order special footwear if you need it. Podiatrists are trained in the treatment of the diabetic foot, including the treatment of wounds and infections. Your podiatrist will do a thorough history and exam and should treat any current problems and advise you about preventing future foot issues. He/she should suggest changes in shoes and socks. You should call your podiatrist immediately if you see any changes in your feet.
Your podiatrist should work closely with your primary health care provider (PCP). In fact, you may already have had a PCP before you chose your podiatrist. Your PCP is an excellent person to ask for a referral to a podiatrist or any medical specialist. Your PCP is the go-to person for any medical problems you may have. Your PCP and podiatrist may suggest these other members of your team:
• Vascular surgeons specialize in surgery on blood vessels and can help restore circulation to your feet. If your feet are cold or you notice your feet looking red or blue you may have poor circulation and require the expertise of a vascular surgeon. Vascular surgeons often help heal wounds and prevent gangrene and amputations.
• A neurologist may join the team if you have neuropathy (numbness or pain due to abnormal nerve function). The neurologist may perform nerve testing and prescribe medications to decrease pain or numbness.
• A physiatrist (a physician specializing in rehabilitation medicine) and a physical or occupational therapist may be consulted if you need rehabilitation. Physiatrists may also test nerves and help treat neuropathy or chronic pain.
• A pedorthist is a professional who fits shoes and insoles for people with foot problems. Pedorthists do not diagnose or prescribe care; they should follow the advice of your podiatrist or primary care physicians. When you visit a pedorthist make sure you have your doctor’s prescription or recommendation with you.
• A certified diabetes educator (CDE) can help teach you how to care for your feet.
• A nutritionist or registered dietician (RD) can help you with your diet plan to assist in your efforts to control your diabetes. Good control may help prevent complications such as peripheral neuropathy.
• An endocrinologist can help with your diabetes management. Good control of your diabetes may be able to prevent complications such as diabetic neuropathy.
Your family members who help you care for your feet at home are also part of your health care team. Family members or friends can be especially important if you cannot see your feet to examine them, or if you cannot reach your feet to clean or treat them.
Have a complete foot examination at least once a year. During this exam, your health care provider or podiatrist will look for any changes in shape (deformity) that alter the way you walk and bear weight on the foot. He or she will also check for loss of feeling by pressing a thin plastic wire that looks like a piece of fishing line, called a monofilament, against the soles of your feet or by holding a vibrating tuning fork against the base of your big toe. The provider will check your circulation and examine your skin, especially between your toes and under the metatarsal heads (the bones in the ball of your foot). If you can’t examine your own feet or if you have foot problems or nerve damage, have your feet checked more often, probably at every visit to your health care provider.
The following are warning signs. You should have your feet checked immediately if you have any of these symptoms.
• pain, redness, swelling, or increased warmth
• a change in the size or shape of the foot or ankle
• pain in the legs at rest or while walking
• tingling or numbness in the feet
• open sores (with or without drainage), no matter how small
• nonhealing wounds
• ingrown toenails
• corns or calluses with skin discoloration
• unexplained high blood glucose levels
About 60% to 70% of people with diabetes have mild to severe forms of nervous system damage. The results of this damage can include impaired sensation or pain, muscle weakness in the feet or hands, slowed digestion of food in the stomach, carpal tunnel syndrome, erectile dysfunction, or other nerve problems. Almost 30% of people with diabetes over the age of 40 have impaired sensation in the feet (i.e., at least one area that lacks feeling). Severe forms of diabetic nerve disease are a major contributing cause of lower-extremity amputations.
Peripheral neuropathy is the name for damage to sensory, motor, and autonomic nerves. Motor and sensory nerves help you move and feel the world around you. In the feet, autonomic nerves control perspiration. Autonomic neuropathy may result in dry, cracked skin. “Peripheral” means at the edges or away from the center, or away from the brain and spinal cord. In this case, the feet are farthest from the center of the body. “Neuro” means nerves and “pathy” means “a disorder of.” Because the longest nerves are usually affected first, symptoms such as tingling, burning, or numbness appear first in the feet and hands.
You can think of the nervous system like the electrical system in your house. The wires to the lights and appliances are the peripheral nerves, and the fuse box and the main electric cable are the central nervous system (the brain and spinal cord). When motor nerves are damaged, muscles in your foot can become weak and allow the shape of the foot to change. Toes can curl up, and the fat pad on the bottom of the foot can shift so that it no longer protects the skin on the bottom of the foot. Bones can get very close to the skin and can cause calluses. The sensory nerve damage prevents you from feeling pain, so a callus can become an ulcer without you being aware of it. Autonomic nerve problems can cause dryness of the skin.
While it is not yet known how diabetes causes nerve damage, it is likely that higher than normal blood glucose levels are part of the cause. Keeping your blood glucose levels close to normal can lower your chances of developing neuropathy. People with high blood glucose levels are more likely to have neuropathy, and the longer a person has diabetes, the more likely he or she is to experience this complication. Researchers are working to better understand the causes of neuropathy and to find treatments to avoid the damage that it causes.
If you have had diabetes for more than 10 years and you have not kept your blood glucose levels close to normal, you likely have some symptoms of nerve damage. It affects as many as 75% of all people with diabetes. Symptoms can range from muscle weakness, cramps, numbness, tingling, pins and needles, and burning sensations, to changes in bowel habits, bladder control, or sexual functioning. Your may also notice that your feet bother you more at night. Even unexplained episodes of fainting or vomiting can be attributed to nerve damage.
Although there is no one specific test that all doctors use to check for neuropathy, there are some that are widely accepted. Your doctor may touch your feet with a small, thin fiber called a monofilament. If you can’t feel this light touch, you have lost sensation. Similarly, you should be able to feel the vibrations of a tuning fork on your feet. A nerve conduction study, which tests the speed of electrical transmission through the nerves, may also be used. A trained neurologist or physiatrist will be consulted to perform this test.
Three types of neuropathy are associated with diabetes: autonomic, sensory, and motor. In the feet, autonomic neuropathy affects perspiration and the dryness of the skin. Although this dryness can be a problem, it does not change the shape of the feet.
Sensory neuropathy affects how the feet feel. This type of neuropathy causes numbness, burning, tingling, and/or pain. If your feet are numb, you often will not feel pain, and you may walk on a foot that is being damaged. You may also step on a nail or piece of glass and not know it. A Charcot foot is a breakdown of the structure of the foot—multiple fractures and a destruction of the bony architecture. The arch area may become so deformed it looks convex rather than concave.
Motor neuropathy affects the way the muscles work. The muscles deteriorate and over time, patients with longstanding diabetes and motor neuropathy may lose as much as half of the muscle volume of their feet. When the muscles of the foot do not work properly, an imbalance occurs and toes are often pulled out of their normal position. These are called hammertoes. When the toes move upward, they also pull with them soft tissue structures like the fat pad on the ball of the foot. This increases pressure on the bottom of the foot, and calluses and ulcers often form. These deformities must be addressed.
The best treatment for neuropathy is to keep your blood glucose levels on target. Studies show that near-normal blood glucose levels can also help prevent nerve damage from getting worse. If you have painful neuropathy and start taking insulin or oral medications to lower your blood glucose, you may notice a short increase in pain until your body becomes accustomed to the lower blood glucose levels.
Medications such as antidepressants, anticonvulsants (seizure medicine), muscle relaxants, local anesthetics (such as a lidocaine patch), and anti-inflammatory drugs, as well as vitamins, evening primrose oil, and capsaicin creams made from hot peppers, have been used to treat neuropathy symptoms.
Capsaicin is a substance found in hot peppers. Capsaicin cream removes a chemical—substance P, from the nerve ends below your skin and may interrupt your feeling pain. Apply it lightly several (3 to 4) times a day. Wear gloves or wash your hands carefully after applying capsaicin—you do not want to get hot pepper cream in your eyes, your mouth, or any other sensitive area! When you first use capsaicin, you may have a stinging or burning sensation that should disappear in a few days to a few weeks. Don’t give up just because it burns.
Do not use capsaicin if you are sensitive or allergic to hot peppers. Capsaicin cannot be used on damaged or irritated skin, wounds, or rashes. Don’t put tight clothing or bandages over the cream. Use it 3 to 4 times a day for 3 to 4 weeks before deciding whether it is working. Since capsaicin comes in different strengths, discuss what strength to use with your health care provider.
Physical therapy treatments such as stretching exercises, massage, and electrical nerve stimulation have also been tried. Some doctors have reported success with surgery performed on affected nerves. Although studies of these therapies report some improvement in painful symptoms for some patients, there is no single treatment that works for everyone. It may be difficult to get complete relief. Discuss your symptoms with your provider and try the treatment you both think might work. If that treatment doesn’t help, let your provider know so you can try another one.
Numbness in your feet is a very serious condition. Most people go to the doctor because their feet hurt, but may not realize if they’ve lost sensation. It is important to look at your feet and touch them every day. Keeping your blood glucose on target may help prevent the numbness from getting worse. See your podiatrist regularly. You may also need to have your shoes fitted properly by a pedorthist (certified shoe fitter) and find out whether you need special shoes to protect your feet. Check your shoes before each wearing for foreign objects, nails, or anything that may injure your foot. Be sure your socks are not wrinkled or twisted. You may want to switch to socks without a toe seam, because seams can put too much pressure on your toes.
If you find that the numbness is uncomfortable, discuss treatments for neuropathy with your health care provider. Whenever there is any injury to your feet or a change in shape or a change in the skin, see your foot care specialist right away. Do not wait until an infection develops!
A decrease in foot sweating can be a sign that diabetic nerve damage is occurring in the nerves that control sweating. This is called autonomic neuropathy. However, foot sweating also tends to decrease as we age, especially if we become less active. Wearing different shoes or socks can affect foot sweating, as well. You may have recently started wearing shoes that do not hold in moisture, so your feet are drier.
The problem with a decrease in foot sweating, whatever the cause, is that the foot skin tends to become very dry and prone to cracking. Cracks in the skin may become infected. It is a good idea to use a moisturizing cream or lotion on your feet (but not between the toes) if you have dry skin.
An unsteady gait can be related to diabetic nerve damage. When a person has loss of feeling in his or her feet, the positioning system of the body does not get normal responses about where the feet are being placed. This can cause the person to feel unsteady or to trip and stumble. An unsteady gait can be a sign of other problems, too—some of which can be quite serious. If you are having trouble with your balance or walking, talk with your provider about a consultation with a neurologist or physiatrist.
If your unsteadiness is due to nerve damage, it may be time to get a cane. It’s better to be safe and use a walking aid than to risk a fall and a broken hip! Your provider or physical therapist can help you get the right length and give you tips on how to walk with a cane. A physical therapist can also teach you balance exercises and how to increase awareness of the position of your feet.
Sometimes diabetes-related muscle weakness can contribute to unsteadiness in walking. Your provider or physical therapist can show you muscle-strengthening exercises. Some people need a lightweight brace or ankle support to stabilize the ankles when muscle weakness is the problem.
Not all pain or numbness in your feet may be diabetes related. Some vitamin deficiencies, such as vitamin B12, can cause neuropathy. A neuroma (sometimes called Morton’s neuroma) can manifest itself with tingling, burning, or pain in your two middle toes. At first this problem may only occur when you wear tight shoes, but the numbness and pain will eventually progress so you feel pain in any shoes. Compression of a nerve in this area, between the third and fourth toes, causes the nerve to thicken and creates these symptoms. People with and without diabetes may get neuromas. Treatment for this problem may include shoe inserts (orthotics), wider shoes, injections of cortisone, injections of alcohol to “kill” the nerve, or surgery to release pressure on the nerve or to remove the neuroma entirely.
One of the most serious complications possible in people with diabetes is peripheral vascular disease (PVD) or peripheral arterial disease (PAD). PAD is commonly called “poor circulation” and refers to blockage in the blood supply, often to the feet. A buildup of plaque inside the arteries that carry blood to the feet causes them to thicken and harden. Plaque is a substance that lines artery walls and is made up of calcium, cholesterol, fat, and other substances found in the bloodstream. People without diabetes get this thickening and hardening of the arteries as well, but unfortunately these problems can happen sooner and can be more severe in people with diabetes. PAD is 20 times more common in people with diabetes than in the general population. Other things that put you at risk of developing PAD are smoking, poor nutrition, lack of exercise, high blood fat levels (including cholesterol), and high blood glucose levels. Gangrene, or the death of tissues, is the most serious stage of PAD.
You can help to avoid or limit PVD by stopping smoking and keeping your blood fats and blood glucose levels as close to normal as possible. See a registered dietitian (RD) for help with your meal plan and add more physical activity to your lifestyle.
Your primary care physician, your endocrinologist, and your podiatrist should check you for PAD at least once a year. He or she will ask about cramping in your legs when you walk and will examine your feet and legs and feel for pulses, located in the groin, behind the knee, at the ankle, and on top of the foot. You may need to have the blood pressure in your ankles, arms, legs, and toes checked. (The arteries in toes don’t get stiff, so measuring blood pressure there may be more accurate.) A Doppler machine may be used; this test is painless. Some experts suggest that people with diabetes who are over the age of 50 should have a baseline Doppler exam (also called an ankle brachial [arm] index) to compare the blood pressure in their feet and arms. You may need a test to measure how much oxygen gets to the skin of your feet.
If you have an ulcer that won’t heal, or areas of your foot that break down despite wearing properly fitted shoes, you may need special X-rays and scans. These tests take pictures of the blood flow from your thigh to your toes. For arteriogram X-rays, you get an intravenous injection of a special solution so that the blood vessels show up clearly on the X-ray. This solution is called “dye,” although it really does not change the color of anything. People with poor circulation should consult with a vascular surgeon—a doctor who specializes in this type of problem. If you have questions, ask your provider and the people performing the tests to explain things to you.
The hallmark sign of poor circulation is pain or cramping in the calf or the thigh (usually the calf) that occurs when you walk a short distance. This pain is a sign that the muscles are not getting enough oxygen. If you slow or stop and rest for a few minutes, the oxygen supply usually catches up with the demand and you can walk a little farther before the pain reoccurs. The medical term for this condition is “intermittent claudication.” Claudication is similar to angina in people with poor circulation to the heart, except it occurs in the leg muscles. With angina there is chest pain that is relieved by resting the heart.
Other signs of poor circulation are pain at rest, nonhealing ulcers, absent or weak pulses in the feet or legs, a decrease in blood pressure in the feet and legs, or a lack of hair growth on the lower legs. A blue or purplish color, especially when your feet are hanging down, is also a sign of circulation problems.
If you think you may have poor circulation, ask your provider to evaluate it. Poor circulation is caused by a blockage in the arteries supplying blood to the feet. The blockage may need to be removed or bypassed with vascular surgery. A simple treatment is to walk every day. This exercise can force the body to form new blood vessels and improve the circulation in your feet and legs. Having poor circulation in your feet also puts you at greater risk for heart disease.
Cold feet may be a sign of poor circulation; however, many things can cause cold feet, so it’s not necessarily a circulation issue. If you think you have poor circulation, have your feet evaluated by your health care provider. The best thing to do for cold feet is to wear one or two pairs of thick socks or warm house slippers—but check to be sure that your shoes are not too tight. Try the thin silk socks that are worn under regular socks for added warmth. There are also special socks available that warm feet safely. Getting up and walking around or getting regular exercise helps keep your feet warmer.
Do not use heating pads or hot water bottles on your feet. Don’t sit too close to a space heater, fireplace, or campfire. If you have any diabetic nerve damage, you cannot feel when your feet are too hot or are getting burned, and you could be badly injured. In addition to making your feet feel cold, nerve damage can affect blood flow and sweating in the feet. It’s best to wear socks and get up and move around.
Smoking is clearly connected to developing cardiovascular (heart and blood vessel) disease. When you smoke, the combustion products of tobacco are absorbed into the bloodstream. These chemicals stimulate the release of other chemicals, which injure the blood vessels and encourage thickening and hardening of the arteries. Smoking also causes your blood vessels to constrict, or clamp down, limiting the amount of blood that can circulate. Because the constriction of the blood vessels by tobacco lasts for hours, smoking even as few as two cigarettes a day can affect your circulation all day long.
Smoking and diabetes are a deadly combination for the vascular system. If you have diabetes and smoke you are greatly increasing the risk of amputation! Fortunately, there are many new medications and good programs to help people quit smoking. If you smoke and you’re ready to quit, ask your health care provider to refer you to one of these programs.
Preventing PVD is much easier than treating it. That is why your health care provider will stress that you quit smoking, keep your blood pressure and blood glucose on target, control your cholesterol and triglycerides, lose weight, and stay active. Your doctor can prescribe some medications to treat PVD. Taking an aspirin a day can help prevent heart attacks and strokes, so some people think that it might help prevent PVD, too. Aspirin is not recommended for everyone and can interact with other medications you may be taking, so ask your provider before you start taking aspirin daily.
If you have intermittent claudication (pain in your calves with walking), you might be asked to walk even more. Usually you are encouraged to walk to the point of pain, pause, and then walk a little more. Ask your provider to give you instructions. Walking may help stimulate new vessels to grow and this will improve circulation.
If the tests for PVD show that you have blockage in the larger arteries to your feet or legs, surgeons may try to correct it. One surgery cleans out the artery that is blocked. Another method—angioplasty—involves passing a deflated balloon on a tube to the point where the blockage occurs. The balloon is carefully inflated to open the narrowed artery, and sometimes a stent (a tiny metal device shaped like a spring) is inserted in the artery to keep it open. This surgery is most successful with a small blockage in a healthy artery. A third surgical method is to bypass the blocked area by using a blood vessel from another part of the body (or an artificial blood vessel). While complicated, this surgery can help save a foot, a leg, or a life. People with diabetes often have blockages in the arteries of the lower legs and feet, making it difficult to restore circulation. The relatively new ability to do bypass surgery on the small arteries of the foot has saved many legs. Not all vascular surgeons do this surgery, so check to be sure that yours can. Your providers will carefully evaluate your condition before recommending surgery.
A foot deformity is any change in the normal shape of the foot. For people with diabetes, a deformity may be complicated by the additional risk factors of poor sensation and poor circulation. It is the combination of these factors that can make foot deformities dangerous.
Common deformities include bunions, hammertoes, claw toes or mallet toes, curving of the toes toward each other, tailor’s bunions, enlargements or bumps of bone behind the heels or on the top or bottom of the foot, and Charcot deformities, which may look like a collapsing of the foot at the arch. These deformities are associated with increased pressure and sheer stress on the skin, resulting in skin breakdown.
A bunion is a deformity in the joint of the big toe that causes the toe to point away from the arch instead of straight ahead. There is usually an unsightly bump on the inside of the foot, just behind the big toe. It is believed that uneven weight distribution during walking and stresses in the joints cause bunions. Heredity is an issue in the cause of bunions, so if you have a family member who suffers with bunions, your risk of developing them is higher. Wearing shoes with pointed toes probably contributes to developing bunions. Tight shoes can exacerbate bunion pain.
