Stacy A. Bacon, MD - Orthopaedic Surgeon
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Diabetes

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The Diabetic Foot - an Overview

If a doctor has ever said you had an elevated blood sugar level -- even just once when you were pregnant -- you are at risk for diabetes. About 18 million people have the disease. Nervous system impairment (neuropathy) is a major complication that may cause you to lose feeling in your feet or hands. This means you won't know right away if you hurt yourself. The problem affects about 60 to 70 percent of people with diabetes.

Foot problems are a big risk. All people with diabetes should monitor their feet. If you don't, the consequences can be severe, including amputation.

Minor injuries become major emergencies before you know it. With a Diabetic foot, a wound as small as a blister from wearing a shoe that's too tight can cause a lot of damage. Diabetes may also decrease your blood flow, so your injuries can be slow to heal. If your wound is not healing, it's at risk for infection. As a Diabetic, your infection may spread quickly, and if you have any loss of sensation (neuropathy) you may not recognize that the problem is getting worse.

If you have diabetes, you should inspect your feet every day. Look for puncture wounds, bruises, pressure areas, redness, warmth, blisters, ulcers, scratches, cuts and nail problems. Get someone to help you, or use a mirror. Feel each foot for swelling. Examine between your toes. Check six major locations on the bottom of each foot: The tip of the big toe, base of the little toes, base of the middle toes, heel, outside edge of the foot and across the ball of the foot. Check for sensation in each foot.

If you find any injury -- no matter how slight -- don't try to treat it yourself. Go to a medical doctor right away.

Here's some basic advice for taking care of your feet

  • Wash your feet every day with mild soap and warm water
  • Test the water temperature with your hand first
  • Don't soak your feet
  • When drying them, pat each foot with a towel and be careful between your toes
  • Use quality lotion to keep the skin of your feet soft and moist -- but don't put any lotion between your toes
  • Trim your toe nails straight across. Avoid cutting the corners
  • Use a nail file or emery board. If you find an ingrown toenail, see your doctor
  • Don't use antiseptic solutions, drugstore medications, heating pads or sharp instruments on your feet
  • Don't put your feet on radiators or in front of the fireplace
  • Always keep your feet warm
  • Wear loose socks to bed
  • Don't get your feet wet in snow or rain
  • Wear warm socks and shoes in winter
  • Don't smoke or sit cross-legged for long periods, as both decrease blood supply to your feet

Here is some basic advice about shoes and socks

  • Never walk barefoot or in sandals or thongs. Choose and wear your shoes carefully. Buy new shoes late in the day when your feet are larger. Buy shoes that are comfortable without a "breaking in" period. There is no break-in period for shoes.  Check how your shoe fits in width, length, back, bottom of heel and sole. Avoid pointed-toe styles and high heels. Try to get shoes made with leather upper material and deep toe boxes. Wear new shoes for only two hours or less at a time. Don't wear the same pair everyday. Inspect the inside of each shoe before putting it on and feel inside it with your hand. Don't lace your shoes too tightly or loosely
  • Choose socks and stockings carefully. Wear clean, dry socks every day. Avoid socks with holes or wrinkles. Thin cotton socks are more absorbent for summer wear. Square-toes socks will not squeeze your toes. Avoid stockings with elastic tops.  Seamless socks are available for those with neuropathy. Consider using compression stockings if your feet tend to swell. Lighter colored socks are preferred allowing you to check for any drainage on the sock and they are cooler in the hotter months

Foot Deformities

When your feet lose their feeling, they are at risk for becoming deformed or injured. One way this happens is through ulcers. Open sores may become infected. Another way is the bone condition Charcot (pronounced "shark-o") foot. This is one of the most serious foot problems you can face. It warps the shape of your foot when your bones fracture and disintegrate, and yet you continue to walk on it because it doesn't hurt.

A doctor may treat your Diabetic foot ulcers and early phases of Charcot fractures with a total contact cast. The cast lets your ulcer heal by distributing weight and relieving pressure. If you have a Charcot foot, the cast controls your foot's movement and supports its contours if you don't put any weight on it. To use a total contact cast, you need good blood flow in your foot. Your doctor monitors it carefully. The cast is changed every week or two until your foot heals.

A custom-walking boot is another way to treat your Charcot foot. It supports the foot until all the swelling goes down, which can take as long as a year. You should avoid putting your weight on a Charcot foot. Surgery is considered if your deformity is too severe for a brace or shoe, or if it is necessary to treat an ulcer.

It is important to be treated by a medical doctor (MD/DO) if you have a foot ulcer or deformity. Only a medical doctor is trained to evaluate and treat you for the spectrum of conditions that affect Diabetic foot problems which could include other causes of disease such as vitamin deficiencies and other metabolic conditions.

How to Care for Your Diabetic Feet

  1. DO NOT SMOKE. It decreases the blood supply to your feet

  2. NEVER walk barefoot, neither indoors nor out

  3. Examine your feet daily for redness, warmth, blisters, ulcers, scratches, cuts and nail problems from shoes or other sources. Look at the bottom of your feet and between the toes. Use a mirror or have someone else look for you

  4. Call your doctor immediately if you experience any injury to your foot. Even a minor injury is an emergency for a patient with diabetes

  5. Examine your shoes for foreign objects, protruding nails and rough spots inside before putting them on. Look and feel

  6. Buy shoes late in the day. Never buy shoes that need "breaking in." They should be immediately comfortable. Request shoes with deep toe boxes and shoes made of leather or other flexible upper material. Do not wear new shoes more than two hours at a time. Rotate your shoes. Do not wear the same ones every day

  7. Never wear sandals or thongs

  8. Lubricate your entire foot if your skin is dry, but avoid putting cream between your toes. Try Curel, Lubriderm, olive oil, vitamin E oil, lanolin or Eucerin cream

  9. Do not soak your feet. Skin can break down and won't heal well

  10. Keep feet away from heat sources (heating pads, hot water pads, electric blankets, radiator, fireplaces). You can burn your feet without knowing it. Water temperature should be less than 92 degrees. Estimate the temperature with your elbow or bath thermometer (you can get one in any store that sells infant products)

  11. Don't use any tape or sticky products such as corn plasters on your feet. They can rip your skin

  12. Do not file down, remove or shave calluses or corns yourself. These should be taken care of by your physician or someone your physician recommends

  13. Do not use any chemicals or strong antiseptic solutions on your feet. Iodine, salicylic acid, corn/callus removers and hydrogen peroxide are potentially dangerous

  14. Trim your toenails straight across, or have a medical provider do it for you

  15. Do not wear stockings or socks with tight elastic backs and do not use garters. Wear only light-colored socks and do not wear any socks with holes. Always wear socks with your shoes

  16. In the winter, wear wool socks and protective footwear. Avoid getting your feet wet in the snow and rain and avoid letting toes get cold

  17. If the circulation in your feet is impaired, tell your medical doctor so he/she can take this into account when prescribing medication for high blood pressure or heart disease

Shoes and Orthotics for Diabetics

Proper footwear is an important part of an overall treatment program for people with diabetes, even for those in the earliest stages of the disease. If there is any evidence of neuropathy, or lack of sensation, wearing the right footwear is crucial. By working with their physician and a footwear professional, such as a certified pedorthist, many patients can prevent serious Diabetic foot complications.

Objectives

Footwear for people with diabetes should achieve the following objectives

  • Relieve areas of excessive pressure. Any area where there is excessive pressure on the foot can lead to skin breakdown or ulcers. Footwear should help to relieve these high pressure areas, and therefore reduce the occurrence of related problems

  • Reduce shock and shear. A reduction in the overall amount of vertical pressure, or shock, on the bottom of the foot is desirable, as well as a reduction of horizontal movement of the foot within the shoe, or shear

  • Accommodate, stabilize and support deformities. Deformities resulting from conditions such as Charcot involvement, loss of fatty tissue, hammer toes and amputations must be accommodated. Many deformities need to be stabilized to relieve pain and avoid further destruction. In addition, some deformities may need to be controlled or supported to decrease progression of the deformity

  • Limit motion of joints. Limiting the motion of certain joints in the foot can often decrease inflammation, relieve pain, and result in a more stable and functional foot

Shoes

If you are in the early stages of diabetes, and have no history of foot problems or any loss of sensation, a properly fitting shoe made of soft materials with a shock absorbing sole may be all that you need. It is also important for patients to learn how to select the right type of shoe in the right size, so that future problems can be prevented. The excessive pressure and friction from the wrong kind of shoes or from poorly fitting shoes can lead to blisters, calluses and ulcers, not only in the insensitive foot, but also in feet with no evidence of neuropathy. It is highly recommended that shoe fitting for patients with any loss of sensation be done by a professionally trained shoe fitter or Board Certified pedorthotist. People with insensitive feet tend to purchase a shoe that is too tight; the size that "feels" right is often too small.

In achieving proper shoe fit, both the shape and size of the shoe must be considered. You should try to match the shape of the shoe to the shape of your foot. This means that you should be sure your shoes have adequate room in the toe area, over the instep, and across the ball of the foot, and there should be a snug fit around the heel. When considering your correct shoe size, remember that the width is just as important as the length. The proper shoe size is the one where the widest part of the foot, which lies across the foot at the base of the toes, is in the widest part of the shoe. There should also be 3/8 to 1/2-inch between the end of the shoe and the longest toe (thumbs width).  In addition, a shoe with laces is recommended to provide the adjustability needed for any swelling or other deformities and to allow the shoe to be fit properly without any danger of slipping off.

Prescription footwear

Many patients with diabetes need special footwear prescribed by a physician. Prescription footwear for patients with diabetes includes

  • Healing shoes. Immediately following surgery or ulcer treatment, some type of shoe may be necessary before a regular shoe can be worn. These include custom sandals (open toe), heat-moldable healing shoes (closed toe), and post-operative shoes

  • In-depth shoes. The in-depth shoe is the basis for most footwear prescriptions. It is generally an oxford-type or athletic shoe with an additional 1/4- to 1/2-inch of depth throughout the shoe, allowing extra volume to accommodate any needed inserts or orthoses, as well as deformities commonly associated with a Diabetic foot. In-depth shoes also tend to be light in weight, have shock-absorbing soles, and come in a wide range of shapes and sizes to accommodate virtually any foot

  • External shoe modifications. This involves modifying the outside of the shoe in some way, such as modifying the shape of the sole or adding shock-absorbing or stabilizing materials

  • Orthoses or inserts. An orthosis is a removable insole which provides pressure relief and shock absorption. Both pre-made and custom-made orthoses or inserts are commonly prescribed for patients with diabetes, including a special "total contact orthosis," which is made from a model of your foot and offers a high level of comfort and pressure relief

  • Custom-made shoes. When extremely severe deformities are present, a custom-made shoe can be constructed from a cast or model of the patient's foot. These cases are rare. With extensive modifications of in-depth shoes, even the most severe deformities can usually be accommodated

Taking good care of your feet means making sure you have the right foot wear. Whether you have been recently diagnosed or have had diabetes for many years, proper footwear can help prevent serious foot problems. Be sure to talk to your physician about the type of shoes, modifications and orthoses that are right for you.

The Diabetic Foot and Risk: How to Prevent Losing Your Leg

1. Don't deny you are a Diabetic

Anyone who has ever had an elevated blood sugar level is at risk for foot complications. It may be as simple as knowing that once in your life (even during pregnancy) you have had an elevated blood sugar level. If so, you are at risk and must begin to monitor your feet. Diet-controlled Diabetics, whether diagnosed as an adult or as a child, have feet at risk of Diabetic complications. The simple rule: If you have ever been told that you are at risk of developing diabetes, you need to consider your feet and work to prevent injury.

2. Don't accept that all Diabetics lose their legs

It starts with daily foot checks -- inspecting all sides, including the bottoms, which can be done best with someone's help or with a mirror. During a foot check, any changes in the foot's shape or color, sense of feeling/sensation, painful areas or skin integrity need to be evaluated. Any new bunions, calluses or corns need to be identified and shown to a medical doctor. The overall shape could change due to a bone fracture that would also need the attention of a physician. Stress fractures are very small breaks in the bone that will not usually change the shape of the foot, but may cause pain, bruising or swelling. The color of the foot is important as it helps show any changes in blood flow to the foot. Darkening or loss of hair may indicate that the blood or nerve supply has decreased. Less blood to the foot can mean slower healing of cuts and scrapes. Bruises indicate injuries. Especially important are the bruises or cuts found during a foot check that the person was not aware of at the time of injury. Any bruises within calluses are particularly important to show to a physician.

To monitor sensation, a feather or facial tissue can be used to brush the foot and test its ability to feel light touch. It is also important to be sure the foot can sense the differences between hot/warm and cold water. Shower water can be first tested with the hand and then with the feet to identify any loss of temperature sensation. Testing for any change in ability to "feel" with the feet is important because Diabetics can hurt themselves and not be aware of the injury or its severity. By checking their feet daily, they can see any new wounds and monitor healing areas. Diabetics should wear more protective shoes, not sandals, to prevent any injuries to the feet and toes. The foot may not feel "numb," but a progressive decrease in ability to feel light touch, temperature or the presence of shoes indicates a foot at risk. The loss of vibrating and touch sensation is gradual and easy to ignore, but the single most important feature to identify with regard to avoiding amputation.

3. Beware of Common Pitfalls

Any areas that are painful need to be examined very closely for any of the above-mentioned changes. Foot injuries that occur without the person's knowledge can be the first sign of diabetes, especially when accompanied with decreased sensation.

Wounds need to be monitored. When wounds take a long time to heal, the foot becomes at risk of infection, ulcers and further damage to local tissue and bone. There are special bandaging techniques and ointments that can be used to help Diabetic wounds heal and concurrently prevent permanent damage.

As with any chronic disease, history is important (both the patient's and his or her family's). Diabetics who have had problems with any of the following (in the past or currently) need to consider themselves at risk: foot ulcers, toenail infections such as fungus, stress fractures or other single fractures of the foot, slow-healing wounds, bunions, corns and thick calluses. In the family history, any amputations of toes, feet or legs (part or whole) need to be shared with a physician. Other family members with known diabetes, suspected diabetes or problems with the feet such as mentioned above should be shared with a physician.

The bottom line is:  take care of your feet, look at them daily, and see a medical doctor if anything is suspicious. It is important to be evaluated by a medical doctor (MD/DO) with an adequate breadth of training to determine an accurate diagnosis of your problem. Consideration of competing diagnoses, such as vitamin deficiencies, genetic conditions, spinal or neurologic conditions is important to your successful care.

Foot Ulcers and the Total Contact Cast

The Diabetic foot is prone to major problems. This is because the foot is the "organ" that expresses many of the underlying effects of diabetes. These are: (1) neuropathy, (2) vascular disease, and (3) diminished response to infection.

As a result of the neuropathy, the foot can become deformed. This happens for two reasons. The first is that the neuropathy causes paralysis of small muscles in the foot, which results in clawing of the toes. Clawing of the toes causes prominence of the metatarsal heads on the bottom of the foot as well as the knuckles on the dorsum or top of the foot. The neuropathy also causes diminished sensation. As the prominent metatarsal heads on the plantar or bottom of the foot are subjected to increased pressure, the skin will begin to hypertrophy and become callused. The callused skin can be subjected to shear forces. The forces will cause a separation between the layers of the skin, which will fill with fluid, which can then become contaminated and infected. The pressure can also cause primary breakdown of the skin in these areas, and the result is a foot ulcer. Once the initial breakdown and contamination occurs, the foot then can go on to significant problems because of infection.

The second route to deformity is through the process known as the "Charcot foot". In this situation, because of the neuropathy or lack of protective sensation, bones in the foot subjected to trauma will actually fracture and disintegrate. The foot, when subjected to the stresses of ambulation, will become deformed. Often, this is in the shape of a rocker, causing prominence of bone in the middle portion of the foot rather than the metatarsal heads. The prominence in the middle portion of the foot is then prone to cause ulceration due to the same mechanism that has just been described.

The "total contact cast" is a casting technique that is used to heal Diabetic foot ulcers and to protect the foot during the early phases of Charcot fracture dislocations. The cast is used to heal Diabetic foot ulcers by distributing weight along the entire plantar aspect (sole) of the foot. It is applied in such a way to intimately contact the exact contour of the foot; hence, the designation "total contact cast."

By relieving the pressure on the prominent areas of the foot, the ulcers are permitted to heal if the cast is applied in such a way that the patient can remain ambulatory during the treatment of the ulcer. The principle involved here is that the cast is molded to the contours of the foot from the back of the heel through the arch region, in the region of the metatarsals, around them and even to the toes. Pressure is expressed in terms of force or pounds over area per square inch. Therefore, if the weight-bearing area is enlarged the pressure per unit of weight-bearing area diminishes. In this way the pressure which has been concentrated on the bony prominence is distributed over the entire plantar aspect of the foot, allowing reversal of the mechanism that caused the ulcer to occur.

For the Charcot foot, the total contact cast is used in two ways. In the initial treatment of the Charcot foot when the breakdown is occurring and the foot is quite swollen and reactive, the cast is applied to control the movement of the foot and support its contours. In this instance the patient is often asked not to bear weight on the foot. In the second instance when the foot has already become deformed and ulceration has occurred, the principle using the cast is the same as described for the foot that has become deformed due to paralysis of the small muscles.

The total contact cast, when used for the described applications, is a very effective treatment. A prerequisite is that the foot must have an adequate blood supply, and therefore, the foot must be monitored quite carefully. The cast must be applied by someone who has experience with the applications and use of this cast. The cast must be changed at regular, short intervals of a week or two. The reason for this caution is that the Diabetic who has insensitive feet runs the risk of having other sores or areas of irritation occur under the cast.

These casts are then changed weekly or every other week depending on the physician, his or her experience with each individual patient, and the amount of swelling in the leg. Casting is continued until the ulcer is healed, and the foot is ready for appropriate shoewear and orthotics. In the case of the Charcot process, casting is continued until the patient's fractures heal and the foot no longer needs a cast for protection. Because of the prolonged need for immobilization, the physician typically may convert the treatment to a removable walking boot. The total contact casting technique is an effective treatment for ulcers and Charcot foot problems.

Charcot Joints or Neuropathic Arthropathy

Charcot Arthropathy, or neuropathic Arthropathy, is a condition that affects some Diabetic patients with peripheral neuropathy (loss of sensation) after eight to 10 years. Jean Martin Charcot was a French physician who in 1868 described neuropathic Arthropathy primarily in patients with advanced syphilis. At that time, people with diabetes did not live very long because insulin was unavailable to treat diabetes. Once insulin was available and diabetes treatable, it was in the 1930s that neuropathic Arthropathy was recognized in Diabetics. It may also occur with several other diseases that affect the sensory nervous system (alcoholism, leprosy, syphilis, Charcot-Marie-Tooth Disease to name a few). In the United States, diabetes is the number-one cause.

So what do all these terms mean?

Neuropathy is a term used to describe problems with the nervous system. In Diabetics this is called peripheral neuropathy and affects the sensory nervous system to the peripheral, or farther, points of the body (i.e. feet and hands) causing loss of feeling or numbness. Diabetic neuropathy also involves the autonomic (involuntary) nervous system which controls regulation of blood vessels and skin moisture, and may result in increased blood flow to the limb, contributing to swelling and osteoporosis of the bones as the Charcot process occurs. Arthropathy is a term used to describe a problem with a joint. Therefore, neuropathic Arthropathy is used to describe problems with joints related to lack of nerve system input. It is believed that as the peripheral neuropathy progresses in long-standing diabetes, the joints are unable to recognize the forces put across them and the relative positions of the various joints, sustaining microtrauma or microfractures because the body does not adjust to these forces and positions. It would therefore be reasonable to assume that most cases of neuropathic Arthropathy would occur in the lower extremities, with their weight-bearing function. This is indeed the case, although on occasion other joints can be involved.

When does neuropathic Arthropathy occur?

Most patients who develop neuropathic Arthropathy have peripheral neuropathy after being Diabetic about 10 years or longer. So a patient with juvenile-onset diabetes (as a child) may develop this in his 20s or 30s. However, most patients with Charcot Arthropathy are in their 40s or older, as more patients have adult-onset diabetes.

What are the signs and symptoms of Charcot Arthropathy or neuropathic Arthropathy?

There are three stages of Charcot Arthropathy. The first stage is a fragmentation or destruction stage. During this stage, as the process begins, the joint and surrounding bone is destroyed. The bone fragments, the joint becomes unstable and in some cases the bone is completely reabsorbed. This stage is clinically identified by significant swelling (often with little pain to the patient) erythema (redness), and warmth or heat to the area. It is easy to see why this is often confused with an infection, especially as there is often no history of injury or trauma. As the bones and joint are affected, fractures and instability develop and the joints can dislocate or shift in relationship to each other. This can lead to severe deformity of the foot and ankle. Most often the midfoot joints are affected and the result is a very flat foot which is wide where the normal foot narrows in the arch. Bony prominences often develop on the plantar (bottom) surface of the foot. Diagnosis and early treatment at this stage is important to try to minimize the bone destruction and deformity. This process may last as long as six to 12 months.

The second stage is termed coalescence. During this stage the acute destructive process slows down and the body begins to try and heal itself. The swelling and heat begin to disappear. Once the acute process is resolved and the healing on-going, the third stage begins. This is a consolidation or reconstruction phase during which the bones and joints heal. Unfortunately, the foot is often deformed, and if there has been enough destruction, there may be residual instability. Fitting shoes may be very difficult,and prescription footwear and Diabetic shoe inserts are important to help prevent ulcer formation over deformed areas.

How is Charcot Arthropathy treated?

Once the diagnosis is made (for most patients in the first stage) there are several important treatment goals. The first is to get the heat and swelling under control. The second is to support or stabilize the foot to minimize deformity. A total contact cast is applied by trained personnel. This cast has more padding than a standard cast and is often applied with the toes completely covered to prevent foreign objects (gravel, stones, etc.) from getting in the cast. The cast will need to be changed frequently initially as it may get loose quickly as the swelling is controlled. Once the initial swelling is controlled and the patient is tolerating the casts without skin problems, the cast change interval may be lengthened to two to four weeks. Another alternative is fabrication of a custom walking boot for Diabetics. The foot must be supported until all heat and swelling has resolved. This may occur in several months but more commonly requires six to 12 months. Minimizing weight-bearing on the affected foot/ankle is also important. Realistically this is extremely difficult for the patient with Diabetic neuropathy and should be encouraged. Assistive aides such as a walker or cast are recommended. During this period the patient will be seen frequently in the office. Continued education about Diabetic foot care and Charcot Arthropathy is necessary. Also, support of the various stages of anger and denial concerning this rather profound change is necessary. After the first stage is completed, molds for appropriate Diabetic footwear, orthotics and braces (if needed) are made. During treatment it is important to check the noninvolved foot and protect it, as that foot is doing much more work.

For patients who develop deformities that are unshoeable or bracable, or who develop unbracable instability, surgery may be considered. The timing for this surgery is important. Surgery done during the inflammatory stage may have a high complication rate. Sometimes, however, surgery must be done during this stage due to joint instability. Another option for severe deformity/instability is amputation and prosthetic fitting. Patients often have multiple medical problems which must be taken into account in consideration for any surgery. It is important to be treated by a medical doctor (MD/DO) who is trained in the breadth of medical problems that affect people with diabetes.

Long-term management of patients with Charcot Arthropathy is important. Once the patient is stable, periodic checkups (six to twelve month intervals) with a qualified foot and ankle specialist is important to identify early complications, address footwear, orthotic and brace issues, and continue patient education regarding the care of Diabetic feet and the special needs of the patient with Charcot Arthropathy. Patients should be counseled to seek medical care if they develop any redness, swelling, or heat in their feet, as this could be the start of another Charcot process.

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