Aging Begins at 30

Diabetics Don't Forget Your Feet

In the United States there are 16 million diabetics. Fifteen percent of these individuals will develop a foot ulcer, and half of those ulcer cases will recur within 18 months. There are 50,000 amputations per year. Of these, 50% of the patients will lose the other foot or leg within three to five years.

There is no substitute for healthy dietary and exercise routines and blood sugar control to prevent "diabetic foot" and possible need for amputation. The elderly have their disease for longer so they get more trouble with diabetic feet. The average age of onset of foot diabetic foot trouble is 63, with a range of 36 to 86 years. When blood vessel disease threatens the patient with the loss of a foot or a leg, some patients feel helpless. They need not.

Diabetic foot problems are often thought to be due to disease of small blood vessels but there is also large vessel disease that may be correctable. This has been shown by microscopic study and by casting or mapping studies of blood vessels of amputated feet.

Diabetic nerve damage can make diabetic patients unaware of recurrent injuries to their feet. Injury can be caused by poorly fitting shoes, pebbles in shoes, stubbing toes, or self imposed corn surgery. An extra-depth, low heeled, laced oxford with a high toe box and molded insole is recommended. Damage occurs especially in the heels or ball of the foot where, because of neurological damage and clawing of the toes, there is maldistribution of weight to the bony bumps at the front of the sole which then bear the body weight when walking. Corns form and infection develops underneath. A cascade of repeated minor damage may occur in an insensitive foot. From small beginnings, a leg-threatening situation rapidly develops.

What’s to be done? First control the blood sugar. Secondly absolutely no smoking. Thirdly maintain warm, lotion softened, clean feet at all times. Daily inspection of the feet is essential. If eye disease makes this difficult a family member needs to help. Toenails should be carefully trimmed or filed, preferably by a companion or podiatrist, to avoid ingrown nails. Fungal infection (athlete’s foot) should be treated promptly.

Most importantly: if an ulcer develops, prompt medical attention is absolutely necessary. Delay can do irreversible damage.

To test for blood vessel disease the blood pressure is measured at the ankle. It should be equal to or greater than the arm pressure. If the blood pressure at the ankle is less than 8 tenths of the arm blood pressure there is blood vessel disease in the legs. Some patients can have disease below the ankle so the doctor will also look for a pulse on top of the foot and measure pressure in the toes. A map can be made of the leg vessel circulation using intra-arterial x-ray opaque dye. Ulcers can be healed by improving the blood supply using the patient's own veins as a graft or dilating the arteries. In carefully selected patients, over 90% of reconstructed vessels are still open five years later.

The rate of amputations is declining in diabetics. With more rapid institution of time proven preventive methods and more care by teams of experienced physicians and surgeons even more amputations can be avoided.

Section Top | Title Page

See related Patient Topics Bones, Joints and Muscles, Diabetes, Diabetic Foot, Endocrine System (Hormones), Food, Nutrition and Metabolism, Immune System/AIDS or Seniors' Health.

See related Provider Topics Bones, Joints and Muscles, Diabetes, Endocrine System (Hormones), Food, Nutrition and Metabolism, Immune System/AIDS or Seniors' Health.

All contents copyright © 1992-2004 the Author(s) and The University of Iowa. All rights reserved.

http://www.vh.org/adult/patient/internalmedicine/aba30/1998/diabetic.html