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Diabetes and associated diabetic complications are on the rise.
The number of individuals with diabetes world wide is expected to reach over 350 million by year 2030. In the United States, diabetes is the 7th leaving cause of deaths and is present in almost 11% of the population. Almost 20% of diabetic patients in the United states are not aware that they have this condition. People with diabetes over 50 years of age, tend to die almost 5 years earlier as compared with their peers without this disease. Neuropathy, or progressive loss of sensation to feet in this case, results in the majority of diabetic foot complications like infections and amputations.
How can you prevent foot injury with diabetic neuropathy?
Because of progressive loss of sensation ultimately resulting in profound numbness, people with diabetes (especially with diabetic nerve damage) should check their feet every day for any areas of cuts, redness or blistering. If neuropathy progressed to the point of numbness, you can no longer trust your sense of pain and must rely on your eyes to alert you to skin damage. Unnoticed and untreated skin breaks will ultimately become infected, which frequently results in wound formation, need for antibiotics, and sometimes surgery to remove infected tissue.
Diabetes is closely associated with increased blood pressure, increased cholesterol, high fat in the blood stream, heart disease, blindness, kidney failure, strokes and amputations of lower limbs.
There is also a link between this disease and increased risk for developing liver, colon, breast, bladder and pancreatic cancer. There is growing body of evidence that links diabetes to development of dementia and Alzheimer’s disease.
These are just a few of the reasons why diabetics tend to develop disability earlier than their peers and tend to stay disabled longer.
The danger of foot ulcers
Considering the prevalence of diabetes, 15% will develop a foot ulcer in their lifetime. The most common place for diabetic foot ulcer is the bottom of the foot over a weight bearing bony prominences such as metatarsal heads, sides along the middle of the foot and over heel bone. Second most common place is over the top of the hammer or rigidly contracted toes or at the very tip of such a toe due to pressure and friction forces.
Developing a foot ulcer not only results in inability to perform weight bearing work but also impacts diabetic patients mental, physical, and emotional well-being. Wounds left untreated or undertreated frequently result in limb loss.
Over 60% of diabetic patients will develop peripheral neuropathy or nerve damage due to persistently high blood sugar bathing nerves in hands and feet. People start losing sensation in their feet much sooner than in hands. Those with advanced neuropathy resulting in numbness are at greatest risk for delayed wound healing, wound formation, infections, and limb loss.
This is why being diagnosed with diabetic neuropathy is so devastating!
This is truly one of those life changing diagnosis that forces you to change how you live every hour of your life. If one is not careful and diligent, terrible complications will arise which may lead to loss of toes, feet and sometimes even legs.
I frequently see patients that realize only too late that they have an infected foot because they see blood or drainage on their sock or start to smell rotting flesh. Their neuropathy progressed to the point where the feet are completely numb and nerves no long carry pain signal to the spinal cord and brain.
How can monitoring of feet help?
If you are unable to visualize your feet, you should try to use standing mirrors or mirror with a handle to visualize your feet and make sure there is no injury. Use of selfie stick with smart phone connected may also be of assistance, as you may be able to take pictures of your feet and then zoom in to check for skin damage.
Other more advanced skin monitoring wound prevention technological modalities are gradually becoming available. Some of these are even covered by medical insurances. For example, there is a smart mat by www.podimetrics.com. The mat is meant to be used in a place like bathroom and designed to monitor for foot temperature increases which correlates with inflammation and thus infection. When an abnormal increase in temperature is noted, the mat sends a message to your smartphone and to your foot doctor.
Another device is called Siren socks at https://siren.care. These are smart socks that are meant to be worn all day. They are machine-washable and do not require charging. These too check for signs of inflammation via temperature monitoring. According to Siren socks website, license nurse monitors your foot health via information gathered by siren socks. You get collected information feedback about temperature and inflammation to your smartphone. If potential injury is noted, the nurse calls you for additional information and gives information to your doctor as well.
Orpyx Si at https://www.orpyx.com/about-orpyx-si are smart insoles. These shoe inserts collect information including real-time pressure monitoring, step count, and temperature increases that again correlate with inflammation. If inflammation is noted on time, proactive steps can be taken to decrease further skin breakdown, ulceration, and infection. Alerts and offloading instructions are sent to your smartphone if any abnormality is noted.
When examining your feet, it is essential to pay attention to spaces in between the toes and to wash and dry those areas daily.
Frequently, residual moisture collects between the toes which results in skin breakdown and fungal/bacterial overgrowth. Before washing your feet, make sure to test the water temperature with your hands as hands tend to be affected by nerve damage later in the neuropathy disease process.
People with diabetic nerve damage should not use heating pads, space heaters, hot water bottle massages on feet, and electrical blankets.
During colder months, I see patients who fall asleep while using one of these modalities or continue using them despite skin damage because of lack of sensation. These can create severe burns requiring months of wound care and sometimes surgery. It is safer to wear socks and to use layers of clothing to warm up.
During warmer months, people come in with foot skin injury because of walking barefoot or with socks only on hot surfaces like asphalt, cement or sand. Even a short trip to take out the garbage, to the backyard, or to pick up mail without foot protection, can result in severe foot skin damage. The floor of swimming pools is frequently made of abrasive material which may cause skin injury. When planning trips to lakes, rivers, oceans (areas where you would expect uneven floor surface with possibly sharp objects), you should be wearing water shoes.
In general, walking barefoot or just with socks is not recommended even at your home. Frequently, there are objects on the floor like needles, splinters, Lego pieces, seeds etc. that may not be noticeable on visual exam but that pose real danger to a diabetic neuropathic person.
Home foot care that was safe prior to diagnosis of neuropathy, now can result in severe injury. Cutting corns and nails and filing down calluses can result in unnoticed skin cuts and wounds. If you are also suffering from poor vision, blindness, poor circulation, or taking medications that make your skin fragile, your risk of skin injury is increased even more. Numbness will lead to delay in treatment and will not alert you to the severity and extent of skin trauma. The same is true when treating ingrowing toenails.
Allowing a podiatrist to provide preventative foot care of your feet should ensure that your feet continue to be safe from injury and in good hygienic shape.
In addition, during every podiatry visit, you will also undergo a complete foot health exam. If problems are discovered, your foot doctor can provide immediate intervention. Use of adhesive tape should also be avoided as it frequently peels top layer of the skin which may result in abrasions. Instead, it is better to use paper tape or tape specifically designed for sensitive skin.
Danger of dry skin
Diabetic neuropathy leads to decreased production of sweat, which is a natural lubricant. With decreased lubrication, skin tends to become persistently dry, flaky, and fragile. Thus, it is essential to apply skin cream to lower extremity skin at least daily. The best time to apply it is after showering or bathing as frequent bathing tends to dehydrate the skin. You must be careful, however, not to apply cream in between the toes where it can get trapped and result in skin maceration, weakness, and breakdown, frequently with associated bacterial and fungal infection.
Once the skin cream goes on, the next item to consider for skin trauma chance reduction is a pair of good fitting socks. There are many designs of diabetic available for sale at this time. So what should you be on the lookout for when selecting diabetic socks? Good diabetic socks are seamless to avoid pressure and indentation on the skin with increased swelling. They should be made of uniform moisture wicking material. Do not mend your torn socks as it creates irregularity in the material which may result in increased pressure and friction on the skin resulting in wound formation.
As previously mentioned, wearing shoe gear indoor and outdoor is the main and simplest way to protect your feet from skin trauma.
Timing of shoe purchase is important as well.
Swelling to legs, ankles and feet naturally increases by the end of the day. Thus, purchasing shoes later in the day should help prevent buying shoes that end up being too tight. It would be best to select shoes with breathable, soft, stretchable upper to allow for swelling and reduce friction on any musculoskeletal deformities like bunions, hammertoes, spurs, etc. Persistently high blood sugar starts to effect tendons, ligaments, and joints. This results in progression of musculoskeletal deformities, joint stiffness, and tightening of soft tissue structures like Achilles tendons and tendons that help move the toes.
Body type and weight must be considered when selecting proper diabetic shoes. A person with normal weight may be ok with a lighter shoes. Someone with high body mass index would be better in a supportive firm shoe. Individuals with high arch and rigid foot would benefit from a softer, shock absorbing, accommodating shoe design. Those with flexible flat feet should consider rigid supportive shoe models. Shoe length must be 0.375 inches longer than longest toe to avoid excessive pressure and ulceration.
Extra depth shoes usually allow for space to fit diabetic insole which tends to be thicker than the standard shoe insole provided by shoe manufacturer. Laces and Velcro closure on shoes facilitates a better fit and prevents foot traction inside the shoe, thus preventing blistering.
Frequently, standard off the shelf diabetic shoes are not sufficient to accommodate for pain, deformity, and arthritic changes. In cases like these, these standard diabetic shoes can be accommodated by adding internal and external modalities to shift the weight away from painful parts of the foot. Shoes can also be softened and stiffened. If these adjustments are not enough, a truly custom shoe made from the mold of your foot can be manufactured by an experienced prosthetics and orthotics facility.
Shoe insert should be made of relatively soft material that reduces both frictional and pressure forces.
The most common material used to manufacture diabetic shoes is plastazote composite but other materials are used as well. However, it is important to keep in mind that not shoe design must be fitting to your foot type. For example, narrow shoes will cause skin abrasions in people with bunions and hammertoes. Shoes that are too wide or too large will result in increased friction which will produce blisters.
Avoid wearing sandals, especially those with strap going into space between toes. Sandals do not provide protection against external injury. Foreign sharp or abrasive objects may easily end up between your sole and the walking surface of the sandal resulting in injury. Inter toe strap may result in irritation and skin breakdown in difficult to see area of the foot and may lead to delayed diagnoses of an injury and infection. Most sandals provide no arch support, which may lead to foot muscle fatigue.
Wearing of water shoes is always better than wearing no shoes when engaging in water activities like walking on the beach or wading in the lake or river. At least, you will get some degree of protection. However, it is highly recommended that you check your feet for skin breakdown, blistering, redness and temperature increase as frequently as you can but definitely every time you come out of the water.
Shoes with curved heel counter may create abrasions and skin breakdown over Achilles tendon area. Wearing the same pair of shoes every day will result in increased bacterial and fungal growth inside the shoe, which then may be transferred onto your skin resulting in infection. Fungal infections of the toenails are particularly challenging to treat. Even if the shoes are a good fit, they must be checked daily before placing them on your feet for any foreign objects that may have fallen inside. The inner lining, seems and lacing of the shoes must be checked for any signs of wear and irregularities in the material which may result in friction on the skin.
The insole must be checked for any prominent stitching and nails used to attach the sole of the shoe to the upper. It is always best to bring the shoes to your podiatry visit for evaluation to ensure proper fit and safety.
Using information presented here should help you stay ahead of the injury and promote more wound free days!
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Author bio:
My name is Dr. Marat Kazak. I have been working as a professional Podiatrist serving Northern California community since 2014. My extensive medical and surgical knowledge combined with an ongoing curiosity to learn about the latest trends define my success in the field of foot, ankle and leg medical and surgical care.
The goal of this website is to give you the tools to better care for yourself, to dispel medical myths, and to empower you with information to save time and money! If you are looking for an answer on foot and ankle pain, this is the place to find it. If you do not see your topic of interest covered, please send me a message and I will do my best to discuss it thoroughly in my next upcoming post.
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