Overview Of Foot Problems In A Diabetic

Overview Of Foot Problems In A Diabetic

C. Munichoodappa
The Bangalore Hospital
202, R.V.Road - Bangalore 560 004.

Management of foot in a patient with diabetes mellitus starts with the first encounter of the patient whether there is a foot lesion or not. Careful and detailed inspection and examination of all parts of foot and footwear and preventive foot care instructions should form part of guidelines during the initial and then every visit.

In the absence of complication it is not uncommon to find fissures, ingrowing toe nails, epidemophytosis and superficial lesions due to ill fitting footwear. They are all potential port of entry for infection. Instruction must be given to prevent these lesions or get them treated.

With sensation and good blood supply being intact trivial lesions generally heal promptly with good control of diabetes, debridement with or without antibiotics.

The problem becomes compounded when a lesion occurs in a foot complicated by

  • Sensory or sensory motor neuropathy with loss of touch, pain and temperature sensation and having increased pressure points.
  • Peripheral vascular disease with poor or no blood supply.
  • Autonomic neuropathy of microvasculature and reduced skin oxygenation.

Eight percent of all admissions (230 patients) in a three year period at the Bangalore Hospital had foot lesion. This does not include outpatients with minor foot lesions. The age of these subjects ranged from 31-96 years. The majority were in the 5th and 6th decade. Male were 152 and female were 78. Duration of DM ranged from 10-20 years. Eight of these were on diet. 96 on oral hypoglycemic agents (OHA), 120 on insulin and six on insulin and OHA.

Neuropathy was present in the majority 132 (57%)
Vascular insufficiency 37 (16%)
None of the above 61 (27%)
A few had both neuropathy and peripheral vascular disease (PVD) in varying degree.

Lesions start at pressure points - plantar aspect of heads of metatarsal (MT), great toe, heal, base of the 5th MT etc; corn, callouses, blisters, foot wear bite and site of entry of foreign body often get infected.

The lack of pain and awareness result in extensive spread along the muscle fasia to deeper and higher levels resulting in cellulitis and high pressure within the tissues often causing destruction of soft parts and bones requiring emergency surgical procedures.

  • The trophic ulcers, lesion involving tendoachilis or calcaneal bone require application of plaster of paris cast.
  • The usefulness of Biobeam therapy is not clear.
  • Infection in neuropathic foot require prolonged and powerful antibiotics, frequent debridiment and take months to heal.
  • Amputation at various levels are more common due to infection in a neuropathic foot. Impaired vessel auto regulation, disturbed microcirculation and reduced transcutaneous oxygen pressure also contribute to the situation.

Is vulnerable to trauma, infection, tissue destruction and gangrene. The level of vascular occlusion can most often be determined by careful palpation of arterial pulsation. Doppler study for arterial blood flow with ankle and toe pressure recordings and arteriography are helpful to know the extent of problem, and plan therapy / procedure.

The Management

Include arterial reconstruction, with or without amputation of the part involved and this depends on presence or absence and the extent of gangrene.

Aspirin is sometimes useful in the presence of thrombosis. Occasionally embolisation and intra arterial ballooning help to relieve arterial occlusion. Vasodilator drugs have no place.

Usually seen in ankle and tarsal bones in the presence of peripheral sensory and motor neuropathy. Weight bearing becomes difficult in these patients. They often need amputation.

Management of foot lesions is not complete without making the patient walk and return to work with proper and individually designed foot wear with microcellular leather insole and soft leather or Kangora rubber all-round.

  1. Poorly controlled diabetes
  2. Cardiac and renal insufficiency
  3. Hemorrheology
  4. Smoking
  5. Poor socio economic condition
  6. Lack of diabetes education
The following is the outcome in 230 patient managed at the Bangalore Hospital.
Improved with conservative (medical and debridiment) management 165 (72%)
Required surgical procedure 57 (25%)
Lost to followup / dead 8 (3%)
Arterial reconstruction 8 (successful 6).
Amputation at various levels in 36, more often in an infected neuropathic foot/limb.

The cost of management of limb or life threatening lesion whether in a neuropathic or ischemic foot ranges from Rs. 25,000 to 75,000. The time and effort required at considerable and often taxing to the patience of patients, family members and medical profession.

Therefore preventure measures assume great importance.

Paraesthesia no (0) yes (2)
Hypoesthesia no (0) yes (4)
Anaesthesia no (0) yes (6)
Veins on dorsum of foot
Empties normally on lying flat (0)
Distended on lying flat (3)
Distended on leg elevation to 45 (6)
H/O intermittent claudication No (0) Moderate (3) Severe (6)
H/O rest pain No (0) Moderate (3) Severe (6)
H/O nocturnal leg pain No (0) Moderate (3) Severe (6)
Peripheral Pulses Normal (0) Feeble (4) Absent (6)
Filling time after blanching of nail beds
By pinching (in seconds) <5 (0) 5-10 (1) 11-15 (2) . 15 (4)
Skin and Nail Changes:
Improper carefoot wear Yes (1)
Skin: cold/dry/thickened/atrophic/shining/loss of hair No (0) Yes (2)
Nails: thickened /ingrown/fungal infections No (0) Yes (2)
Presence of corns No (0) Yes (2)
Presence of calluses No (0) Yes (2)
Deformaties of toes & foot
Based on the points scored, patients are classified into categories A to E with increasing risk for developing foot problems.
A <5: B 5-10: C 11-15: D 15-20: E . 20:

1. Patients in categories C,D and E require intensive foot care education and corrective therapy is possible.

2. Patients should be evaluated every six months; if the number of points increases, need for evaluation for increase and corrective measures.

3. A history of a previous foot problem puts a patient in the high risk category irrespective of points scored.