Diabetic Footcare

Your Feet Are For A Lifetime!

Dr. S.M.Sadikot.
Hon. Endocrinologist,
Jaslok Hospital and Research Centre,
Mumbai 400026

Foot complications are, unfortunately, still the most important complication in our people with diabetes. Ask your doctor and you will be told that this is the most common problem which is seen in their patients with diabetes. Go to any hospital, and you will be told that the vast majority of patients who are admitted with diabetes related problems are with foot complications. Not only this, they have the longest stay in the hospital and most often they come so late that they end up with an amputation.

About 30% of people with diabetes will develop foot ulceration at some point, and 14% to 24% of these will have to have an amputation. The majority of these - almost 60% - occur in people who are 40 and older. The risk for foot ulceration leading to amputation increases in people over 40 who have had diabetes for 10 years or longer.

In fact, the second biggest cause of foot amputations is diabetes. The first…..accidents!

And yet this should not be so.

Let us meet Dr. Foot and let him tell us how.Foot Problems

Of all the complications associated with diabetes, foot problems are not only the most preventable, but even if you get a foot problem, early and correct treatment can definitely save your foot.

First let us understand why people with diabetes are more prone to foot problems.

Why People with Diabetes are Prone to Foot Ulcers.

Foot Ulcers

Individuals with diabetes share a common disorder that results in elevated blood sugars. The effects of the elevated blood sugars will vary from individual to individual.

There are four major risk factors for developing a foot ulcer:

(1) Neuropathy: Many of you with diabetes have neuropathy. In many cases, this leads to a numbness and insensitivity. People with neuropathy are unable to "feel" pain, heat or cold. It is like having "Burglar alarms" on your feet which do not work. You will not be warned if you develop minor cuts, scrapes, blisters, boils or other injuries. This is made worse by our habit of walking barefoot at home and many other places where one is asked to take off one's shoes or sandals such as religious places etc. If you have neuropathy, you may not realize that your shoes or sandals are too small and are "biting" your feet until an ulcer has formed.

If these minor injuries are left untreated, because you do not "realize" that you have an injury, complications may result and lead to infection, ulceration and possibly even amputation. Your doctor can test you for neuropathy, but chances are you will recognize the signs of neuropathy, signs that include burning, tingling or numbness in the feet. In fact, as we have discussed below, you can ask your doctor for a monofilament and check it out yourself!

(2) Foot deformity: Neuropathy also leads to foot deformities such as bunions, hammer toes and other deformities. Moreover, many foot conditions which would be minor in most people become risky if you have diabetes.

(3) Prior history of foot ulcers

(4) Loss of circulation: Diabetes may also affect blood flow in your legs and feet, making it harder for cuts or sores to heal. Then a small infection can become very serious. Smoking when you have diabetes makes blood flow problems much worse.

(5) Proneness to infections: People with high blood glucose levels and deficient blood supply to the legs makes one prone to infections. These also are more difficult to treat and take much longer to heal. It is important to treat foot ulcers and infections as soon as possible, because the longer one delays treatment, the greater the chance of developing a more serious problem which may even lead to an amputation. The signs that an ulcer is infected include redness, swelling, increased drainage, sudden elevations in blood sugar, fever, chills and fatigue. Pain may be lacking because of neuropathy.

The risk for developing a foot ulcer increases with the number of risk factors.

The overall risk of an individual developing a diabetic foot ulcer is determined by a combination of factors. In general, the risk is higher if:

Proneness to infections

  • Neuropathy is more severe (because more sensation is lost)
  • Peripheral vascular disease is more severe (because there is less circulation to bring enough oxygen to repair tissue damage)
  • There are coexisting abnormalities of the shape of the foot which make the local effects of neuropathy or vascular disease more severe (because it increases local pressure and callus)
  • The person is unable to practise reasonable self care to maintain general condition of the feet and to prevent trauma (because there are more chances of damaging the feet)
  • The diabetic control is very poor (because of susceptibility to infection and poor wound healing)
  • There is a past history of foot ulceration due to diabetes (because the above factors often persist)

At the same time, it is worth remembering that with a little care, you can avoid foot problems. In many cases, even if you get a minor foot problem, serious problems can be prevented by an understanding of what can happen to feet and how to take care of them, correctly and promptly!

1) Inspect your feet daily for blisters, cuts, and scratches. The use of a mirror can aid in seeing the bottom of your feet. Always check between your toes.

Foot Corns

2) Wash your feet daily, using warm (not hot) water and a mild soap. If you have neuropathy, you should test the water temperature with your elbow before putting your feet in the water. Do not soak your feet in hot water or in any water for a long time, as the skin can get macerated and infected.

Dry your feet carefully with a soft towel, especially between the toes. Dry with a soft cloth. Apply a moisturiser cream if they are dry or a powder if they are prone to excessive perspiration. Do not use oil or cream between your toes as this increases the chances of an infection.

Foot Corns

3) Avoid walking barefoot! This is especially true about walking on hot surfaces such as footpaths, hot floor tiles, hot sand, rocks, etc. Always wear shoes and sandals that fit. Place protective slippers or shoes right beside your bed to wear as soon as you get out of bed to avoid walking barefooted.

Foot Corns

4) Examine your shoes before putting them on to make sure they have no tears, sharp edges, or objects in them that might injure your feet. Always wear shoes and sandals that fit. Do not wear shoes without stockings. Wear socks that fit you properly. Choose socks that are made of cotton or wool. Be cautious not to wear socks that are too tight that can cut off circulation to the feet.

Foot Corns

Choosing the correct shoes is extremely important. Below we will discuss how you should choose shoes for yourself.

5) Avoid exposing your feet to excessive heat or cold. If your feet feel cold at night, wear socks. Do not apply hot water bottles or heating pads.

Foot Corns

6) Learn to cut your nails correctly! The best time to trim toenails is after bathing. The nails are softer and easier to trim at that time. Cut your toenails straight across and not too short. Do not cut into the corners of your nails. Be careful not to leave any sharp corners that could cut the next toe. Consult a doctor if your nails are too thick and difficult to cut.

Foot Corns

7) Have any corns, calluses, bunions, warts etc., treated by a doctor. Do not use chemical agents for the removal of corns and calluses. Do not use strong antiseptic solutions on your feet. Do not use adhesive tape on your feet.

Foot Corns

Don't try any home remedies!

8) Wiggle your toes and move your ankles up and down for 5 minutes, 2 or 3 times a day. This increases the blood flow to your feet.

Dangerous Signs To Look Out For

Any change in the colour of your foot or toe.

Dangerous Signs To Look Out For

Any new pain or throbbing in your feet. Report any foul smell even if your feet do not hurt.

Dangerous Signs To Look Out For

Any swelling in the leg, foot or toes

Dangerous Signs To Look Out For

Any boils, cracks, corns, blisters should be reported to you doctor at once.
Do NOT try any home remedies.

5) Avoid sitting with your legs crossed. Crossing your legs can reduce the flow of blood to the feet.

10 recommendations when buying new shoes for shoe fitting in patients with diabetes

Dangerous Signs To Look Out For

  • 1. Patients with diabetes and neuropathy should never walk barefoot because they are at substantially higher risk for puncture wounds when barefoot than nondiabetics.
  • 2. Patients with foot ulcers should not wear a show on the affected foot while the ulcer is healing. Even the most ideally fitting prescription shoes will not take the pressure off a wound or ulcer nearly as well as a total contact cast or removable cast walker.
  • 3. Before putting on any shoe, the patient should inspect the inside for wear, sharp or irritating seams and stitching, and foreign objects.
  • 4. New shoes should be broken in slowly. We typically advise patients to wear new shoes for short periods of time (i.e. one to four hours), slowly increase wear from that point, and inspect their feet frequently. Any signs of irritation should be brought to the attention of physician.
  • 5. Buy shoes at the end of the day, when the foot is usually at its largest (because of swelling). Shoes will be more accurately and safely sized at that time.
  • 6. All shoes should be sized while the patient is standing since the foot increases in length and width when it is bearing weight. Shoes should be approximately one-half inch longer than the longest digit when sized while the patient is standing.
Foot Size
  • 7. The "break" of the shoe, should correspond to the widest part of the patient´s foot (typically at the metatarsophalangeal joints). Heel-to-ball length is as different from person to person as is heel-to toe length and should be taken into account when sizing shoes.
Foot Length
  • 8. An experienced shoe fitter should size and fit all patients with diabetes. Patients with sensory neuropathy have a tendency to select shoes that are too small because they are better able to "feel" a tight shoe on the foot.
  • 9. Even prescription shoes don´t last forever. The insole should be changed frequently at least three times a year, depending on the patient´s activity level. The shoe should be changed at least once a year as well. Ideally, patients should rotate the shoes they wear and change shoes in the middle of the day, if possible.
  • 10. The shoe should be acceptable to both the patient and the physician. However, the most comfortable and accommodating shoe may not be aesthetically or functionally appealing to the patient. Conversely, the most aesthetically appealing shoe may not be acceptable to the clinician.

Sensation threshold screening using a 10 gram monofilament(also known as Semmes-Weinstein monofilament)

How to Screen Your Feet

  • 1. Use the 10g monofilament to test sensation.
  • 2. The sites to be tested are indicated on the foot diagram below.
  • 3. Apply the filament perpendicular to the skin's surface ( see Diagram A).
  • 4. The approach, skin contact and departure of the monofilament should be approximately 1.5 seconds duration.
  • 5. Apply sufficient force to allow the filament to bend ( see Diagram B).
  • 6. Do not allow the filament to slide across the skin or make repetitive contact at the test site.
  • 7. Randomise the order and timing of successive tests.
  • 8. Do not apply to an ulcer site, callous , scar or necrotic tissue.
Foot Circle

The circles represent the places on the foot to test with the monofilament.

Diagram A

Foot Diagram A

Diagram B

Foot Diagram B

Consider your feet to be "at risk" if you cannot feel the 10gm monofilament at any of the sites marked.

Caring for your feet is easy if you follow some of these simple tips. Many of you will be able to avoid getting a foot problem. But if you do get a foot problem, do NOT take it lightly. See your doctor at once. Prompt treatment can heal your foot problems.

Remember, give an "inch" to your diabetes foot problem and it will take a "foot"!

Your feet are in your "hands"

Take good care of them and they will last you a lifetime!

Dr. Foot's Take Home Message