Foot amputation is one of the most serious complications that diabetics may encounter. Fortunately, diabetics do not have to bear the burden of keeping their feet healthy alone. Not all amputations associated with diabetes can be avoided, but with routine foot examinations by a podiatrist and daily self-examination of the feet by the patient, diabetic foot complications may be prevented. In order to thwart these complications, an understanding of how and why these problems occur must be recognized.
Understanding Diabetic Foot Complications: Diabetes causes an increase of sugar levels in the blood, which causes a process of “glycosylation” to be increased. Glycosylation is a normal process in the body that attaches chains of molecules to protein found in nerves, tendons, and cartilage. Increased glycosylation, over time, begins to damage the function of these structures.
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A vital function of nerves is the ability to convey pain, which allows us to recognize problems with our body. Due to the importance of pain as our body’s fire alarm, damaged nerves become a major risk factor for formation of diabetic foot wounds. Increased glycosylation of nerves leads to decreased pain sensation and therefore results in the loss of protective sensation. This situation becomes detrimental to diabetics, who are now unaware of small lacerations, wounds or callus on their feet that might lead to more serious complications such as ulcers and bone infections. If wounds are left untreated, they may result in amputation.
In addition to increased sugar levels, diabetics also tend to have high lipid concentrations in the blood. This produces the build up of plaque in the arteries, which results in poor circulation to tissues. Tissues depend on blood circulation for nutrients and oxygen to stay healthy and fight infections. Consequently, circulatory problems may not directly lead to ulcers on the feet, but exacerbates diabetic foot complications by creating a poor environment for wounds to heal.
The Role of the Podiatrist in Diabetic Foot Care: Podiatric diabetic foot examinations are used to assess the risk of diabetic wounds and usually follow a methodical procedure that examines the entire foot from joint mobility and skin condition to nerve and vascular function.
Vascular Exam: In a routine diabetic foot exam, circulation is determined by feeling for pulses in the feet. If pulses are not felt or are weak, then an ultrasound Doppler test may be used to listen and record the status of the pulses. If the Doppler test indicates poor circulation, the podiatrist may refer the patient to a vascular physician in order to treat the patient to enhance the blood circulation to the feet. The podiatrist may also observe any swelling, skin color changes, and cold temperature in the feet, as this may indicate poor circulation as well.
Neurological Exam: In a neurological exam of the foot, the loss of protective sensation is assessed by using an instrument called a Semmes-Weinstein Monofilament, which is made out of a thin plastic wire. While the podiatrist touches the patient’s feet with the monofilament wire, the patient closes his or her eyes and tells the doctor whether or not they feel the instrument. An inability to feel the wire indicates that the patient cannot appropriately protect himself or herself from injury. These injuries can be cuts, callus or foreign body. It is important to note that neglecting the discovery of any of these injuries even for a single day can lead to an ulcer and later, an amputation.
Skin Exam: During the skin exam, calluses, cracking, and nail conditions are noted and evaluated. Thick nails may result in painful ingrown nails or pressure soars that can harbor bacteria and lead to infections in the foot.. The condition of the skin is examined as well to ensure that there is no fungal growth, foreign bodies, and excessive moisture or dryness that promotes bacteria growth and skin deterioration.
Muscular Exam: In order to prevent excessive pressure on the feet, bony prominences will be identified. The range of motion of joints is assessed by measuring joint motion with a tractograph. If there are painful bony prominences and decrease joint mobility, specialized diabetic shoes may be needed to provide extra depth for the feet and decrease friction against the skin. The combination of increased pressure and loss of protective sensation increases the risk of ulcers in diabetic patients. Additionally, muscle strength is evaluated in order to determine the stability of the foot. If muscle strength is found to be weak, bracing may be recommended to provide support.
The Role of the Diabetic Patient and Family Members in Diabetic Foot Care: The responsibility of the diabetic patient and family members in preventing diabetic foot complications is just as important as the roles of the podiatrist. Here are tips to take care of diabetic feet:
1. Since diabetics are at risk of losing sensation in their feet, it is imperative that self-inspection of the feet is performed every day. If it is difficult to bend the knees to see the bottom of the foot, a magnifying mirror can be used. The mirror can be placed on the ground, while the patient looks to find any sores or foreign objects in the feet. If there are family members to assist the patient, they can inspect the feet for any wounds as well. If lesions are noted, the patient should see a podiatrist promptly to ensure timely and proper treatment of the wound.
2. Routine podiatric visits are important in maintaining diabetic foot health, especially since during these visits, calluses and nails can be debrided to relieve any excessive pressure to the feet. Furthermore, routine visits can provide early warning signals of impending problems, as detailed in this article.
3. Diet and blood sugar level should be controlled to decrease the progression of loss of protective sensation in the feet.
4. Daily foot hygiene should be incorporated into diabetic foot care. This includes washing the feet and changing socks daily. Making sure that the foot has adequate moisture, which can be ensured by moisturing lotion. Be careful with over-moisturized feet for this may lead to the breakdown of skin.
5. Ensure that shoes fit comfortably to avoid pressure to the feet. When buying shoes, a wide toe box is advised.
6. Avoid walking barefoot to prevent stepping on foreign objects.
7. Be cautious when taking baths or going to steam rooms because with decreased sensation, the chances of getting burns increases. When taking baths, test the water first with a thermometer or your hand.
Copyright (c) 2009 Bruce Lashley
Bruce Lashley, DPM
Dr. Lashley is a podiatrist practicing in midtown Manhattan for the past 27 years. He specializes in the conservative and surgical management of the foot. In October 2009, Dr Lashley moved his office to a new modern facility at 353 Lexington Avenue, in NYC.
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