What you don’t know can hurt you

People with diabetes have a lot to pay attention to in order to manage their disease. Blood sugar levels, diet, weight, exercise, blood pressure, and medication all play a role in overall health. But, what some people with diabetes don’t realize – or sometimes choose to ignore – is that paying attention to their feet is also critical to maintaining their health. Why? “Over time, high blood glucose levels can begin to cause nerve damage,” explains Donald R. Bohay, MD, FACS, specialist at the Orthopaedic Associates of Michigan Foot & Ankle Center. “This condition is called neuropathy, and it’s very common in the feet. It’s frequently referred to as diabetic foot, and it typically starts with numbness and tingling in the feet and toes.” According to the US Department of Health and Human Services National Diabetes Information Clearinghouse, between 60 and 70 percent of people with diabetes have some form of neuropathy. The most common single form is diabetic foot, and it affects people with Type 1 and Type 2 diabetes, alike. Left unmanaged, diabetic foot can lead to foot and ankle injuries, ulcerations, infections, bone loss, deformities, and worse. Denying the problem won’t make it go away. In fact, if you have any symptoms of diabetic foot, ignoring the problem will almost certainly lead to worsening complications.

How do you know if you have diabetic foot?

If you have diabetes, ask yourself these questions:

  • Do I have numbness or insensitivity to pain or temperature in my feet?
  • Do I experience a tingling, burning, or prickling sensation in my feet?
  • Do I have unexplained sharp pains my feet or regular night cramps in my legs?
  • Have I ever been surprised to find sores, cuts or ulcers on my feet, but felt no pain from them?
  • Are my feet extremely sensitive to touch?
  • Do I experience loss of balance and coordination because I can’t feel my feet when I walk?

“If you have any of these symptoms, you should consult an experienced foot and ankle specialist to diagnose and help manage the condition,” advises Dr. Bohay. “Ideally, I would recommend that every diabetic with neuropathy gets a 6 month check by a foot and ankle specialist, just to make sure that they don’t develop further complications and get into an overwhelming situation.”

Complications of Diabetic Foot

Neuropathy in the feet can lead to a host of complications – from ulcerations and infection, to bone loss and severe deformities. “Patients with numbness may not feel a cut or blister on their foot,” says Dr. Bohay. But that lack of pain doesn’t mean there isn’t a problem. Small wounds can quickly turn into severe ulcerations and are susceptible to infection. “Patients who notice wounds or ulcers on their feet should take immediate action before things spiral out of control,” warns Dr. Bohay. “Because of their neuropathy, they don’t have the sensation to protect against further injury. Plus, diabetics don’t have the same ability to fight infection that others have. This can lead to severe infections and complications that could include the need for a very significant type of surgery or even amputation.” As the nerves that supply the muscles with information are damaged and other physiologic changes occur, people with neuropathy can also experience bone loss and breakdown of the foot and ankle joints. This condition is known as Charcot foot, and it leads to a range of foot deformities. “In the worst case scenario Charcot involves the ankle, the back of the foot and the front of the foot to the point to where the patient is literally walking on the outside or the inside of their ankle. It can be almost a 90 degree deformity,” says Dr. Bohay. “Another deformity we see is called a rocker bottom foot, where the arch is collapsed and is now upside down so the patient is walking on the middle of their foot rather than their heel and balls of their feet.” Despite the typical numbness associated with neuropathy, patients with these deformities can develop deep bone pain as the foot begins to crumble underneath them. Not all diabetic foot deformities are this severe, but any deformity can result in pressure blisters, ulcerations and infection if not managed properly.

Managing diabetic foot

“People with diabetes should understand that they have a potential to develop neuropathy and that it is something they should look out for,” says Dr. Bohay. “If you start to get neuropathy, it can’t be cured, but it can be addressed. There are things that we do to help prevent severe complications.” What does a foot and ankle specialist like Dr. Bohay do to help patients with diabetic foot? “Our treatment is based on what the patient comes to us with,” he explains. “If it’s simply numbness and tingling with no deformity, we’ll protect the foot with a custom made orthotic – an insert that is designed by one of our orthotists to accommodate all the nooks and crannies of their foot so that, when they get into a shoe, they’re protected appropriately.” Dr. Bohay points out that no orthotic device will keep an arch up if it’s falling. “Orthotics just aren’t powerful enough for that. We’re talking about an accommodative orthotic. For instance, if the patient’s developed a small deformity underneath their foot where a bone is a little prominent, our orthotists would customize an orthotic that fits the bump so it falls into a little crevice in the orthotic. This protects the patient from walking on the bump and developing an ulcer.” Similarly, patients who have an ankle deformity can be fitted for an ankle brace to protect and support the area. “In the case of Charcot foot, our early intervention is to immobilize the limb, get the patient off the foot, rest it and try to get the bone and joint deterioration to slow or stop before it becomes a substantial deformity,” says Dr. Bohay. “We would follow this with an accommodative orthotic, possibly a modified shoe and observation.” If the condition has progressed, treatment becomes more complex. “The worst case scenario is that the Charcot wasn’t addressed in a timely fashion, the deformity is severe, the foot is unstable, it can’t fit into a shoe and the patient is in pain – that’s when an operation is indicated,” says Dr. Bohay. “To get the foot or the ankle straight again so the patient can walk usually requires a significant operation by a specialized orthopedic foot and ankle surgeon, designed to put the bones back in place and stabilize the joint, possibly with plates, screws, rods and a bone graft. The operation is extensive with a significant prolonged recovery.” Before choosing a surgeon, Dr. Bohay recommends that patients do their research. “They need to find an orthopaedic surgeon in their area who is most qualified for this complex procedure. They’ll want to make sure that the surgeon has been well trained and performs this type of procedures on a regular basis.”

Take charge of your foot health

So, if you suspect you have diabetic foot:

  • Visit your primary care physician to make sure you are effectively managing your blood sugar, blood pressure, weight and other risk factors.
  • See a foot and ankle specialist who can evaluate your feet, determine the best treatment to help prevent serious complications, and regularly monitor your condition.
  • Get a bone density screening at a center like the OAM Bone Health Clinic to make sure you don’t have an underlying condition like osteoporosis.
  • Check your feet twice a day, every day. Take off your socks and inspect the tops and bottoms of your feet – use a mirror if necessary. Look for swelling and redness (a sign of Charcot), open wounds, hot spots and early callous formation. Call your doctor at the first sign of trouble.

Remember, ignoring the problem will only make it worse. You can take charge of your foot health, address the problems and prevent serious complications.