I

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Fooot Clinic
Foott care is an esspecially impoortant part of care for peopple
with diabetes. Som me of the effeects of the disease increasee the
risk of foot probleems and also increase the likelihood of
complications.

But proper
p diabettic foot care and
a attention ccan prevent most
m
serioous foot compplications. On this site we ppresent the latest
advice from the experts
e in diabbetes and diabbetic foot
probblems.

Foott Clinic - At a Glance

Introductiion Why is foott care imporrtant to peoople with diaabetes?

What kind of
o foot problems do peoople with diaabetes
have?
Checklist foor healthy feet
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Risks Why are they worse for people with diabetes?

How will I know if I'm at risk for diabetic foot problems?

Prevention What can I do to prevent diabetic foot problems?

Preventive foot care - for all
Choose the proper footwear
Special care for high-risk conditions

Treatment What if I do get a diabetic foot ulcer?

How are diabetic foot ulcers treated?
Treat the infection
Off-load pressure
Improve blood flow
Promote healing

Tips box Checklist for healthy feet

Warning signs of foot complications
Components of good foot exam

Related Articles

• A New Foot Tip from NIH

• New Foot Care Checklist
• Medicare Now Covers Foot Exams
• New Treatment for Foot Ulcers Approved
• Is Special Diabetic Footwear Worth the Cost?
• Preventing Minor Trauma is Key to Healthy Feet

Introduction
Why is foot care important to people with diabetes?
Diabetes can cause nerve damage (called peripheral neuropathy) that reduces sensation in your feet.
If you have neuropathy, you can have an injury or condition on your foot that requires medical care
without even knowing it. Small injuries may become infected. 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. Foot infection is the most common reason for hospitalization of people with diabetes. And
   III
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foot ulcers and non-healing

n wounds are the primary caauses of ampuutation in peoople with diabbetes.
Withh proper foot care, howeveer, it is estim
mated that as many as half of these ampputations couuld be
prevvented.

Whhat kind off foot prooblems doo people with

w diabeetes havee?
Just like anyone elsse, people withh diabetes can develop the folllowing kinds of foot conditionns:

Cornss and callusess are thick layyers of skin caaused by too m

much rubbing or
presssure on the saame spot.

Blisters can form if shoes alwayys rub the sam

me spot, or froom wearing shoes
that do
d not fit or wearing shoes without sockss.

Ingrowwn toenails occcur when an edge of the nail

n grows intoo the skin, whiich
can thhen get red annd infected. Inngrown toenaiils can happenn if you cut intto
the coorners of yourr toenails wheen you trim thhem. This conddition can alsoo be
causeed by wearing shoes that arre too tight.

A bunion forms wheen the big to slants

s towardd the small toees, and a bumpp
formss at the base of
o the big toe. This spot cann get red, sore, and infecteed.
Bunions often run ini the family and
a can also be b caused by w wearing shoess
with pointed
p toes.

Plantaar warts, whicch form on the bottom of thhe feet, are caaused by a virrus.
They tend
t to go away without treeatment.

Hammmertoes form when a foot muscle

m gets weak,
w shortening the tendonns,
whichh then retract the toe, caussing it to curl under
u the fooot and creatingg a
bump at the joint onn the top of thhe toe. These areas can beccome sore, annd
hammmertoes can caause problem ms in walking and
a in finding comfortable
shoess.
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Dry skkin can becom

me cracked, allowing germss to enter.

Athlette's foot is cauused by a fungus that causses redness annd cracking of the
skin.

Cheecklist for Healthyy Feet

Dailyy exam:

• Look for cuts or soress

• Check for warning signs: redness, swelling,
s warmmth, pain, slow
w healing,
• dry craccks, bleeding corns
c or calluuses, tenderness, loss of seensation

Dailyy care:

• a dry them carefully, esppecially between the toes

Wash youur feet daily and
• Use talcuum powder
• Do not cuut corns or caalluses - use a foot care sppecialist if neeeded
• Keep toenails trimmedd and smooth
• Promptlyy treat dry skin or athlete'ss foot
• Keep bloood glucose unnder control

Periodic foot exam

m by your heaalthcare proviider:

• Once a yeear for everyyone, every 3 - 6 months foor people at hiigh risk
  V
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• Take off shoes

s and soccks at every doctor
d visit
• Check for sensation annd foot pulsess
• Ask for a risk evaluatiion

Footwear:

• Wear shooes and sockss at all times

• Don't weaar shoes or socks that aree too tight
• Wear well-cushioned shoes
s
• Buy shoees that are roomy and "breeathe"
• People with
w diagnosedd foot problem ms may need special
s footweear

Rissks:
Diabetic foot probblems cann be serioous | Are you at riisk?
Whhy are theey worse for peoplle with diabetes?
In peeople with diabbetes, these problems
p freqquently lead too infections. Iff blood glucosse levels are high,
h
yourr ability to fighht infection is weakened. Hiigh glucose leevels cause twwo other problems that cann
signiificantly hurt your feet:

• Nerve damagge: High blood sugar can daamage the nerrves in your leegs
and feet. Withh damaged neerves, you migght not feel paain, heat, or coold in
your legs andd feet. A sore or cut on youur foot can get worse becauuse
you don't knoow it is there. This lack of feeeling is called diabetic
neuropathy. ItI can make a small problem m much worse.

• Poor blood flow: Diabetes often

o affects the blood vessels, reducingg the
amount of bloood flowing too your legs and feet. This m
makes it hard for
f a
sore or infecction to heal. Smoking
S whenn you have diaabetes makes
blood flow prroblems much worse.

Thesse two conditions can workk together to cause

c a foot problem,
p or too make it hardder for a foot
conddition to heal. See the exam
mple in the boxx.

For exampple . . . . . . say you

y get a blister from shoes thatt don't fit rigght. You don't feel
f the pain froom the blister because
you have ner
n ve damage in i your foot. Neext, the blister gets infected. If blood sugar is high, the infeection gets worrse. You
still don't feel
f any pain. Poor P blood flow to your legs and feet can sloow down healingg by failing to bbring needed oxxygen and
nutrients tot the area. Sometimes this kindk of bad infecction never heaals. It can causse gangrene, in which the skinn and tissue
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around the sore die. When that happens, amputation is needed to keep the gangrene from spreading.

How will I know if I'm at risk for diabetic foot problems?

About 15% 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 65 and
older. The risk for foot ulceration leading to amputation increases in people over 40 who have had
diabetes for 10 years or longer.

People are at high risk for foot problems if they have loss of protective sensation - such that you
can't feel an injury, or vascular disease causing poor blood flow in your feet and legs. Other risk
factors are skin disorders such as calluses, especially with redness or bleeding under a callus, and
nail abnormalities such as very thick nails. Structural/bony deformities such as hammertoes or
bunions and limited joint mobility are also risk factors.

In addition, people who do not have good control of their blood glucose are at increased risk, as are
those who have cardiovascular, eye, or kidney complications. People who have had foot ulcers or
amputation previously have, by definition, the necessary risk factors for future problems.

The American Podiatric Medical Association has identified specific conditions that warn of impending
foot problems - see the box.

Warning Signs of Foot Complications

• Changes in skin color
• Elevation in skin temperature
• Swelling of the foot or ankle
• Pain in the legs
• Open sores on the feet that are slow to heal
• Ingrown and fungal toenails
• Bleeding corns or calluses
• Dry cracks in the skin, especially around the heel

If you experience any of these conditions, contact your healthcare provider or podiatrist right away.
They should be properly managed in order to avoid complications.

Prevention:
What can I do? | Preventive foot care | Proper footwear | High-risk conditions
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What can I do to prevent diabetic foot problems?

Every person with diabetes - with or without any of these risk factors - should take proper care of
their feet. Routine foot inspection and preventive care can minimize or prevent foot problems. Below
are things to make sure you ask your doctor about:

• You should have a thorough foot examination by a professional at least once a year. This
includes checking the sense of feeling and the pulses in your feet. (See box.)
• Ask for a risk evaluation. Specific follow-up and treatment will be based on what risk
category your feet are in. Ask for special instructions for people with high-risk feet, if
applicable.
• If you have lost some sensation in your feet, they should be visually inspected at every visit.
Take off your shoes and socks at every visit and make sure this happens.
• Ask your provider to check your footwear to make sure that the style and fit are
appropriate for the condition of your feet. Ask if special shoes would help your feet stay
healthy.

Components of a good foot exam:

At least once a year, everyone with diabetes should have a thorough foot examination. It should include an
assessment of:

• Protective sensation - using a monofilament or vibratory sensation test

• Foot structure
• Biomechanics - including any limits in joint mobility or problems with gait and balance
• Vascular status - including questions about painful walking and determination of pulses in your
feet
• Skin integrity - especially between your toes and on the ball of your foot
• Increased pressure on the soles of your feet; areas of warmth, redness, or callus formation may
be indicative of tissue damage

Many diabetes treatment programs operate regular foot clinics to help patients with routine foot
care and to make sure that preventive measures are taken. Some pharmacists specializing in
diabetes care offer similar programs. Be sure to take advantage of any foot care programs that are
available to you.

Preventive foot care - for all

Of course, the best way to prevent foot problems is to keep your blood glucose under control. But
there are also specific things you should do EVERY DAY to make sure your feet stay fit. Here are
some of them:
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1. Examine your feet EVERY DAY to look for cuts, sores, blisters, redness, etc. If you have
anything of that nature, and it doesn't heal in a day or two, notify your doctor. If you have
trouble seeing or reaching your feet, ask someone to help, or use a mirror to help you see
better.
2. Wash your feet EVERY DAY with lukewarm water and mild soap. Dry them carefully and
thoroughly with a soft towel. Dust your feet with talcum powder, which will help keep them
dry.
3. Don't soak your feet - this will make your skin too dry.
4. If you have dry skin on your feet, use a moisturizing lotion to prevent cracking - but NEVER
use a lotion or cream between your toes, as this can lead to infection.
5. If you have corns or calluses, DO NOT cut them, don't use corn plasters or liquid corn and
callus removers - they can damage your skin. Check with your doctor or foot care specialist
who may advise you to use a pumice stone to smooth calluses or corns.
6. Keep your toenails trimmed. Trim them with toenail clippers after you have washed and
dried your feet. Trim the nails following the shape of your toes, and smooth them with an
emery board or nail file. Don?t cut into the corners of the nail, which could trigger an
ingrown toenail. If your nails are very thick or yellowed, have a foot care specialist trim
them.
7. Don't go barefoot - not even indoors. Always wear socks, stockings, or nylons with your
shoes to help avoid blisters and sores. Choose soft socks made of cotton, wool, or a cotton-
polyester blend, which will help keep your feet dry. Avoid mended socks or those with seams,
which can rub to cause blisters.
8. Avoid wearing socks or hose that are too tight around your legs. Knee-high or thigh-high
stockings as well as elasticized men's dress socks can constrict circulation to your legs and
feet.

Choose the proper footwear - for all

Choosing the right footwear is an important part of foot care, since poorly fitted shoes are involved
in as many as half of serious foot problems. Here are some tips for choosing the best footwear:

1. Wear well-cushioned walking shoes or athletic shoes. If you have foot deformities such as
hammertoes or bunions, you may need extra-wide shoes or depth shoes. Depth shoes have
more room in them to allow for different shaped feet and toes or for special inserts made to
fit your feet. If problems are severe, custom-molded shoes are available. Medicare provides
coverage for some special shoes; your doctor or foot care specialist can help determine if
you qualify.
2. Don't wear shoes with high heels or pointed toes. They can create pressure, which might
contribute to bone and joint disorders as well as diabetic ulcers.
3. Don't wear open-toed shoes or sandals with a strap between the first two toes. They
increase the chance that you'll injure a toe.
4. When you buy new shoes, be sure your feet are properly measured and fitted. Your feet can
change size and shape, so an experienced shoe fitter should measure them whenever you
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get new shoes. Shoes should fit both the length and width of your foot, with room for your
toes to wiggle freely.
5. Your new shoes should be sturdy and comfortable. They should have leather or canvas
uppers, which breathe to keep your feet from getting sweaty. Avoid vinyl or plastic shoes,
because they don't stretch or breathe.
6. When you get new shoes, break them in gradually so you won't get blisters.
7. Shake your shoes before you put them on. Even a small pebble in your shoe can lead to
problems.

Special care for high-risk conditions

If you do have any of the high-risk conditions, there are specific things you should do to keep your
feet healthy.

• If you have neuropathy or evidence of increased pressure on the soles of your feet, wear
well-cushioned walking shoes or athletic shoes.
• If you have lost some sensation in your feet, be sure to carefully inspect them often to
identify any problems early.
• If you have calluses, have a foot care specialist treat them.
• If you have bony deformities such as hammertoes or bunions, you may need extra-wide
shoes or depth shoes. In extreme cases, custom-molded footwear may be needed.
• Promptly treat minor skin conditions such as dry skin or athlete's foot to keep them from
progressing.
• Have a complete foot examination every 3 to 6 months.

A formal, comprehensive program has been developed at the Gillis W. Long Hansen's Disease Center
in Carville, LA, known as the "LEAP program" for Lower Extremity Amputation Prevention. It consists
of 5 relatively simple activities:

• Annual foot screening to identify people who have lost protective sensation
• Patient education in self-management, with emphasis on proper foot care
• Daily self-inspection of the foot
• Appropriate footwear selection
• Management of simple foot problems such as dry skin, nail and callus care, and basic wound
management

In a number of large clinical centers where formal preventive care programs such as this have been
implemented, the rate of amputations has been reduced by as much as 85%.

Related articles

• Preventive Foot Care Programs Work

• Cholesterol Drugs May Protect Against Leg Infections
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Treatments:
Foot ulcer | Ulcers treatment | Infection | Off-load Pressure | Improve blood flow |
Promote healing

What if I do get a diabetic foot ulcer?

It is estimated that about 15% of people with diabetes will develop a foot ulcer sometime during their
lifetime. Fortunately, up to 86% of foot ulcers will heal when treated properly. A foot ulcer is defined
as a break in the skin or deep sore; they are most often located on the ball of the foot, an area of
repeated stress.

If you develop any kind of sore or wound on your feet that doesn't heal in a day or two, it's very
important that you see your doctor or foot care specialist right away. Untreated lesions or ulcers
can become infected quickly; even when treated, foot ulcers may not heal well in people with diabetes.

How are diabetic foot ulcers treated?

Your doctor may x-ray your feet to make sure the bone is not involved. If the results are not clear,
you may have an MRI scan to help your doctor determine the extent of the lesion.

Treatment must address all of the factors involved in wound healing:

• Infection - which stops or delays the normal wound repair process.

• Repeated trauma during the wound healing process - which continually destroys new tissue.
• Decreased blood flow - which reduces the amount of oxygen and nutrients getting to the tissues.

Treat the infection

The doctor will thoroughly clean the wound to remove all infected tissue; in severe cases, this may be
done in the operating room. Early, aggressive wound cleaning (called "debridement") has been shown
to heal these wounds more rapidly. If there is an infection, your doctor will prescribe antibiotics. If
the infection is serious, you may be hospitalized to receive intravenous antibiotics.

Dressings are used to prevent further trauma, to minimize the risk of infection, to relieve local pain,
and to optimize the environment for healing. A moist wound environment is important for wound
healing to occur.

You can help by keeping the area clean and moist at all times and using the medications your doctor
has prescribed for you. It's important that you only use the medications your doctor has suggested.
People used to use cleansers or antiseptics such as hydrogen peroxide on these types of wounds, but
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it is now known that they actually delay wound healing. They also dry out the tissue, and it is now
believed that a moist environment stimulates more rapid wound healing.

Off-load pressure
Depending on the location of your foot ulcer, you may need to keep pressure off the area. This is
called "off-loading" and means avoiding all mechanical stress on the wound so that it can heal. If
there is no infection, a total contact cast may be used to relieve pressure. Or your doctor may
recommend using "non-weight-bearing" devices such as orthopedic shoes, a walker, crutches, or
even a wheelchair or bed rest - these can help healing by relieving pressure on the injured part of
your foot. If your doctor has suggested keeping weight off of your foot, it's important to do so. Keep
your foot elevated as much as possible.

Improve blood flow

If there is evidence of impaired blood flow to your feet, then your doctor may consider a surgical
procedure called "revascularization." This involves bypassing or implanting a graft past lesions in the
arteries that are obstructing blood flow. These procedures have been as successful in restoring
blood flow for people with diabetes as in others and have been shown to help achieve rapid and
durable healing of diabetic foot ulcers. They have also been shown to decrease the need for
amputation.

Promote healing
New treatments such as recombinant growth factors and bioengineered skin patches are now
available to help improve healing of foot ulcers. Growth factor gels contain a protein that helps the
ulcer fill in with healthy tissue, so it heals faster and better than it would otherwise. Human skin cells
are processed and grown in the laboratory to produce bioengineered skin, or skin equivalents, which
are applied to the foot ulcer to enhance the process of wound healing. Foot care experts are
encouraged by the early results of these treatments, which they say "are healing diabetic foot
wounds faster and preventing amputations." Used with traditional approaches such as removing
pressure, the new high-tech treatments reduce healing time, infection, hospitalization, and
amputation while improving the quality of life. They've been called "a winning combination to reduce
the needless number of lower extremity amputations in this country."

Other treatments are sometimes used but, according to the American Diabetes Association, they
have not been adequately tested in clinical trials to prove their worth. These include hyperbaric
oxygen, electrical stimulation, cold laser, and heat treatments.

Related articles

• Good News about Treating Foot Ulcers

• Total-Contact Casts Better for Healing Foot Ulcers
• Infrared Treatment Helps Heal Foot Ulcers
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DR.TTORKI@ @YAHOO.C COM
  YOUR   WAY Y  FOR  HEA ALTHY  LIFFE
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Thiss handout prrovides a geeneral overvview on thiss topic and may

m not apply to everyoone.
To find
f out if this handout applies
a to yoou and to geet more infoormation on this subjecct,
talk to your fam
mily doctor.

Visit HTTP://TARIKTORKI
T .JIMDO.COM
M for inform
mation on thhis and manny other heaalth-
relaated topics.