An ounce of prevention keeps feet healthy

Diabetic foot problems are growing

By Tamara D. Fishman, DPM 

President, The Wound Care Institute 

North Miami Beach, FL

The feet of people with diabetes are prone to vascular disease and neuropathy. About 15% of diabetics will develop an ulceration on at least one foot during a lifetime, and 20% of these ulcerations will lead to extremity amputations. One in five of all diabetic admissions to hospitals are related to foot problems. 

Many diabetics also are susceptible to severe complications such as blindness, kidney disease, and impotence. The costs of diabetes are devastating: An estimated $92 billion dollars are spent annually to treat patients with the disease. According to some estimates, about 5.6 million chronic wounds are treated annually in the United States. Of these, pressure ulcers, including heel and plantar ulcers, number 2.1 million. Diabetic ulcers number about 3 million. Vascular ulcers, mostly venous stasis on the lower legs and feet, add another 500,000. 

Ulcers in diabetic people are most commonly caused by neuropathy, which is the loss of sensation in the feet. Neuropathy engenders ischemic changes that make feet vulnerable to a wide variety of problems such as blisters, corns, calluses, fissures, interdigital fungal infections, paronychias, ingrown toenails, skin lesions, and mycotic nail infections. 

Most traumas and pressure sensations are not well recognized by diabetics through the normal mechanisms of pain. Thus, many orthopedic changes that take place in the diabetic foot lead to additional lower-extremity problems, such as ulcer formation and infections, that may necessitate amputation. An increased incidence of atherosclerosis also may be a contributing factor in the formation of foot ulcers. For instance, arterial ischemia may be a primary or contributing factor in the formation of foot wounds. 

The role of the podiatric physician in recognizing and treating diabetic foot ulcers should not be overlooked. As specialists with medical and surgical skills, podiatrists treat conditions such as ingrown toenails, painful corns and calluses, traumas, fungal and bacte rial infections, and diabetic ulcers. As the primary care physician for the podiatric wound care patient, the podiatrist manages wound assessment and actions taken to facilitate the healing process. The podiatrist’s goals are to maintain an optimal wound environment, control infection (if present), prevent further ulceration, and debride the wounds.

Coordinate care among disciplines

Because diabetes is a systemic disease that affects many organs, treatment requires a multidiscipliniary team approach. Often, podiatrists first notice or treat the above disorders. It is important for them to coordinate their efforts with an internist to ensure proper overall management of patients. Patients also may be referred to a vascular surgeon for more comprehensive vascular assessment. 

Ulcerations of the lower extremities have several etiologies and assume various presentations. The cause of the ulcer must be determined, because wound treatment will vary based on the etiology. Medical and clinical management should include the identification of underlying factors that lead to wound formation on the lower extremities; for example, arterial disease, trauma pressure, neuropathy, or venous disease. 

Primary treatment of patients with diabetic foot ulcers should be aggressive. Once healing has begun, preventive treatments should be instituted. Preventive measures include patient education and daily inspection of the patient’s feet and legs. Therapeutic footwear and insoles are a must to prevent recurrence in healed areas. 

A comprehensive approach to the prevention of many diabetic foot problems should include the following elements: 

• food glucose control; 

• an exercise program; 

• regular foot care; 

• adherence to a well-monitored diet; 

• good hygiene; 

• specialized shoe gear; 

• early recognition and management of foot ulcerations; 

• teamwork among medical professionals; 

• patient education; 

• smoking cessation. 

Diabetic patients should be urged to: 

• wash (not just soak) their feet in warm water every day; 

• examine their feet daily for areas of redness, dryness, and cracks in the skin; 

• wear properly fitting shoes; 

• cut toenails straight across; 

• stop smoking. 

Diabetic patients should not use over-the-counter medicines without consulting a physician, walk barefoot, or perform self care, which is sometimes called "bathroom surgery." Diabetic patients who perform bathroom surgery or neglect their own care may experience the serious consequences of infection, ulceration, or gangrene. 

Neuropathic and vascular problems cannot be prevented. Patient education, therefore, is the single most valuable tool we have in preventing amputations. 

[Editor’s note: Tamara Fishmen, DPM, is president of The Wound Care Institute and a podiatric wound care consultant at the Primary Foot Care Center. Contact her at: 1541 NE 167th St., North Miami Beach, FL 33162. Telephone: (305) 919-9192. The Wound Care Institute also offers newsletters on the World Wide Web. The Web address is:]
American Diabetes Association Council on Foot Care. ADA Foot Guidelines. Diabetic Foot Care. Washington, DC; 1990.
Bryant JL. Preventive foot care program: A nursing perspective. Ostomy Wound Mgmt 1995; 41:29-33.
Smith & Nephew Corp. Diabetic Foot Ulcer Prevention & Treatment Modalities. Largo, FL; 1997.