Foot complications in diabetes always start small, but with some bad luck they grow into a major problem. How does a foot problem actually start and why?

The name “diabetic foot” sounds rather vague and the thoughts associated with it are scary: wounds and, in the worst case, amputation. Does that just happen because of a stubbed toe? Here you can read briefly how wounds of a diabetic foot can arise.

Foot ulcer (ulcer) — What is it?

Diabetes is a very complex disease that can affect different organs and systems. For example, calcification can clog the arteries, which reduces the blood supply, and nerves can become inflamed (polyneuritis), which can reduce or disappear the sensation. This also affects the foot. There are changes in the position of the foot whereby more pressure is created in some places (pressure points). In addition, diabetes also makes people more susceptible to infections by fungi and bacteria.

Foot injuries are common in people with diabetes. Sometimes small wounds are not noticeable because the pain is not felt. Poor circulation will also make these wounds difficult or impossible to heal. Poorly cared for wounds are also more likely to become infected. The chronic foot problem in diabetics is called the diabetic foot.

A wound on the foot that gets out of hand grows into an ulcer. This is called an ulcer (plural ulcers). An ulcer is usually caused by a combination of circumstances. Neuropathy plays a role in more than half of foot ulcer cases. Those who have neuropathy also have an increased risk of a foot ulcer.

How often does diabetes Foot ulcer occur?

In America, an estimated 250,000 people suffer from diabetes. Foot problems from diabetes are never the first sign of the disease, but rather a late complication. A diabetic foot is most common in type 1 diabetes, after the age of 30 in people who have had diabetes for more than 15 years, and in type 2 diabetes, because these people are often older and have other diseases that contribute to it.

How can you recognize it?

Small to large poorly healing wounds develop on the pressure points of the foot, usually the ball and the heel. The bottom of the wound is often not beautifully red, but covered with pus, a dirty-yellow batter or dark crust. You see no recovery at the wound edge. The wound therefore does not tend to shrink. Sometimes you see dark blue bruises in the calluses. It is considered a precursor to a foot ulcer.

With poor circulation, the foot often feels colder and even turns a bit blue.

The nerve damage changes the feeling: sometimes you no longer feel pain, heat or cold, then again there are tingling.

Often there are also deformities of the foot such as hammertoes, flat feet, etc. A special form is Charcot’s disease, which starts with swelling, mild pain, redness and an increase in temperature. This is followed by severe deformities due to damage to the joints and fragmentation of the bone.

Less feeling in feet

People with neuropathy often feel less on their feet. A poorer circulation in the foot also means that you feel less, because the nerves then transmit signals less well. If you feel less with your feet, you don’t just notice pinching shoes and small wounds and you keep walking around with them.

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Different pressure when walking

In addition to wounds that you can get from the outside in all kinds of ways, you can also get deeper invisible damage. That also starts with insensitive feet, which may cause you to walk differently and put a different strain on your feet. There are other pressure and shear forces on your feet, causing them to become overloaded in certain places.

In combination with less good blood flow to subcutaneous tissues, these shocks can absorb less well and become damaged internally.

callus

In response to the other pressure and shear forces on the foot, the skin starts to form calluses. But too much calluses is not good either. Because calluses can actually make the wrong forces on the foot worse. A subcutaneous blister or bleeding may develop, which you do not always notice if you have less feeling in the foot. As a result, you keep walking with it and it cannot heal. Calluses are often a preliminary stage of an underlying ulcer.

Vulnerable skin

One of the consequences of (autonomic) neuropathy can also be that the foot sweats less, making the skin drier and more vulnerable. Also, circulation can be disrupted by neuropathy, which leaves feet too warm and more likely to retain water and become swollen. These are all things that cause wounds to develop earlier and heal less.

bone infection

Half of the people with diabetes and a foot wound develop a foot infection. Of these, one in five people will get an infection of a bone in the foot (osteomyelitis). Such a bone infection greatly increases the chance of an amputation.

Fortunately, problems can often be prevented or treated in time with good shoes, check the feet yourself at home and the annual check-up by a specialist.

Treatment of a diabetic foot

How does your doctor diagnose the condition?

The doctor systematically checks the feet of all people with diabetes at least once a year. He pays particular attention to sensory disorders, blood circulation disorders and deformities of the foot.

There is an increased risk in case of:

• presence of calluses with bruising,
• foot ulcers and/or infection problems in the past,
• presence of skin lesions and blisters on the foot,
• foot or toe deformities,
• poor foot hygiene,
• changes in sensation in the feet (numbness, tingling),
• poor blood flow and operations on the blood vessels in the past,
• poor blood sugar control under treatment, eye and kidney damage,
• social isolation and psychiatric problems,
• to smoke.

The doctor classifies the foot problems into one of 4 risk classes:

• Class 0: no sensory disturbances, no circulation problems, slight deformities at the foot.
• Class 1: sensory disorders, otherwise as class 0.
• Class 2: sensory disturbances, plus at least one of the following symptoms: muscle damage,

limited mobility of the joints, change in the gait and position of the foot, blood circulation disorders.

Based on these findings, he decides whether further investigation is necessary, possibly in collaboration with an orthopedic specialist and/or a vascular specialist.

What can you do yourself to prevent diabetes Foot ulcer?

To prevent a diabetic foot, the following advice is extremely important:

- Make sure your diabetes treatment is on point. A normal blood sugar level is between 80 and 150 mg of glucose per 100 ml of blood. Measure your blood sugar levels carefully, record them and adjust the treatment if necessary. If that is not possible, consult your doctor to adjust the treatment in time.

1. Watch your body weight and, if necessary, be guided by a dietician. Stop smoking.
2. Inspect your feet daily, including the soles of the feet and the space between the toes. Pay special attention to calluses, blisters, wounds, fissures and bruises.
3. Do not walk barefoot, even in the house. Wear soft socks or stockings in cotton or wool.
4. Make sure that your shoes do not pinch and check them for pressure points. Make sure they fit spacious, without pointy tops and with a wide forefoot, hard counter (inner padding at the heel) and a heel about two cm high.
5. Avoid using a hot water bottle or cherry pit pillow; never sit with your feet close to a heating appliance, because you may not feel small burns!
6. Do not use strong, irritating ointments to treat corns.
7. Foot care:

* wash your feet with a soft washcloth and lukewarm water and a non-irritating soap.

* if you have little feeling in your feet, it is useful to measure the temperature of the water. Ideal temperature is around 37°C.

* do not leave your feet in the water for more than 5 minutes. This way you prevent the skin from softening.

* dry your feet with a soft towel and don’t forget the space between the toes!

* file the nails straight so that they protrude just above the edge; use a file made of hard cardboard for this. Do not use metal nail clippers.

In many cases you are entitled to annual reimbursement of two sessions of foot care with a podiatrist. Use this to have your feet properly checked and cared for.

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What can your doctor do?

• In case of wound infection, your doctor will prescribe antibiotics and/or antifungal medication. In case of a foot ulcer, it removes dead material and the calluses around it.
• Appropriate footwear and the use of insoles help to reduce the pressure on the wound. A walking cast can be temporarily installed if necessary.
• If the wound does not heal, your doctor will seek the advice of the specialist. If necessary, treatment takes place in the hospital.
• Sometimes the infection spreads into the tissue around the ulcer (cellulitis), sometimes even into the bone. In that case, hospital treatment with high doses of antibiotics is required.
• In Charcot’s disease, a long-term plaster immobilization of up to six months and sometimes a surgical correction is indicated.

Investigation and diagnosis

• Your internist or diabetes nurse will regularly check your feet. This way we can discover wounds as quickly as possible. When examining your foot, the internist or diabetes nurse will look at:
• The sensitivity of your foot. The better the feeling in your foot, the sooner you feel a shoe pinching and the better protected you are against pressure marks and wounds.
• The blood circulation in your foot.
• Your shoes. Your foot is fragile and good footwear can help prevent problems.
• Your overall health.
• Your knowledge about diabetic feet. After all, you have to inspect your feet every day.
• Your eyes. If your eyes are not functioning properly, you will not be able to see abnormalities in your foot.
• Possible fluid buildup in your legs. This can hinder healthy wound healing.

Treatment and prevention of recurrence for foot ulcers in diabetes

The Initial question that almost everyone with diabetes mellitus usually ask is, Which interventions are effective in reducing the risk of a (recurring) foot ulcer in someone with diabetes mellitus?

Treat a pre-ulcer in someone with diabetes mellitus and an increased risk of a foot ulcer, which includes removing excessive calluses, protecting small blisters, draining large blisters, treating an ingrown nail, treating a hematoma, fungal infections of the skin and other relevant skin or nail pathology. For any patient with pre-ulcer and signs of PAD, consider whether referral to a foot team should be made

To protect the foot, advise someone with diabetes mellitus and an increased risk of a foot ulcer not to walk barefoot indoors and outdoors, only socks or slippers.

Advise anyone with diabetes mellitus and an increased risk of a foot ulcer to wear well-fitting footwear to prevent a first or recurrent foot ulcer. If necessary, involve the partner or carer. If a foot deformity or pre-ulcer is present, consider the use of an orthopedic fitting of ready-to-wear (OVAC), (semi) orthopedic footwear and/or a toe orthosis. It is recommended that these intervention(s) be checked regularly by an expert healthcare professional.

To prevent a recurrence of plantar foot ulcers in someone with diabetes and a strongly increased risk of a foot ulcer, prescribe (semi-)orthopedic footwear with a proven pressure-reducing effect during walking and motivate this person to wear these shoes. A demonstrated pressure-reducing effect means that at high pressure locations a minimum of 30% reduction of the peak pressure compared to the current orthopedic footwear, or a peak pressure 2.2°C for at least two consecutive measurements) at a location between the left and right foot, advise to reduce walking activity and to contact the primary care provider or case manager for possible further diagnosis and treatment.

In someone with diabetes mellitus, hammertoes and a pre-ulcus or ulcer on the top of a toe, consider a flexor tendon tenotomy of a toe to prevent a (recurring) toe ulcer if conservative treatment fails.

In someone with diabetes mellitus and an active plantar forefoot ulcer where conservative treatment fails, consider Achilles tendon lengthening, joint arthroplasty, osteotomy, or single or multiple metatarsal head removals to prevent recurrent foot ulcers after healing.

Do not use nerve decompression to prevent a foot ulcer in someone with diabetes mellitus and an increased risk of a foot ulcer.

Divided by diabetic foot risk classification (see Foot control module module), the recommendations are as follows:

For someone with diabetes mellitus and a slightly increased risk of a foot ulcer (Diabetic Foot Risk Classification Sims 1), take the following preventive measures:

To protect the foot, advise not to walk barefoot indoors and outdoors, only socks or slippers. If necessary, involve the partner or carer.

Advise to wear well-fitting footwear. If necessary, involve the partner or carer. If a foot deformity or pre-ulcer is present, consider shoe adjustment.

Treat a pre-ulcer, which includes protecting small blisters, draining large blisters, treating an ingrown nail, treating a hematoma and/or fungal skin infections. For any patient with pre-ulcer and signs of PAD, consider whether referral to a foot team should be made.

For someone with diabetes mellitus and an increased risk of a foot ulcer (Diabetic Foot Risk Classification Sims 2), take the following preventive measures:

To protect the foot, advise not to walk barefoot indoors and outdoors, only socks or slippers. If necessary, involve the partner or carer.

Advise to wear well-fitting footwear. If necessary, involve the partner or carer. If a foot deformity or pre-ulcer is present, consider shoe modification or use of orthopedic footwear or toe orthosis.

Remove excessive calluses, treat a pre-ulcer, which includes protecting small blisters, draining large blisters, treating an ingrown nail, treating hematoma and/or fungal skin infections. For any patient with pre-ulcer and signs of PAD, consider whether referral to a foot team should be made.

Consider a flexor tendon tenotomy of a toe if conservative treatment fails in someone with hammertoes and a pre-ulcer on the tip of a toe

For someone with diabetes mellitus and a greatly increased risk of a foot ulcer (Diabetic Foot Risk Classification Sims 3), take the following preventive measures:

Provide integrated foot care, consisting of professional foot treatment, appropriate footwear (see above), and education, which is repeated or evaluated every month for up to three months. See below for the content per measure.

Click to Watch this simple video on: How to Cure/ Manage Diabetes Without Drugs

To protect the foot, advise not to walk barefoot indoors and outdoors, only socks or slippers. If necessary, involve the partner or carer.

Advise to wear well-fitting footwear. If necessary, involve the partner or carer. If a foot deformity or pre-ulcer is present, consider shoe modification or use of orthopedic footwear or toe orthosis.

For people with a plantar foot ulcer, prescribe (semi-)orthopaedic footwear with a proven pressure-reducing effect during walking and motivate this person to wear these shoes. A demonstrated pressure-reducing effect means that at high pressure locations a minimum of 30% reduction of the peak pressure compared to the current orthopedic footwear, or a peak pressure <200kPa (if measured with a validated and calibrated pressure measurement system with a sensor size of 1cm2) is achieved.

Remove excessive calluses, treat a pre-ulcer, which includes protecting small blisters, draining large blisters, treating an ingrown nail, treating hematoma and/or fungal skin infections. For any patient with pre-ulcer and signs of PAD, consider whether referral to a foot team should be made.

To prevent a recurrent foot ulcer, consider advising someone with diabetes mellitus and a greatly increased risk of a foot ulcer to measure the skin temperature once a day at risk locations under the foot with a thermometer intended for that purpose. This serves to identify inflammation as an early signal of tissue damage. If necessary, involve the partner or carer. In the event of a persistently increased temperature difference (>2.2°C for at least two consecutive measurements) at a location between the left and right foot, advise to reduce walking activity and to contact the primary care provider or case manager for possible further diagnosis and treatment.

Consider a flexor tendon tenotomy of a toe if conservative treatment fails in someone with hammertoes and a pre-ulcer or ulcer on the tip of a toe.

Consider if conservative treatment fails in someone with a plantar forefoot ulcer, Achilles tendon lengthening, joint arthroplasty, osteotomy, or single or multiple metatarsal head removals.

Considerations and recommendations

1

The benefits of treating a pre-ulcer clearly outweigh its drawbacks. Nothing is known about complications of treating a pre-ulcer. Instrumental foot care to treat a pre-ulcer is easy to apply by a foot care professional at relatively low cost. However, the cost-effectiveness is unknown.

Based on the positive balance of benefits versus harms and the relatively low cost, we recommend treating pre-ulcer in people with diabetes mellitus and an increased risk of foot ulcer, which includes removing excessive calluses, protecting small blisters, drainage of large blisters, treating nail ingrowth, treating hematoma and fungal skin infections

2

Some patients prefer to walk barefoot at home, with only socks or slippers. The advantages of walking barefoot, only socks or slippers compared to adequate footwear probably do not outweigh the disadvantages. In addition to the high pressure under the foot, there are other possible adverse effects such as lack of protection against thermal or external trauma.

Based on the increased risk of foot ulcers, we recommend that people with diabetes mellitus and an increased risk of foot ulcers, to protect the foot, not walk barefoot indoors and outdoors, only socks or slippers.

3

There are no controlled studies on the specific role of footwear in the prevention of non-plantar foot ulcers. However, poorly fitting footwear is a major cause of non-plantar foot ulcers (Apelqvist, 1990), suggesting that well-fitting footwear prevents ulcers. Patients with a foot deformity or pre-ulcer may require further footwear adjustments, which may include orthopedic footwear or a toe orthosis

It seems that the benefits of wearing well-fitting footwear outweigh the drawbacks. Patient preferences are unknown. Little is known about patients’ compliance with wearing well-fitting footwear before an ulcer has developed. Our clinical experience is that patients do not prefer to wear “large” orthopedic shoes if they have not had a foot ulcer before. The cost-effectiveness is unknown.

Based on the above, we recommend that someone with diabetes mellitus and an increased risk of a foot ulcer be advised to wear well-fitting footwear to prevent a first or recurrent foot ulcer. If a foot deformity or pre-ulcer is present, consider the use of orthopedic footwear or a toe orthosis.

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4

The advantages of continuously wearing orthopedic shoes with proven pressure-relieving effects outweigh the possible disadvantages. The available RCTs have reported few or no complications related to this shoe use. Practitioners should motivate and encourage patients to wear orthopedic footwear at all times. The cost of prescribing orthopedic footwear with demonstrated pressure-relieving effect can be significant because a barefoot pressure measurement or in-shoe pressure measurement is required, for which equipment is currently relatively expensive. However, these costs should always be considered in relation to the yield of ulcer prevention. Cost-effectiveness is unknown, however, in our opinion, orthopedic footwear designed and/or evaluated using foot pressure measurements will be cost-effective if the ulcer risk is reduced by 50% (an effect that has been demonstrated in most RCTs on this topic) .

Based on the average quality of the evidence, the advantages that outweigh the disadvantages, the low rate of complications, some resistance of patients to wear these shoes and the assumed cost-effectiveness, we recommend (semi-)orthopedic footwear with a proven pressure-relieving function. effect during walking to patients with a strongly increased risk of a foot ulcer and to motivate the patient to wear these shoes, in order to prevent a recurrence of plantar foot ulcers. A demonstrated pressure-reducing effect means that at high pressure locations a minimum of 30% reduction of the peak pressure compared to the current orthopedic footwear, or a peak pressure <200kPa (if measured with a validated and calibrated pressure measurement system with a sensor size of 1cm2) is achieved.

An implementation barrier to complying with the recommendation regarding orthopedic footwear with a proven pressure-reducing effect during walking is the availability of (adequate) pressure measuring equipment. Not all centers or orthopedic shoe technology companies in the Netherlands have an electronic pressure measurement system, even though this number is growing rapidly. A solution for this is to refer patients for a pressure measurement to an institution or company that can do this measurement.

5

The effectiveness of education to prevent a first foot ulcer has not been demonstrated and no information is available on costs or cost-effectiveness. Despite the absence of controlled studies in this area, the working group believes that patients at increased risk for foot ulcers should be educated. This education should consist of information about foot complications and their consequences, about preventive behaviour, such as wearing adequate footwear and self-management of foot health and seeking professional help in a timely manner if the patient notices a foot problem.

Based on expert opinion, we recommend that people with diabetes mellitus who are at increased risk of a foot ulcer should be given education to promote foot care knowledge and behavior and motivate the patient to follow the advice .

6

The benefits of integrated foot care probably outweigh the drawbacks. None of the studies reported a complication or other risks of integrated foot care. No information is available on costs and cost-effectiveness of integrated foot care. A recent publication from the United States did show a sharp increase in costs in hospital admissions for a diabetic foot ulcer after Medicare removed reimbursement for preventive foot care by the (diabetes) podiatrist from the insurance package in one US state (Skrepnek, 2014).

Based on a likely positive balance of benefits versus harms, the working group recommends that people with diabetes mellitus at high risk of a foot ulcer should receive integrated foot care to prevent a recurrent foot ulcer.

7

The benefits of measuring skin temperature under the foot at home most likely outweigh the drawbacks, which were not reported in any of the studies. Patient preferences are unknown. The method is easy to use, inexpensive and is likely to enhance the patient’s self-management of foot care. However, adherence to foot temperature measurement was an important factor in the RCTs and some patients, especially those who have not yet experienced foot ulcers, may experience the need for daily measurement as a burden. False-positive and negative outcomes can potentially cause unwarranted concern for patients and erode confidence in the method. The cost-effectiveness of the method is unknown; this technique can also be experienced as too burdensome, for example in the elderly.

Based on a most likely positive balance of benefits versus harms, especially in patients with a previous foot ulcer, the working group recommends that in people with diabetes mellitus and a strongly increased risk of a foot ulcer, the daily skin temperature at risk locations below should be considered. to have the foot measured to prevent a recurrent foot ulcer. Good and concrete agreements on when/who should be approached in the event of deviations are important here.

8

Flexor tendon tenotomy

The potential benefits of flexor tendon tenotomy probably outweigh its drawbacks, as only a few complications have been reported. Patient preferences are unknown. The procedure is easily performed on an outpatient basis without the need for immobilization of the leg and does not appear to adversely affect foot function, although there is no known study. Costs and cost-effectiveness are unknown.

Based on the lack of evidence from controlled studies, the likely benefits to outweigh the risks, the low complication rate and ease of procedure, the working group recommends considering a flexor tendon tenotomy to prevent a foot ulcer in a patient. with diabetes mellitus and an increased risk of foot ulcers, if conservative treatment proves unsuccessful.

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Achilles tendon lengthening, resection, arthroplasty and osteotomy

Possible complications of Achilles tendon lengthening, resection of one or more metatarsal heads, arthroplasty of the base of the proximal phalanx of the hallux, and a erecting osteotomy of a head or base of a metatarsal include postoperative infections, new deformities, the occurrence of acute Charcot neuro-osteo -arthropathy, walking difficulties and ulcers in other areas of the foot. It is therefore not clear whether the advantages outweigh the disadvantages. These surgeries can be performed in patients with an active foot ulcer — with adequate blood flow and no signs of infection — that heals poorly under conservative treatment. These interventions can also be considered if it is expected that there is a high risk of a recurrent foot ulcer if the foot structure is not changed. The costs for these procedures are higher than for conservative treatment, but cost-effectiveness is unknown. The practitioner should discuss the consequences and risks of these procedures with the patient.

Based on a limited number of controlled studies showing major effects, the unknown whether the benefits outweigh the harms and the higher expected costs compared to conservative treatment, the working group recommends in someone with diabetes mellitus and an active foot ulcer requiring conservative treatment. fail to consider Achilles tendon lengthening, resection of one or more metatarsal heads, arthroplasty of the base of the proximal phalanx of the hallux, or an erecting osteotomy of a head or base of a metatarsal to prevent a recurrent plantar forefoot ulcer after healing.

Nerve Decompression

In studies of the effect of nerve decompression, no comparison has been made with the accepted standard of preventive foot care. Since several alternative interventions are available, and given the risks, disadvantages and costs of this procedure, the working group recommends that nerve decompression should not be used as an intervention for the prevention of a foot ulcer in someone with diabetes mellitus and an increased risk of foot ulcer, until more evidence for the effectiveness of this intervention based on good quality research is available.

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Originally published at https://khalories.com on October 6, 2021.