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Foot wounds are a major source of concern
for people with diabetes. Simple sores can lead to infected
ulcers and serious complications. Daily inspections
of your feet are the best way to prevent infections,
but if they do occur, you need a healthcare team with
special expertise in diabetic foot problems.
Cyrus Mitchell was putting on his shoes
back in February of 2002 when he experienced pain in
his right foot, which was beginning to swell. The 48-year-old
Newark man had been diagnosed with Type II diabetes
four years earlier in 1998, and he knew that this wasn't
something he should shrug off. He took a step in the
right direction and sought treatment from his podiatrist.
Mr. Mitchell was hospitalized
and given intravenous antibiotics to ward off infection,
but a sore between his fourth and fifth toes was filled
with pus. Dr.
George F. Wallace, director of podiatry services
at University Hospital, told him that he might lose
those two toes, and ultimately, that was the case. Mr.
Mitchell, who now wears specially designed shoes, is
back to work and relieved that his loss wasn't more
severe.
"I'm grateful that the infection
was caught when it was, and that I didn't lose the foot,"
he says. "It could have been much worse."
That's true. Foot wounds are a major
source of concern for people with diabetes. According
to the American Diabetes Association (ADA), 15 percent
of diabetics will develop a foot ulcer (an open sore
on the foot), and between 14 percent and 24 percent
of that group will require some type of amputation.
Actually, the risk of leg amputations is 15-40 percent
higher for someone with diabetes, and each year, more
than 82,000 people lose their foot or leg to diabetes.
The decision to amputate never is taken lightly, and
as little is removed as possible.
Diabetes is a chronic disease in which
a person's body doesn't produce enough insulin or properly
use it. Now it is recognized as a public health concern
of epic proportions that's expected to increase even
more. "In 2002, about 13 million people had been
diagnosed with diabetes, with another 5.2 million people
unaware they had the disease," says Dr. Wallace.
"It's estimated that by 2050, 29 million people
will have diabetes-an increase of 165 percent."
Type II, or adult onset, diabetes accounts
for most cases of the disease. People who are overweight,
have a family history of diabetes, are over age 45,
were gestational diabetics (women who had high blood
sugar levels during pregnancy), or are African American,
Latin American, Native American, or Asian and Pacific
Islanders, have a higher risk of developing diabetes
than others. Symptoms of Type II diabetes include extreme
thirst, excessive urination, unexplained weight loss,
blurred vision, and tingling or numbness in the hands
or feet. However, some people never experience any signs
of the disease.
Diabetes affects many areas of the body,
especially the kidneys, eyes, and feet. "Uncontrolled
diabetes can lead to poor circulation. The feet contain
tiny blood vessels that are far away from the heart,
which adds to the circulatory problem," explains
Dr. Wallace. "The nervous system is also affected,
causing what is known as diabetic neuropathy. This nerve
damage reduces or completely eliminates the patient's
ability to feel pain in the feet. If he or she is not
daily checking their feet for changes in the skin, they
could develop an infection and not even be aware of
it." Among diabetics, those most at risk to develop
these sores are people who have had the disease for
more than 10 years and those who have poorly controlled
diabetes or other diabetic complications. If the patient
has peripheral vascular disease, for example, a wound
can take longer to heal.
The sole, or plantar surface, of the
foot is the most common location for an ulcer. Problems
can begin with something as seemingly innocuous as a
bunion or a hammertoe and a poorly fitting shoe that
rubs against these deformities. The pressure breaks
down tissue, and an ulcer can very quickly develop.
That's a critical time for medical intervention. "Not
all ulcers are infected, and there are excellent treatments
that can be used to keep them that way," says Dr.
Wallace, who is board certified in podiatric foot and
ankle surgery and podiatric orthopaedics. One method
is to "off load" pressure from the affected
foot with the use of special orthotics, sandals, shoes,
padding, or walking casts.
If an ulcer is infected, the goal is
to prevent spread into the bone and/or tissue death,
or gangrene. The patient may be hospitalized, and a
two-prong approach begins: oral or intravenous antibiotic
therapy and an incision and drainage surgery to clean
up the site. Three to five days after the first surgery,
a second procedure is done to close the wound. Often,
timely intervention is effective enough that amputation
can be avoided or, as in Mr. Mitchell's case, be minimal.
"People are often afraid to seek treatment when
they have a foot ulcer. They assume that there's a need
for amputation, or that if they lose one toe, they lose
their sense of balance, which isn't true," says
Dr. Wallace. "The fact is, the sooner they come
in, the more we are able to help them."
It's important for patients to remain
vigilant after treatment. Research indicates that among
people who have had foot wounds, more than half develop
another within two to five years. Regular visits to
a podiatrist and wearing shoes with diabetic inserts
designed to redistribute pressure along the foot can
be helpful in preventing recurrence.
In the most severe scenarios, a foot
or a leg is amputated to save the patient's life. In
all, an estimated 67,000 diabetes-related lower-extremity
amputations are performed each year in America. Dr.
Wallace is among those healthcare professionals who
believe that number can be reduced if people with diabetes
practice preventive foot care, keep their blood sugar
levels well controlled, and stop smoking.
Team Players in Diabetic Foot
Care
It takes a comprehensive, team approach
to address the many facets of diabetes, and podiatrists--foot
and ankle specialists--play a key role. Doctors of podiatry,
like their medical doctor counterparts, complete four
years of post-graduate education; however, they attend
podiatric medical colleges. Their course work includes
anatomy, histology, physical diagnosis, pharmacology,
radiology, and surgery, as well as clinical rotations
at affiliated hospitals. Afterward, podiatrists typically
complete a two- to three-year residency, rotating in
areas from orthopaedics to sports medicine. They can
also become board certified in certain specialties.
In addition to treating the "every
day" foot complaints--hammertoes, heel spurs, and
corns--podiatrists are well versed in keeping diabetic
feet healthy. Along with its staff podiatrists, University
Hospital has a certified diabetes educator available
to answer questions during the diabetic foot clinic
held every Friday.
"ADA guidelines call for the primary
care physician to examine a diabetic patient's feet--with
socks and shoes removed--at every visit," says
Dr. Wallace, "but that doesn't replace the need
for regular podiatric care." A newly diagnosed
patient typically is referred to a podiatrist for a
complete foot exam, which provides a "baseline"
for the specialist to refer to in future visits and
the opportunity to address any concerns, such as thickened
toenails that need trimming. The patient receives comprehensive
instruction in daily foot care, from keeping feet clean
to recognizing changes in the skin.
After the initial visit, says Dr. Wallace,
the patient might be asked to return in a year, six
months, or three months for another exam--it all depends
on the condition of the patient's feet. But he says
patients with diabetes should take a careful look at
their feet every day.
"The most important part of preventive
diabetic foot care is daily inspections," he says.
"People with diabetes need to check their feet
every day, or have someone in their household look for
them. Unfortunately, because of diabetic neuropathy,
these patients can't rely on how their feet feel. The
best time to check is after a shower or bath while drying
the feet."
"Above all, patients
shouldn't panic or procrastinate. Early treatment can
be beneficial and possibly eliminate any need of amputation.”
As for Mr. Mitchell,
Dr. Wallace says he’s “doing great.”
“He’s doing an excellent
job of managing his diabetes, inspecting his feet, and
visiting us regularly,” he says. “When our
patients are compliant as Mr. Mitchell has been, that’s
when we know we’ve been successful.”
To make an appointment
with University Hospital's Podiatry Services, call (973)
972- 2500.
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