Due to weakened immunity, injuries often become infected and can easily result in amputation of the affected area. Infections are difficult to treat due to the effects of arteriopathy, which reduces the blood flow to the legs and feet. Studies have shown cases of infections being so severe that they result in death, and diabetic foot and ankle complications are currently the most common cause of amputations in the developed world. The presence of neuropathy and arteriopathy perpetuates foot deformity, which further increases the chance of foot injuries occurring.
The prevalence of diabetes is continuously increasing not only in India but also all over the world. In India, the prevalence of diabetes is very high. According to the Indian state report on diabetes, the percentage of diabetes in India is 12.1%, which is very high compared to other countries. The major concern about diabetes is its complications, which occur in different parts of the body. One of these complications is the diabetic foot and ankle. The diabetic foot and ankle is a symptom complex characterized by neuropathy, weakened immunity, arteriopathy, and metabolic abnormalities in the skin. High levels of blood sugar are a prime cause of neuropathy (damage to the nervous system that can lead to numbness in the extremities), and this nerve damage makes the patient more susceptible to injury. This is often unfamiliar to the patient, despite causing severe damage to the nervous system and loss of proper function in foot muscles.
Overview of diabetes and its impact on foot and ankle health
Even though this has been known to be an extremely destructive disease by nature, there still is hope towards maintenance and prevention measures for the feet.
Each year, about one-third of diabetics in America have foot-related problems requiring medical attention. High blood sugar levels over a long period of time is another factor that can lead to the crippling of feet in diabetics. Uncontrolled diabetes can cause significant damage to the muscle, skin, and bone; an extreme case of damage to bones and joints is known as Charcot foot. Recognizing the early stage of Charcot foot is essential in treating the disease.
The most dramatic and severe consequences of diabetes are seen in the lower extremities. A high percentage of diabetics require amputations because of complications of the disease. Infections are common because of poor blood circulation. Wounds heal poorly, and often the development of ulceration can be a sign of bone infection; this may result in higher amputation, even of the entire limb.
Nerve damage causes loss of feeling in your feet, taking away your ability to feel pain and changes in temperature. You may not feel a pebble inside your sock, blister, or a sore. Damage to the blood vessels causes problems with the blood flow to the feet. With no or a slow healing response to infection, the following could result in ulceration and infection being present, and an infection may lead to amputation.
Diabetes is a serious, potentially worldwide health-threatening condition that affects most of our body’s functions. There are close to 16 million people in the United States with diabetes, who account for 15% of the population diagnosed with this condition. Five to ten percent of diabetic patients will develop foot problems severe enough to require amputation. Amputation affects 8% of people with diabetes. Foot problems in diabetes are usually caused by damage to blood vessels and nerves.
Common Foot and Ankle Problems in Diabetics
Foot pain is often followed by the bent appearance of the toes. This is caused by atrophy of the intrinsic foot muscles. Foot and ankle problems in diabetics are wide and varied and can often have serious implications. It is not the case that problems are inevitable, with careful monitoring and maintenance of the diabetes, foot problems can be avoided. The trouble is that there is great propensity for foot problems to go undetected until they become more severe with a more serious impact on the individual. To avoid complications, it is useful for the individual to carry out regular self-examinations of the feet, a family member or carer can also help with this. The individual should look out for any skin damage or color change, the skin temperature, condition of the toenails, presence of hair on the foot or lack of, any pain or discomfort, and any change in shape or size of the foot. If the individual detects any problems, they should seek the advice of a health professional. High-risk patients (those with changed foot shape, loss of sensation, or peripheral arterial disease) may be eligible for referral to a foot protection service with a chiropodist/podiatrist and in some cases a foot protection team (including a diabetologist, podiatrist, orthotist, and/or foot surgeon and specialist nurses). Regular assessments and appropriate objective setting can help to prevent problems and improve foot health.
Foot pain in diabetics
If the pain is under a specific area, it may be caused by a corn or callus. A corn is an area of hard skin which is often painful and causes discomfort when wearing shoes. Hard skin is often caused by ill-fitting footwear. A corn is a small area of concentrated hard skin. A callus is a larger area of hard skin, which often has a wide base and these are usually painless. A corn can be removed by a chiropodist. A chiropodist or podiatrist can remove hard skin to relieve the discomfort of a callus.
Pain in the forefoot, which is the front of the foot before the toes, is a common problem that may be due to the collapse of the transverse arch. This is an arch that runs width-ways across the foot. As it collapses, the joints in the foot above it become forced out of their normal alignment and this makes them painful. This problem may be helped with specially made insoles that will support the arch.
Any blow or damage to a foot should be given special consideration if you are diabetic because of the risk of infection developing in the damaged tissues. Damage may be caused by ill-fitting shoes or socks. Studies have shown that ill-fitting footwear is a common cause of foot pain in diabetes. Footwear choice can prevent pain if the shoes are well-fitted and supportive.
Foot pain is a major problem in diabetes. The pain can be caused by a number of different problems, some of which can be successfully treated. In fact, sometimes the pain or discomfort will be the early warning that a foot problem is developing. Any change in sensation to the feet should be acted upon. This is especially so if it is a new symptom and has developed quickly.
Ankle pain in diabetics
In a recent survey, over 37% of 300 diabetics (with the average age of 45 years) reported that they had significant, persistent ankle pain during the previous year. It has been noted that pain in the ankle joint has debilitating effects on both mobility and quality of life. It also appears that pain from non-traumatic causes is significantly more common in people with diabetes since the odds of diabetics having ankle pain is roughly 1.1 to 1 compared to 1 to 1 for those without diabetes. The reason for this increase is likely multifactorial. People with diabetes are at increased risk for musculoskeletal problems secondary to metabolic disease. Edema, ligament laxity, Charcot neuroarthropathy, and tenosynovitis have all been reported to be more common in diabetic patients, and all can lead to pain in the ankle joint. Another reason is that diabetics are at increased risk for peripheral neuropathy. In the aforementioned survey, the odds ratio for ankle pain in diabetics with sensorimotor polyneuropathy was 2.9 to 1 compared to diabetics without neuropathy. This is significant since neuropathic ankle and foot pain can be particularly severe and is often chronic. Pain of a neuro-ischemic nature can also be intense and is often due to necrosis or osteomyelitis in the setting of peripheral vascular disease. An additional factor to consider is that diabetics are prone to traumatic ankle injuries due to an increased risk of falls and a decrease in bone quality which predisposes them to fracture following low energy trauma. All these elements make ankle pain a common, often underappreciated aspect of diabetes and are a frequent cause of increased morbidity in affected patients.
Preventive Measures for Diabetic Foot and Ankle Health
In order to prevent a foot ulcer, regular podiatry treatment is advised to remove callous and manage nail care. This can be done by a state registered chiropodist or podiatrist ideally with experience in diabetic foot care. A diabetic with a history of foot problems and particularly one with neuropathy should avoid high street beauty salons where the risk of infection is high. Podiatry treatment is widely available in the NHS, and if you meet clinical criteria, a referral can be made by your GP. Often a foot with neuropathy will have deformity, but customized orthoses can be used to redistribute pressure and prevent skin breakdown on an at-risk area. If an ulcer does occur, it should be treated as a medical emergency due to the risk of infection and complication. Treatment is usually based on removing pressure, infection control, and wound care. An unhealed ulcer or a history of multiple ulcers is the prime indication for orthopedic referral to prevent further complications.
Neuropathy can affect sensory, motor, and autonomic nerves. It can result in muscle weakness, loss of sensation, and muscle imbalance leading to structural changes and deformity. The foot is at particular risk due to the nerve supply being longest and most prone to damage. A diabetic with neuropathy may not feel an irritation due to pressure from footwear or a minor injury from walking barefoot inside or out. An unnoticed high-pressure area on the foot can result in a callous, and in combination with motor neuropathy, a chronic callous can lead to an ulcer. Loss of autonomic nerve function makes the skin dry and hairless, so it no longer protects the foot from pressure and shear forces. This makes the foot more prone to skin breakdown.
Preventive measures can be taken to avoid complications in diabetes affecting the foot and ankle. These can be of great importance and well worth the effort in the long term for the diabetic. The cornerstone to preventing complications is to achieve a stable blood sugar. This is a difficult task and often requires the assistance of a diabetic nurse specialist, dietician, and/or your GP, in addition to your physician. It involves regular monitoring of your blood sugar and HbA1c, and the use of medications to control blood sugar and avoid highs and lows. By effectively managing blood sugar, a diabetic can avoid circulation complications and neuropathy that greatly increase the risk of infection and ulceration in the feet.
Importance of regular foot examinations for diabetics
One of the primary reasons for this finding is the high-risk diabetic patient’s lack of awareness of foot problems. Many people are simply unaware that high blood sugar levels can cause damage to nerve fibers, which can lead to a loss of sensation in the feet. It can also lead to narrowing of blood vessels and reduced blood flow to the feet. These conditions increase the time taken for a cut or blister to heal and increase the risk of infection. In severe cases, a chronic non-healing wound can form, and there is a risk it may become infected and lead to ulcers, cellulitis, and abscesses. It is estimated that one in ten diabetics will get a foot ulcer. Indeed, many of these problems can be prevented with increased awareness and preventative measures.
Research has shown that preventing wounds can significantly reduce the risk of amputation. The best way to prevent wounds is through a regular foot assessment and routine preventative care. Foot assessment has been ranked number one on the National Health Service’s list of the 15 measures that will prevent diabetes-related amputations. A recent research and meta-analysis published in the Journal of the American Medical Association supports this fact. The study drew the conclusion that regular foot assessments, patient education, and routine preventative care were the most effective means of preventing ulcers and amputations.
A diabetic foot ulcer is a divergent condition that can lead to amputation. People with diabetes are at a high risk for developing a kind of chronic wound. High blood sugar levels cause harm to the nerves and affect blood circulation. It also reduces the skin’s resistance to infection. These factors make it easy to comprehend why diabetes is the leading cause of below the knee amputations.
Proper footwear and foot care for diabetics
Proper footwear is an essential part of preventing diabetic foot complications. It is important to wear the right type of shoes. There are several things to consider when choosing shoes such as activity level, foot shape, previous history of ulcerations, and general fitting guidelines. Often times, diabetics require extra depth shoes to accommodate custom molded insoles or orthotics. In these cases, it’s important to ensure that the top of the shoe is high and wide enough that it does not rub against the toes. Certain foot deformities such as hammertoes or bunions require shoes with a wide and deep toe box to prevent rubbing. If there is a history of foot ulcerations, it is important to recognize the cause of the ulcer. If it was due to excessive pressure on one part of the foot, the shoe at that site should be modified to relieve pressure. This can be done using special shoe inserts or modifications done by a pedorthist. In some cases, an “offloading” shoe or boot is required to completely take weight off the affected area. This can be seen with a patient who has a diabetic foot infection and requires a total contact cast to offload the foot and promote quicker healing.
Managing blood sugar levels to prevent complications
An aspect of blood sugar control that is often overlooked is the effect of diet and exercise. The body’s supply of glucose is closely regulated with a balance of glucose production and glucose utilization. When a person takes insulin or other hypoglycemic medications, it is important to match the dose with the body’s needs. Giving too much insulin to a person who then goes and exercises vigorously can be quite dangerous. This is because the exercising muscles will take up glucose at a much faster rate than usual. On the other hand, giving the usual insulin dose to a person who is ill in bed and eating less food will also cause problems, as the reduced glucose production will not be matched by the insulin dose and will lead to high blood sugar levels. A similar effect can be seen with alcohol consumption. People with diabetes are recommended to avoid consumption of large amounts of alcohol on an empty stomach as this can cause dangerously low blood sugar levels. In any case, alcohol and mixers contain a lot of sugar and act to raise blood sugar levels over the proceeding hours. By observing the above relationships and planning the timing and type of meals, a person with diabetes can exercise a great deal of control over their blood sugar levels. This is of great importance as diabetes management is a day-to-day task and small mistakes can accumulate over time to cause complications.
In recent decades, there have been a range of breakthroughs in the technologies used to monitor blood glucose levels. Home blood glucose meters are smaller, faster, and more accurate than they used to be. At any given time, a person can use the meter to test a small sample of blood (obtained by pricking the finger with a lancing device) and get an accurate measure of their blood sugar level. This is the basic equipment used for day-to-day management of diabetes, but there are now more advanced methods available.
Historically, people with Type I diabetes would test their urine for the presence of glucose, using Clinistix or similar reagent strips. When blood sugar levels were elevated, glucose would “spill” into the urine. By testing the urine several times a day, a person could make an estimate of their blood sugar level. This method is far from accurate, but does show that people have been interested in monitoring their blood sugar levels for many years.
High blood sugar levels can cause damage to the blood vessels, interfere with the immune system, and impair the body’s ability to heal. When a person has diabetes, these complications are magnified. The good news is that by managing blood sugar levels, a person can prevent or control many of these conditions. This includes damage to large blood vessels (e.g. in the legs) and also the microvascular damage that affects the eyes, kidneys, and nerves.
Treatment Options for Diabetic Foot and Ankle Problems
Deformity correction: Patients with ankle or hindfoot deformities may be candidates for reconstruction arthrodesis or osteotomy. The athletic or very active patient may be best served with reconstructive procedures so as to optimize joint motion and function. In patients with fixed bony deformities and no possibility for continued joint preservation, arthrodesis remains the procedure of choice to relieve pain and stabilize hindfoot and ankle. Osteotomies are used to relocate bony prominences so as to re-establish normal foot anatomy.
Pes planovalgus: Charcot foot or ankle may coexist with numerous deformities. Long-standing hindfoot deformity, for instance, may lead to a round calcaneal deformity with loss of the longitudinal arch. A varus heel may lead to lateral ankle instability.
Insulin-dependent diabetics with plain radiographic changes and/or attendant peripheral hypoesthesia or neurologically impaired feet may often, as not, have symptomatic pes planovalgus.
Medications and therapies for foot and ankle pain in diabetics
Physical therapy is a beneficial and often underused modality for painful foot and ankle conditions in diabetics. Many patients with painful diabetic neuropathy benefit from balance activities and strengthening exercises to reduce the risk of falls and injuries related to weakness and sensory loss. Several published studies have shown that specific exercise therapy improves physical function in patients with diabetes, but the literature is lacking in foot and ankle specific conditions. Orthoses may be used to provide support, protection, and off-loading for painful foot and ankle conditions. Accommodative orthotics offer support and cushioning to reduce pressure and shearing forces on painful neuropathic ulcers. Functional orthoses, including ankle foot orthoses (AFOs), may be used to improve gait, provide support for weak musculature, and decrease deformity in patients with diabetic Charcot arthropathy or neuropathy. A variety of orthotic modifications may be employed to provide off-loading to painful foot conditions secondary to acute or chronic trauma. While orthoses are a viable intervention for many foot and ankle conditions, controlled studies and evidence of their efficacy in diabetics are often lacking.
Many treatment options are available for patients with diabetes and painful foot and ankle conditions. Initial therapy should be directed at the control of blood sugar levels and prevention of diabetic neuropathy. Appropriate pain medications may be used singly or in combination to provide pain relief. Medications including NSAIDs, opioid narcotics, and other analgesics may be used for painful neuropathic or musculoskeletal conditions. Topical medications, including capsaicin and lidocaine, may be of benefit for local pain relief. In patients with diabetic neuropathy, the use of tricyclic antidepressants or anticonvulsant medications may lessen symptoms. Though these medications are commonly used, evidence of their effectiveness specific for foot and ankle pain in diabetics is often lacking.
Surgical interventions for severe diabetic foot and ankle conditions
Surgical intervention for diabetic foot and ankle problems usually falls into one of three categories: attempting to heal the wound, preventing future wounds, or fixing a deformity. The most common of these is attempting to heal a wound, whether it is infection or ulcer. There are several studies that show good results for healing diabetic foot ulcers through surgical debridement. While this may not always fall under the context of “healing a wound,” removal of a Charcot deformity may be done in an attempt to prevent an ulcer from occurring. Fixing a deformity can be more complex. It is not uncommon for a diabetic to exhibit a partially torn peroneal tendon leading to a flatfoot deformity; an operation may be done to clean the tendon and tenosynovium followed by a split-thickness tendon transfer and lateral ankle reconstruction. High arch deformities can be particularly difficult to fix, and the surgery may not always yield positive results in the diabetic. A last-ditch effort to fix chronic foot and ankle problems may be arthrodesis of one or more joints. While this effectively stops all movement at the joint and can remove pain, it also can significantly alter one’s gait and lead to further ulceration at a different site.
