Care of the Diabetic’s Feet
My husband’s uncle always liked to joke that he had had “a good understanding”. No, he wasn’t referring to the wisdom he had accumulated during his 80-plus years of life. He was simply laughing about his very big feet which “stood under” him for all those years.
A diabetic needs to have “a good understanding” too. He needs healthy feet to stand under him all through his life. But he also needs the wisdom to know how to keep his feet healthy in spite of his diabetes.
As we saw briefly in the previous chapter, the diabetic has a serious risk of foot complications. In Singapore alone, there are about 200 amputations each year because of diabetes. In Malaysia, if you don’t count those amputations which occur because of motor vehicle accidents, 90 percent of the amputations performed are on diabetics.
The International Diabetes Federation estimates that foot problems are the reason for 47 percent of all the days which diabetics spend in hospitals for problems related to their diabetes.
Let’s take a closer look at the various causes of foot problems in the diabetic. Then, because so many diabetics have preventable foot complications, we will take a good look at what can be done to protect the diabetic’s feet.
In the last chapter we saw how diabetes may cause damage and narrowing of the blood vessels of the legs in what we call peripheral vascular disease or peripheral artery disease. Many people develop circulation problems in their feet and legs when they are between 60 and 75 years of age. A diabetic, however, may begin having those circulation problems 10 or more years earlier in life.
In the early stages of peripheral artery disease, as the arteries begin to narrow, the blood still circulates adequately for normal activity. However, during exercise—such as taking a walk—the blood flow is not sufficient. When the muscles fail to eat enough blood supply, they may start to cramp after a short distance. The cramping may be in just one leg or in both, and it may occur in the hip, the buttock, the thigh muscle, or the calf of the lower leg. After a short rest, the blood circulation catches up and the cramp usually goes away. This rather predictable cramping is called intermittent claudication.
As the arteries of the feet and legs become harder, the cramping symptoms which used to come only during exercise begin to come even when the person is resting. This can be a warning sign that the feet are not getting enough blood circulation. When such “rest pain” occurs in the diabetic, there is a real danger that the muscles and other tissues may die—the condition we know as gangrene.
With poor circulation, the person may have cold feet. The hair on his feet or legs may gradually fall off. His feet may become red whenever he is sitting with his feet hanging down and not touching the floor. As the condition worsens, ulcers may form on the toes or on the bony parts of the foot.
When the diabetic does develop poor circulation, wounds and infections do not heal as well or as quickly as they should. Even antibiotics may not be effective when the blood circulation is poor. The medicines, oxygen and nutrition are not able to reach the affected area to help in the germ killing and healing process. Then gangrene may develop, and it may become necessary to amputate one or more toes, a foot, or even a leg.
If the large arteries of the legs become narrowed, blood clots form more easily. If a clot breaks loose from where it was formed, it may travel to where it completely blocks a large blood vessel of the leg. This is a very serious condition, and is likely to result in gangrene in whatever part of the leg is below the blockage.
In addition to blood vessel damage, a person with diabetes may also have damage to the nerves of the legs—what we called peripheral neuropathy. This is the biggest cause of foot amputations in diabetics.
Having either nerve or blood vessel disease alone is bad enough. But in both the nerves and the blood vessels of the feet and legs are damaged, that spells double trouble! With nerve damage, the diabetic doesn’t feel that he is being injured. Then, with blood vessel damage, that injury doesn’t heal like it should. Foot injuries and their resulting infections can be very serious in anyone with diabetes.
A person with peripheral neuropathy may experience numbness, tingling, weakness, burning or pain. These symptoms usually begin in the fingers or toes and move up the arms or legs. They are usually worse at night and less in the morning.
There are some real dangers of peripheral neuropathy. Because of the numbness or loss of feeling, a person may not feel pain, heat, cold or pressure. Without pain as a signal of trouble, the diabetic may get burns, blisters or other injuries and develop a serious infection before he even knows he has been hurt.
The little grain of sand that I felt in my walking shoe this morning soon caused enough annoyance that I stopped, sat down, and took off my shoe and sock. I quickly got rid of the trouble-maker and went on with my walk. Unfortunately, the diabetic with neuropathy might not have discovered the little bit of sand until damage had been done.
A bath that’s too hot, a hot water bottle, a hot sidewalk when barefooted—all may quickly and seriously burn a diabetic’s foot. A shoe that’s too tight, a little stone in the shoe—may blister or cut without causing any pain or even discomfort. Then, in the diabetic, those otherwise minor injuries often become major if they develop into ulcers.
A middle-aged diabetic man opened a bottled drink one afternoon, carelessly letting the bottle cap drop onto the floor. After a while, he got up and started walking around the room, not concerned that he was wearing no shoes or slippers on his feet. He thought no more about the bottle cap—until the next morning when he found it firmly stuck into the bottom of his foot! Even then he felt no pain. But he did have a real problem with the healing of that interesting bottle-cap shape on the sole of his foot.
What we have just been talking about is sensory nerve damage, causing a loss of feeling and pain sensation. Neuropathy can also cause damage to the bones and the muscles. When this happens, the bones may become deformed the muscles may not function as well.
It is not uncommon to see an older diabetic with badly deformed toes. Some of the toes are lifted up so that they no longer touch the floor, but rub on the tops of the shoes. The diabetic with hammer toes or clawed toes may soon get ulcers on the tops or ends of his toes.
The worst foot deformity is called Charcot (pronounced shar-koh’) foot. It occurs when the bones do not get enough minerals such as calcium. Then the small bones in the arch of the foot break down. As this gets worse, the center—the arch—of the foot curves and drops until what used to curve up now curves down instead. Finally the foot becomes like a rocker, with the center of the foot taking much of the pressure when the person tries to walk. That pressure is likely to cause ulcers and serious problems.
Any changes in the bones and the muscles will cause the person to walk differently. As his walking changes, he will start to put pressure on different parts of the foot. Gradually, ulcers may form on these new pressure spots, and if they are not treated properly, infection and finally gangrene may take control.
Another part of the body’s nervous system—the “autonomic” nerve—may also be damaged by poorly controlled diabetes. One of the results of this autonomic neuropathy is that the body does not perspire as much as before. Although this may not seem like a serious thing, it does cause the skin to become dry. Dry skin can crack, the cracks can become infected. And any infections of the diabetic’s foot may lead to gangrene and amputation.
The United States Department of Health and Human Services estimates that more than half of all diabetes-related foot amputations could be prevented with good foot care and diabetes control.
Doctors in Singapore and the Philippines have also shown that teaching diabetics how to properly care for their feet is one of the best ways to reduce the number of amputations. In the 1970s and early 1980s, more than 400 Singaporeans had amputations every year. By the early 1990s, however, better medical care and greater understanding of the dangers helped to cut the number of amputations in half.
As the International Diabetes Federation’s IDF Bulletin says, “A patient with poor knowledge is at high risk for foot problems….”
And such complications which lead to amputations cause tremendous losses to the individual. The person who has to have a foot amputated loses much more than just his foot. He may also lose his job and his income. He loses his freedom of movement—and possibly his independence. He may lose much of the quality and joy in life.
So far doctors do not have any cure or any sure prevention for neuropathy or many of the other foot complications of diabetes. The best advice they can give right now is for the diabetic to keep his diabetes in good control and to have regular medical checkups. And to take good care of his feet!
Care of the Feet
Because of the seriousness of even such a minor thing as a scratch or a blister, a diabetic must always treat his feet with tender loving care. If you or someone you love has diabetes, let’s look now at some of the best ways to avoid trouble:
*Inspect your feet every day. Here are some things you should look for:
--Redness, bruises, or any change in color
--Cuts or scratches
--Cracks or fungus infections between the toes
--Irritation or rubbing
*Wash your feet every day, making sure to clean between your toes. Use warm water and mild soap. Dry your feet thoroughly after washing them, putting them dry rather than rubbing, since rubbing can cause breaks in fragile skin. This is a good time to do your foot inspection.
*Test bath water with your hand or elbow instead of with your feet. Avoid using a hot water bottle, heating pad, or anything else that might burn without your realizing it.
*Trim your toenails straight across, not curved. Do not cut them too close to the flesh, or you might injure the flesh, which could cause an infection. Never try to treat an ingrown toenail yourself—let your doctor care for such problems.
Many doctors recommend using an emery-board, or wooden nail file, instead of clippers or scissors for keeping toenails the right length. The emery-board is the safest and least likely to cut or injure the toes.
The toenails should be filed or trimmed even with the end of the toe:
*Inspect your shoes every day. Before putting on your shoes, check to see that there are no tiny stones or other foreign objects that might injure your feet. Also check to see whether the lining of each shoe is smooth, or whether it might be torn or wrinkled. Do not even buy shoes that have seams which will rub on your foot.
Wear only shoes that fit properly and comfortably. In choosing what shoes to buy, specialists in diabetic foot care recommend doing a little “art work”. Stand up, with one foot on a piece of paper that is bigger than your foot. With your full weight on that foot (or on both feet equally), have someone trace around your foot with a pen or pencil. Then place the shoe you like on top of the foot drawing. Which is larger, the foot or the shoe?
If the foot is wider than the shoe, or if the toes touch the end of the shoe, you’re looking at the wrong shoes! We often squeeze our feet into pointed-toed shoes which pinch and cramp our feet—just to be fashionable! But deformed feet aren’t fashionable, and poor-fitting shoes can cause deformities.
If your feet are already deformed, or if you already have problems buying shoes which fit correctly, you should consult a doctor who specializes in foot care. Some foot specialists and large hospitals, such as the University Hospital in Kuala Lumpur, Malaysia, or the San Lazaro Hospital in Manila, Philippines, will take ordinary shoes and make inserts to exactly fit the feet of diabetics with foot problems. These can help to prevent foot injury and further deformity.
One of the very best kinds of shoe for the diabetic is a sports shoe. Sports shoes are wider, and they usually have good support under the arch and around the back of the foot. In closed shoes, however, your feet are more likely to perspire. And feet that stay moist or wet are more likely to get fungus infections.
Sandals, with good straps around the back of the feet, may be acceptable in hot climates, although they do not give a much protection as a closed shoe. They may also allow the skin to become dry and cracked. If you wear sandals, you will have to be especially alert for cracks in the skin.
Wooden clogs and rubber slippers—also known as thongs or flip-flops—provide almost no protection for the feet.
*If you wear socks, use socks which are made of cotton, wool or toweling rather than nylon or other synthetic materials. Cotton will absorb the perspiration better and help prevent fungus infections. Be sure to wear clean socks every day.
Do not wear socks which are tight around the top, such as men’s socks with a tight band at the top, or women’s ankle-high or knee-high stockings. They interfere with the blood circulation.
*Do not go barefoot, either in the house or outside. In the diabetic, bare feet are endangered feet! Always wear something to protect your feet from harm.
*At night, turn on a light if you get up—don’t take a chance of stubbing your toes or stepping on something that could hurt your feet.
*When you are wearing new shoes, check your feet every 30-60 minutes to be sure that the shoes are not rubbing and causing blisters on your feet. It is probably best not to wear the new shoes for more than an hour on the first day, then break them in gradually to avoid foot problems.
*If you do get a blister, do not break it. The unbroken skin over a blister is your best defense against the germs that could cause infection.
*If the skin on your feet is very dry, rub the dry areas—but not between the toes—with a good moisturizing cream or lotion such as a lanolin-based cream. For dry skin, petroleum jelly (Vaseline) is inexpensive but quite effective. Olive oil is another inexpensive treatment which many Asians have found helpful for dry skin.
When my own feet get very dry and start to crack. I rub a generous amount of petroleum jelly on the dry areas just before going to sleep at night. Then I put on a clear pair of socks to protect my bed from getting greasy.
*In tropical climates, your feet may perspire and tend to stay moist. If so, you may wish to use a good talcum powder or cornflour between your toes to absorb moisture. You can sprinkle the powder on after bathing and drying your feet, but be sure to wash away all the old powder each day.
*Do not try to treat your own foot problems. Commercial cures for corns or calluses may destroy skin tissue and allow infections to get started. Go to see your physician right away if you notice any of these problems:
--Pain or throbbing in your feet
--Change in color of a toenail, toe, or part of your foot
--Calluses, corns, or thick, hard skin
--Breaks in the skin, such as cracks, blisters, or sores
--Any infection, no matter how minor it may seem
*Make sure the doctor checks your feet at each checkup. You should have your feet checked by your doctor at least once a year. Some of the things he should check include:
--Sense of feeling. Can you feel a tiny pinprick or vibrations on your feet?
--Reflexes. Do your legs and feet respond normally?
--Flexibility. Do your feet and legs move freely, or have they become stiff and difficult to move?
--Blood flow. Do you have a normal pulse in your feet, or is it blocked? Are your feet warm or cool—or is one warm and the other cool? If he presses down on your toenail, now soon does the color return?
--Automatically nerves. Do your feet perspire normally, or are they very dry?
--Bone structure. Are your feet their normal shape, or are there some deformities beginning? He may also check your shoes to see if there are any unusual signs of pressure either inside or on the bottoms of the shoes.
--Skin. Are there any cracks in your skin? Do you have cracks or infections between your toes? Are your toenails either thicker or thinner than usual? Does the skin on your feet or legs look very thin?
--Intermittent claudication. Do you have any pain in your feet, either when you walk and exercise or when you are resting?
*Exercise your feet and your whole body every day. We have talked more about exercise of the body in earlier chapter, but let us look now at some of the foot and leg exercises which can help to prevent serious foot complications.
Exercises for the Feet
Besides good hygiene, exercise is one of the best ways to avoid foot complications. Exercise does much to improve the blood circulation in the feet. That increased circulation will help to prevent the infections, intermittent claudication pain, and other foot problems which the diabetic may develop.
Let’s take a look at some of the exercises which may prove helpful in preventing foot problems from developing or becoming worse:
*Walk away from cigarettes! I admit that this isn’t really considered exercise. If you are a smoker, however, it may be one of the best things you can do to improve the blood circulation in your feet.
*Walk for at least 30-40 minutes each day. (Or substitute other sports if you are a more active, athletic person.) Fast walking increases the circulation more, but your walking speed will depend on your general physical condition and on your doctor’s advice. You may need to start out at a slower pace, but gradually you should be able to walk farther and faster.
*Stand by a chair, table or wall if needed to help keep your balance, and do the tiptoe exercise. Raise yourself from standing flat on the floor onto your tiptoes. Raise and lower your heels about 20 times, and repeat the exercise several times a day.
*While sitting in a chair, keep a round plastic bottle by your feet, and roll it back and forth with one foot then with the other.
*Drop a small towel or washcloth on the floor. Use your toes to pick up the towel and move it to another place. Keep moving the towel back and forth for several minutes, then repeat the exercise several times each day. This is a good exercise for stretching the muscles in the feet.
*If you spend a lot of time sitting at home, at work, or traveling, spend a few minutes each hour wriggling your toes, stretching your feet, and rotating your ankles. You can exercise your feet even while you work.
Each hour during the day you should also stop what you are doing and walk around for a few minutes to improve the blood circulation in your feet and legs.
*Remember to take your walk and do your exercises everyday if you want them to be effective.
Have a good understanding of your feet and their care, and they will stand under you for years to come.