Diabetes and its complications are the leading cause of non-traumatic lower extremity amputations in the United States. Neuropathy, a common complication of diabetes, is a major contributing force leading to lower extremity amputation. Neuropathy leads to an anesthetic foot with increased pressure on the sole of the foot. This increased pressure can lead to a diabetic neuropathic ulceration. The vast majority of amputations are sequela of a non-healing foot ulcer.
The precursor to ulcer formation is the development of a callus. The callus is the body’s response to the unnatural increased pressures on a neuropathic foot. The callus production actually increases the pressure below the prominence, i.e., metatarsal head. Hence, the callus is adding pressure to the increased pressure being observed on that area. If left untreated the callus and the underlying skin will begin to break down further. This process is noted when the callus presents with dark, discolored areas within it. The breakdown causes bleeding within the callus and an ulcer is eminent. It is imperative that the callus formation be removed.
Who and how the callus should be removed is another question. Depending on the patient’s diabetes control, eye site, access to his or her foot, and understanding of the disease process, patients may play a role in removal of the callus formation by using a pumice stone or a callus file. Patients with diabetes should not use over-the-counter corn or callus removal medicines. These medicines contain acids that can be detrimental to their feet. Patients who are unable to see well, who cannot reach their feet, whose diabetes is out of control, and who do not have an understanding of how diabetes affect their feet should be seen by their podiatrist or medical doctor for this care.
Removal of the callus formation is just one component of complete off loading of the diabetic insensitive foot. Many different type of insoles, shoes and shoe modifications can be used to reduce pressure on an anesthetic foot. A podiatrist can prescribe and evaluate these devices and make sure that the devices, shoes, and shoe modifications are being used in a correct manner.
Prevention is the cornerstone of diabetic foot care. A patient with diabetes and its complications need to take extra care of his or her feet. To help prevent patients with diabetes from losing their limbs we recommend the following:
Their feet should be inspected daily. If the patient has neuropathy, it would be wise to inspect them more than once a day. A mirror can be used to see the plantar aspect of their feet.
Before putting on any shoe, it should be inspected for any foreign bodies that may have been placed there while not in use. It is important to make sure there are no staples or nails in the sole of the shoes, which can penetrate the sole and cause skin damage.
Patients with diabetes and low risk feet, i.e., no complications, should be seen by their podiatrist at least once a year for a full comprehensive diabetic foot exam.
Patients with high risk feet, i.e., neuropathy should be seen every three to six months depending on any other complicating risk factors they may have.
Self-care may be limited, but only in certain circumstances. Nail care can be done by the patient if the patient again has well control of his or her diabetes, has no complicating factors, and whose eye site is good. Correct care of nails and callus is paramount for saving lower extremities and preventing diabetic ulcerations.
Patients with diabetes and neuropathy should check their bath water with their hands or with a thermometer prior to stepping into the bathtub. A patient with neuropathy would not be able to feel the temperature of the water and it may very well cause a serious burn to their lower extremities if too hot.
People with diabetes and neuropathy may have hammertoe deformities, bunion deformities, and bony prominences. The correct shoe is paramount to protecting the bony prominence from forming a callus and leading to an ulceration. The patient’s podiatrist can prescribe and evaluate appropriate shoe wear to accommodate the deformities the foot may have.
Remember, just because the patient has diabetes does not automatically doom them to an ulceration or an amputation. People with diabetes must take control of their disease process and not allow it to take control of them. By following the steps outlined above, people with diabetes can ensure that their feet will last a lifetime.
Dr. Joseph M. Caporusso, of McAllen, Texas, has been in private podiatric medical practice since 1991. A graduate of the Pennylvania (now Temple) College of Podiatric Medicine, Dr. Caporusso has been an active leader in his profession from the start of his career, eventually rising to the presidency of the Texas Podiatric Medical Association in 1996. This past year, Dr. Caporusso was elected to the Board of Trustees of the American Podiatric Medical Association (APMA). He has served as a member of the Diabetes Advisory Committee of APMA, the Diabetes Committee of the American College of Foot and Ankle Surgeons, and a member of the South Central Regional Board of the American Diabetes Association. Dr. Caporusso is currently a clinical associate in the podiatry service at the University of Texas Health Science Center in San Antonio, where he also completed his residency training in 1991. He is a member of the APMA’s Public Education and Information Committee and is certified by the American Board of Podiatric Surgery. A prolific speaker on diabetes prevention and care, especially among the Hispanic population, Dr. Caporusso is a widely sought lecturer and author. He is committed to expanding podiatric medical care to minority patient groups, noting the alarming incidence of diabetes among the growing Hispanic population in the United States.