A Comprehensive Guide to Diabetic Foot Problems

A Comprehensive Guide to Diabetic Foot Problems

A deep dive on how to care for diabetic foot issues and what to do about it

Table of Contents

Diabetes itself is a fundamental problem,
and diabetic neuropathy places the diabetic foot at such extreme risk.

Diabetic neuropathy increases with age and duration with numbness, and therefore without warning, trivial injuries can become threats to limb–even life-threatening– long before the patient complains. Yet evaluation of the diabetic patient’s feet by their physician or health professional often does not occur.

The Healthy foot bears the pressure of walking over 100,000 miles in a lifetime.

Diabetic Neuropathy Critical factor:

Most diabetic patients with neuropathy aren’t aware of what’s happening to their feet. Thus, their physician is the primary person to help them reduce the risk of ulcers and or amputation.

Contributory factors for foot ulceration

• Neuropathy

• Deformity

• High plantar pressure

• Poor glucose control

• Duration of diabetes

• Male gender

Diabetic patients with neuropathy tend to have an increase in foot pressure, even more so with ulcerations.

High plantar foot pressures have been identified as a significant risk factor for ulceration

The precise cause of diabetic neuropathy remains unclear, but both vascular and metabolic factors are implicated.

It parallels both the duration and severity of hyperglycemia. The most critical injury is the loss of specific nerve fibers (myelinated and myelinated), injury being the loss of myelinated and on myelinated nerve fibers.

“Most importantly, once the foot becomes numb, the patient is unaware of what is happening. Not surprisingly, the typical diabetic foot ulcer forms on the foot’s bottom surface in areas of maximum pressure. “

In the absence of trauma, ulcers are usually preceded by;

• redness
• blisters
• callous over the affected areas

“The skin thickening produces the callus as a bodily defense mechanism.”

Still, it’s also an abnormality that leads to crushing of the small vessel capillaries and tissue beneath it and subsequent necrosis or dying of the tissue with the onset of ulceration. Therefore, the callus on the diabetic foot is to treat it as a precursor to an ulcer, probably indicative of abnormal pressure and probably diminishing sensation.

Additionally, anatomic deformity to the foot is a common accompaniment of diabetic neuropathy. The most Frequent deformity is;

• Crooked up toes
  1. claw toes
  2. hammertoes
  3. mallet toes
• An imbalance from muscular atrophy
• Tightening of the tendons
  1. Tightening of the heel cord in plantar fascia ligament on the bottom of the foot and the most profound formally been the so-called Charcot foot.

Why are foot problems so common with Diabetes?

The Semmes-Weinstein monofilament (10 g0 wire is sufficient to identify those individuals at risk for ulceration
other testing for assessment of diabetic neuropathy includes vibration with a tuning fork 128 cycle at the level of the ankle and first metatarsal. Vibration perception threshold assessment with Biosthesiometer is also useful in predicting those patients at high risk for ulceration

Diabetes, a multisystem disease with effects on;

• nervous systems
• cardiovascular systems
• dermatologic systems
• musculoskeletal systems

Diabetic neuropathy

Diabetic neuropathy is a primary factor leading to higher pressure areas on the foot’s bottom.

Symptoms of neuropathy may include;

• numbness
• burning
• tingling
• pins and needles
• weakness.
• Alterations in blood flow and sweating.

1. Peripheral neuropathy eventually affects 40-60% of diabetic patients and is a major contributing cause of lower-extremity amputation.

2. It presents a “stocking-and-glove type” distribution of symptoms. Alterations in blood flow and sweating can contribute to foot problems such as dryness and cracked skin in fissuring, a portal of entry for bacteria.

1. Two ways to provide an index of the neuropathy extent;
   1. Proprioception sense of up and down of the big toe
   2. Patellar and Achilles reflexes
2. To differentiate between sharp and dull
   1. Sharp and blunt touch via a pinprick test
   2. Dull contact via Cotton ball test

More sophisticated studies, such as nerve conduction studies, are rarely necessary to diagnose peripheral sensory neuropathy.

What’s in session loss varies from patient to patient;

1. Vibratory perception is the first to be lost
2. Followed by Achilles reflex
3. Finally, perception of pain in touch

Neuropathy is progressive.

Decrease feeling in the feet can lead to injuries and cuts that may go unnoticed. Such patients are particularly vulnerable to trauma while barefoot and from repetitive stress while wearing conventional footwear on both the feet’ tops and bottoms.

To help prevent skin breakdown and wounds.

Patients should not walk barefoot and only wear protective shoes prescribed by their physician.

Protective footwear is available from a qualified Durable Medical Equipment footwear professional, including;

• extra depth shoes
• protective accomadative insoles
• specialized padding

It can help prevent skin breakdown and wounds.

The level of risks for wounds and ulcerations in patients with neuropathy is high due to partial or complete foot insensitivity.

Peripheral neuropathy eventually affects

• 40 to 60% of diabetic patients
• a major contributing cause of lower-extremity amputation

Probability of patients with diabetes develop neuropathy;

• 20 % after 10 years*
• 50 % after 20 years*

*The number of neuropathy patients may decrease as more patients strive for and achieve tight control of blood sugar glucose.

Nerve Damage of 3 different type levels can result in ‘neuropathy:’

Sensory Nerve Damage

1. 1. Results in a gradual loss of feeling to the bottom of the feet
   2. Gradual onset and patient is often unaware of how extensive it is.
   3. Associated with
      1. burning
      2. tingling
      3. pins and needles
      4. coldness
      5. full feeling
   4. The tissue becomes less elastic and less flexible, localized circulation becomes diminished ‘a perfusion deficit’ there is less nutritive flow with the dissipation of electrolytes and toxic metabolites.

Autonomic Nerve Damage

1. 1. There is a gradual loss of control of the vessels, which results in decreased perspiration, creating dryness, scaling, and breaks in the skin.

Motor Nerve Damage

1. 1. A more severe case. A patient may notice changes with the fat pad under the “ball of the foot” moving forward, thereby making the bone heads more prominent and susceptible to increased pressures.
   2. The arches may become higher or lower with tightening of the heel cord and plantar fascia ligament.
      1. Susceptible to plantar fasciitis.
   3. The toes can contract and become crooked with bone prominences notable, these includes;
      1. hammertoes
      2. claw toes
      3. mallet toes
   4.  Weakness or unsteadiness while walking.
   5.  Walking/ gait abnormalities with abnormal biomechanics
      1.  Can lead to foot deformities.

Together with soft tissue and environmental stress, these types of nerve damage together can lead to ulceration.

Poor Circulation

Diabetes can lead to poor blood flow and a decrease in the immune system’s ability to fight infections.

1. The incidence of peripheral arterial disease in diabetic patients is at least four times that of non-diabetics and increases with age.

2. Vascular disease may complicate up to 60% of non-healing ulcers associated with diabetes mellitus**

Peripheral vascular disease

Peripheral vascular disease below the knee contributes to;

1. limb ulceration
2. impaired wound healing

decreases the ability to fight infection

• • preventing delivery of oxygen
  • nutrients
  • antibiotics to the infected areas.

Diabetic patients can develop calcifications of their arteries below the knee, causing vessels to lose their elasticity and flexibility:

• the vessels function more like ‘pipes.’
• The byproducts of high blood sugars’ hyperglycemia’ can lead to blockages in vessels.

Pain can be worse at night or with exercise and activity.

Peripheral vascular disease appearance

The foot can present with a spotty red appearance;
toes may become bluish or even black ‘gangrene.’

The integrity of the skin’s compromised due to diminished blood flow created ulceration (ischemia).

• The skin temperature will be cool to the touch without hair growth on the toes.
• The skin can be thin and shiny (atrophic). Wounds can develop in pressure areas such as bone Deformities.
• May alter the mechanics of the foot end of walking prominences or even areas of resting pressures such as the heels.
• Patients with peripheral vascular disease fall into a ‘high risk’ category for ulceration.

Signs and symptoms of vascular disease in the lower extremity include;

• • intermittent claudication (cramping of the calves with walking)
  • cold feet
  • pain at night
  • rest pain
  • rest pain and night pain relieved with dependency and dangling of the feet below heart level
  • absent pulses
  • blanching of the skin and paleness of the feet on elevation
  • delayed filling a blood into the big toe after elevation
  • redness with gravity dependence
  • atrophy of the fatty tissues
  • shiny appearance of the skin,
  • loss of hair on the foot and toes
  • thickened nails often with fungal infection
  • gangrene.

“The indication for vascular consult includes; 

• Lower extremity ankle-brachial index of less than 0.7
• Toe pressures less than <40 mm Hg or transcutaneous oxygen TcPO2 levels of less than 30 Hg

Since these measures of arterial perfusion are associated with impaired wound healing.”

Treatment for peripheral arterial disease:

• smoking cessation
• weight, cholesterol lipid reduction
• protective footwear
• revascularization
• patient education.

Other Problems people with diabetes are susceptible to:

Infections:

• Local elevation in temperature
• redness
• swelling
• possible pain
• odor history of recent trauma.

Systemically:

• Nausea
• vomiting
• fever
• chills
• lymphadenopathy (swelling of the lymph nodes)

The diabetic foot may be predisposed to developing both;

• common and usual infectious
• non-infectious processes.

This predisposition is partly due to the disease’s complex nature and its associated vascular and neuropathic complications.

As a result, imaging presentations will vary in complex clinical circumstances.

Evaluation of infections:

• clinical examination
• appropriate lab work
• cultures
• imaging (X-ray, MRI, Nuclear Bone Scan, CT).

Treatment:

• antibiotics
• debridement
• irrigation cleansing
• wound care
• surgery

Sores & Ulcers

1. Diabetic foot ulcers account for more than 20% of total hospital days for patients with diabetes and are the leading cause of hospital admissions among patients with diabetes.

2. Peripheral sensory neuropathy is the foremost independent risk factor for diabetic foot ulcerations.

Deformities may alter the mechanics of the foot and affect the biomechanics of walking.

Depending on the patient’s level of neuropathy and activity,
these developments frequently result in injury to the skin that may create conditions at high risk for ulceration.

Calluses and blisters

Are considered ‘pre-ulcerative.’
They have been shown to increase pressures and are most commonly associated with bone prominences.

These bone prominences includes;

1. prominence at the balls of the foot (metatarsal heads)
2. bony prominences bunions or bunionettes inside or outside the forefoot
3. bone spurs underneath the toenails or the midfoot level*
   1. which may be associated with significant deformity of fallen arches (Charcot Fracture) and sites of previous amputation.

Additionally, when there is less motion or arthritis changes within the joints, pressure can also be increased, leading to calluses.

Calluses and Corns

Calluses and corns imply excessive pressure areas at specific locations.

They can include;

• Bleeding within a callous
• Blistering created by repetitive friction or stress and pressure of the heels of diabetic patients on bed rest

A callus or corn that presents with a build-up on the skin should be;

1. Reduced by a podiatrist
2. Accommodated with padding or adjusting footwear.

Hereditary Calluses (porokeratosis)

Certain hereditary calluses can appear in non-weight bearing areas and are not considered pre ulcerative but can be painful and may require treatment.

Fungal Infections

Infections in patients with diabetes are common but are often more severe than those found in a non-diabetic person.

It is well documented that diabetic foot infections are polymicrobial in nature.

High blood sugar with impaired immune response, neuropathy, and poor circulation are the main predisposing factors leading to limb-threatening diabetic foot infections. High, uncontrolled diabetes results in impaired ability of blood cells to fight bacterial pathogen’s while ischemia will also affect the ability to fight infections since delivery of antibiotics to the site of the infection will be impaired. Consequently, infections can develop and spread rapidly and produce significant irreversible tissue damage.

Even when perfusion is adequate, underlying peripheral neuropathy will often allow the progression of infection through continued walking or delay in recognition.

EARLY SIGNS OF INFECTION:

Loss of skin integrity from wounds, cracks, fissures provides a portal of entry for bacteria that results in infection and micro clotting, which allows the infection to progress. Poor glucose control leads to impairment of leukocyte (white blood cell) function and the body’s ability to fight infection. Fungi can predispose the patient to more severe infections from colonization by bacteria, potentially resulting in cellulitis and gangrene. This is often facilitated by ill-fitting shoes that traumatized the skin.

“Because infection often progresses unnoticed in diabetic patients due to neuropathy until it is quite advanced, careful examination of the patient’s feet in between the toes is critical. ”

The development of a large population of kidney disease associated with diabetes requires particular attention with early identification and treatment of infection to preserve the foot.

“They are at higher risk for foot problems, slow healing, And have higher amputation rates.”

Why Nail Care is Important

Nail care is essential to prevent ingrown toenails, infections, and damage to the toes.

This is especially necessary when toenails are fungal in appearance with;

• thickness
• yellow or black
• discoloration
• debris underneath the nail
• loosening of the toenail plate.

Fungal toenails (onychomycosis)

Common environmental pathogens with a predilection for colonizing under the nail or on the skin includes;

• fungus
• mold
• yeast
• bacteria

“Fungal toenails prevalence in diabetic patients is as high as 33%.”*

It is significantly harder to fight off when the immune system is compromised. Fungal toenails can contribute to foot complications, including;

• ulceration
• bacterial infection
• gangrene
• amputation.

A regular schedule for screening generalized foot and nail care should be established with a podiatrist.

Fungal conditions can also affect the skin in the form of athletes’ feet with dryness (xerosis), scaling, which can be treated with antifungal Topicals or medicated foot gels or soaks.

Toenail and skin infections can be identified by standard would cultures or more sensitive and specific DNA cultures. The latter is becoming more common as these infections become more complicated with time. DNA cultures can identify certain infections that standard cultures cannot identify. Upon review of the culture results, appropriate treatment may be instituted consisting of topical gels, creams, emollients, foot soaks, or oral medications depending on the treatment goals and overall health, including other medications, liver and kidney function. In many instances, the safest and most effective treatment may be regular scheduled generalized foot care with callus and toenail reductions for the prevention of foot problems.

Treatment of infections:

• Blood sugar control
• proper nutrition
• early aggressive treatment of compromised tissues
•  medicines to reduce swelling
• non-weight-bearing or off-loading pressure on wound sites
• cultures to identity or rule out infection
• no use of whirlpools or soaking
• appropriate antibiotics
• patient education.

Treatment of wounds:

Early, aggressive removal of affected tissue involved (debridement), relieve pressure, culture for infection, protective footwear, skin protection/moist dressings and moisturization, proper nutrition, mechanical alleviation of pressures, adjunctive therapies such as wound care products, skin substitutes, grafts, stem cells, hyperbaric oxygen therapy, and patient education.

A vital aspect of treating the diabetic wound is non-weight bearing on the wound site as even a few steps on the healing foot may destroy the effects of an entire day of healing. Although protective footwear is important, the human foot needs to heal without the added weight of the shoe. Elevating the healing foot to decrease swelling is necessary. There are many devices designed to relieve pressure on the foot, ranging from wheelchairs, crutches, and walkers to total contact casts, total contact sandals, and healing shoes (Catanzarite 1999). Unweighting a wound on the bottom of the foot can be accomplished by strict non-weight bearing with wheelchairs, crutches, walkers, or transfer devices. However, for true weight-bearing to be successful, tremendous emphasis on patient education, training in the use of their own waiting devices, and intense compliance are necessary.

Total Contact Casting allows for walking with a complete reduction of pressures. This casting off-loads the forefoot and midfoot and even the heel to facilitate healing. They are considered to be the ‘gold’ standard’ for neuropathic foot ulcers, designed to reduce the vertical and horizontal pressures on the bottom of the foot while allowing ambulation. Total contact casts are also useful in controlling edema. This specialized cast is closely molded to the bottom of the foot and requires training an application technique with careful surveillance infrequent changing. This cast decreases swelling, which can cause looseness, so it must be changed regularly. There are additional assistive devices to help off-load pressure areas, including custom orthotics, ankle-foot orthotic braces prefabricated or specialized cane, walker, immobilization boots in rigid-soled Darco shoes with foam covering.

H2 Peripheral Arterial Disease

Peripheral Neuropathy or Nerve Damage

Treatment:

• pressure reduction
• skin protection with moisturization and use of emollients
• limited exposure of skin to water
• reduction of calluses and corns
• regular toenail care
• daily inspection of the feet
• heel protection for bed rest patients
• protective footwear (durable medical equipment: diabetic shoes and insoles, orthotics, braces)
• accommodative padding of prominences or deformity
• prophylactic surgery for prevention of problems
• non-weight bearing exercises
• emergency podiatry referral for Charcot’s foot
• patient education.

Peripheral Arterial Disease

Peripheral Neuropathy or Nerve Damage

Treatment:

• pressure reduction
• skin protection with moisturization and use of emollients
• limited exposure of skin to water
• reduction of calluses and corns
• regular toenail care
• daily inspection of the feet
• heel protection for bed rest patients
• protective footwear (durable medical equipment: diabetic shoes and insoles, orthotics, braces)
• accommodative padding of prominences or deformity
• prophylactic surgery for prevention of problems
• non-weight bearing exercises
• emergency podiatry referral for Charcot’s foot
• patient education.

PROPHYLACTIC SURGERY (OPEN OR MINIMALLY INVASIVE)

Adequate circulation and infection control must be present before any elective surgery. A variety of procedures exist for surgical intervention, such as removal of a small segment of bone in order to alleviate small areas of high pressure (osteotomy). A bunion reconstruction realigns the great toe to prevent ulceration on the inside of the ball of the foot and reduce joint stress. Crooked toes may be straightened by the Release of tight tendons to rebalance the toe into a normal alignment and arthroplasty as needed to release the joint to allow for straightening of the hammertoe and alleviate high pressures on the tops and tips of the toes. Metatarsal realignment of a prominent bone in the ball of the foot with increased pressures can reduce callous and recurrent ulcer formation. A metatarsal head resection can be performed with the removal of the bonehead to completely eliminate the pressure of the prominent bonehead. A problematic toenail can be removed permanently via matricectomy used to treat recurrent infected ingrown nails. Removal of a small bone of the forefoot (sesamoidectomy) can be performed to relieve high-pressure areas directly under the first metatarsal.

Such procedures can be performed minimally invasively through 2 mm portals under a local injection via a minimally invasive trained Podiatrist or as an open procedure in an outpatient Or inpatient facility with sedation.

Charcot Foot

Patients with lots of protective sensations are at high risk for the development of Charcot fracture that may go undiagnosed. History of trauma, mechanical stress, local elevation and temperature, redness and swelling, and possible pain, all in the presence of bound impulses, can help with the identification of a Charcot fracture. Suspicion of such a fracture requires immediate non-weight-bearing status to prevent compromise of the architecture of the foot with arch collapse leading to bony prominence.

Charcot foot will go through different stages of development. Initially, it will present as joint swelling and redness with bounding strong pulses, at which time micro fracturing of bone is occurring. This (Osteoarthropathy) originates with failure of the sympathetic nerves that cause vessels to tighten (constrict) that supply the foot. The unregulated vessels dilate, causing increased circulation. Pedal pulses are strong, and bounding in the foot becomes swollen, red, and hot to the touch. The condition is often mistaken for an infection or gout, although the white blood cell count level is usually normal. Proper identification and immobilization are required to get weight completely off the foot to prevent immediate damage to the architecture of the foot, such as arch collapse during the active phase of development. This will be followed by a healing and remodeling phase with less swelling. The phases can last days to months. Ultimately, proper diabetic footwear is imperative to support the foot, which may have become architecturally compromised with new bony prominences such as on the bottom of the foot. This can be accomplished with diabetic shoes with custom insoles or orthotics and Ankle-Foot orthotic bracing to prevent future ulcerations.

Diabetes mellitus

Diabetes mellitus is the most common cause of the development of Charcot (Neuroarthropathic Foot). Other disorders that produce Charcot foot joints include:

• chronic alcoholism
• Hansen’s Disease (Leprosy)
• Tabes dorsalis
• syringomyelia
• Meningomyelocele
• spinal cord injury
• peripheral nerve injury.

AMPUTATION PREVENTION:

Complications from diabetes account for approximately 50% of all non-traumatic amputations in the United States.

While 14-20% of patients with foot ulcers will subsequently require an amputation, foot ulceration is the precursor to approximately 85% of lower extremity amputations in people with diabetes.

One of the most important measures for preventing amputation is patient education. Amputation is preventable when patients wear appropriate footwear, take care to avoid foot injury and repetitive high stressors, and check their feet on a daily basis for warning signs of injury or disease progression.

Diabetic Footwear (Durable Medical Equipment)

Prescribing appropriate therapeutic footwear for these patients requires a review of their medical history and careful evaluation of their deformities and activity levels. Patients should be cautioned that prevention of injury depends largely upon their serious and continued adherence to foot care and careful maintenance of use of their prescription footwear. Prescription footwear is not a temporary measure but rather a lifelong commitment.

What are the early signs of foot ulcers

Diabetic Foot Ulcers:

Pressure areas such as calluses, corns, and blisters are considered ‘pre ulcerative.’ They can lead to wounds classified as ulcers based on the level of the tissue layer the wound extends. Ulcerations can lead to infections of the soft tissue (cellulitis, abscess) or of the bone (osteomyelitis) and amputation of the infected bone.

15% of patients with diabetes will develop a lower extremity ulcer during the course of their disease

The cumulative effects of neuropathy cause deformity from high plantar pressure for glucose control duration of diabetes and gender all contributory factors for foot ulceration

14% of diabetics are hospitalized yearly, with 25% for foot problems.
Ulcers are present in 20% of all hospital admissions associated with diabetes.

Risk increases significantly when the patient is a smoker, over 40, hypertensive, obese, black, Hispanic, or Native American.

The multifactorial nature of diabetic foot ulcer ration has been elucidated by numerous observational studies.

Risk factors identified include peripheral neuropathy, faster to see is limited joint mobility for the formal is abnormal foot pressure, minor trauma history of ulceration reputation, and impaired visual acuity. The multifactorial nature of diabetic foot ulceration has been elicited by numerous observational studies. Risk factors identified include peripheral neuropathy, faster disease, limited joint mobility for deformities, abnormal foot pressure, minor trauma history of ulceration reputation, and impaired visual acuity.

Peripheral sensory neuropathy in the absence of perceived trauma is the primary factor leading to diabetic foot amputation.

Approximately 45 to 60% of all diabetic ulcerations are purely neuropathic, while up to 45% have neuropathic in ischemic components.

Other forms of neuropathy may also play a role in foot ulcerations. Motor neuropathy results in muscular atrophy or waste and can lead to

• deformities such as drop foot
•  Equinas with a tight heel cord contracture
• hammertoes and clog toes
• prominent plantar metatarsal heads

Autonomic neuropathy may commonly result in dry skin with cracking and fissuring, thus creating a portal of entry for bacteria.

Frykberg, Robert G., et al. “Risk of Ulceration.” Diabetic Foot Disorders, Dec. 1999

Frykberg, Robert G., et al. “Risk of Ulceration.” Diabetic Foot Disorders, Dec. 1999

The failure of the sympathetic nerves to control the micro blood flow in Temperature regulation dysfunction impairs normal tissue perfusion and microvascular response to injury. These alterations can subsequently be implicated in the pathogenesis of ulcerations.

For deformities resulting from neuropathy, abnormal biomechanics, inherited foot disorders, and prior surgical intervention may result in high focal foot pressures

This may lead to vulnerable areas of the foot predispose to ulcerations. These are primarily located on the bottom of the foot, although on the top and sides may occur from footwear irritation.
Trauma to the foot in the presence of peripheral sensory neuropathy is an important component cause of ulcerations. While trauma may include puncture wounds or blunt injury, a common injury leading to ulceration is moderate repetitive stress resulting from walking or day-to-day activity. This is often manifested by callus formation under the metatarsal heads. shoe-related trauma has been identified as a frequent precursor to foot ulceration.

The peripheral vascular disease rarely leads to foot ulcerations directly. However, once ulceration develops, arterial insufficiency will result in prolonged healing and imparts an elevated risk for amputation. Attempts to resolve an infection will be impaired due to lack of oxygenation and difficulty in delivering antibiotics to the side of infection. Early recognition and aggressive treatment of lower extremity ischemia are therefore vital to lower limb salvage.

Limited joint mobility has recently been described as a potential risk factor for ulcerations.

Stiffening of capsular structures and ligaments due to the enzymatic modification of collagen by the addition of sugar in long-standing diabetes The subsequent reduction in ankle, rearfoot, midfoot and forefoot joint mobility has been shown to result in high focal plantar pressures with increased risk of ulcerations

Stages of foot ulcers

The description of the ulcer characteristics on presentation is critical for mapping of its progress during treatment.

the presumed cause needs to be determined. The evaluation should include the size, depth of the ulcer, as well as a description of the margins, base, and geographic location of the extremity or foot. The description should note to which level the ulcer probes. It should comment on the margins and extension and if there are any sinus tracts. A positive probe finding to bone has a high predictive value for osteomyelitis

The existence of odor and exudative drainage should be noted. Culture may be necessary when signs of inflammation are present. Current recommendations for culture and sensitivity include thorough surgical preparation of the wound site with curettage of the wound base for specimen or with the aspiration of abscess material

Frykberg, Robert G., et al. “Ulcer Evaluation.” Diabetic Foot Disorders, Dec. 1999, pp. S18

Seemingly superficial wounds are often like the cap of a volcano, masking seething layers of infected, necrotic tissue below. Without aggressive debridement, the true extent of the wound is obscured, the character of the infection is unappreciated, and the wound simply won’t heal. Superficialhealing (granulation) may occur, but as soon as pressure is reapplied (As in ambulation), it breaks down. Wounds or ulcers not responding to aggressive treatment or that occur in atypical areas should be biopsied to rule out possible malignancy.

There are many different staging systems for foot ulcers;

Level 1: onset of a pre ulcerative callus, corn or blister affecting the epidermis directly over a pressure area with bony deformities

Level II: Extension through the epidermis and into the dermal tissue layer over a pressure area but bony deformities

Level III: Extension through the epidermal, dermal tissue layer to the subcutaneous tissue layer.

Level IV: Extension through the epidermal, dermal and subcutaneous tissue layers to the level of the tendon or deep fascia.

Level V: Extension through the epidermal, dermal, subcutaneous, muscular, and fascial layers to the level of the bone. If the ulcer can probe to the bone, an infection of the bone is likely (osteomyelitis). Infection can spread and invade the surrounding tissues and tendons. The wound bacteria are commonly many (polymicrobial) and resistant to the usual oral antibiotics. The infection can spread inside the bone to other bones.

Although no single system has been universally adopted, the classification system most often used was described and popularized by Wagner. Subsequent authors have modified the classification system by including descriptors for considerations of the role of infection, ischemia, and other comorbid factors for consideration.
Wagner Grading System for Diabetic Foot Ulcers (A, page 8)
In the Wagner classification system, foot lesions are divided into six grades based on the depth of the wound and the extent of the tissue necrosis.

Grade 0 Skin intact, lead to “foot at risk” Shoe modifications with serial exams.

Grade 1 Superficial ulcer extending through the epidermis of the skin to the dermal tissue layer. Office debridement

Grade 2 Deeper, full-thickness extension Operative formal debridement and contact casting

Grade 3 Deep abscess formation or osteomyelitis Operative formal debridement and contact casting

Grade 4 Partial Gangrene of forefoot Local vs. larger amputation

Grade 5 Extensive Gangrene Amputation

Tips on working with your diabetes care team

Principles of wound management: ensure adequate blood flow via clinical examination and vascular studies, prevent or control infection, protect and off-load pressure areas with durable medical equipment such as diabetic shoes and insoles, custom orthotics or Ankle-foot orthotic bracing, accommodative padding, ensure adequate nutrition, optimize the wound environment for healing with adequate and debridement to remove compromised tissue and promote healthy tissue.

Management of ulcers involves;

• pressure relief
• debridement
• wound cleansing
• application of dressings
• therapy

should be undertaken using an interdisciplinary team approach.

The method of debridement should be appropriate to the patient’s condition and clinical goals and should remove all debris from the wound. Advanced stage wounds that are devitalized in infected tissue require aggressive sharp surgical debridement. When there is no urgent clinical need for drainage removal of the fertilized tissue or the patient is not a surgical candidate, mechanical and surgical debridement may be employed.

With deep wounds penetrating to level of bone to bone, biopsy should be performed for bacterial and fungal cultures to rule out a bone infection. The objective of surgical debridement is to remove all necrotic or infected tissue from the wound and convert a chronic wound into an acute wound to facilitate wound healing. Additionally, surgical debridement is the only procedure that effectively removes the thickened epithelium from around the room of the chronic wound.

Optimal wound healing cannot proceed until all inflammatory material is removed from the wound bed, with cleansing and debridement. Irrigation is a cleansing methodology that can be used to remove materials and bacteria. Fluids can be applied to the wound with a scrubbing matrix such as gauze pad, sponge, brush, or simply poured into the wound. When used at the proper pressure, irrigation is an excellent wound cleansing technique.

The method of debridement should be appropriate to the patient’s condition and clinical goals and should remove all debris from the wound. Advanced stage wounds that are devitalized in infected tissue require aggressive sharp surgical debridement. When there is no urgent clinical need for drainage removal of the fertilized tissue or the patient is not a surgical candidate, mechanical and surgical debridement may be employed.

With deep wounds penetrating to level of bone to bone, biopsy should be performed for bacterial and fungal cultures to rule out a bone infection. The objective of surgical debridement is to remove all necrotic or infected tissue from the wound and convert a chronic wound into an acute wound to facilitate wound healing. Additionally, surgical debridement is the only procedure that effectively removes the thickened epithelium from around the room of the chronic wound.

Optimal wound healing cannot proceed until all inflammatory material is removed from the wound bed, with cleansing and debridement. Irrigation is a cleansing methodology that can be used to remove materials and bacteria. Fluids can be applied to the wound with a scrubbing matrix such as gauze pad, sponge, brush, or simply poured into the wound. When used at the proper pressure, irrigation is an excellent wound cleansing technique.

• Healing process would include;
• Topical wound healing agents
• Enzymatic debriding agents
•  Wound care products with dressings

1. 1. hydrogels
   2. foams
   3. alginates
   4. Collagen-based products

to augment the healing process,
Anodyne or Revitamed infrared light therapy

Employ a multidisciplinary approach to prevent a recurrence.

The multidisciplinary team can include:

• Internal medicine
• endocrinologist
• podiatrist
• visiting nurse
• vascular surgery
• pedorthist (custom shoe specialist)
• prosthetists
• nutritiondietitian
• compression specialist
• physical therapist
• rehabilitation medicine
• neurologist
• plastic surgeon
• orthopedic surgeon
• social worker
• pharmacologist

Follow your diabetes treatment plan

Exercise such as prolonged walking and running and jogging, and use of the treadmill is not recommended for patients with diabetic neuropathy. Appropriate fitted diabetic protective footwear is used to limit pressure areas. Swimming, bicycling or encouraged, but one must be cautious and wear protective footwear to avoid severe burns from hot sand or hot concrete, such as around swimming pools. Protective footwork and also guard against abrasion from the pool floor or deck. Fishers, cracks, and dry skin require aggressive therapy, and simple Mr. Iser alcohol-based creams, in general, should be avoided because they cause excessive drying to the skin.

• Ensure adequate nutrition
•  maintain ideal body weight and
• glycohemoglobin HbA1C levels
• total albumin levels above 3.5
• Low serum albumin and total lymphocyte counts can result in slow healing or non-healing wounds for at-risk patients.

Keep your doctor’s appointment-be sure to get a foot exam at least once a year.

An individual’s risk factors will be assessed based on the complete medical picture, including medical history, clinical examination, medications, and active foot problems.

Daily Do’s and Don’ts to protect your feet (Proper Diabetic Foot Care)

• Do not smoke! It causes vessels to narrow at points furthest from the body’s core, such as the feet, decreasing blood flow and increasing risk for injury or slow healing.
• Inspect your feet daily for blisters, cuts, and scratches. The use of a mirror can aid in seeing the bottom of the feet. Always check between the toes. Check for dryness, redness, tenderness, and localized areas that rub (hot spots).
• Wash feet daily. Dry feet carefully, especially between the toes. Keep toes clean and free of debris between them.
• Avoid extremes of temperatures. Test water with your hand or elbow before bathing.
• If feet feel cold at night, wear loose socks to bed. Do not apply hot water bottles or heating pads. If feet are hot, do notice down. Avoid exposing your feet to extremes in temperature.
• Do not walk on hot surfaces, such as sandy beaches or cement around swimming pools.
• Do not walk barefoot. Your feet may be numb, and you will not feel an injury as it occurs.
• Protect your feet against sunburn with sunscreen.
• Beware of car heaters on long trips.
• Exercise needs should be reviewed for protecting the diabetic foot with possible neuropathy while at the same time increasing cardiovascular function.
• Do not use commercial chemical agents for the removal of corns and calluses.
• Do not use robust antiseptic solutions for your feet which may dry them out excessively.
• Do not use footpads or arch supports.
• Do not use adhesive tape on your feet.
• Buy only comfortable well fit shoes, have a Clark fit them for you. Walk around in them and be sure they are comfortable immediately. People whose feet are numb tend to wear shoes that are too small, causing the rubbing spots.
• Buy new shoes late in the day. Feet in large slightly during the day, and shoes that fit in the morning may be too tight by noon.
• Choose shoes with soft leather uppers that can mold to the shape of your feet. It should be wide enough Across the toes. Modern walking or running shoes may be beneficial. Never buy shoes with open toes or heels. Inspect the inside issues daily for foreign objects, nail points, torn lining in rough areas.
• Have your podiatrist inspect new shoes to be sure of proper fit in construction.
• Never wear new shoes more than two hours at a time. If they are tight in an area, wearing them for a short period of time will reduce the risk of skin breakdown. Slowly increase wearing time over several days. I don’t wear any shoes for more than five hours at a time. You should have one pair from a warning, one for the afternoon and one for an evening around the house.
• Never wear or buy sandals, particularly those with thongs between toes.
• Always scrutinize the inside of your shoes before putting them on and after taking them off.
• Inspect the insides of shoes daily for foreign objects, nail pints, torn lining, and rough areas.
• If vision impaired, have a family member inspect your feet daily.
• For dry feet, use a thin coat of lubricating oil or moisturizer cream. Apply after bathing and dyeing the feet. Do not put oil or cream between the toes as it may cause too much moisture and cause the skin to break down. Never use antiseptic solutions or astringents on your feet; this may be too drying for the skin.
• Never wear socks or stockings with seams. Seams can cause areas of pressure and rubs, which cause skin breakdown.
• Check with your podiatrist for socks or stockings specifically for people with diabetes. Some synthetics can be a source of dryness, and diabetic feet tend to be dry.
• Wear only clean socks, and change them daily.
• Inspect socks or stockings carefully before and, particularly after, wearing them.
• Never wear socks or stockings with seams. The seams can cause pressures and rubs, which can break down.
• Check with your podiatrist for stockings made specifically for people with diabetes. Some synthetics can be a source of dryness, and diabetic feet tend to be dry.
• Wear only clean socks, and change them daily.
• Inspect socks or stockings carefully before and, particularly after, wearing them.
• Wear properly fitting stockings. Do not wear mended stockings. Avoid stockings with seams. Change socks daily.
• Do not wear garters or panty girdles that are too tight around the legs. Girdles may be too tight and cause swelling of the lower legs.
• Shoes should be comfortable at the time of purchase. Do not depend on them to stretch out. Shoes should be made of leather. Running shoes may be worn if fitted appropriately.
• Do not wear shoes without stockings.
• Do not wear sandals with thongs between the toes.’
• Take special precautions during wintertime. Wear wool socks and protective shoe gear.
• Toenails should be trimmed straight across. Do not cut deep down on the sides or borders. Gently round the corners using an emery board.
• Do not cut corns and calluses or reduce thickened, ingrown or problematic toenails. Follow instructions from your podiatrist.
• Do not use commercial corn or callus removers, footpads, or arch supports.
• Do not use adhesive tape on your feet.
• See your physician regularly and be sure that your feet receive examination upon each visit.
• Notify your podiatrist at once should you develop a blister or sore on your foot.
• Be sure to inform your podiatrist that you have diabetes.
• Be sure to inform your podiatrist promptly if you develop a blister, puncture, or sore on your foot or if a callus or corn appears.

H3 Stages of foot ulcers

Treatment

• a comprehensive guide to diabetic foot problems
  a deep dive on how to care for diabetic foot issues and what to do about it
  table of contents
  diabetes itself is a fundamental problem,and diabetic neuropathy places the diabetic foot at such extreme risk.
  diabetic neuropathy increases with age and duration with numbness, and therefore without warning, trivial injuries can become threats to limb–even life-threatening– long before the patient complains. yet evaluation of the diabetic patient’s feet by their physician or health professional often does not occur.
  the healthy foot bears the pressure of walking over 100,000 miles in a lifetime.
  diabetic neuropathy critical factor:
  most diabetic patients with neuropathy aren’t aware of what’s happening to their feet. thus, their physician is the primary person to help them reduce the risk of ulcers and or amputation.
  contributory factors for foot ulceration

  neuropathy

  deformity

  high plantar pressure

  poor glucose control

  duration of diabetes

  male gender

  diabetic patients with neuropathy tend to have an increase in foot pressure, even more so with ulcerations.
  high plantar foot pressures have been identified as a significant risk factor for ulceration
  frykberg, robert, et al“epidemiology of diabetic foot.” diabetic foot disorders, dec. 1999, pp. s6
  the precise cause of diabetic neuropathy remains unclear, but both vascular and metabolic factors are implicated.
  it parallels both the duration and severity of hyperglycemia. the most critical injury is the loss of specific nerve fibers (myelinated and myelinated), injury being the loss of myelinated and on myelinated nerve fibers.
  “most importantly, once the foot becomes numb, the patient is unaware of what is happening. not surprisingly, the typical diabetic foot ulcer forms on the foot’s bottom surface in areas of maximum pressure. ”
  in the absence of trauma, ulcers are usually preceded by;

  redness
  blisters
  callous over the affected areas

  “the skin thickening produces the callus as a bodily defense mechanism.”
  still, it’s also an abnormality that leads to crushing of the small vessel capillaries and tissue beneath it and subsequent necrosis or dying of the tissue with the onset of ulceration. therefore, the callus on the diabetic foot is to treat it as a precursor to an ulcer, probably indicative of abnormal pressure and probably diminishing sensation.
  additionally, anatomic deformity to the foot is a common accompaniment of diabetic neuropathy. the most frequent deformity is;

  crooked up toes

  claw toes
  hammertoes
  mallet toes

  an imbalance from muscular atrophy
  tightening of the tendons

  tightening of the heel cord in plantar fascia ligament on the bottom of the foot and the most profound formally been the so-called charcot foot.

  why are foot problems so common with diabetes?

  the semmes-weinstein monofilament (10 g0 wire is sufficient to identify those individuals at risk for ulcerationother testing for assessment of diabetic neuropathy includes vibration with a tuning fork 128 cycle at the level of the ankle and first metatarsal. vibration perception threshold assessment with biosthesiometer is also useful in predicting those patients at high risk for ulceration
  frykberg, robert, et al“neurologic procedures” diabetic foot disorders, dec. 1999, pp. s17
  diabetes, a multisystem disease with effects on;

  nervous systems
  cardiovascular systems
  dermatologic systems
  musculoskeletal systems

  diabetic neuropathy
  diabetic neuropathy is a primary factor leading to higher pressure areas on the foot’s bottom.
  symptoms of neuropathy may include;

  numbness
  burning
  tingling
  pins and needles
  weakness.
  alterations in blood flow and sweating.

  1. peripheral neuropathy eventually affects 40-60% of diabetic patients and is a major contributing cause of lower-extremity amputation.
  2. it presents a “stocking-and-glove type” distribution of symptoms. alterations in blood flow and sweating can contribute to foot problems such as dryness and cracked skin in fissuring, a portal of entry for bacteria.
  brill, leon r.”prevention of lower extremity amputation in patients with diabetes” treatment of chronic wounds, no. 7, oct. 1996, p. 2. accessed 31 dec. 2020.

  two ways to provide an index of the neuropathy extent;

  proprioception sense of up and down of the big toe
  patellar and achilles reflexes

  to differentiate between sharp and dull

  sharp and blunt touch via a pinprick test
  dull contact via cotton ball test

  more sophisticated studies, such as nerve conduction studies, are rarely necessary to diagnose peripheral sensory neuropathy.
  what’s in session loss varies from patient to patient;

  vibratory perception is the first to be lost
  followed by achilles reflex
  finally, perception of pain in touch

  neuropathy is progressive.
  decrease feeling in the feet can lead to injuries and cuts that may go unnoticed. such patients are particularly vulnerable to trauma while barefoot and from repetitive stress while wearing conventional footwear on both the feet’ tops and bottoms.
  to help prevent skin breakdown and wounds.
  patients should not walk barefoot and only wear protective shoes prescribed by their physician.
  protective footwear is available from a qualified durable medical equipment footwear professional, including;

  extra depth shoes
  protective accomadative insoles
  specialized padding

  it can help prevent skin breakdown and wounds.
  the level of risks for wounds and ulcerations in patients with neuropathy is high due to partial or complete foot insensitivity.
  peripheral neuropathy eventually affects

  40 to 60% of diabetic patients
  a major contributing cause of lower-extremity amputation

  probability of patients with diabetes develop neuropathy;

  20 % after 10 years*
  50 % after 20 years*

  *the number of neuropathy patients may decrease as more patients strive for and achieve tight control of blood sugar glucose.
  nerve damage of 3 different type levels can result in ‘neuropathy:’
  sensory nerve damage

  results in a gradual loss of feeling to the bottom of the feet
  gradual onset and patient is often unaware of how extensive it is.
  associated with

  burning
  tingling
  pins and needles
  coldness
  full feeling

  the tissue becomes less elastic and less flexible, localized circulation becomes diminished ‘a perfusion deficit’ there is less nutritive flow with the dissipation of electrolytes and toxic metabolites.

  autonomic nerve damage

  there is a gradual loss of control of the vessels, which results in decreased perspiration, creating dryness, scaling, and breaks in the skin.

  motor nerve damage

  a more severe case. a patient may notice changes with the fat pad under the “ball of the foot” moving forward, thereby making the bone heads more prominent and susceptible to increased pressures.
  the arches may become higher or lower with tightening of the heel cord and plantar fascia ligament.

  susceptible to plantar fasciitis.

  the toes can contract and become crooked with bone prominences notable, these includes;

  hammertoes
  claw toes
  mallet toes

  weakness or unsteadiness while walking.
  walking/ gait abnormalities with abnormal biomechanics

  can lead to foot deformities.

  together with soft tissue and environmental stress, these types of nerve damage together can lead to ulceration.
  poor circulation
  diabetes can lead to poor blood flow and a decrease in the immune system’s ability to fight infections.

  1. the incidence of peripheral arterial disease in diabetic patients is at least four times that of non-diabetics and increases with age.
  2. vascular disease may complicate up to 60% of non-healing ulcers associated with diabetes mellitus**
  brill, leon r.”prevention of lower extremity amputation in patients with diabetes” treatment of chronic wounds, no. 7, oct. 1996, p. 3.
  peripheral vascular disease
  peripheral vascular disease below the knee contributes to;

  limb ulceration
  impaired wound healing

  decreases the ability to fight infection

  preventing delivery of oxygen
  nutrients
  antibiotics to the infected areas.

  diabetic patients can develop calcifications of their arteries below the knee, causing vessels to lose their elasticity and flexibility:

  the vessels function more like ‘pipes.’
  the byproducts of high blood sugars’ hyperglycemia’ can lead to blockages in vessels.

  pain can be worse at night or with exercise and activity.
  peripheral vascular disease appearance
  the foot can present with a spotty red appearance;toes may become bluish or even black ‘gangrene.’
  the integrity of the skin’s compromised due to diminished blood flow created ulceration (ischemia).

  the skin temperature will be cool to the touch without hair growth on the toes.
  the skin can be thin and shiny (atrophic). wounds can develop in pressure areas such as bone deformities.
  may alter the mechanics of the foot end of walking prominences or even areas of resting pressures such as the heels.
  patients with peripheral vascular disease fall into a ‘high risk’ category for ulceration.

  signs and symptoms of vascular disease in the lower extremity include;

  intermittent claudication (cramping of the calves with walking)
  cold feet
  pain at night
  rest pain
  rest pain and night pain relieved with dependency and dangling of the feet below heart level
  absent pulses
  blanching of the skin and paleness of the feet on elevation
  delayed filling a blood into the big toe after elevation
  redness with gravity dependence
  atrophy of the fatty tissues
  shiny appearance of the skin,
  loss of hair on the foot and toes
  thickened nails often with fungal infection
  gangrene.

  “the indication for vascular consult includes;

  lower extremity ankle-brachial index of less than 0.7
  toe pressures less than <40 mm hg or transcutaneous oxygen tcpo2 levels of less than 30 hg

  since these measures of arterial perfusion are associated with impaired wound healing.”
  frykberg, robert g., et al”extremity assessment.” diabetic foot disorders, dec. 1999, pp. s17
  treatment for peripheral arterial disease:

  smoking cessation
  weight, cholesterol lipid reduction
  protective footwear
  revascularization
  patient education.

  other problems people with diabetes are susceptible to:
  infections:

  local elevation in temperature
  redness
  swelling
  possible pain
  odor history of recent trauma.

  systemically:

  nausea
  vomiting
  fever
  chills
  lymphadenopathy (swelling of the lymph nodes)

  the diabetic foot may be predisposed to developing both;

  common and usual infectious
  non-infectious processes.

  this predisposition is partly due to the disease’s complex nature and its associated vascular and neuropathic complications.

  as a result, imaging presentations will vary in complex clinical circumstances.
  frykberg, robert g., et al.”imaging studies.” diabetic foot disorders, dec. 1999, pp. s15
  evaluation of infections:

  clinical examination
  appropriate lab work
  cultures
  imaging (x-ray, mri, nuclear bone scan, ct).

  treatment:

  antibiotics
  debridement
  irrigation cleansing
  wound care
  surgery

  sores & ulcers

  1. diabetic foot ulcers account for more than 20% of total hospital days for patients with diabetes and are the leading cause of hospital admissions among patients with diabetes.
  2. peripheral sensory neuropathy is the foremost independent risk factor for diabetic foot ulcerations.
  frykberg, robert g., et al.”neurologic procedures.” diabetic foot disorders, dec. 1999, pp. s17
  deformities may alter the mechanics of the foot and affect the biomechanics of walking.
  depending on the patient’s level of neuropathy and activity,these developments frequently result in injury to the skin that may create conditions at high risk for ulceration.
  calluses and blisters
  are considered ‘pre-ulcerative.’they have been shown to increase pressures and are most commonly associated with bone prominences.
  these bone prominences includes;

  prominence at the balls of the foot (metatarsal heads)
  bony prominences bunions or bunionettes inside or outside the forefoot
  bone spurs underneath the toenails or the midfoot level*

  which may be associated with significant deformity of fallen arches (charcot fracture) and sites of previous amputation.

  additionally, when there is less motion or arthritis changes within the joints, pressure can also be increased, leading to calluses.
  calluses and corns
  calluses and corns imply excessive pressure areas at specific locations.
  they can include;

  bleeding within a callous
  blistering created by repetitive friction or stress and pressure of the heels of diabetic patients on bed rest

  a callus or corn that presents with a build-up on the skin should be;

  reduced by a podiatrist
  accommodated with padding or adjusting footwear.

  hereditary calluses (porokeratosis)
  certain hereditary calluses can appear in non-weight bearing areas and are not considered pre ulcerative but can be painful and may require treatment.
  fungal infections
  infections in patients with diabetes are common but are often more severe than those found in a non-diabetic person.

  it is well documented that diabetic foot infections are polymicrobial in nature.
  high blood sugar with impaired immune response, neuropathy, and poor circulation are the main predisposing factors leading to limb-threatening diabetic foot infections. high, uncontrolled diabetes results in impaired ability of blood cells to fight bacterial pathogen’s while ischemia will also affect the ability to fight infections since delivery of antibiotics to the site of the infection will be impaired. consequently, infections can develop and spread rapidly and produce significant irreversible tissue damage.
  even when perfusion is adequate, underlying peripheral neuropathy will often allow the progression of infection through continued walking or delay in recognition.
  frykberg, robert g., et al.”risk for infection.” diabetic foot disorders, dec. 1999, pp. s11, s12
  early signs of infection:
  loss of skin integrity from wounds, cracks, fissures provides a portal of entry for bacteria that results in infection and micro clotting, which allows the infection to progress. poor glucose control leads to impairment of leukocyte (white blood cell) function and the body’s ability to fight infection. fungi can predispose the patient to more severe infections from colonization by bacteria, potentially resulting in cellulitis and gangrene. this is often facilitated by ill-fitting shoes that traumatized the skin.
  “because infection often progresses unnoticed in diabetic patients due to neuropathy until it is quite advanced, careful examination of the patient’s feet in between the toes is critical. ”
  the development of a large population of kidney disease associated with diabetes requires particular attention with early identification and treatment of infection to preserve the foot.
  “they are at higher risk for foot problems, slow healing, and have higher amputation rates.”
  why nail care is important
  nail care is essential to prevent ingrown toenails, infections, and damage to the toes.
  this is especially necessary when toenails are fungal in appearance with;

  thickness
  yellow or black
  discoloration
  debris underneath the nail
  loosening of the toenail plate.

  fungal toenails (onychomycosis)
  common environmental pathogens with a predilection for colonizing under the nail or on the skin includes;

  fungus
  mold
  yeast
  bacteria

  “fungal toenails prevalence in diabetic patients is as high as 33%.”*
  it is significantly harder to fight off when the immune system is compromised. fungal toenails can contribute to foot complications, including;

  ulceration
  bacterial infection
  gangrene
  amputation.

  a regular schedule for screening generalized foot and nail care should be established with a podiatrist.
  fungal conditions can also affect the skin in the form of athletes’ feet with dryness (xerosis), scaling, which can be treated with antifungal topicals or medicated foot gels or soaks.
  toenail and skin infections can be identified by standard would cultures or more sensitive and specific dna cultures. the latter is becoming more common as these infections become more complicated with time. dna cultures can identify certain infections that standard cultures cannot identify. upon review of the culture results, appropriate treatment may be instituted consisting of topical gels, creams, emollients, foot soaks, or oral medications depending on the treatment goals and overall health, including other medications, liver and kidney function. in many instances, the safest and most effective treatment may be regular scheduled generalized foot care with callus and toenail reductions for the prevention of foot problems.
  treatment of infections:

  blood sugar control
  proper nutrition
  early aggressive treatment of compromised tissues
  medicines to reduce swelling
  non-weight-bearing or off-loading pressure on wound sites
  cultures to identity or rule out infection
  no use of whirlpools or soaking
  appropriate antibiotics
  patient education.

  treatment of wounds:
  early, aggressive removal of affected tissue involved (debridement), relieve pressure, culture for infection, protective footwear, skin protection/moist dressings and moisturization, proper nutrition, mechanical alleviation of pressures, adjunctive therapies such as wound care products, skin substitutes, grafts, stem cells, hyperbaric oxygen therapy, and patient education.
  a vital aspect of treating the diabetic wound is non-weight bearing on the wound site as even a few steps on the healing foot may destroy the effects of an entire day of healing. although protective footwear is important, the human foot needs to heal without the added weight of the shoe. elevating the healing foot to decrease swelling is necessary. there are many devices designed to relieve pressure on the foot, ranging from wheelchairs, crutches, and walkers to total contact casts, total contact sandals, and healing shoes (catanzarite 1999). unweighting a wound on the bottom of the foot can be accomplished by strict non-weight bearing with wheelchairs, crutches, walkers, or transfer devices. however, for true weight-bearing to be successful, tremendous emphasis on patient education, training in the use of their own waiting devices, and intense compliance are necessary.
  total contact casting allows for walking with a complete reduction of pressures. this casting off-loads the forefoot and midfoot and even the heel to facilitate healing. they are considered to be the ‘gold’ standard’ for neuropathic foot ulcers, designed to reduce the vertical and horizontal pressures on the bottom of the foot while allowing ambulation. total contact casts are also useful in controlling edema. this specialized cast is closely molded to the bottom of the foot and requires training an application technique with careful surveillance infrequent changing. this cast decreases swelling, which can cause looseness, so it must be changed regularly. there are additional assistive devices to help off-load pressure areas, including custom orthotics, ankle-foot orthotic braces prefabricated or specialized cane, walker, immobilization boots in rigid-soled darco shoes with foam covering.
  h2 peripheral arterial disease
  peripheral neuropathy or nerve damage
  treatment:

  pressure reduction
  skin protection with moisturization and use of emollients
  limited exposure of skin to water
  reduction of calluses and corns
  regular toenail care
  daily inspection of the feet
  heel protection for bed rest patients
  protective footwear (durable medical equipment: diabetic shoes and insoles, orthotics, braces)
  accommodative padding of prominences or deformity
  prophylactic surgery for prevention of problems
  non-weight bearing exercises
  emergency podiatry referral for charcot’s foot
  patient education.

  peripheral arterial disease
  peripheral neuropathy or nerve damage
  treatment:

  pressure reduction
  skin protection with moisturization and use of emollients
  limited exposure of skin to water
  reduction of calluses and corns
  regular toenail care
  daily inspection of the feet
  heel protection for bed rest patients
  protective footwear (durable medical equipment: diabetic shoes and insoles, orthotics, braces)
  accommodative padding of prominences or deformity
  prophylactic surgery for prevention of problems
  non-weight bearing exercises
  emergency podiatry referral for charcot’s foot
  patient education.

  prophylactic surgery (open or minimally invasive)
  adequate circulation and infection control must be present before any elective surgery. a variety of procedures exist for surgical intervention, such as removal of a small segment of bone in order to alleviate small areas of high pressure (osteotomy). a bunion reconstruction realigns the great toe to prevent ulceration on the inside of the ball of the foot and reduce joint stress. crooked toes may be straightened by the release of tight tendons to rebalance the toe into a normal alignment and arthroplasty as needed to release the joint to allow for straightening of the hammertoe and alleviate high pressures on the tops and tips of the toes. metatarsal realignment of a prominent bone in the ball of the foot with increased pressures can reduce callous and recurrent ulcer formation. a metatarsal head resection can be performed with the removal of the bonehead to completely eliminate the pressure of the prominent bonehead. a problematic toenail can be removed permanently via matricectomy used to treat recurrent infected ingrown nails. removal of a small bone of the forefoot (sesamoidectomy) can be performed to relieve high-pressure areas directly under the first metatarsal.
  such procedures can be performed minimally invasively through 2 mm portals under a local injection via a minimally invasive trained podiatrist or as an open procedure in an outpatient or inpatient facility with sedation.
  charcot foot
  patients with lots of protective sensations are at high risk for the development of charcot fracture that may go undiagnosed. history of trauma, mechanical stress, local elevation and temperature, redness and swelling, and possible pain, all in the presence of bound impulses, can help with the identification of a charcot fracture. suspicion of such a fracture requires immediate non-weight-bearing status to prevent compromise of the architecture of the foot with arch collapse leading to bony prominence.
  charcot foot will go through different stages of development. initially, it will present as joint swelling and redness with bounding strong pulses, at which time micro fracturing of bone is occurring. this (osteoarthropathy) originates with failure of the sympathetic nerves that cause vessels to tighten (constrict) that supply the foot. the unregulated vessels dilate, causing increased circulation. pedal pulses are strong, and bounding in the foot becomes swollen, red, and hot to the touch. the condition is often mistaken for an infection or gout, although the white blood cell count level is usually normal. proper identification and immobilization are required to get weight completely off the foot to prevent immediate damage to the architecture of the foot, such as arch collapse during the active phase of development. this will be followed by a healing and remodeling phase with less swelling. the phases can last days to months. ultimately, proper diabetic footwear is imperative to support the foot, which may have become architecturally compromised with new bony prominences such as on the bottom of the foot. this can be accomplished with diabetic shoes with custom insoles or orthotics and ankle-foot orthotic bracing to prevent future ulcerations.
  diabetes mellitus
  diabetes mellitus is the most common cause of the development of charcot (neuroarthropathic foot). other disorders that produce charcot foot joints include:

  chronic alcoholism
  hansen’s disease (leprosy)
  tabes dorsalis
  syringomyelia
  meningomyelocele
  spinal cord injury
  peripheral nerve injury.

  amputation prevention:

  complications from diabetes account for approximately 50% of all non-traumatic amputations in the united states.
  while 14-20% of patients with foot ulcers will subsequently require an amputation, foot ulceration is the precursor to approximately 85% of lower extremity amputations in people with diabetes.
  frykberg, robert g., et al“epidemiology of diabetic foot.” diabetic foot disorders, dec. 1999, pp. s6
  one of the most important measures for preventing amputation is patient education. amputation is preventable when patients wear appropriate footwear, take care to avoid foot injury and repetitive high stressors, and check their feet on a daily basis for warning signs of injury or disease progression.
  diabetic footwear (durable medical equipment)
  prescribing appropriate therapeutic footwear for these patients requires a review of their medical history and careful evaluation of their deformities and activity levels. patients should be cautioned that prevention of injury depends largely upon their serious and continued adherence to foot care and careful maintenance of use of their prescription footwear. prescription footwear is not a temporary measure but rather a lifelong commitment.
  what are the early signs of foot ulcers
  diabetic foot ulcers:
  pressure areas such as calluses, corns, and blisters are considered ‘pre ulcerative.’ they can lead to wounds classified as ulcers based on the level of the tissue layer the wound extends. ulcerations can lead to infections of the soft tissue (cellulitis, abscess) or of the bone (osteomyelitis) and amputation of the infected bone.

  15% of patients with diabetes will develop a lower extremity ulcer during the course of their disease
  the cumulative effects of neuropathy cause deformity from high plantar pressure for glucose control duration of diabetes and gender all contributory factors for foot ulceration
  14% of diabetics are hospitalized yearly, with 25% for foot problems.ulcers are present in 20% of all hospital admissions associated with diabetes.
  risk increases significantly when the patient is a smoker, over 40, hypertensive, obese, black, hispanic, or native american.
  the multifactorial nature of diabetic foot ulcer ration has been elucidated by numerous observational studies.
  risk factors identified include peripheral neuropathy, faster to see is limited joint mobility for the formal is abnormal foot pressure, minor trauma history of ulceration reputation, and impaired visual acuity. the multifactorial nature of diabetic foot ulceration has been elicited by numerous observational studies. risk factors identified include peripheral neuropathy, faster disease, limited joint mobility for deformities, abnormal foot pressure, minor trauma history of ulceration reputation, and impaired visual acuity.
  frykberg, robert g., et al“epidemiology of diabetic foot.” diabetic foot disorders, dec. 1999, pp. s6

  peripheral sensory neuropathy in the absence of perceived trauma is the primary factor leading to diabetic foot amputation.
  approximately 45 to 60% of all diabetic ulcerations are purely neuropathic, while up to 45% have neuropathic in ischemic components.

  other forms of neuropathy may also play a role in foot ulcerations. motor neuropathy results in muscular atrophy or waste and can lead to

  deformities such as drop foot
  equinas with a tight heel cord contracture
  hammertoes and clog toes
  prominent plantar metatarsal heads

  autonomic neuropathy may commonly result in dry skin with cracking and fissuring, thus creating a portal of entry for bacteria.
  frykberg, robert g., et al. “risk of ulceration.” diabetic foot disorders, dec. 1999
  frykberg, robert g., et al. “risk of ulceration.” diabetic foot disorders, dec. 1999
  the failure of the sympathetic nerves to control the micro blood flow in temperature regulation dysfunction impairs normal tissue perfusion and microvascular response to injury. these alterations can subsequently be implicated in the pathogenesis of ulcerations.
  for deformities resulting from neuropathy, abnormal biomechanics, inherited foot disorders, and prior surgical intervention may result in high focal foot pressures
  this may lead to vulnerable areas of the foot predispose to ulcerations. these are primarily located on the bottom of the foot, although on the top and sides may occur from footwear irritation.trauma to the foot in the presence of peripheral sensory neuropathy is an important component cause of ulcerations. while trauma may include puncture wounds or blunt injury, a common injury leading to ulceration is moderate repetitive stress resulting from walking or day-to-day activity. this is often manifested by callus formation under the metatarsal heads. shoe-related trauma has been identified as a frequent precursor to foot ulceration.
  the peripheral vascular disease rarely leads to foot ulcerations directly. however, once ulceration develops, arterial insufficiency will result in prolonged healing and imparts an elevated risk for amputation. attempts to resolve an infection will be impaired due to lack of oxygenation and difficulty in delivering antibiotics to the side of infection. early recognition and aggressive treatment of lower extremity ischemia are therefore vital to lower limb salvage.
  limited joint mobility has recently been described as a potential risk factor for ulcerations.
  stiffening of capsular structures and ligaments due to the enzymatic modification of collagen by the addition of sugar in long-standing diabetes the subsequent reduction in ankle, rearfoot, midfoot and forefoot joint mobility has been shown to result in high focal plantar pressures with increased risk of ulcerations
  stages of foot ulcers
  the description of the ulcer characteristics on presentation is critical for mapping of its progress during treatment.
  the presumed cause needs to be determined. the evaluation should include the size, depth of the ulcer, as well as a description of the margins, base, and geographic location of the extremity or foot. the description should note to which level the ulcer probes. it should comment on the margins and extension and if there are any sinus tracts. a positive probe finding to bone has a high predictive value for osteomyelitis
  the existence of odor and exudative drainage should be noted. culture may be necessary when signs of inflammation are present. current recommendations for culture and sensitivity include thorough surgical preparation of the wound site with curettage of the wound base for specimen or with the aspiration of abscess material
  frykberg, robert g., et al. “ulcer evaluation.” diabetic foot disorders, dec. 1999, pp. s18
  seemingly superficial wounds are often like the cap of a volcano, masking seething layers of infected, necrotic tissue below. without aggressive debridement, the true extent of the wound is obscured, the character of the infection is unappreciated, and the wound simply won’t heal. superficialhealing (granulation) may occur, but as soon as pressure is reapplied (as in ambulation), it breaks down. wounds or ulcers not responding to aggressive treatment or that occur in atypical areas should be biopsied to rule out possible malignancy.
  there are many different staging systems for foot ulcers;
  level 1: onset of a pre ulcerative callus, corn or blister affecting the epidermis directly over a pressure area with bony deformities
  level ii: extension through the epidermis and into the dermal tissue layer over a pressure area but bony deformities
  level iii: extension through the epidermal, dermal tissue layer to the subcutaneous tissue layer.
  level iv: extension through the epidermal, dermal and subcutaneous tissue layers to the level of the tendon or deep fascia.
  level v: extension through the epidermal, dermal, subcutaneous, muscular, and fascial layers to the level of the bone. if the ulcer can probe to the bone, an infection of the bone is likely (osteomyelitis). infection can spread and invade the surrounding tissues and tendons. the wound bacteria are commonly many (polymicrobial) and resistant to the usual oral antibiotics. the infection can spread inside the bone to other bones.
  although no single system has been universally adopted, the classification system most often used was described and popularized by wagner. subsequent authors have modified the classification system by including descriptors for considerations of the role of infection, ischemia, and other comorbid factors for consideration.wagner grading system for diabetic foot ulcers (a, page 8)in the wagner classification system, foot lesions are divided into six grades based on the depth of the wound and the extent of the tissue necrosis.

  grade 0 skin intact, lead to “foot at risk” shoe modifications with serial exams.
  grade 1 superficial ulcer extending through the epidermis of the skin to the dermal tissue layer. office debridement
  grade 2 deeper, full-thickness extension operative formal debridement and contact casting
  grade 3 deep abscess formation or osteomyelitis operative formal debridement and contact casting
  grade 4 partial gangrene of forefoot local vs. larger amputation
  grade 5 extensive gangrene amputation
  tips on working with your diabetes care team
  principles of wound management: ensure adequate blood flow via clinical examination and vascular studies, prevent or control infection, protect and off-load pressure areas with durable medical equipment such as diabetic shoes and insoles, custom orthotics or ankle-foot orthotic bracing, accommodative padding, ensure adequate nutrition, optimize the wound environment for healing with adequate and debridement to remove compromised tissue and promote healthy tissue.
  management of ulcers involves;

  pressure relief
  debridement
  wound cleansing
  application of dressings
  therapy

  should be undertaken using an interdisciplinary team approach.
  the method of debridement should be appropriate to the patient’s condition and clinical goals and should remove all debris from the wound. advanced stage wounds that are devitalized in infected tissue require aggressive sharp surgical debridement. when there is no urgent clinical need for drainage removal of the fertilized tissue or the patient is not a surgical candidate, mechanical and surgical debridement may be employed.
  with deep wounds penetrating to level of bone to bone, biopsy should be performed for bacterial and fungal cultures to rule out a bone infection. the objective of surgical debridement is to remove all necrotic or infected tissue from the wound and convert a chronic wound into an acute wound to facilitate wound healing. additionally, surgical debridement is the only procedure that effectively removes the thickened epithelium from around the room of the chronic wound.
  optimal wound healing cannot proceed until all inflammatory material is removed from the wound bed, with cleansing and debridement. irrigation is a cleansing methodology that can be used to remove materials and bacteria. fluids can be applied to the wound with a scrubbing matrix such as gauze pad, sponge, brush, or simply poured into the wound. when used at the proper pressure, irrigation is an excellent wound cleansing technique.
  the method of debridement should be appropriate to the patient’s condition and clinical goals and should remove all debris from the wound. advanced stage wounds that are devitalized in infected tissue require aggressive sharp surgical debridement. when there is no urgent clinical need for drainage removal of the fertilized tissue or the patient is not a surgical candidate, mechanical and surgical debridement may be employed.
  with deep wounds penetrating to level of bone to bone, biopsy should be performed for bacterial and fungal cultures to rule out a bone infection. the objective of surgical debridement is to remove all necrotic or infected tissue from the wound and convert a chronic wound into an acute wound to facilitate wound healing. additionally, surgical debridement is the only procedure that effectively removes the thickened epithelium from around the room of the chronic wound.
  optimal wound healing cannot proceed until all inflammatory material is removed from the wound bed, with cleansing and debridement. irrigation is a cleansing methodology that can be used to remove materials and bacteria. fluids can be applied to the wound with a scrubbing matrix such as gauze pad, sponge, brush, or simply poured into the wound. when used at the proper pressure, irrigation is an excellent wound cleansing technique.

  healing process would include;
  topical wound healing agents
  enzymatic debriding agents
  wound care products with dressings

  hydrogels
  foams
  alginates
  collagen-based products

  to augment the healing process,anodyne or revitamed infrared light therapy
  employ a multidisciplinary approach to prevent a recurrence.
  the multidisciplinary team can include:

  internal medicine
  endocrinologist
  podiatrist
  visiting nurse
  vascular surgery
  pedorthist (custom shoe specialist)
  prosthetists
  nutritiondietitian
  compression specialist
  physical therapist
  rehabilitation medicine
  neurologist
  plastic surgeon
  orthopedic surgeon
  social worker
  pharmacologist

  follow your diabetes treatment plan
  exercise such as prolonged walking and running and jogging, and use of the treadmill is not recommended for patients with diabetic neuropathy. appropriate fitted diabetic protective footwear is used to limit pressure areas. swimming, bicycling or encouraged, but one must be cautious and wear protective footwear to avoid severe burns from hot sand or hot concrete, such as around swimming pools. protective footwork and also guard against abrasion from the pool floor or deck. fishers, cracks, and dry skin require aggressive therapy, and simple mr. iser alcohol-based creams, in general, should be avoided because they cause excessive drying to the skin.

  ensure adequate nutrition
  maintain ideal body weight and
  glycohemoglobin hba1c levels
  total albumin levels above 3.5
  low serum albumin and total lymphocyte counts can result in slow healing or non-healing wounds for at-risk patients.

  keep your doctor’s appointment-be sure to get a foot exam at least once a year.
  an individual’s risk factors will be assessed based on the complete medical picture, including medical history, clinical examination, medications, and active foot problems.
  daily do’s and don’ts to protect your feet (proper diabetic foot care)

  do not smoke! it causes vessels to narrow at points furthest from the body’s core, such as the feet, decreasing blood flow and increasing risk for injury or slow healing.
  inspect your feet daily for blisters, cuts, and scratches. the use of a mirror can aid in seeing the bottom of the feet. always check between the toes. check for dryness, redness, tenderness, and localized areas that rub (hot spots).
  wash feet daily. dry feet carefully, especially between the toes. keep toes clean and free of debris between them.
  avoid extremes of temperatures. test water with your hand or elbow before bathing.
  if feet feel cold at night, wear loose socks to bed. do not apply hot water bottles or heating pads. if feet are hot, do notice down. avoid exposing your feet to extremes in temperature.
  do not walk on hot surfaces, such as sandy beaches or cement around swimming pools.
  do not walk barefoot. your feet may be numb, and you will not feel an injury as it occurs.
  protect your feet against sunburn with sunscreen.
  beware of car heaters on long trips.
  exercise needs should be reviewed for protecting the diabetic foot with possible neuropathy while at the same time increasing cardiovascular function.
  do not use commercial chemical agents for the removal of corns and calluses.
  do not use robust antiseptic solutions for your feet which may dry them out excessively.
  do not use footpads or arch supports.
  do not use adhesive tape on your feet.
  buy only comfortable well fit shoes, have a clark fit them for you. walk around in them and be sure they are comfortable immediately. people whose feet are numb tend to wear shoes that are too small, causing the rubbing spots.
  buy new shoes late in the day. feet in large slightly during the day, and shoes that fit in the morning may be too tight by noon.
  choose shoes with soft leather uppers that can mold to the shape of your feet. it should be wide enough across the toes. modern walking or running shoes may be beneficial. never buy shoes with open toes or heels. inspect the inside issues daily for foreign objects, nail points, torn lining in rough areas.
  have your podiatrist inspect new shoes to be sure of proper fit in construction.
  never wear new shoes more than two hours at a time. if they are tight in an area, wearing them for a short period of time will reduce the risk of skin breakdown. slowly increase wearing time over several days. i don’t wear any shoes for more than five hours at a time. you should have one pair from a warning, one for the afternoon and one for an evening around the house.
  never wear or buy sandals, particularly those with thongs between toes.
  always scrutinize the inside of your shoes before putting them on and after taking them off.
  inspect the insides of shoes daily for foreign objects, nail pints, torn lining, and rough areas.
  if vision impaired, have a family member inspect your feet daily.
  for dry feet, use a thin coat of lubricating oil or moisturizer cream. apply after bathing and dyeing the feet. do not put oil or cream between the toes as it may cause too much moisture and cause the skin to break down. never use antiseptic solutions or astringents on your feet; this may be too drying for the skin.
  never wear socks or stockings with seams. seams can cause areas of pressure and rubs, which cause skin breakdown.
  check with your podiatrist for socks or stockings specifically for people with diabetes. some synthetics can be a source of dryness, and diabetic feet tend to be dry.
  wear only clean socks, and change them daily.
  inspect socks or stockings carefully before and, particularly after, wearing them.
  never wear socks or stockings with seams. the seams can cause pressures and rubs, which can break down.
  check with your podiatrist for stockings made specifically for people with diabetes. some synthetics can be a source of dryness, and diabetic feet tend to be dry.
  wear only clean socks, and change them daily.
  inspect socks or stockings carefully before and, particularly after, wearing them.
  wear properly fitting stockings. do not wear mended stockings. avoid stockings with seams. change socks daily.
  do not wear garters or panty girdles that are too tight around the legs. girdles may be too tight and cause swelling of the lower legs.
  shoes should be comfortable at the time of purchase. do not depend on them to stretch out. shoes should be made of leather. running shoes may be worn if fitted appropriately.
  do not wear shoes without stockings.
  do not wear sandals with thongs between the toes.’
  take special precautions during wintertime. wear wool socks and protective shoe gear.
  toenails should be trimmed straight across. do not cut deep down on the sides or borders. gently round the corners using an emery board.
  do not cut corns and calluses or reduce thickened, ingrown or problematic toenails. follow instructions from your podiatrist.
  do not use commercial corn or callus removers, footpads, or arch supports.
  do not use adhesive tape on your feet.
  see your physician regularly and be sure that your feet receive examination upon each visit.
  notify your podiatrist at once should you develop a blister or sore on your foot.
  be sure to inform your podiatrist that you have diabetes.
  be sure to inform your podiatrist promptly if you develop a blister, puncture, or sore on your foot or if a callus or corn appears.