-Seena Rajsekar & S. Bamila
Dept. of Foot Care and Podiatry
Diabetes is the leading cause of amputation of the lower limbs. And problems with their feet are the most frequent reasons for hospitalization in patients with diabetes. Many of these amputations and hospitalizations could have been prevented through simple preventive foot care. If you have diabetes, you should ask your doctor for foot check-ups too during your routine examination.
The American Diabetes Association estimates that diabetic-related amputation could be reduced by 50 percent if patients were routinely tested for neuropathy, educated to prevent injury or complications, and fitted with appropriate footwear as needed.
People with
diabetes are prone to many foot problems, often because of two complications of
diabetes:
Nerve damage (neuropathy) - which causes loss of feeling in your feet, taking away your ability to feel pain and discomfort, so you may not detect an injury or irritation;
and
Poor blood circulation - which reduces your ability to heal, making it hard for even a tiny cut to resist infection.
When you have
diabetes, you need to be aware of how foot problems can arise from disturbances in the skin, nails, nerves, bones, muscles, and blood vessels. Furthermore, in
diabetes, small foot problems can turn into serious complications.
* Neuropathy is one of the most common complications of
diabetes, resulting in the loss of protective sensation which signals pain and helps patients avoid injury.
* As many as half of the 16 million people with
diabetes have or will develop neuropathy, or nerve damage, in their legs or feet that can lead to injuries, sores, chronic infections, gangrene or amputations.
* An estimated 2.4 million people with
diabetes will develop foot ulcers.
* Every year, an estimated 54,000 patients with
diabetes have amputations as a result of complications from
diabetes.
* Patients with
diabetes have a 15-fold increase in the risk of amputation over that of the general population.
You can do much to prevent amputation by taking two important steps:
• See your foot and ankle surgeon regularly.
• Follow the proactive measures discussed below.
Examination and evaluation of the patient with
diabetes, with a focus on the lower extremity, is the first step in identifying the patient’s risk factors and preventing lower extremity amputations.
The three core parameters to be tested in a valid foot ulcer and leg amputation prevention examination include:
Vascular testing through the evaluation of pedal pulses, also by checking the Ankle brachial index (A\B index) for detecting Periphiral vascular disease,
Neurological testing to assess loss of protective sensation (LOPS), determined by the Monofilament test.
Vibratory perception threshold can be checked by testing with Biothesiometer .
Deformity identification with regard to the bones, soft tissues and toenails should also be carried out.
Bone deformities in the foot can be the result of faulty biomechanical function, diabetic motor neuropathy or a combination of both. In motor neuropathy, the nerves that innervate the 13 lumbricales and interossei muscles in the foot malfunction. The result is muscle atrophy that causes joint contractures in the toes that lead to bone and soft tissue deformities.
Bone deformities cause new pressure points against the foot that can be triggers to an amputation. These include:
1. Hallux Abducto Valgus- A medial deviation of the first metatarsal and lateral deviation and/or rotation of the hallux.
2. Hammer Toe- A joint contracture deformity of the proximal interphalangeal joint
3. Mallet Toe- A joint contracture deformity of the distal interphalangeal joint
4. Claw Toe- A joint deformity involving the metatarsophalangeal joint and both the proximal and distal interphalangeal joints
5. Tailor’s Bunion- An angular joint deformity of the fifth toe at the metatarsophalangeal joint on the lateral aspect of the foot.
Soft tissue deformities, primarily keratoses, result from the body’s natural protective mechanism to shield the underlying bony structure from excessive pressure, caused by shoes or the environment. Due to sensory neuropathy and the loss of protective sensation, the patient with
diabetes often cannot feel the pressure against the foot from the thickened skin lesions. This can result in the formation of an abscess under the keratosis. If not detected in time, these abscesses can lead to infection, ulceration and osteomyelitis.
Appropriate preventive care includes professional foot care for debridement of the keratosis tissues. Then padding, good fitting insoles, or biomechanical orthotics with essential devices to offload the pressure sites are required. Modified shoes, with customized moulded insoles, and therapeutic footwear have to also be considered.
Too often, toenails are overlooked. The nails can become thick and deformed due to mold, yeast and fungal infections. Shoe pressure against these deformed toenails can cause a subungual abscess.
Amputation and
Diabetes prevention depends on proper diet, regular and continuous exercise and proper
Diabetes foot care. Self monitoring blood glucose and maintaining healthy blood sugar levels to avoid infection is the best way to prevent
diabetes complications that can lead to amputation.
Programs to reduce amputations among people with
diabetes in primary-care settings should identify those at high risk; clinically evaluate individuals to determine specific risk status; ensure appropriate preventive therapy, treatment for foot problems, and regular follow-up; provide patient education; and, when necessary, refer patients to podiatrist for diagnostic and therapeutic interventions.
Steps you can take to have healthy feet include:
Eat a healthy, balanced diet.
Control your weight
Check feet each day for small cuts or blis ters, since most diabetic foot problems begin with the sores on the skin.
Create awareness among patients.
• Test routinely for nerve damage.
• Never go barefoot either indoors or outdoors.
If your feet become excessively dry, lubricate them with a thin film of
moisturizing cream on the soles immediately after bathing.
• Avoid exposing feet to extreme temperature.
File nails straight across.
• Wear comfortable well- fitting therapeutic footwear
Do not wear shoes without socks or stockings. Socks or stockings with seams should be avoided. Cotton and cotton blends are recommended.
If non-healing foot ulcers occur, consult with a PODIATRIST.
Conclusion
A valid foot examination for amputation prevention involves the identification of pedal risk factors of the vascular and neurological systems and deformities of the bones, soft tissues and toenails. Identification of the patient’s pedal risk factors and establishing a preventive foot care plan to prevent ulcers, infections, and amputation in the patient with
diabetes is critical to ulcer and amputation prevention. This increases the patient’s quality of life, and controls health care costs to the individual and to the society.
The MVH Initiative - CHENNAI AMPUTATION FORUM
The Chennai Amputation Forum was launched at
M.V Hospital for Diabetes, under the able guidance of our Managing Director, Dr.Vijay Viswanathan on World Disabled Day - December 3, 2011 . This is a platform for our amputee patients to meet once a year. They are provided with free walker and free therapeutic footwear.
The New Year is the right time to get rid of unhealthy habits and pave the way for good health during the golden years.
Sleep soundly. Irregular sleep habits can expose you to heart conditions, diabetes and obesity and can even affect your personality, mood and behaviour. Sleep at least 7-8 hours a day with regular schedules of bed time and rising.
Get your daily dose of Vitamin D - Sunshine is the most natural source of the vitamin and it is free!Go out in the sun for 10 – 15 minutes each day. Your bones will be stronger .This vitamin is also important for muscle movement. 
Boost your body with iron - It is the most important substance for body activities and we have to depend on foods for this nutrient. Eat iron rich foods such as dates, jaggery, green leafy vegetables and organ meats. So beat fatigue both mental and physical by being aware of what you eat. 
Walk briskly - for at least ½ an hour a day . it will help you feel more alert and energetic and also help control heart conditions and diabetes. 
Smile - Look after your teeth and gums. Visit the dentist regularly. Don’t wait for those cavities. 
Go for regular health check-ups –. Take time off for physical check-ups to spot those silent killers - diabetes, hypothyroidism, osteoporosis, cancer, high cholesterol and blood pressure. 
