The affect Diabetes has on our feet

Peripheral neuropathy, vascular disease, infection and deformity are predisposing factors in ulceration and amputation in Diabetic populations.

According to Campbell et al. (2000) in The Position Statement from the Australian Diabetes Society,

“Amputation is about 15 times more common in people with Diabetes. Half of the amputations are major involving above or below the knee amputations. The remaining half are termed relatively minor with the removal of toes or feet. Unfortunately amputation rates increase with age.”

“Peripheral neuropathy affects about 30% of people and is the major predisposing disorder for Diabetic foot disease” Campbell et al. (2000)

What is Peripheral Neuropathy?

Peripheral neuropathy is a term used to describe damage to the nerves outside of the brain and spinal cord. The peripheral nerves are what bring and send messages from your limbs back to the central nervous system (the brain) and from the brain to the limbs.

The peripheral nerves most relevant to Diabetics are the Sensory and Autonomic nerves.

  • Sensory nerves transmit information such as the feeling of a light touch, temperature, or the pain from a cut.
  • Autonomic nerves control organs to regulate activities that people do not control consciously, such as breathing, digesting food, and heart and gland functions.

 What happens if I have Neuropathy in my feet?

When Neuropathy is present, changes in sensation may or may not arise within the feet.

According to Pop-Busui et al. (2017) in the Position Statement by the American Diabetes Association up to half of the patients with neuropathy have no symptoms of neuropathy at all. In other words a patient’s may have developed a complete loss of sensation in the feet but not be aware of this occurrence.  A diagnosis in these cases is often only made following an examination or when painless foot ulceration presents.

A reduction in balance may arise. The ability to detect hot, cold and sharp objects may diminish. Tingling, numbness, burning, shooting or sensations of cold feet may be present.

Autonomic sensation may lead to dry skin as the glands controlling sweet regulation may be affected.

What should I do?

If you experience a change in sensation or experience strange sensations in the feet or hands, arms or legs it is important to see your general practitioner. Initially it is important to find out why peripheral neuropathy has developed.

If your Neuropathy is Diabetes related it is then important to establish your level of risk for amputation. This is where your Podiatrist can help.

A Podiatrist can test your protective sensation with a simple monofilament test and tuning fork in their office.

A foot with normal blood supply and normal sensation is generally at a low risk of ulceration. A foot with a peripheral neuropathy is generally at a higher risk of ulceration and amputation as discussed earlier.

When should I be tested?

Testing should commence at the initial diagnosis of Diabetes. From there, the frequency of testing will be determined by the results of the initial test and other risk factors for complications.

According to the Royal Australian College of General Practitioner’s publication General practice management of type 2 diabetes (2016–18, pg 91) low risk patients should receive foot care education and assessment annually. Patients with either Neuropathy, Poor circulation or a combination should receive assessments every 6 months and receive a program of ongoing Podiatric general foot care between assessments.

From a Podiatry perspective, Low risk patients may receive an annual test and education on self foot care management.  A high risk patient may be seen every 8-10 weeks in the clinic for foot inspections and general foot care, education and ongoing assessments.

Why is this all relevant to me?

A loss of sensation or feeling in the feet means that an individual is no longer able to detect trauma to the feet.

A real life example of this being a problem is below.

While working at St Vincent’s Hospital in Melbourne, I provided primary care to high risk patients. At one consultation a gentleman attended the clinic feeling generally unwell with flu like symptoms. On inspection of the gentleman’s foot it was red, hot and swollen. On closer inspection of the sole of the foot a large abscess had formed and was full of pus.  As the patient had peripheral neuropathy (numbness) his foot felt fine. The gentleman was not aware of this abscess as he had never checked his feet with his eyes as instructed in our education sessions.  As part of the care at the Hospital, the gentleman was referred for an x-ray which subsequently revealed a paper clip lodged in the sole of the foot. Unfortunately due to the infection the gentleman lost his foot to amputation.

The take home message from this story is that with Diabetes or any condition causing peripheral neuropathy the feet may feel fine. This feeling however may be only due to the fact that there is no sensation present at all.

Therefore if you have peripheral neuropathy or Diabetes

  • It is important to visually check your feet on a daily basis for signs of trauma or breaks in skin. If you then detect any issues at all, see your Podiatrist or G.P as soon as possible.
  • Clean and dry between the toes thoroughly to prevent cracking and splits.
  • Apply moisturising cream to the feet daily, avoiding between the toes.
  • Wear well fitted shoes to prevent rubbing and blistering.
  • Check inside your shoes for stones or any seems that may rub
  • Keep your feet away from heat sources such as heater or hair dryers
  • If you suspect you have or know of anybody with Diabetes or Peripheral Neuropathy please seek assistance from you General Practitioner or relevant health care professional.

Authored by Backfocus Podiatrist Andrew Apolloni (Podiatry-La Trobe University). Andrew offers Podiatry services at 2 Bacfocus clinics, located in the CBD and Epping districts.

References:

By Janice F. Wiesman

  • Pop-Busu R, Boulton AJ, Feldman EL, Bril V, Freeman R, Malik RA, Sosenko JM and Ziegler D: Diabetic Neuropathy: A position Statement by the American Diabetes Assosciation. Diabetes Care 2017;40:136-154.
  • The Royal Australian College of General Practitioners. General practice management of type 2 diabetes: 2016–18. East Melbourne, Vic: RACGP, 2016