Save your feet :Letter from a Surgeon to All Diabetics of the Past ,Present and Future

Dear Reader ,

This is my first blog so I will assume that it will not be perfect and have many drawbacks but as 

someone who believes that " it is better to  have tried and failed than not to have tried at all"

( I have replaced the word love ,but then I think its completely irrelevent in the present setting😏).

So much has been written  and discussed on the topic that I initially felt I cannot do anything  

different from what has already been written and said .  But then I realised that most of the 

information that doctors have, remains restricted to the medical community and rarely 

does it percolate to the masses in the unadulterated form ,simple and devoid of any 

complicated medical jargon .I have attempted to connect with you in a format that 

may appear to be casual and personal as a letter from a doctor to his patient..i.e blog in the new era.

I must admit that I have been influenced in my childhood by Pt Jawaharlal Nehru’s :Letters from a 

Father  to his daughter and I have found it to be the most effective way of explaining and       

communicating complex problems, ideas and solutions that was palatable to me all through my 

growing years

So my blog has been divided into sections that try and analyse the problem and in the process explain 

the possible solutions

Before we find the solution to any problem it is necessary to answer these questions

Is it a problem?What is the problem?Where is the problem?When is the problem?

The second step is  we try to find out: 

What is the extent of the problem ?

What causes the problem ?

What factors leading to the problem can be changed so that the 

problem does not arise?

The last step is Damage control, and correction once the  problem has occurred .

Diabetic foot:Is it a problem?

Pain is  one of the most unpleasant sensations we know and  it is difficult to accept that 

it is actually a blessing in disguise.No one likes pain but like all necessary evils its 

role in the human body is very important.Pain is a protective sensation .It indicates 

there is something wrong with the body and draws our attention to it.Any activity which 

causes pain is potentially injurious to health and is better avoided.(exceptions are 

medically administered injections).So without pain we would ignore all the danger signs 

till it is too late.

What is the problem?

The primary problem in diabetic foot is loss of pain sensation or altered sensation due 

to nerve damage called neuropathy.The patient is blissfully unaware of any acute or 

subtle ,chronic injury to the foot and continues to neglect it till the problem presents 

itself as an ulcer ,abscess ,gangrene or deformity of the foot.Acute (immediate )injuries 

like burns, pin/needle penetrations ,abrasions cut injuries while trimming nails ,shoe 

bites ,scratch marks that usually would draw immediate attention of the affected person 

resulting in immediate treatment and avoidance of weight bearing till pain subsides and 

wound heals is absent in a diabetic with neuropathy.The patient usually continues to walk 

on the injured foot resulting in worsening of the wound.A small wound that should have 

healed with rest and treatment in a person with normal sensation becomes bigger and  

infected very often needing admission ,antibiotics and surgery.The second type (subtle /chronic)  

injury is something that happens very slowly initially hidden from everyone but later progresses 

so fast that the it catches us off guard and is often too late.

The three most common types of such injuries are 

1)callosities

2)ingrowing toe nails and 

3 )Intertrigo

1)Callosities: A normal person cannot stand comfortably in the same position for 

long.This is because when a person stands he exerts pressure on certain points on his  

feet.The skin over these points is pressed between the bones of the feet and the hard 

surface outside,which maybe the ground if person walks barefoot or inner sole  if 

patient is  wearing footwear.When the skin is pressed the blood supply to skin stops and 

the uncomfortable sensation is transmitted to the brain so that the person changes 

position, pressure is transferred to another point and blood flow to the previous point is 

restored.this stoppage of blood flow is momentary in normal people  but in a diabetic 

with neuropathy this sensation is not transmitted soon enough resulting in formation of 

layers of dead hardened skin called callosities.If callosities continue to develop in the 

pressure point then they become hard as stone and the effect is similar to sticking a 

stone beneath the foot and walking.The soft tissue between the callosity and the bone 

breaks down resulting in diabetic foot ulcerations.Usually the patient notices these 

ulcers once the callosity is removed or the ulcer gets infected releasing foul smelling 

discharge./pus.

2)Ingrowing toe nails:The toe nails are supposed to grow straight over the edges and nails 

but  sometimes due to injuries to nailbed ,improper footwear and hereditary causes they 

grow curved and push into soft tissue edges of the nail or tip of the toe.This results in 

injuries which later become infected .Since in a normal person pain develops soon after 

the nail starts pushing on the edges they trim the nail edges,but in a diabetic since there 

is no sensation the nail edges continue to grow and damage the surrounding tissue 

causing infection that very often result in toe or higher amputations if neglected.

3)Intertrigo: Intertrigo or fungal infection between toes is very common in our 

state.This is because of the humid climate and rains where the foot may remain wet 

between the toes.Prolonged excessive moisture is ideal for growth of fungus.These 

fungus slowly dissolve the skin barrier and webspaces become portals of entry for 

infection causing, microorganisms  ,abscesses which compromise the  blood supply to 

adjacent toes leading to gangrene.

The Second problem is decreased blood supply to the feet both at level of big vessels 

called macroangiopathy and very small vessels reaching skin called 

microangiopathy.This is usually attributed to the high glucose levels in the blood that 

damage cells  lining  the lumen of blood vessels called endothelium.Damage of 

endothelium makes it more prone to attract cholesterol deposits forming 

plaques that gradually obliterate the lumen of the vessel cutting of the blood 

supply.Since blood supply to tissue decreases sufficient oxygen, nutrition and protection 

in the form of WBC(our soldier cells) and antibodies (our artillery)do not reach the 

injury prone areas resulting in gangrene ,formation and non healing of ulcers.

The Third problem is decreased immunity.High blood sugar levels make the white blood 

corpuscles lazy by affecting their cell membrane. They become slow in their responses  

to target and eliminate the infection causing microbes.Also the blood with high sugar is 

perfect medium for growth of microbes providing enough and more nutrition for  

growth and spread of the the bacteria.

The Fourth and rarer problem is deformity of the foot.This usually occurs due to 

damage and structural changes at molecular level to the nerves ,bones ,muscles and 

tendons caused by their interaction with high  blood sugar  called glycosylasion .This 

foot deformity shifts pressure from areas that are usually designed to withstand pressures 

to areas of foot not having enough fat pad cushioning thereby resulting in callosities and 

ulcers on weight bearing and walking.Also deformed feet cannot be accommodated in 

normal shaped footwear so it makes them more prone to shoe bite injuries.

Where is the problem?

Diabetes is basically raised sugar or glucose levels in the blood.So anyplace where the 

blood flows through will be affected by diabetes.This means from head to the foot 

diabetes takes its toll.The nervous system ,the heart, the kidney, the liver the hands and 

legs all are affected.Why foot requires special mention is because it is the part of the 

body that bears all the weight and is subjected to maximum physical trauma during                 

 walking.So the feet are most susceptible .

Also the nerves and vessels to the feet are longest as they are most distant from the heart 

and spinal cord so they are exposed to maximum amount of raised glucose levels.Hence 

the clinical effects of diabetes can be seen first detected here.One of the first sensations 

to be lost in diabetes is vibration so to detect and assess the neuropathic damage it is 

necessary to do a test known as VPT to vibration perception test every 6 months.Also 

similarly the vessels to the leg are affected and the effects can be detected in initial stages  

by doing ABI test or Ankle Brachial Index where the blood pressures of the leg are 

compared to that of arm.

When is the problem??

Initially we were under the impression that it is only after long years of diabetes that the 

nerves are affected but tests are showing that neuropathy has already set in in 49 % 

patient by the time we detect increased sugar levels called IGT or impaired glucose 

tolerance even before diabetes levels are reached.Many times it is the clinical symptoms 

of neuropathy like tingling sensation or cramps of feet that raise suspicions and blood 

glucose levels are tested.Similarly vasculopathy or damages to blood vessels happens 

early especially in the small vessels or microvasculature.These changes can easily be seen 

in the vessels of the retina of eye which may reflect the changes in the vessels of the feet.

What is the extent of the problem?

Every 30 seconds a limb is lost to diabetes.India will very soon be the diabetic capital of 

the world, at present 2nd place with 72.96 million diabetics.15-20 percent of these 

diabetics will develop ulcers on the feet and 12 percent of them will end up with 

amputations.A person after Below knee amputation  has a 50 percent chance having   

another amputation within 5 years.Once amputation is done the workload on the heart  

increases from 30 to 50 percent depending on whether it is  below or above the knee 

and this makes the patient almost 4 times more prone to heart failure .Another eye 

opening statistic is  that in patients with foot ulcers the 5 year mortality is 40 percent i.e 

of 100 people with diabetic foot ulcers only 60 will be alive after 5 years.and after an 

amputation the mortality rate of 5years is 45 percent that is of 100 people following 

amputation 45 will die before completing 5 years.

What causes the Problem?

The main problem is raised sugar levels.As discussed earlier raised glucose levels lead to 

damage of nerves, blood vessels ,immunity .So there is a loss of sensation which results 

in formation of ulcers followed by non healing of the ulcer because the patient 

continues to walk on it and also because there is decreased blood supply to the 

region.Decreased blood supply means not enough nutrition reaches the 

ulcer.Not only that it also means that less white blood corpuscles(which are already 

weakened by diabetes) and immunity agents reach the site.So the ulcer gets infected 

easily and also spreads easily because our immunity or defence mechanism is very 

weak.Once it spreads throughout the body  life is in danger ,so to save the life before the 

infection spreads further the infected part which cannot be further treated or saved by 

medicine has to be removed or amputated.

How to prevent the problem?

This can be done by taking care of two things :

1)Good control of blood sugar levels.

2) Adequate protection for your feet.

To control your sugars you have to follow the advice of your diabetologist/physician

To protect your feet you have to at least follow the ten commandments

1. DO NOT walk barefoot.Buy 2 pairs of diabetic footwear with MCR/MCP -microcellular rubber/microcellular polymer insoles for inside and outside use.
2. INSPECT the feet daily for blisters ,wounds , bleeding ,smell ,increased temperature ,pressure points of feet and edema .Use a mirror to inspect your feet if you cannot bend the knees enough to directly examine them or ask someone else.
3. DO NOT apply hot fomentation/cold compresses/electric heating pads ,strong balms or pumis stone to rub the legs and feet
4. USE correct foot wear .Choose your foot wear after consulting your doctor.Always wear footwear with socks with loose elastic .It is better to purchase footwear during the evenings as foot size is maximum due to evening swelling.
5. DO NOT walk bearing weight on an affected /ulcerated foot or after a surgery on the foot.
6. DO NOT sit cross legged for long time
7. DO NOT remove footwear during travel and expose your feet to a hot or cold surface
8. CUT the nails regularly ,trimmed square.If it is too thick and too deformed to cut safely by oneself get help from a podiatrist.we have special tools to manage such nails
9. DO NOT cut corns /calluses with a blade or a knife .Home surgery is dangerous.Get help from a trained podiatrist who can do it for you safely using different special operative techniques
10. CLEAN the feet twice daily with soap and water .Wipe the web spaces dry and apply softening agents.

Few guidelines for choosing footwear

Wide toe box :so that toes will not get crowded and compressed together

Soft inner lining : inside the straps and upper body of the foot wear so that feet are not injured

Heel counter :for better protection and stability of the foot 

Velcro fittings :On all straps and no metal buckles to be used .Adjustable straps to accommodate for edema.Elastic bands should be avoided to prevent constriction of blood flow.

Best insoles :MCR/MCP/EVA/Plastizote with 30 shore hardness

Leather upper: soft leather upper body with soft linings for comfort.

Rigid and tough outsole: to protect the feet from penetrating injuries and helps control the muscles of the feet .

Light weight :to give more comfort and no ankle joint pains for smooth walking

Aesthetically pleasing: should look like any other foot wear so that patients will not hesitate to wear it outside 

Damage control:

Let us look into each problem graded on basis of severity

Callosity: even if we use proper footwear at times the callosities occur and have to be removed /scraped or abraded in time so that they do not form ulcers

Intertrigo/fungal infection between the toes .This usually happens because of increased moisture and crowding of toes preventing air circulation.So simple steps are to keep the space between toes dry ,apply anti fungal ointment and separate the toes with a simple gauze piece

Ingrowing toe nails and infection.Infections resulting from IGTN (ingrowing toe nails ) may initially be controlled by antibiotics but it tends to recur because the sharp edge of the nail continues to bite into the toe .The treatment for it is to remove that part of the nail and destroy the part of the nail bed from which originates either using a chemical or heat.This is usually done in operation theatre after numbing the toe with injection.

Cellulitis of foot or leg.This is the earliest sign of  infection of the leg.The affected part toe, sole, ankle, heel or leg shows reddish discolouration, may be associated with swelling and feels hotter than rest of the body.It is a danger sign and should be taken seriously.antibiotics need to be prescribed ,dressings may be needed and most importantly non weight bearing is mandatory for early and complete resolution of the infection.

Abscess :This is the next stage where the infection has spread deeper and results in formation of collection of pus .This requires cleaning the  infection surgically ,sending the pus or tissue from the abscess for culture to see which organisms are growing and which antibiotics will kill  them.

Osteomyelitis: Sometimes the infection reaches the bone and infected pieces of bone have to be removed and sent to study them to know what microorganisms are causing the infection and to treat them accordingly.

Necrotising fasciitis :in this stage the infection starts spreading rapidly in a layer below the skin.it is a surgical emergency which needs antibiotics and early surgery to control the infection.

Gangrene :In this stage the part of the foot dies but remains attached .Usually this happens because of the lack of blood supply to the part or rapid infection .It has to be removed surgically or amputated , ideally after measures are taken to increase the blood supply to the remaining  parts .

Deformity:

Usually the blood supply to feet decrease in diabetes but in some cases paradoxically there is an increase in blood supply because of damage to the nerves controlling the blood vessels to the leg.This results in washout of the calcium resulting in softening of bones ,small fractures and change in shape of foot .These changes are together termed Charcot foot.In initial stages this may be even mistaken for cellulitis and treated incorrectly with antibiotics.The treatment may include  to putting the foot in plaster or in special footwear to prevent further fractures and deformity.In case of severe deformity correction of alignment of bones may be required using many screws and plates followed by a lifelong commitment to wear special footwear while walking .

Another type of deformity occurs in the toes called clawing ,where the toes become bent .This is due to damage to nerves and weakening of certain group of muscles that control toes.Specially designed footwear or in some cases surgery may be required to prevent formation of ulcers and straighten the toes.

Correction:

The steps are relatively are easy to understand but difficult to implement .

1)Control of sugar levels by adjusting dose of insulin

2)Control of infection with antibiotics and surgical removal

3)Amputation of the dead part or that part that is too infected to be saved and is a threat to life and rest of the limb

4)Improving the blood supply by angioplasty or bypass(similar to the heart) so that healing is improved

5)Application of VAC or Vacuum assisted closure devices that improve blood supply , continuosly suck and remove the infected material and decrease the size of the wound.

6)Grafting or flap surgery uses skin or other body parts to cover the wound and heal it.

7)Designing of foot wear and prosthesis for the remaining or reconstructed foot to prevent recurrence of problems and rehabilitate the patient .

All said and done the after spending nearly a decade focussing on this grave problem of diabetic foot amputation that we are facing  I realised that the solution does not lie in complicated surgical gymnastics or high end antibiotics but in simple measures like awareness ,proper foot care ,appropriate foot wear and timely intervention .I sincerely hope you realise it too.

Regards 

Dr Visakh Varma

Podiatric and Plastic surgeon 

SUT Pattom

Trivandrum

Kerala

India