How to avoid problems with your diabetic feet

causes your blood sugar levels to be higher than normal. Over time, high blood sugar levels can damage the blood vessels and nerves in your body.People with diabetes often have trouble with their feet. Part of the problem is that the loss of feeling in your feet makes it hard for you to tell if you have a blister or sore. If little sores aren’t taken care of, they can get worse and turn into ulcers (serious, deep sores). If these ulcers become infected, you may have to go to the hospital or, in very serious cases, have a foot amputated (removed). This handout will give you some tips on how to care for your feet.

The estimated 20 million Americans with diabetes need to remember that simple foot care can reduce their risk of toe, foot or leg amputations, say experts at the American College of Foot and Ankle Surgeons (ACFAS). People with diabetes are 10 times more likely to have a lower limb amputated than people who don’t have the illness, which can cause poor blood circulation and nerve damage in the feet. This makes feet more vulnerable to ulcers, infections, deformities and brittle bones. Keep your blood sugar level as close to normal as possible. Also, follow your doctor’s advice on diet, exercise and medicine. Here are some other ways to protect your feet.

The following foot care tips for people with diabetes:

• Inspect feet daily for injuries that could lead to dangerous ulcers.
• Gently wash feet in lukewarm — not hot — water.
• Moisturize feet but avoid the areas between the toes.
• Never trim corns or calluses. Doing so can lead to serious infections.
• Inspect the inside of shoes before you put them on.
• At the first sign of trouble, see a doctor. Early treatment can prevent foot problems from worsening and reduce the risk of amputations.
• Dry your feet well, especially between the toes. Use a soft towel and pat gently; don’t rub.
• Keep the skin of your feet smooth by applying a cream or lanolin lotion, especially on the heels.
• If the skin is cracked, talk to your doctor about how to treat it.
• Keep your feet dry by dusting them with nonmedicated powder before putting on shoes, socks or stockings.
• Check your feet every day. You may need a mirror to look at the bottoms of your feet. Call your doctor at the very first sign of redness, swelling, pain that doesn’t go away, or numbness or tingling in any part of your foot.
• Cut toenails straight across to avoid ingrown toenails. It might help to soak your toenails in warm water to soften them before you cut them.
• Don’t let your feet get too hot or too cold.
• Don’t go barefoot.

Products for Diabetic Feet

Diabetic Foot Care Products

If you have diabetes, using podiatrist recommended products for diabetic feet to prevent skin damage is an important part of diabetic foot care. Wearing diabetic shoes and diabetic socks at all times, and seeing a podiatrist at the first sign of any foot injury or skin irritation can also help keep your feet healthy and free of diabetic foot complications such as diabetic foot ulcers.

Diabetic Socks, Insoles, and Wound Care Shoes

foot care products and diabetic shoes to cover their feet at all times. Your diabetic feet should never be barefoot even in the home. The risk is too great that stepping on a tack or banging your toe against a table leg could result in serious foot wounds. In addition to providing foot coverage; diabetic socks, diabetic insoles, and wound care shoes each have their own unique benefits.

Made from anti-bacterial fibers engineered to wick away moisture, seamless diabetic socks help to minimize the rubbing, friction, and irritation that can lead to diabetic foot complications.Diabetic insoles, made from gel or another moldable material can provide diabetic feet with padding and arch support that conform to the specific contours and shape of each individual foot.If you are recovering from foot surgery or have developed of a diabetic foot ulcer, wound care or postoperative shoes allow you to remain minimally ambulatory without further damage to your feet.

Diabetic Foot Cream, Lotion, Spray, and Powder

Dry, cracked skin and calluses are common problems for diabetic feet. Take advantage of the many diabetic foot creams, diabetic foot lotions, and other diabetic foot care products available to keep the skin on your feet smooth, supple, and free of fissures.

Diabetic feet also tend to be more susceptible to athlete’s foot and other foot infections. Products for diabetic feet such as diabetic antibacterial sprays can be used to eliminate potentially harmful foot microbes. Diabetic antibacterial powders have many of the same benefits as diabetic foot sprays and can also control moisture and reduce friction in perspiration-prone diabetic feet.

Diabetic Feet Treatment and Prevention

Diabetes, a systemic disease resulting in an elevated blood sugar level, affects approximately 16 million Americans. Many complications are associated with diabetes, primarily vascular and neurologic problems. But diabetes can also result in many foot ailments, so sufferers need to pay special attention to their feet.

There are two types of diabetes

Type I
 is hereditary and often starts at an early age. These sufferers manufacture little or no insulin, and must inject insulin into their bloodstream to control their blood glucose level.
Type II
 or adult onset diabetes, typically occurs in the obese. The insulin they produce is either not enough or does not work properly. Type II diabetes, however, can be managed with diet, exercise and oral medication. Occasionally, an injection of insulin may be required.

Causes

Diabetes results from either the body’s decreased production of insulin or when the body cannot properly utilize insulin. Blood glucose levels then rise, bringing on symptoms.

Symptoms

Diabetes can be a silent disease. Initially, you may not even know you have it without a blood test from your doctor. But after time, symptoms will develop, including:

• Diminished sensation or the inability to feel pain, associated with numbness or tingling of the hands or feet. The feet can easily become infected when sufferers don’t notice they have a pebble in their shoes
• Peripheral Vascular Disease, or poor circulation leading to ulcers, infections and other serious foot conditions.
• Decreased resistance to infection.
• Kidney failure resulting in dialysis.
• Eye problems resulting in blurred vision and possible blindness.
  Increased thirst and hunger.
• Dry mouth and frequent urination.
• Unexplained weight loss or gain.
• Relief and Prevention:

If you have a diabetic foot, follow these tips to avoid infection:

DOs

• Inspect your feet daily for blisters, bleeding and lesions between the toes. Use a mirror to examine the bottom of your feet as well.
• Wear therapeutic footwear, including specially made diabetes socks, slippers, insoles, orthotics and other diabetic footwear.
• Wear high and wide toe box shoes.
• Wear footwear that fits well and protects your feet.
• Wear conforming removable insoles in your footwear.
• Wear seamless diabetes socks and stockings to keep moisture away from your feet.
  Use diabetic foot creams – just not between the toes.
• Use bed cradles to reduce the weight of heavy bedding on your diabetic foot.
• Diabetic skin care is important! Wash your feet daily with warm, soapy water and dry them thoroughly, especially between the toes.
• Trim your toenails carefully, straight across, and do not gouge into the corners.

DON’Ts

• Don’t excessively soak your diabetic foot… especially in hot water.
• Don’t use hot water bottles or heating pads on your feet .
• Don’t use acids or chemical corn removers on diabetic feet.
• Don’t perform “bathroom surgery” on corns, calluses or ingrown toenails.
• Don’t smoke.
• See your podiatrist on a regular basis, and contact one immediately if your foot becomes swollen, painful, red or infected.

Diabetic Feet Care

Tips for Diabetic Feet Care

• Wash your feet in warm water every day. Make sure the water is not too hot by testing the temperature withyour elbow. Do not soak your feet. Dry your feet well, especially between your toes.
• Look at your feet every day to check for cuts, sores, blisters, redness, calluses, or other problems. Checking every day is even more important if you have nerve damage or poor blood flow. If you cannot bend over or pull your feet up to check them, use a mirror. If you cannot see well, ask someone else to check your feet.
• If your skin is dry, rub lotion on your feet after you wash and dry them. Do not put lotion between your toes. File corns and calluses gently with an emery board or pumice stone. Do this after your bath or shower.
• Cut your toenails once a week or when needed. Cut toenails when they are soft from washing. Cut them to the shape of the toe and not too short. File the edges with an emery board.
• Always wear slippers or shoes to protect your feet from injuries.
• Always wear socks or stockings to avoid blisters. Do not wear socks or knee-high stockings that are too tight below your knee.
• Wear shoes that fit well. Shop for shoes at the end of the day when your feet are bigger.Break in shoes slowly. Wear them 1 to 2 hours each day for the first few weeks.Before putting your shoes on, feel the insides to make sure they have no sharp edges or objects that might injure your feet.

How can diabetes hurt my feet?

High blood glucose from diabetes causes two problems that can hurt your feet:

Nerve damage

One problem is damage to nerves in your legs and feet. With damaged nerves, you might not feel pain, heat, or cold in your legs and feet. A sore or cut on your foot may get worse because you do not know it isthere. This lack of feeling is caused by nerve damage, also called diabetic neuropathy (noo-ROP-uh-thee). Nerve damage can lead to a sore or an infection.

Poor blood flow

The second problem happens when not enough blood flows to your legs and feet. Poor blood flow makes it hard for a sore or infection to heal. This problem is called peripheral (puh-RIF-ur-uhl) vascular disease, also called PVD. Smoking when you have diabetes makes blood flow problems much worse.

These two problems can work together to cause a foot problem.

For example, you get a blister from shoes that do not fit. You do not feel the pain from the blister because you have nerve damage in your foot. Next, the blister gets infected. If blood glucose is high, the extra glucose feeds the germs. Germs grow and the infection gets worse. Poor blood flow to your legs and feet can slow down healing. Once in a while a bad infection never heals. The infection might cause gangrene. If a person has gangrene, the skin and tissue around the sore die. The area becomes black and smelly. To keep gangrene from spreading, a doctor may have to do surgery to cut off a toe, foot, or part of a leg. Cutting off a body part is called an amputation.

Diabetic Neuropathy

What is diabetic neuropathy ?

Diabetic neuropathy means damage of nerve fibres in people with diabetes. How the nerves are injured is not entirely clear but research suggests that high blood glucose changes the metabolism of nerve cells and causes reduced blood flow to the nerve. There are different types of nerves in the body. These can be grouped as :

• sensory (detect sensation such as heat, cold, pain)
• motor (contract muscles to control movement)
• autonomic (regulate functions we cannot control directly, such as heart rate and digestion)
  The most common type of diabetic neuropathy affects the nerves in the legs and is usually known as peripheralneuropathy. This is the type of neuropathy that causes foot problems. It affects mainly the sensory nerves although the motor and autonomic nerves can also be involved with important consequences.

What problems can be caused by diabetic neuropathy ?

Neuropathy can result in two sets of what superficially appear to be contradictory problems. Most patients who have neuropathy have one of these problems but some can be affected by both.

• loss of ability to feel pain and other sensation which leads to neuropathic ulceration.
• symptoms of pain, burning, pins and needles or numbness which lead to discomfort

 Patients with neuropathy lose their sensation of pain. As a result, they exert a lot of pressure at one spot under the foot when they walk, building up a callus at that site without causing discomfort. The pressure becomes so high that eventually it causes breakdown of tissues and ulceration. The patient hardly notices any pain.

Therefore a typical neuropathic ulcer is :

•  painless
• surrounded by callus
• associated with good foot pulses (because the circulation is normal)
• at the bottom of the foot and tips of toes

Are you at high risk of developing a neuropathic ulcer?

This will be dealt with more thoroughly in the section on “Foot examination- Checking your risk of developing a diabetic foot ulcer”.Briefly, you are at risk if :

• you have had a foot ulcer before
• you have lost a lot of sensation in the feet when your doctor tested it
• you do not follow advice to protect your feet with good footwear and hygiene

Remember that even if you have no pain in the feet, it does not mean you are not at risk. On the other hand, just because you have pain in the feet does not necessarily mean you are facing ulceration and amputation.

What sort of treatment is required for a neuropathic ulcer ?

This is dealt with in greater detail under the technical info button at the bottom of this page. In principle, these are the important measures:

Remove the precipitating cause eg. replace shoes that are too tight. Remove the callus regularly to relieve pressure. This usually needs to be done every week. It is best carried out by a podiatrist accustomed to treating diabetic foot ulcers because experience is important to ensure adequate removal of callus. It is better for healing if the wound is kept moist under a foam dressing which protects the ulcer from further trauma and yet allows oxygen to get through.
The old edict of keeping a wound dry and painting it with antiseptics is no longer thought to be the treatment of choice. Do not clean the ulcer with anything that is too caustic (eg strong Eusol or hydrogen peroxide) because this can damage the tissue further. A good rule of thumb is not to put anything on the ulcer that you wouldn’t put in your eye.

Taking Antibiotics

if the ulcer is infected. Remember, most foot ulcers are infected. Many weeks of antibiotics may be required if the ulcer is not completely healed or if there is underlying osteomyelitis.Rest the feet as much as possible because this helps to reduce pressure on the ulcer. Walking is not a good exercise for someone who has a neuropathic ulcer (or someone who is at great risk of developing one).

Wearing an Orthowedge

If a neuropathic ulcer does not heal with the above conservative measures, more specialised methods of relieving the pressure may be needed. These may include wearing an Orthowedge designed to reduce pressure at the front of the foot where most of the neuropathic ulcers are situated

Using a Contact Cast to heal a neuropathic ulcer

Sometimes application of contact casting (a special form of cast not unlike what is used to treat a fracture, except it is better padded inside) can promote ulcer healing, again by reducing pressure on the ulcer. Sometimes when all the above measures have been tried but the ulcer still does not heal, it may be necessary to ask a surgeon to correct some foot deformities which are causing too much pressure. Examples of this include removal of a clawed toe or a prominent metatarsal head.Although blood supply is normal in a purely neuropathic ulcer, in real life many ulcers are neuro-ischaemic. In other words, there is a combination of impaired nerve function and poor blood supply. Therefore it would also be wise to check that blood supply is normal. Sometimes a neuropathic ulcer will only heal when blood supply is improved.

Diabetic Foot and Amputation

It is estimated that 15 percent of all diabetics will develop a serious foot condition at some time in their lives. If you are diabetic, foot problems are a big risk. Like all diabetic people, you should monitor your feet. If you don’t, the consequences can be severe, including amputation, or worse.

 Why do diabetics have foot problems?

 There are three factors that are involved in the development of the foot problems in a diabetic: 

•  Disease of the arteries due to diabetes. When cholesterol plaques form in the large arteries of the legs, they start to reduce the blood flow to the lower legs and feet. A common first hint that something is wrong will be the onset of intermittent claudication — pain in the calf or foot muscles when walking. This indicates that the arteries in the legs can no longer deliver sufficient blood to the muscles to keep them working properly.
• Diabetic neuropathy which is usually worse in the feet. Your ability to detect sensations or vibration may be diminished. Neuropathy allows injuries to remain unnoticed and untreated for lengthy periods of time. Neuropathy can also affect the nerves that supply the muscles in your feet and legs. This ‘motor neuropathy’ can cause muscle weakness or loss of tone in the thighs, legs, and feet, and the development of hammertoes, bunions, and other foot deformities.
• Infection. Persons with diabetes are generally more prone to infections than non-diabetic people. Due to deficiencies in the ability of white blood cells to defend against invading bacteria, diabetics have more difficulty in dealing with and mounting an immune response to the infection. Poor cleanliness and nail trimming practices of the feet and toes often are causes.

 Why should amputation be necessary?

 The infection-fighting ability of a diabetic’s body may be impaired; if so, a tiny cut or abrasion may cause a serious wound, or ulcer. And many of those with diabetes tend to have poor circulation. In addition to hindering feeling in the feet (causing cuts and bruises to go unnoticed), poor circulation can make an injury heal far more slowly.

 Thus, it is possible for a wound on your foot to become very infected and difficult to treat. Your doctor may clean the wounded area, which is known as debriding. This involves removing the outer skin and debris in the wound to facilitate blood flow to the injury, thereby lowering the chance of infection.

 Just like a bacterial infection in your throat, an infection in a wound on your foot is treated with antibiotics. However, many drugs don’t work as a treatment for foot infections because some bacteria have become resistant to treatment.

 Typically, amputation is required in two circumstances: when gangrene of the toes develops due to inadequate blood supply, or when infection of the skin or deeper tissues develops which cannot be controlled with antibiotics and other measures.

  What does one do to avoid amputation?

 There are many things that a diabetic individual can do to prevent the occurrence of foot infections, and thereby amputation.

• Control blood glucose and do not allow it to get too high
• Avoid smoking
• Keep blood pressure and cholesterol under control 
•  Exercise to stimulate blood flow
• Keep feet clean, dry, and warm
• Check your feet every day for blisters, scratches, and skin that is hard, broken, inflamed or that feels hot or cold when touched
• After bathing, carefully dry feet and apply thin coat of petroleum jelly or hand cream to prevent dry skin from cracking
• Use a pumice stone and emery board to trim calluses
• Do not neglect an ulcer, should one develop.

Diabetic Foot Health: Podiatric Treatments for Diabetes

As anyone who’s either been afflicted with diabetes, or had a family member who’s had it knows, diabetics have to be especially mindful of podiatric health. A diabetic’s foot can be one of the hidden frontlines in the body’s battle against diabetes, and ensuring proper diabetic foot health can save much pain and misery far down the road.

You’re probably aware that diabetes is a serious disease that develops when the body does not produce enough insulin, or the insulin produced is not able to perform the functions that it must. Insulin (from the Latin, insula for island) is a hormone, produced by the pancreas gland that takes glucose from the blood, stores it as glycogen, a short term energy source. There are two types of diabetes – Type 1 diabetes is often a result of heredity and appears in the juvenile stage of development; and Type 2 is known more commonly as adult onset diabetes, and is characterized by a high levels of blood sugars, mainly resulting from a combination of poor diet and being overweight.

Because of diabetes, you may experience poor bloodflow, which can cause problems with your feet that can range from neuropathy (loss of sensation in the foot), and even lead to amputation. Therefore, it’s very important to include proper diabetic foot care as part of your diabetes treatment plan. Here are some methods to encourage healthy feet in diabetics.

Compressed Air Foot Massage

Compressed air foot massage is a treatment for neuropathy that helps increase blood flow on local skin, reduce swelling, or edema, and prevents the development of foot ulcers. Using a machine that forces compressed air through a perforated applicator head, the massotherapist massages the foot. A recent study of 57 diabetic patients found that patients receiving 15 to 20 minutes daily of compressed air foot massaging (in addition to traditional forms of therapy, such as topical medications) were able to heal existing foot ulcers on average 24 days faster than those who received no such treatment.

Orthotics

Many podiatrists recommend orthotics as a non-invasive and inexpensive way to protect an insensitive diabetic foot. Many orthotic shoes for diabetics are made with a material named Plastazote that conforms to heat and pressure, thus protecting and providing comfort to the diabetic foot.

Diabetic foot infections

Definition

Diabetic foot infections are infections that can develop in the skin, muscles, or bones of the foot as a result of the nerve damage and poor circulation that is associated with diabetes.

Description

People who have diabetes have a greater-than-average chance of developing foot infections. Because a person who has diabetes may not feel foot pain or discomfort, problems can remain undetected until fever, weakness, or other signs of systemic infection appear. As a result, even minor irritations occur more often, heal more slowly, and are more likely to result in serious health problems.

With diabetes, foot infections occur more frequently because the disease causes nervous system changes and poor circulation. Because the nerves that control sweating no longer work, the skin of the feet can become very dry and cracked, and calluses tend to occur more frequently and build up faster. If not trimmed regularly, these calluses can turn into open sores or ulcers. Because diabetic nerve damage can cause a loss of sensation (neuropathy), if the feet are not regularly inspected, an ulcer can quickly become infected and, if not treated, may result in the death of tissue (gangrene) or amputation.

The risk of infection is greatest for people who are over the age of 60 and for those who have one or more of the following:

• poorly controlled diabetes
• foot ulcers
• laser treatment for changes in the retina
• kidney or vascular disease
• loss of sensation (neuropathy)

Causes and symptoms

Bacteria can cause an infection through small cracks (fissures) that can develop in the dry skin around the heel and on other parts of the foot or through corns, calluses, blisters, hangnails, or ulcers. If not treated, the bacterial infection can destroy skin, tissue, and bone or spread throughout the body.

Common sites of diabetic foot infections include the following:

• blisters, corns, or callouses that bleed beneath the skin
• bunions, hammertoes, or other abnormalities in the bones of the foot
• scar tissue that has grown over the site of an earlier infection
• foot ulcers caused by pressure, nerve damage, or poor circulation (Ulcers occur most often over the ball of the foot, on the bottom of the big toe, or on the sides of the foot due to poorly fitting shoes.)
• injuries that tear or puncture the skin

Diagnosis

A physician who specializes in the treatment of the foot (podiatrist) or the doctor who normally treats the patient’s diabetes will treat the infection. An x ray of the foot will be taken to determine whether the bone has become infected. A sample from the wound will be cultured to identify the organism that is causing the infection so that the appropriate antibiotic can be selected.

Treatment

From the results of the culture, the appropriate antibiotic will be prescribed. Any dead or infected tissue will be surgically removed and, if necessary, a cast and/or special shoes may be used to protect the area. In addition, the patient will be instructed to keep off their feet. If the ulcer does not heal, the physician may perform surgery to increase blood flow to the foot. It is also important for the patient to practice good diabetes control and keep blood glucose levels from getting too high.

Alternative treatment

Acupuncture and vitamin C can boost the body’s infection-fighting ability. A variety of other vitamins and herbs may improve general health and diabetes control. Because diabetes is a potentially deadly disease, it can be dangerous to try alternative approaches without a doctor’s approval or without consulting a trained practitioner of alternative medicine.

Prognosis

Without proper treatment, diabetic foot infections can lead to serious illness, gangrene, amputation, and even death if the infection spreads throughout the body. If treated properly and the patient practices good foot care, the prognosis is generally optimistic.

Prevention

There are many things that a diabetic individual can do to prevent the occurrence of foot infections, including the following:

• control blood glucose and do not allow it to get too high
• avoid smoking
• keep blood pressure and cholesterol under control
• exercise to stimulate blood flow
• keep feet clean, dry, and warm
• check your feet every day for blisters, scratches, and skin that is hard, broken, inflamed, or feels hot or cold when touched
• after bathing, carefully dry feet and apply thin coat of petroleum jelly or hand cream to prevent dry skin from cracking
• use a pumice stone and emery board to trim calluses
• do not neglect an ulcer, should one develop

Diabetic Feet Followup and Prevention

Follow-up

• Read any instructions from the doctor while the patient are still in the emergency department or doctor’s office. Ask questions about any instructions you don’t understand. Follow all of your doctor’s or nurse’s instructions. Let a doctor know if the patient’s condition is not improving within a reasonable time.
•  Be sure to finish the entire course of antibiotics if prescribed by the doctor. Not finishing the entire course can lead to bacteria becoming resistant to antibiotics.
• Less pain, swelling, redness, warmth, or drainage are generally all signs of improvement in an infected wound. Shrinkage of the wound or ulcer is a good sign. Absence of fever is also generally a good sign. Generally, some improvement should occur within the first two to three days. Let a doctor know if the patient is not improving as expected.
• Be especially vigilant about the patient’s diabetes care while they are healing a foot or leg infection. Good glycemic control is good not only for healing an ulcer the patient already has, but also for preventing future ulcers. Check blood sugar regularly and let a doctor know the pattern of low and high levels.

Prevention

Prevention of diabetic foot problems involves a combination of factors.

• Good diabetes control
• Regular leg and foot self-examinations
• Knowledge on how to recognize problems
• Choosing proper footwear
• Regular exercise, if able Avoiding injury by keeping footpaths clear
• Having a doctor examine the patient’s feet at least once a year using a monofilament, a device made of nylon string that tests sensation

Outlook

Age:

The older the patient, the more likely they are to have serious problems with the feet and legs. In addition to diabetes, circulatory problems and nerve damage are more common in the elderly person with diabetes. The elderly may also be more prone to sustaining minor trauma to the feet from difficulties with walking and stumbling over obstacles they cannot see.
 
Duration of diabetes:

The longer the patient has had diabetes, the more likely they have developed one or more major risk factors for diabetic lower extremity problems.

Seriousness of infection:

Infections that involve gangrene almost universally go on to amputation and also carry a high risk of death. Ulcers larger than about 1 inch across have a much higher risk of progressing on to limb amputation, even with proper treatment. Infections involving deep tissues and bone carry a much higher risk of amputation.

Quality of circulation:

If blood flow is poor in the patient’s legs as a result of damage to the blood vessels from smoking or diabetes or both, it is much more difficult to heal wounds. The likelihood of more serious infection and amputation is greater.

Compliance with the treatment plan:

How well the patient follows and participates in the treatment plan developed with doctors and nurses is crucial to the best recovery possible. Ask questions if any aspects of the care or treatment plan are unclear. Let the doctor know if something in the plan doesn’t seem to be working.

Wound care centers:

A wound care center is an excellent resource if available. It brings together many specialists and approaches to aid in the treatment of the diabetic foot problem. These centers will often be able to offer the most up-to-date therapies and even may have experimental protocols available for people who have not responded to traditional therapy.

Individual physician and nurse skills:

 Ask about your doctor or nurse’s expertise in dealing with diabetic lower extremity problems. Knowledge about and experience with these problems may lead to earlier diagnosis and more appropriate therapy.

Diabetic Feet Diagnosis and Treatment

Exams and Tests

Medical evaluation should include a thorough history and physical examination and may also include laboratory tests, x-ray studies of circulation in the legs, and consultation with specialists.

• History and physical examination: First, the doctor will ask the patient questions about their symptoms and will examine them. This examination should include the patient’s vital signs (temperature, pulse, blood pressure, and respiratory rate), examination of the sensation in the feet and legs, an examination of the circulation in the feet and legs, a thorough examination of any problem areas. For a lower extremity wound or ulcer, this may involve probing the wound with a blunt probe to determine its depth. Minor surgical debridement of the wound (cleaning or cutting away of tissue) may be necessary to determine the seriousness of the wound.
• Laboratory tests: The doctor may decide to order a complete blood cell count, or CBC, which will assist in determining the presence and severity of infection. A very high or very low white blood cell count suggests serious infection. The doctor may also check the patient’s blood sugar either by fingerstick or by a laboratory test. Depending on the severity of the problem, the doctor may also order kidney function tests, blood chemistry studies (electrolytes), liver enzyme tests, and heart enzyme tests to assess whether other body systems are working properly in the face of serious infection.
• X-rays: The doctor may order x-rays studies of the feet or legs to assess for signs of damage to the bones or arthritis, damage from infection, foreign bodies in the soft tissues. Gas in the soft tissues, indicates gangrene – a very serious, potentially life-threatening or limb-threatening infection.
• Ultrasound: The doctor may order Doppler ultrasound to see the blood flow through the arteries and veins in the lower extremities. The test is not painful and involves the technician moving a non-invasive probe over the blood vessels of the lower extremities.
•  Consultation: The doctor may ask a vascular surgeon, orthopedic surgeon, or both to examine the patient. These specialists are skilled in dealing with diabetic lower extremity infections, bone problems, or circulatory problems.
• Angiogram: If the vascular surgeon determines that the patient has poor circulation in the lower extremities, an angiogram may be performed in preparation for surgery to improve circulation.

With an angiogram, a catheter is inserted through the artery in the groin and dye is injected while x-rays are taken. This allows the surgeon to see where the blockages are and plan an operation to bypass the blockages. This procedure is usually performed with local anesthesia and a light sedative given through a tube inserted in the patient’s vein (an intravenous or IV line).

Diabetic Foot Care Treatment

Self-Care at Home

A person with diabetes should do the following:

• Foot examination: Examine your feet daily and also after any trauma, no matter how minor, to your feet. Report any abnormalities to your physician. Use a water-based moisturizer every day (but not between your toes) to prevent dry skin and cracking. Wear cotton or wool socks. Avoid elastic socks and hosiery because they may impair circulation.
• Eliminate obstacles: Move or remove any items you are likely to trip over or bump your feet on. Keep clutter on the floor picked up. Light the pathways used at night – indoors and outdoors.
• Toenail trimming: Always cut your nails with a safety clipper, never a scissors. Cut them straight across and leave plenty of room out from the nailbed or quick. If you have difficulty with your vision or using your hands, let your doctor do it for you or train a family member how to do it safely.
• Footwear: Wear sturdy, comfortable shoes whenever feasible to protect your feet. To be sure your shoes fit properly, see a podiatrist (foot doctor) for fitting recommendations or shop at shoe stores specializing in fitting people with diabetes. Your endocrinologist (diabetes specialist) can provide you with a referral to a podiatrist or orthopedist who may also be an excellent resource for finding local shoe stores. If you have flat feet, bunions, or hammertoes, you may need prescription shoes or shoe inserts.
• Exercise: Regular exercise will improve bone and joint health in your feet and legs, improve circulation to your legs, and will also help to stabilize your blood sugar levels. Consult your physician prior to beginning any exercise program.
• Smoking: If you smoke any form of tobacco, quitting can be one of the best things you can do to prevent problems with your feet. Smoking accelerates damage to blood vessels, especially small blood vessels leading to poor circulation, which is a major risk factor for foot infections and ultimately amputations.
• Diabetes control: Following a reasonable diet, taking your medications, checking your blood sugar regularly, exercising regularly, and maintaining good communication with your physician are essential in keeping your diabetes under control. Consistent long-term blood sugar control to near normal levels can greatly lower the risk of damage to your nerves, kidneys, eyes, and blood vessels.

Medical Treatment

• Antibiotics: If the doctor determines that a wound or ulcer on the patient’s feet or legs is infected, or if the wound has high a risk of becoming infected, such as a cat bite, antibiotics will be prescribed to treat the infection or the potential infection. It is very important that the patient take the entire course of antibiotics as prescribed. Generally, the patient should see some improvement in the wound in two to three days and may see improvement the first day. For limb-threatening or life-threatening infections, the patient will be admitted to the hospital and given IV antibiotics. Less serious infections may be treated with pills as an outpatient. The doctor may give a single dose of antibiotics as a shot or IV dose prior to starting pills in the clinic or emergency department.
• Referral to wound care center: Many of the larger community hospitals now have wound care centers specializing in the treatment of diabetic lower extremity wounds and ulcers along with other difficult-to-treat wounds. In these multidisciplinary centers, professionals of many specialties including doctors, nurses, and therapists work with the patient and their doctor in developing a treatment plan for the wound or leg ulcer. Treatment plans may include surgical debridement of the wound, improvement of circulation through surgery or therapy, special dressings, and antibiotics. The plan may include a combination of treatments.
• Referral to podiatrist or orthopedic surgeon: If the patient has bone-related problems, toenail problems, corns and calluses, hammertoes, bunions, flat feet, heel spurs, arthritis, or have difficulty with finding shoes that fit, a physician may refer you to one of these specialists. They create shoe inserts, prescribe shoes, remove calluses and have expertise in surgical solutions for bone problems. They can also be an excellent resource for how to care for the patient’s feet routinely.
• Home health care: The patient’s doctor may prescribe a home health nurse or aide to help with wound care and dressings, monitor blood sugar, and help the patient take antibiotics and other medications properly during the healing period.