Chronic and complex wounds of the lower extremity frequently recur. It is difficult to determine the precise recurrence rate across patients with different lower extremity wound types, including diabetic foot ulcers, arterial ulcers, pressure injuries, and venous ulcers. However, we know that...
By the WoundSource Editors
The term diabetic foot refers generally to the increased occurrence of complications in the feet of patients with diabetes mellitus. The most common foot problems related to diabetes are peripheral neuropathy leading to ulceration, vascular disease, increased risk of infection, and deformities like Charcot arthropathy. Complications arising from diabetes are the most common non-traumatic injury to cause lower extremity amputation.
Four Common Diabetic Foot Complications
Diabetic neuropathy can present as a localized lack of sensation over pressure points on the foot that can lead to extended microtrauma, breakdown of overlying tissue, and eventual ulceration. In addition, neuropathy can result in minor scrapes or cuts failing to be properly noticed and treated, which also can lead to the development of foot ulcers.
Peripheral Vascular Disease:
Diabetes increases the number of platelets and coagulants in the blood, increasing the risk of thrombosis (blood clots) and atherosclersosis (the hardening of the arteries due to plaque buildup). Diabetic vascular disease leads to decreased circulation to the extremities, especially the legs and feet. Poor circulation causes wounds to heal slower due to lack of nutrients and can lead to swelling and dry skin, both of which can increase the risk of ulceration and infection.
Patients living with diabetes are significantly more prone to infection than individuals who do not have diabetes. When coupled with poor circulation due to the abovementioned vascular issues, immune responses take even longer to reach the site of infection. Foot ulcers also provide a wound environment that is highly susceptible to infection.
Charcot arthropathy, or Charcot foot, is a bone condition that results in the bones of the foot becoming deformed, dislocated or fractured. Believed to be related to poor glucose control, arthropathy (simply meaning any joint abnormality) and neuropathic ulcers have similar origins. The combination of neuropathy (lack of sensation) in the feet and microtrauma leads to repetitive damage to the joint. This traumatized bone gets broken down by osteoclasts, beginning a vicious cycle by rendering the region weak and thus more susceptible to trauma.
Additionally, diabetes affects wound healing in several ways. As diabetes is a metabolic disease, changes in the metabolism of lipids and proteins can affect the formation of granulation tissue, the fibrous tissue that supports wound healing. Also, diabetes impairs the production of nitric oxide, which plays a key role in bonding between collagen fibers and the overall tensile strength of newly formed tissue.
Preventing Foot Problems in Patients with Diabetes
The following precautions can help minimize the risk of developing foot complications in patients with diabetes:
- Manage diabetes to reduce vascular or neuropathic complications.
- Quit smoking.
- Consider regular podiatric care to remove excessive callouses and monitor for potential ulcerations.
- Examine feet daily for any unusual changes in color or the development of sores or callouses, using a mirror to inspect the sole if necessary.
- Clean feet daily, making sure that the area between the toes is dried thoroughly. Apply lotion when done, except between the toes (excess moisture can attract bacteria).
- Trim toenails straight across to avoid ingrown toenails, using an emery board for the corners.
- Avoid tight fitting clothing.
- Avoid crossing legs while sitting.
- Ensure that footwear is properly fitted to avoid points of rubbing or pressure and to allow adequate room for any deformities.
- Protect feet from injury, infection and extreme temperatures.
- Never walk barefoot. Wear shoes or slippers while in the house.
- Avoid soaking feet. Insensate feet can easily be scalded without the patient realizing it.
- Exercise as frequently as is comfortable.
American Academy of Orthopaedic Surgeons. Care of the Diabetic Foot. OrthoInfo. http://orthoinfo.aaos.org/topic.cfm?topic=A00148. Updated December, 2011. Accessed November 12, 2014.
Armstrong DG, Lavery LA. Diabetic foot ulcers: prevention, diagnosis and classification. Am Fam Physician. 1998 Mar 15;57(6):1325-32, 1337-8.
Creager MA, Luscher TF, Cosentino F, Beckman JA. Diabetes and vascular disease: pathophysiology, clinical consequences, and medical therapy: part I. Circulation. 2003; 108:1527–1532.
Foot.com. The Diabetic Foot. Foot.com. https://www.foot.com/foot-conditions/the-diabetic-foot/. Accessed November 12, 2014.
Voyatzis Norwood D. Diabetic Foot Ulcer. NYU Langone Medical Center Cardiac and Vascular Institute. http://cvi.med.nyu.edu/conditions-we-treat/conditions/diabetic-foot-ulcer. Updated January, 2009. Accessed November 12, 2014.
Editor's Note: This article was originally published November 12th, 2012 and has been updated for accuracy and comprehension.