Diabetic foot complications prevention -
Diabetes is usually caused by insulin deficiency type 1 diabetes or insulin resistance type 2 diabetes. Insulin is an essential hormone responsible for helping cells absorb sugar from the blood to use for energy. When this process does not work correctly, sugar remains circulating in the blood, causing health problems.
Prolonged periods of high sugar levels in the blood can cause nerve damage and circulation problems, which can injure the feet. In this article, we look at foot problems that can occur in people with unmanaged or poorly managed diabetes and discuss how to prevent and manage these effects.
People with diabetes have a higher risk of peripheral vascular disease PVD , especially if they do not take their medication or have difficulty controlling blood sugar. PVD occurs when fatty deposits narrow the blood vessels, reducing circulation.
PVD tends to affect blood vessels leading to and from the extremities, such as the hands and feet, reducing blood flow to both.
Reduced blood flow can lead to pain, infection, and wounds that heal slowly. Over time, peripheral vascular disease can cause nerve damage that leads to numbness in the feet.
This can make it hard for people with diabetes to feel sensations in their extremities. High blood sugar also damages the nerves and interferes with their ability to send signals.
The condition also makes it difficult for a person with diabetes to feel irritation, soreness, or infection in the feet. A person may not notice when their shoes are rubbing. This lack of sensation can increase the risk of cuts, sores, and blisters.
It can also delay treatment for an infection, since a person may not realize they have one. Diabetes increases the risk of blisters in several ways. First, diabetic neuropathy may make it more difficult for a person to know when their shoes do not fit.
It may also change the way a person moves, increasing the risk of blisters. People with diabetes may also develop a condition called bullous diabeticorum , which refers to the spontaneous formation of blisters. Doctors do not know why the blisters appear.
Blisters can become infected, causing pain and increasing the risk of an infection that spreads throughout the body. A combination of poor circulation and nerve damage means that a person may not notice the ulcers until they are severe.
Weak circulation can also slow healing. Left untreated, ulcers can damage the foot and become infected.
Calluses are areas of hard, thickened skin cells. Large calluses on the feet can make it hard to walk and may change how shoes fit. The primary issue with calluses is that they increase the risk of ulcers and infections.
Keeping calluses clean and removing them when necessary is important for protecting the feet. Diabetic ulcers can become infected, especially if a person does not treat them or keep them clean.
Foot infections can damage the underlying structures of the foot, including the bones. Poor circulation also damages underlying structures. This can change the shape of the foot, causing further pain and difficulty walking.
Doctors call this Charcot foot. Charcot foot increases the risk of developing more ulcers. Diabetic foot problems can lead to serious infections. To prevent an infection from spreading and minimize damage to nearby regions such as the legs, a doctor may recommend amputation.
Amputation means removing a part of the body, such as a toe, foot, or portion of the leg. Diabetes is a leading cause of amputations. Severe diabetic foot problems can be life threatening, especially when an infection spreads. Having foot problems severe enough to require amputation is a major risk factor for death, even when a doctor amputates the foot to prevent the infection from spreading.
Foot symptoms of diabetes vary from person to person and may depend on the specific issues a person is experiencing at the time. Any person with diabetes who experiences symptoms of an infection, especially on the feet, should seek emergency treatment.
Diabetic neuropathy and peripheral vascular disease are serious conditions that a doctor must monitor closely. Both cause complications that can have serious, ongoing effects.
These complications may include:. Sometimes, doctors can reverse complications, such as infections. However, other complications, including gangrene, may lead to permanent physical changes. Read more about gangrene here.
People who have diabetes should see a doctor regularly as part of their care. A doctor may recommend specific foot care, including daily foot exams. Treatment for diabetic foot problems varies according to the severity of the condition.
A range of surgical and nonsurgical options may help. A doctor will first attempt to treat diabetic foot problems without using surgery. Some methods include :. When nonsurgical treatment does not successfully heal diabetic foot problems, a doctor might consider surgery.
Surgical options include :. Preventing foot problems is essential for people who have diabetes. Keeping feet healthy is critical, and a person should be vigilant about foot hygiene. An individual can take the following steps :.
Learn more about whether people with diabetes can soak their feet in salts here. Diabetes can cause serious foot problems that can result in foot or limb loss, deformity, and infection.
The disease process was originally described in patients with tertiary syphilis and usually presents as a unilateral red, hot, swollen foot and ankle The diagnosis for the hot, swollen diabetic foot is often delayed by weeks or months or missed entirely, resulting in severe deformity, loss of function, ulceration, infection, and lower-extremity amputation.
Perhaps the easiest screening tool is to ask whether a patient has symptoms of neuropathy i. The classic presentation is of a patient with painless unilateral swelling without a history of trauma.
Sometimes, the patient will recall an incidental injury such as making a misstep when stepping down from a curb or a slight inversion of the ankle. The foot and ankle are usually swollen, red, and warm to the touch compared to the contralateral foot. The unilateral swelling could have lasted for days, weeks, or even months by the time of presentation.
Patients sometimes comment that what brought them to see the doctor was that they could no longer fit their foot into a shoe or that the shape of their foot had changed, rather than that they were in pain.
Diagnosis of Charcot neuroarthropathy is based on medical history, physical examination, and plain radiographs 54 , The differential diagnosis includes cellulitis, deep venous thrombosis, and trauma.
Often, patients are treated with antibiotics, surgery, or amputation for infection, or they have multiple ultrasound examinations for deep vein thrombosis before the correct diagnosis is made.
The duration of the swelling and redness is important to ascertain in attempting to pinpoint the timing of the injury. Musculoskeletal deformity may be absent, or there can be severe deformity at initial presentation Patients with an early presentation often have normal X-rays and a normal musculoskeletal clinical examination.
Untreated injuries of longer duration have more severe bone and joint destruction and dislocation. Patients who seek medical care later in the disease process on inspection may have loss of the medial longitudinal arch of the foot compared to the contralateral foot, or their feet do not appear to be symmetrical.
Patients will have a history of neuropathy symptoms with a symmetrical distribution. Occasionally, patients will say that they feel as if they have a thick stocking on their feet when they are barefoot or that their feet feel cold when they are not.
Simply put, if you ask these patients whether they have symptoms of neuropathy, they will often help to make the diagnosis before you do a physical examination Clinical examination often shows good peripheral pulses and severe sensory loss.
Sensory testing can be quickly accomplished with a Hz tuning fork or a g monofilament or by testing light-touch perception. Examination of the joints of the foot and ankle can show abnormal alignment, joint effusion, and dislocations that are painless when examined.
Plain X-rays maybe appear normal early in the Charcot process, or the radiographic signs can be subtle. Dislocation at the Lis Franc joint in the midfoot is a common presentation that can be missed even by experienced radiologists unless concerns regarding possible Charcot neuroarthropathy are voiced when imaging is ordered 54 , It is uncommon for adults to have infections without a wound.
Inspect the skin for ulceration. Charcot patients sometimes also have ulcerations. If there is a wound, fractures and dislocations, and cellulitis, the patient may have both disease processes. Many people with diabetes who have cellulitis do not have leukocytosis, so using this in the decision process will be helpful to confirm infection when there are both leukocytosis and other systemic signs of infection.
If there is no leukocytosis, you have not ruled infection out. If there is purulence from the wound or exposed bone when the wound is examined with a sterile probe, there is infection 54 , Treatment of Charcot neuroarthropathy requires prompt referral to a podiatric or orthopedic surgeon with experience in treating this complication.
Early treatment requires immobilization and non-weight-bearing in a cast or wheelchair until the acute inflammatory process subsides, which may take weeks or months.
Late treatment requires reconstructive surgery to repair the deformity and obtain a plantar-grade foot 54 , This risk increases to 7.
In fact, re-ulceration is not only common, it is likely. Our goal is not necessarily to prevent every wound, but to maximize ulcer-free, hospital-free, and activity-rich days 59 — 61 by making each wound recurrence as uncomplicated as possible. There are currently four key strategies associated with maximizing ulcer-free days: integrated foot care, self-management, therapeutic footwear, and, as necessary, reconstructive foot surgery.
These are summarized in Table 5. Effect Sizes in Studies of Interventions to Reduce the Risk of Foot Ulcer Recurrence. Specifically, integrated foot care focuses on regular visits to podiatrists and other members of the diabetes foot care team as described earlier in this monograph.
Self-management involves daily evaluation by patients, family members, or caregivers and the use of thermometry. If these non-surgical methods are problematic, foot surgery appears to provide benefit in reducing the severity of deformity and plantar pressure and therefore reduces the risk of recurrence 63 — Diabetic foot complications are, as has often been said, common, complex, and costly.
Demographic trends suggest that these complications, including ulcers, infections, PAD, and amputations, will continue to be highly prevalent Future directions should focus not only on the promising therapeutic advances discussed in this monograph, but also on novel monitoring systems 59 , 66 — For example, efforts designed to identify pre-ulcerative inflammation through the past generation have now culminated in home-based monitors that can alert patients up to several weeks in advance of a potential complication Similarly, smart insoles paired with smart watches may be able to identify potentially damaging pressure, which over time can cause blistering or callusing and tissue loss Combining the evidence-based and common-sense therapies described here with emerging technologies has the potential to help us maximize ulcer-free, hospital-free, and activity-rich days for our patients.
The authors acknowledge Jayson N. Atves, DPM, CO, for contributions to the section on debridement. Editorial and project management services were provided by Debbie Kendall of Kendall Editorial in Richmond, VA.
and D. served as co-editors and, as such, co-wrote the introduction and conclusion and reviewed and edited the entire manuscript. are the guarantors of this work. have no relevant dualities of interest to disclose. is a consultant for Acelity and Integra.
has received honoraria for participation in educational programs for Healogics. is a consultant for Medimmune, Microbion, and Debiopharm.
is a consultant for Integra and Syntactx. Suggested citation: Boulton AJM, Armstrong DG, Kirsner RS, et al. Diagnosis and Management of Diabetic Foot Complications.
Arlington, Va. The opinions expressed are those of the authors and do not necessarily reflect those of Healogics, Inc. The content was developed by the authors and does not represent the policy or position of the American Diabetes Association, any of its boards or committees, or any of its journals or their editors or editorial boards.
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Diagnosis and Management of Diabetic Foot Complications Andrew J. Author Information and Affiliations Authors Andrew J. Affiliations 1 University of Manchester, Manchester, U. Address correspondence to Andrew J. Boulton, Email: ude. dem notluoBA , and David G. Armstrong, Email: ten.
asu gnortsmra. Arlington VA : American Diabetes Association ; Oct. Copyright and Permissions. All rights reserved. None of the contents may be reproduced without the written permission of the American Diabetes Association. Pathways to Diabetic Foot Complications Although evidence is weak that foot care education reduces the risk of first ulceration 2 , a thorough understanding of the etiopathogenesis of ulceration is essential if we are to succeed in reducing the incidence of foot lesions and ultimately amputations.
FIGURE 1 Pathways to diabetic foot ulceration. Screening for Foot Complications Risk It is important to assess the neurological, vascular, dermatological, and musculoskeletal status of people with diabetes at least annually. TABLE 1 Modified ADA Diabetic Foot Risk Classification.
FIGURE 2 SVS WIfI classification system. When and Where to Refer Diabetic Foot Problems Appropriate patient referral is predicated on a complete history and foot examination. TABLE 2 Results of Selected RCTs Evaluating Different Off-Loading Approaches: Proportion of Ulcers That Heal and Time to Healing 2.
Enzymatic Enzymatic debridement involves using chemical agents to slough necrotic wound tissue. Biologic Biologic debridement employs medical maggots that have been grown in a sterile environment.
Surgical Surgical debridement is arguably the most common and varied type of debridement Figure 3. FIGURE 3 Progression of a diabetic foot ulcer from necrotic wound base A , to surgical debridement B , to complete healing C.
Management of Infection Among patients with diabetes presenting with a foot wound, about half have clinical evidence of infection DEFINING INFECTION Because all open wounds will be colonized with microorganisms, we define DFIs by the presence of classic signs and symptoms of inflammation.
CULTURES It is not necessary to obtain a wound specimen for culture of clinically uninfected diabetic foot wounds because they do not require antimicrobial therapy , but cultures are indicated for all DFIs. TREATMENT While awaiting the results of cultures and any additional diagnostic studies , clinicians should initiate empiric antibiotic therapy for DFIs.
OUTCOME In addition to the involvement of bone in an infection, factors that appear to decrease the likelihood of successful treatment include isolating antibiotic-resistant pathogens especially methicillin-resistant S. Recognizing and Treating Peripheral Artery Disease Although it has been repeatedly demonstrated that creation of well-organized diabetic foot care teams is a highly effective means of reducing major limb amputations associated with DFUs and PAD, such teams are not the norm in many parts of the world, including the United States, where management of DFUs is often fragmented.
TABLE 3 SVS Threatened Limb Classification System, With Clinical Stages 1—4 Based on Severity of Wound, Ischemia, and foot Infection WIfI. Evidence-Based Adjunctive Therapies for Diabetic Foot Ulcers DFUs are common and costly 34 — TABLE 4 Comparison of Evidence-Based Treatments for Refractory Ulcers.
CTPs: Cell-Based Products Two cellular constructs are FDA-approved class III devices to treat DFUs. CTPs: Acellular Products Three acellular constructs have been shown to improve DFU healing. The Acute Hot, Swollen Foot: Charcot or Infection?
TABLE 5 Effect Sizes in Studies of Interventions to Reduce the Risk of Foot Ulcer Recurrence. Conclusions and Future Directions Diabetic foot complications are, as has often been said, common, complex, and costly.
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This publication has been supported by unrestricted educational grants to the American Diabetes Association from Healogics, Inc. Bookshelf ID: NBK PMID: DOI: PubReader Print View Cite this Page Boulton AJM, Armstrong DG, Kirsner RS, et al.
Arlington VA : American Diabetes Association; Oct. doi: In this Page. Pathways to Diabetic Foot Complications Screening for Foot Complications Risk When and Where to Refer Diabetic Foot Problems Off-Loading the Diabetic Foot Wound Wound Debridement: Surgical or Otherwise Management of Infection Recognizing and Treating Peripheral Artery Disease Evidence-Based Adjunctive Therapies for Diabetic Foot Ulcers The Acute Hot, Swollen Foot: Charcot or Infection?
Related information. NLM Catalog Related NLM Catalog Entries. Similar articles in PubMed. Diagnosis and treatment of diabetic foot infections. Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew DP, Mader JT, Norden C, et al.
Plast Reconstr Surg. Review Systematic reviews of wound care management: 3 antimicrobial agents for chronic wounds; 4 diabetic foot ulceration.
Complicatiohs diabetes is extremely dangerous Diabetic foot complications prevention preventipn feet. Even root small cut xomplications have serious consequences. Diabetes Diabetiv also reduce blood flow to the feet, making it harder to heal an Diabetic foot complications prevention Tips for athlete nutrition resist infection. Because of these problems, you might not notice a pebble in your shoe. You could develop a blister on your foot, a foot ulcer, which can lead to an infection. Infections left untreated commonly lead to amputation of your foot or leg. To avoid serious foot problems that could result in losing a toe, foot or leg, be sure to follow these diabetic foot care rules.
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