Age Well BY Datuk Dr CHARLES DAVID
PATIENTS with diabetes mellitus often have trouble with their feet. High blood sugar levels over a period of time causes damage to the nerves – peripheral neuropathy – leading to a loss of feeling in the extremities. Damage also occurs to the blood vessels of the feet.
In the first instance, the loss of feeling in your extremities makes you prone to injury. Initially, there is blistering, and then ulcers may develop. If these get infected, they progress to gangrene and you may end up in hospital and may need an amputation because of the ischaemic ulceration and infection.
Diabetic ulcers leading to amputation are the most common cause of non-traumatic lower limb amputations. Foot complications are the most common causes for hospitalisations with diabetes. In a Malaysian study (David and Balasubramaniam, 1981), ulceration with gangrene in diabetes was the main indication for amputations of the lower limb (75 out of 148 patients).
Early detection and treatment of these ulcers can prevent up to 85% of these amputations. Careful inspection of the feet of diabetics is an integral part of this preventive measure. Unfortunately, doctors and even the patients themselves rarely do so.
The risk factors must be recognised. These include:
History of foot ulcer/amputation
Poor sensation due to peripheral neuropathy
Foot deformity and callus formation due to abnormal pressure ulcers
Poor blood supply – ischaemia
Stiff joints
Obesity
Impaired vision (retinopathy)
Poor glucose control, poor healing and poor immune response to infection
Inadequate footwear
The most important risk factors are poor sensation from peripheral neuropathy, structural foot deformities, infections and poor blood supply.
Ischaemia
Arterial ischaemic disease is four times more common in diabetes. Hypertension, smoking and hyperlipidaemia together contribute to increased arterial occlusive disease. There is pain at rest or on walking, absence of hair on the leg/foot, abnormal nails and absent pulses.
Neuropathy
Neuropathy is a group of nerve disorders caused by diabetes. There is damage to the nerves over a period of time. They lead to numbness, pain and weakness in the hands, feet and legs.
Every organ system can be affected, including the digestive tract, heart and sex organs.
Neuropathy is more common amongst those with poor blood sugar control, those with high blood pressure and those having diabetes for more than 20 years.
The most common type is peripheral neuropathy affecting the legs and feet. Symptoms can include numbness to pain, burning sensation, sharp pain and loss of balance and coordination. These are often worse at night. It can lead to muscle weakness and walking difficulties.
Foot and toe deformities may occur. Blisters and ulcers may appear on numb areas and get secondarily infected.
The lack of protective sensation exposes patients to undue and repetitive stress that leads to ulcer formation, with a risk of infection and amputation.
Foot deformities/stiff joints
Foot deformities usually result from atrophy of the muscles of the toes. This leads to focal areas of high pressure and resulting foot ulcers. Occasionally, patients with poor sensation get burns from hot water soaks.
Ulcers
A diabetic with a history of previous ulceration or amputation has a higher risk of further ulcers and amputation. Foot and toe deformities can alter foot dynamics with abnormal distribution of pressure and result in ulceration.
Ulcers should be treated as a serious problem. Since there is no sensation, there is no pain; hence, patients are not aware till very late the extent of the damage. Patients should be referred to centres where adequate assessment and treatment can be made, including any surgery that may be needed. Early treatment will prevent major surgery or even loss of life.
Amputations
When amputation becomes necessary because of the severity of the problem, then make sure that you are seen in a centre where the facilities include a vascular surgeon and good rehabilitation facilities.
If treated aggressively and early, the amputation may be limited to only the toes. If the problem sometimes necessitates a below or above the knee amputation to save the life of the patient, the rehabilitation process as well as the types of prosthesis available today will allow most of the patients to walk again.
Prevention
Foot care and good management of minor foot injuries can prevent ulcer formation. There must be daily foot inspection by the patient or caretaker if there is poor vision. Feet should be gently cleaned with soap and water with topical moisturisers after the wash. Blisters, cuts and abrasions should be cleaned the same way, but with the application of topical antibiotics. Home remedies including Dettol, hot soaks and heating pads should be avoided.
Shoes
Shoes should be comfortable and fit well, i.e. sports shoes. Some patients will need custom-made shoes.
It is important to carry out regular foot examinations and preventive foot care by a podiatrist or family doctor. The recognition of such risk factors can result in early diagnosis and preventive measures can be instituted.
When ulcers develop despite preventive measures, then early and adequate treatment of the infection will considerably reduce the burden of major limb amputations.
Excerpt from The Star
References
1. Armstrong DG, Lavery LA, Quebedeaux TL, Walker SC. Surgical morbidity and the risk of amputation due to infected puncture wounds in diabetic versus nondiabetic adults. South Med J 1997;90:384-9.
2. Brand PW. The insensitive foot (including leprosy). In: Jahss MH, ed. Disorders of the foot & ankle: medical and surgical management. 2d ed. Philadelphia: Saunders, 1991:2173-5.
3. David V. Charles, P. Balasubramaniam. Amputations of the lower limb. The Journal of the Western Pacific Orthopaedic Association, 1981:18-2.
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