Diabetic Foot Disorders
People don’t realise the importance of their feet until their ability to walk or move becomes impacted.
Lets face it, any uncertainty surrounding a diagnosis from your doctor can be a scary thought. The fear amounts in the form of the unknowing and from here all sorts of questions start to arise. Questions asking yourself about the severity of the condition or whether or not this new diagnosis will impact on your quality of living. The ‘how, when & why’ start to build up and you feel like you have more questions than answers.
For many diabetics this is an ongoing battle.
To understand how Diabetic Foot Disorders come about we need to delve into the condition itself. We will solely be focusing on Type 2 Diabetes Mellitus – Yes there are more than 2 types.
Type 2 Diabetes is a progressive condition that tends to develop gradually. The body becomes resistant to the effects of insulin and/or gradually loses its ability to produce enough ‘effective’ insulin. According to Diabetes Australia; type 2 diabetes can develop over a period of years. Within this period this is where insulin resistance starts and the cycle of mismanaged blood glucose control becomes apparent.
The Cycle of Insulin Resistance vs Glucose Control
High Blood Glucose > Insulin Resistance > Insulin production increases in pancreas > Overproduction of Insulin > Insulin producing cells are worn out > 50-70% of insulin producing cells lost
To maintain these high blood glucose levels the pancreas must produce insulin to offset the imbalance. However this increased amount of production results in both overproduction of ineffective insulin and the body building a natural resistance to insulin itself. From this process it becomes difficult to maintain these higher levels of glucose resulting in the pancreas unable to meet the demand of effective insulin vs glucose.
Now you may be asking how we get from high sugar levels to foot amputation? The answer to that lies in the complications that are most common in diabetes. Peripheral Neuropathy (loss of feeling & sensation) and Peripheral Vascular Disease (Poor Circulation = Poor Healing). Individuals who suffer from peripheral neuropathy and peripheral vascular disease are at risk of foot ulceration, infection & amputation and both are the main causes for non-traumatic lower limb amputation.
Most research suggests that high blood glucose levels can do one of two things or even both.
1. Damaged nerve vessels which in turn interfere or completely break the nerves ability to send signals from the brain down to the feet
2. Damaged blood vessels which cause thickening of the arteries; causing a reduction or slowing of blood moving from the heart to the feet.
When collectively combining the effect of high glucose levels; essentially we are left with no feeling at the level of the foot and an inability to heal from any open cuts or abrasions which in turn increase the risk of foot infection. Usually the presence of a foot infection may start within the area of the wound; as this wound becomes non-healing (secondary to poor circulation) the infection will proceed to spread into the blood and furthermore inside the bone. If the infection becomes apparent at the level of the bone the likelihood of amputation becomes certain. Amputation at this stage may be essential to stop the spread of infection moving further up the chain.
So how do we prevent this from getting to this stage? Over the past decade several national bodies have published statements aimed at stimulating awareness and action to reduce the national Diabetic Foot Disorder burden. From a Podiatry standpoint, the importance of building education and awareness about the diabetic foot becomes even more critical. Here’s how we can help.
It is well known that signal loss and nerve damage can occur with poor control of high glucose levels. Well if you picture how far away the brain is to the foot it becomes easier to understand how these lost signals would have a harder time getting down to the level of the feet. The disconnect between brain, muscle and nerves has a significant impact on the receptors around the foot; when these receptors aren’t able to detect feeling it becomes an issue where the individual will have loss of protective sensation (refers to feeling or sensation that protects from hot, cold & sharp).
Podiatrists will utilise their training to assess the severity of any reduction in sensation loss or feeling loss. Monofilament devices, vibration devices and sharp/blunt devices are used to determine if an individual is at risk of peripheral neuropathy (refers to total loss of feeling). The difference between having adequate feeling as opposed to no feeling will determine the individual’s risk level of protecting themselves from sharp, hot and cold.
Blood Flow Testing
The heart and brain follow a similar pattern. If the distance between the brain and feet are risk factors that can cause sensation loss; the distance between the heart and feet can be a predisposing factor to a reduction in circulation and blood flow. Generally the arteries would bring the blood away from the heart and to the rest of the body. If an individual has poor cardiovascular history (blood pressure, cholesterol, vessel thickening) the smooth flow of blood to the feet can be affected. If blood flow slows down the healing ability of the individual is reduced; a reduction in healing would mean a higher risk of infection.
To help manage this; podiatrists will usually look for the signs and symptoms that may warrant blood flow loss. If this happens to be the case ultrasound machines, blood pressure and oxygen machines are used to determine its severity. Footwear modification and special diabetic orthotics can be used to offload weight and pressure from areas that may be at risk of developing a non-healing ulceration. Prevention of non-healing wounds at this stage is critical.
Individuals who suffer from diabetes should be getting their feet checked as regularly as they need. It is important to detect problems that can arise from the diabetic foot. Early detection and early intervention can definitely go a long way. Most amputations are a result of prolonged and delayed treatment. Podiatrists are highly trained health professionals who look after the feet and lower limb. They deal with prevention, diagnosis and management of foot problems.
For the diabetics out there, it is essential that you are educated about the risks involved with the diabetic foot. More importantly it is crucial that you seek advice from your podiatrist if there is anything you are unsure about.
B.Hlth.Sc; M.PodMed (Podiatric Medicine)