Daily foot care can prevent later problems
In this issue, Susan Weiner, MS, RDN, CDE, CDN, talks with podiatrist Mark Hinkes, DPM, about foot problems that commonly affect people with diabetes.
What should a person with diabetes be doing on a daily basis to ensure good foot health?
Hinkes: Neuropathy, vasculopathy and a faulty immune system affect the feet of patients with diabetes and can lead to needless and preventable foot pathology. People with diabetes on a daily basis should be visually and manually inspecting both their feet and their shoes. The foot inspection is to identify a crack in the skin or a locally red swollen or warm area. The shoe inspection is to identify any defect in the shoe itself and any foreign objects in the shoes.
People with diabetes who notice dry skin on their feet or legs due to autonomic neuropathy should apply a urea-based moisturizing lotion. They also need to wear appropriate socks and shoes for their activities. They should practice preventive foot care to avoid developing foot ulcers from the combination of sensory neuropathy and mechanical, chemical or thermal trauma. Foot ulcers can lead to infection, hospitalization and the most dreaded complication of the diabetic foot, amputation. People with diabetes have a list of recommended tasks they are to perform daily to manage their foot health. They should be aware of any changes to their foot health, and if they find a problem, they should seek professional attention promptly.
Every person with diabetes should have a yearly comprehensive diabetic foot exam by their foot specialist that includes a monofilament test.
What are the most common foot problems?
Hinkes: A quick list of the most common foot problems includes those of the nails; keratosis, or corns and calluses; bone and joint deformities; and nerve and heel pain. No matter what the foot problem, visiting a podiatrist for a comprehensive diabetic foot exam, X-rays and laboratory tests is the first step to resolution.
The most common foot problem involves the toenails, which can be thick or discolored, ingrown or deformed. Trimming toenails can be difficult and often not realistically possible for people with diabetes, who should seek professional care for nail trimming and medical treatment of mold yeast or fungal nail infections. I have witnessed patients with diabetes who unknowingly have cut the end of their toes off while trimming their nails. How does this happen? The reasons include poor vision, poor lighting, poor eye-motor coordination, and inappropriate and nonsterile instruments. A person with diabetes who has nail problems and poor vision should have professional foot care by a podiatrist.
Keratosis, or corns and calluses, is another common foot problem. Corns can develop on the tip, top or in between the toes and calluses on the bottom of the feet. These hyperkeratotic skin lesions act as a natural pad to protect the underlying bony structures from excessive pressure. These soft tissue lesions can create pain and functional disability. However, a person with diabetic neuropathy may lack the ability to feel pain, and this is where the risk of complicating problems is likely to happen. Hyperkeratotic skin lesions can cause abscesses and develop into ulcers that can become infected. Self-trimming and the use of over-the-counter medications that contain salicylic acid should be avoided. Patients with diabetes who have corns or callouses should wear extra-depth shoes or diabetic shoes with offloading insoles. Corns and callouses can be professionally trimmed or permanently eliminated with minor surgical procedures.
What are the problems concerning bone deformities?
Hinkes: Bone and joint deformities are extremely common in the feet and can create pain and functional disability. They also create new pressure points where the feet rub against the shoes and become the triggers for developing corns and callouses, abscesses, ulcers and bone infections. Treatment of osteomyelitis may require oral antibiotics or hospitalization and IV antibiotics for 6 weeks. If these conservative measures fail to eliminate the bone infection, surgery may be necessary to remove infected bone by amputation.
Common bone and joint deformities include hallux abducto valgus (bunion); digital deformities, such as hammer toe, mallet toe and claw toe; tailor’s bunions; bone spurs; and Charcot’s foot. Bone deformities can be painful and interact with shoes to cause mechanical trauma that can lead to foot ulcers and infections, but the danger to patients with diabetic neuropathy is that they may not feel any pain with these deformities. A podiatrist may recommend shoe inserts, extra-depth or custom molded shoes, or preventive foot surgery.
What nerve and heel problems may a person with diabetes develop?
Hinkes: Chronically elevated blood glucose levels cause vascular and neurologic pathology in the feet. The loss of protective sensation for pain is the hallmark of diabetic sensory neuropathy, which can cause burning, tingling, numbness or, ironically, pain to the feet. Other causes of neurologic pain can include intermetatarsal neuritis/neuroma, tarsal tunnel syndrome, radiculopathy and spinal stenosis. Often, overlapping or multiple etiologies contribute to neuritic pain. Lumbar spine X-rays and MRI can help to differentiate the etiology of the pain. If pathology is noted, the patient can be sent to pain-management services for treatment. An electromyography or nerve conduction study can determine whether the problem is tarsal tunnel syndrome. An intermetatarsal nerve entrapment may be identified clinically and treated conservatively with steroid injection, orthotics, physical therapy, shoe modifications or surgical excision. Nerve irritation and entrapments, along with tarsal tunnel syndrome and radiculopathy, are common in patients with diabetes and should be differentiated from the pain of diabetic sensory neuropathy.
Heel pain can be a vexing problem with multiple etiologies, including fractures, tumors, inflammatory processes of fasciitis, tendonitis, bursitis, arthritis, capsulitis, heel spurs and nerve entrapments. Heel pain is typically seen in patients with overweight or obesity who work standing on their feet. However, patients with faulty biomechanical function (abnormal gait) may also complain of heel pain. A good history will start the process of understanding the etiology of the pain. Lab workup is essential and should include X-rays and blood tests for antinuclear antibody, C-reactive protein, rapid plasma reagin, erythrocyte sedimentation rate, uric acid and rheumatoid factor. Treatment depends on the etiology and can include oral anti-inflammatory drugs, steroid injections, physical therapy, orthotics, change in foot gear, stretching and offloading from weight bearing. Recalcitrant heel pain may be due to a stress fracture not seen on X-ray and can be treated successfully by a bone stimulator.
Patients with diabetes have a set of base problems that include the circulatory, neurologic and vascular systems. Additionally, a variety of common foot problems can affect people without diabetes. If foot a problem unrelated to diabetes arises, patients with diabetes should seek prompt evaluation and management to prevent a small problem from becoming a larger and more complex problem.
- For more information:
- Mark Hinkes, DPM, is chief of the podiatry service and director of podiatric medical education for the Veterans Affairs Medical Centers in Nashville and Murfreesboro, Tennessee. He is author of Healthy Feet for People With Diabetes. He can be reached at firstname.lastname@example.org.
- Susan Weiner, MS, RDN, CDE, CDN, is the 2015 AADE Diabetes Educator of the Year and author of The Complete Diabetes Organizer and Diabetes 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition, PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at email@example.com.
Disclosures: Hinkes reports no relevant financial disclosures. Weiner reports she is a clinical adviser to Livongo Health.