Diabetic foot

Diabetic foot: description

The term “diabetic foot” or “diabetic foot syndrome” (DFS) refers to various clinical pictures whose common cause is the elevated blood sugar level in diabetes mellitus:

• In about 30 to 40 percent of those affected, the diabetic foot is caused by diabetesnerve damage (Diabetic polyneuropathy). This variant is also called neuropathic diabetic foot.
• In about 20 percent of those affected are vascular damage and resulting Circulatory disorders the trigger for the diabetic foot. Then there is a lower-blooded (ischemic) diabetic foot.
• In about 40 percent of patients with a diabetic foot are both nerve damage and circulatory disorders responsible.

A diabetic foot is a serious consequence of diabetes mellitus. The longer the diabetes persists and the worse the blood glucose levels are set, the more likely it is to occur. Overall, diabetics have a 25 percent risk of developing a diabetic foot during their lifetime. The treatment can be tedious. In the worst case, a complete amputation of the toe, foot or whole leg threatens.

Diabetic foot: symptoms

A diabetic foot expresses itself individually with the affected persons differently. Symptoms depend on the underlying cause and stage of the disease. A neuropathic diabetic foot has other symptoms than an ischemic (less well-fed) diabetic foot.

Ischemic diabetic foot – symptoms

The reduced blood flow (reduced perfusion) usually discolors the skin pale or bluish. In addition, the skin often feels cool, and the pulse of the foot arteries can no longer be felt.

Due to the lack of blood flow (ischemia), the muscles are no longer supplied with sufficient blood. Many sufferers complain about cramping pain after short stretches (Claudicatio intermittens). If there is a marked circulatory disturbance, this pain can already exist at rest.

The toes and heels are usually supplied with the worst blood, which is why injuries heal especially bad. A banal injury easily leads to an open ulcer (ulcer). The surrounding tissue ignites or even dies (necrosis). Typically, necrotic tissue turns jet black and looks like charred.

Neuropathic Diabetic Foot – Symptoms

The sensitivity of the cutaneous nerves is impaired here. Therefore, the patients only perceive pressure points and pain less or not at all: as affected persons, for example, do not notice injuries to the foot, they do not spare the injured area sufficiently. As a result, the wound can not heal, but even increases with time.

In addition, misalignment of the foot can result in muscle atrophy. Incorrect stress on the feet also causes increased pressure on the cornea. These corneal structures, however, promote pressure and shear forces under the skin, which can cause deep bruising. These often break up later – the result is an open diabetic foot ulcer (Malum perforans).

The open ulcer can easily become infected with bacteria. These often infect the surrounding healthy tissue as well. Since a diabetic foot is still sufficiently perfused due to a polyneuropathy, the skin of the feet is dry (due to a lack of nerve supply to the sweat glands), but still warm and rosy (because it still has sufficient blood supply).

Symptoms with combination of both clinical pictures

Patients whose diabetic foot is at the same time due to a circulatory disorder and damage to the nerves show signs of ischemic diabetic foot, but do not experience any pain.

Severity classification of foot lesions

Diabetic foot syndrome refers to the above-mentioned clinical pictures (polyneuropathy, PAOD), which in diabetics can result from an injury to the foot to an infected ulcer (ulcer). The foot lesions are divided into different stages (according to Wagner) depending on their severity:

Grade 0	Risk: No injuries but possibly foot deformities
Grade I	Superficial wound
Grade II	Deep wound that reaches to the tendon or capsule
Grade III	Deep wound reaching to the bone or joint
Grade IV	Dead tissue (necrosis) on the heel or toes
Grade V	Dead tissue (necrosis) on the entire foot

Diabetic foot: causes and risk factors

A diabetic foot is the result of years of high blood sugar levels. This damages both the blood vessels (diabetic angiopathy) and the nerves (diabetic neuropathy) in the foot and in the rest of the body.

Ischemic diabetic foot – causes

In an ischemic diabetic foot, especially the blood vessels are damaged, whereby the circulation in the foot is impaired. Circulatory disturbance due to constriction of the arterial blood vessels is also commonly referred to as peripheral arterial disease (PAOD). It can be caused by diabetes, but also by other diseases.

The many sugars in the blood of diabetes patients are particularly causing Damage to the inner wall of the blood vessels, Usually the vessels of the feet and the lower leg are affected first. In addition to high blood sugar, there are often other vascular damaging factors. These include smoking, high blood pressure and elevated cholesterol.

Due to the continuous damage of the inner vessel layer, the vessel diameter becomes smaller and smaller. As a result, less and less blood can flow through the vessels – the tissue becomes insufficient blood circulation, That has one lack of oxygen in the tissue, which affects all metabolic processes in the cells. For example, the Wound healing disturbedso that injuries in a diabetic foot heal much worse. If the lack of oxygen is very pronounced, the cells in the tissue section in question also die without a causative injury (necrosis).

The circulatory deficiency also affects the body’s defense function. Pathogens such as bacteria or fungi therefore have an easy game: Even the smallest wounds may be sufficient for germs to enter the body and cause an infection.

Neuropathic Diabetic Foot – Causes

In a diabetic foot, especially the nerve tracts are damaged by the increased blood sugar, there is a neuropathic diabetic foot. Due to the nerve damage many patients do not notice injuries and wounds on the foot. Without treatment, however, these can easily become infected. Even pain caused by too tight or wrong footwear, often go unnoticed.

The nerve damage can also cause deformations of the foot and foot skeleton. Doctors then speak of Charcot foot, Due to the reduced sensation of pain, small fractures, for example in the area of ​​the tarsal bones, are often not noticed for a long time. They can lead to acute and chronic changes in the ankles by removing and rebuilding bones and stiffening joints.

Diabetic foot: examinations and diagnosis

The right contact person for suspected diabetic foot is a specialist in internal medicine and diabetology or a specialized specialist in foot surgery.

The doctor first conducts a detailed conversation with the patient to record his medical history (anamnese). The patient should describe all current complaints and possible pre-existing diseases in detail. The doctor will also ask questions, for example:

• Since when is diabetes mellitus?
• Do you feel a tingling or a numbness on the feet?
• Are you experiencing pain, pressure, or temperature changes on the feet?
• Do you suffer from hypertension?
• Do you smoke? If so, how much and for how long?
• Which footwear do you wear?
• Do you perform regular foot care?
• Do you suffer from nail fungus?

Physical examination

Afterwards, the doctor will examine you physically and in particular take a close look at your feet. The doctor, for example, feels the skin temperature and the foot pulses to get information about a possible circulatory disorder.

Further investigations

As a rule, further investigations are necessary in order to be able to determine the extent of a circulatory disturbance or nerve damage precisely.

examination	Significance of the investigation method
Ultrasound (duplex)	The duplex ultrasound gives indications of possible circulatory disorders.
Ankle-brachial index	The ankle-brachial index is the ratio of systolic blood pressure in the lower leg and upper arm. If it is less than 0.9, it speaks for arterial occlusive disease.
Angiography (DSA)	This x-ray examination with contrast agent can represent the vessels. Constrictions or closures can be identified.
reflex tests	In a neuropathic diabetic foot, the self-reflexes of the lower leg / foot may be weaker or no longer triggerable.
tuning fork test	With the help of a struck by the doctor tuning fork vibration is tested by sustained vibrations of the fork. In a neuropathic diabetic foot it is degraded.
Monofilament test	By applying a 0.1 mm wide thread to the sole of the foot, the touch sensitivity of the skin is checked.
Smear of the wound	For wounds on the feet, a smear should be taken to determine the exact bacterial pathogen. Then the right therapy can be initiated.
Pedography (pressure measurement of the foot)	The patient stands and walks on a sensor-equipped plate. This can show an altered pressure load of the foot due to misalignments.

Diabetic foot: treatment

A diabetic foot can only be treated successfully if the causes are corrected. The blood sugar levels must therefore be set as good as possible so that the vascular or nerve damage does not progress further. Existing nerve damage can not be cured, but circulatory disorders can be improved with various measures.

In the treatment of a diabetic foot different occupational groups are involved: In addition to doctors (diabetologists, foot surgeons) are also specialized wound therapists, podiatrists and orthopedic technicians indispensable.

Blood glucose control

The most important measure to prevent the progression of the disease is the most accurate possible blood glucose control. Whether the blood sugar is well adjusted, shows the “long-term blood glucose value” HbA1c. Patients diagnosed with diabetic foot should have a HbA1c of below 6.8 percent aspire.

Switching off risk factors

Eliminating risk factors for peripheral arterial disease (PAD) is also very important: sufferers should not smoke as this will severely damage the vessels. In addition, an existing high blood pressure and high cholesterol should be lowered with a suitable therapy.

Training and regular check-up with the doctor

Various training courses for diabetics are offered. There, patients learn everything important about diabetes. This also includes information on how to prevent a diabetic foot with the right foot care and appropriate footwear. In addition, patients are trained to recognize changes such as skin tears, pressure sores or nail changes early.

In addition, diabetics should always go to the family doctor regularly to examine the feet and lower legs and to control the blood sugar levels.

Daily inspection and care of the feet

Even you as a patient should daily inspect your feet, especially with already existing vascular and nerve damage. This allows you to detect any changes and minor injuries early on. In poorly visible places, you can use a mirror to detect possible thickening of the cornea, bruises or corns (Clavus).

You should wash the toe gaps and soles every day. Use for it mild, neutral and moisturizing soaps, Watch out for a water temperature of 37 to 38 degrees Celsius and bathe your feet in it for three to five minutes. Afterwards you should have your feet dry carefully.

Avoid such footbaths skin lesions, Instead, you should treat the wound with a skin disinfectant, cover it with a sterile gauze bandage and go to the doctor.

It is also recommended, every day to cream the feet (with the exception of the inter-toe spaces). This prevents the skin from drying out and tearing. Use an ointment or cream that contains a lot of fat but little water. In addition, there should be no emulsifiers, perfumed additives and preservatives on the ingredient list.

Pay attention to the proper nail care: You should file the nails (do not cut) and round off the corners. Tip nail scissors pose a risk of injury.

Some patients can not do the regular chiropody on their own, for example because they have difficulty bending over. Then you should definitely one professional medical foot care take advantage of.

Podiatric therapy as a remedy

Patients with Diabetic Foot Syndrome may be prescribed podiatrics as part of the Cure regimen for the care of their feet – either for one or both feet only.

When is a podiatry therapy in question?

Such a therapy comes into question if consequential damage to the feet such as inflammation and wound healing disorders threaten. If inflammation and ulcers have already formed, the treatment must be performed by a doctor. The podiatrist may then continue to take care of those areas of the foot that have not yet been damaged.

What do you do in the context of podiatric therapy?

The podiological foot care begins with a foot bath, a detailed medical history, an inspection of the feet. Then follows the actual medical foot care for diabetics. This includes:

• Corneal ablation: By removing the thickened cornea, skin damage such as cracks, ulcers and inflammation can be prevented. For this, the cornea is gently peeled off and ground off.
• Nail processing: Nail treatment can help prevent damage to the nail bed and nail wall, including ingrown nails. For this purpose, thickened and deformed nails are cut, ground and milled off.

Note: The combination of corneal ablation and nail processing is referred to as complex podiatry treatment.

In addition, the podiatrist treats foot problems such as ingrown nails or fungal infections during a session.

What are the risks of a podiatric therapy?

When working on the nails, he can slip off podiatrist and hurt his toe or foot. This wound can – especially in diabetics – easily infect and heals bad. In addition, if too much cornea is removed, they can stimulate new formation. Performed by experienced people, podiatry is very safe.

What should I pay attention to in a podiatric therapy?

The most important thing about a podiatric treatment is that you put yourself in the hands of a trained professional.

drugs

For circulatory disorders, the doctor may prescribe the daily intake of acetylsalicylic acid (ASA). The active ingredient has a “blood thinning” effect.

If a diabetic foot has already become inflamed, the responsible pathogens must be identified by a smear test and treated with a suitable antibiotic. Often there are different germs in the wound. Then the doctor can prescribe either different antibiotics or a broad-spectrum antibiotic that helps against multiple germs. It may be necessary to have bed rest for a while, so that the open skin can heal in peace.

wound cleansing

Wounds on the feet and lower legs should not only be treated with medication, but should also be cleaned daily by trained professionals. If necessary, dead tissue must be removed (debridement). The wound must also be stored soft, so that no more pressure points arise, and can heal the wound better. Many hospital departments of foot surgery offer consultations on the treatment of the diabetic foot.

Suitable footwear and diabetic socks

Properly fitting footwear is very important for healing wounds on diabetic feet and preventing them from enlarging or reoccurring. The feet must have enough space in the shoes and they must not push anywhere. If necessary, the footbed can be adjusted with inserts.

An orthopedic consultation can be very helpful in choosing the right shoes. The patient may also need specially made diabetic shoes.

There are also special socks for diabetics that allow better ventilation of the feet. The diabetic socks have a high percentage of cotton and have no seams that could cause pressure sores. Diabetic stockings are available in special stores for medical footwear.

Balloon dilatation, stent insertion, bypass surgery

If an ischemic diabetic foot is accompanied by a vasoconstriction, it can be distended with the help of a so-called catheter (angioplasty). In principle, several methods are available for this. Very often one will balloon carried out. A tube is advanced over the leg artery (femoral artery) from the groin to the narrowed site. At its top is a deployable small balloon. At the destination (constriction) the balloon is filled with air or liquid via the hose. So he can stretch the bottleneck.

This procedure alone does not always bring the desired success: In many patients, it soon comes to a renewed narrowing in the same place. Therefore, after dilating the vessel, a small metal tube (stent) to keep the vessel open.

If the constriction affects a longer vessel section, one can Bypass surgery make sense. The bottleneck is bypassed with a surgically inserted, other blood vessel.

amputation

In very severe cases of diabetic foot, it may be necessary to amputate toes, feet or even the leg. Before that, however, all other therapeutic options should be exhausted and the condition of the affected limb examined by a second doctor (second opinion).

Diabetic foot: disease course and prognosis

Diabetic foot is a serious and common complication of diabetes mellitus. Diabetes patients have a 25 percent risk of developing a diabetic foot during their lifetime. Every year, around 40,000 foot amputations are performed in Germany because of a diabetic foot. This makes it clear that the disease is a very serious complication of diabetes. Those affected have a very large influence on the disease process. If you manage to get the most out of your blood sugar, eliminate risk factors, and take care of a thorough foot hygiene every day, then you can diabetic foot often avoid.