Why does my diabetic foot hurt?

In diabetics, neuropathy is defined as a loss of protective sensation.  The condition occurs in what we call and stocking and glove distribution.  It starts at the distal ends of the toes and fingers, and moves proximally up the foot/hand into the leg/arm.  While there are many causes of peripheral neuropathy, diabetes is the most common.

Neuropathy can occur in several forms.  The most common is sensory neuropathy.  This is a change in the ability of the patient to feel their feet and hands.  Starting in a stocking and glove distribution, a patient will not feel items touching their toes and feet.  Over time, patient can step on objects such as glass shards, nails, or tacks, and will not feel it.  This is a significant risk for infections and amputation.

Neuropathy can also occur as a motor neuropathy.  This is a loss of function in the distal most muscles, and can be combined with sensory neuropathy to be called sensorimotor neuropathy.  The most common examples of this include the development of hammertoes in a neuropathy foot, or ankle contractures causing ulcerations in the ball of the foot.

Lastly, neuropathy can cause an autonomic issue.  This will be symptoms such as a loss of ability to sweat or release oils (also called sebum) from the skin.  This is the type of neuropathy that also involves the cardiovascular system, gastrointestinal system, and genitourinary system.

With loss of sensation and function, patients become higher risk for infections, wounds and amputation.  Daily foot examinations, proper shoe gear, and regular diabetic foot care can prevent many problems.   So that begs the question, if I can’t feel it, why does it hurt?

60-70% of diabetics will eventually suffer from this condition.  The best way to think about it, is to use the telephone as an analogy.  If you are on the phone, and there is static, you can still hear, right?  The more static, the louder you have to yell to have the person on the other end hear you, until eventually there is so much static that you can’t hear anything, and they you hang up.  This is what happens with your nerves.

Each and every nerve in your body is connected directly to your brain.  Millions and millions of individual wires, from every aspect of your body, connected directly to your brain.  As neuropathy advances, the static to your brain increases.  Patients perceive this as neuropathic symptoms, burning, tingling, fire, ices, etc.  The louder the static, the more symptoms, until finally your brain hangs up, and then you have a complete loss of sensation.  This basically means that you can remove portions of your foot without anesthesia and not know it.

Treatments for painful diabetic neuropathy include proper glucose control, diet, exercise, and many different medication options.  You may have even seen a television commercial for Lyrica for example.  There are also sensory feedback options, cold laser and other light treatments, and even surgical options for releasing the nerves.

Best treatment for diabetic Neuropathy is prevention.  Good glucose control, exercise, and preventive foot care are essential.  Treatment once you have symptoms has been successful, but not for everyone.  You may not know you even have it.  The doctors at WeTreatFeet are well versed in this process and can offer you many cutting-edge treatments.  Call today if you want to have t

What is a diabetic foot skin graft?

Open wounds on diabetic feet is a significant and often expensive problem to treat.  Diabetic foot wounds, according to Medscape, direct costs for these specific wounds are   $9-13 million dollars yearly. [1]  While we have many different modalities for treating wounds, one treatment type stands out, skin grafts.

A Cochrane review done in February 2016 indicated that these grafts are effective in increasing healing rates.[2]  However, long term success, and cost effectiveness remains uncertain.  The grafts themselves are expensive, running between a few hundred to a few thousand dollars.  However, the overall cost to the community of diabetic wounds is astronomical.  These range from $11,710 to $16,883 per patient with a foot ulcer. [3]

When one says skin graft, most people naturally are thinking autografts.  These are skin grafts that come from the patient.  Skin, removed from another area such as the thigh, is transplanted over a wound.  This treatment originated 3000 years ago in India.  In 1804, an Italian surgeon, Boronio performed a full thickness graft on a sheep.  However, it was 1823 when Bunger reconstructed a nose with graft that these started to be used on a regular basis in medicine.[4]  While these remain a popular option for burns and traumatic wounds, it has fallen out of favor in diabetic foot wounds due to the high comorbidities, such as graft site infection.  I always tell my own patients that I am not a big fan of making a new wound to fix an old wound.

Allografts are grafts from the same species, placed on a different individual.  We often us a product called Theraskin, which is cadaveric skin.[5]  While this is actual human skin, it doesn’t incorporate as well as autograft, and may require several applications.  Apligraf® is a unique, advanced treatment for healing. It is created from cells taken from fetal foreskin, that are cultured and grown to form healthy human skin.[6]  It is actually alive in a dish when it arrives, and must be applied in a specified time frame, or it will die.

Xenografts are a group of grafts that are made from animal products.  These include fish skins, cow bladder, pig intestine, etc.  These contain collage that is the building blood for skin, and often work as scaffolding, helping wounds heal but providing the building blocks for skin.

The latest groups of grafts are amniotic.  These are grafts made from placenta, umbilical cord, or amniotic sac.  These are harvested at birth, prepared to remove all diseases and viruses, then transplanted into wounds.  These are the grafts that possess stem cells, and help the wound develop its own skin.

Not every wound responds to every treatment, and not all wounds were alike.  The challenge wound care physicians face is using an appropriate graft in the correct situation.  Venous wounds, arterial wounds, traumatic wounds, etc. will respond differently to treatments.  Only a skilled, experienced physician, who deals with large quantities of wounds on a regular basis, can tell you which one of the grafts may be right for your wound.  Due to the high costs of these products, this is critical, because applying the wrong product may actually make the wound worse, delaying healing, increasing the risk of infection or amputation.

If you have questions about your wound, or if you need treatment for a chronic wound, call our experts, and we will do everything we can to prevent complications, reduce amputation risk, and help treat the wound.

 

[1] http://www.medscape.com/viewarticle/821908

[2] http://www.cochrane.org/CD011255/WOUNDS_skin-grafting-and-tissue-replacement-treating-foot-ulcers-people-diabetes

[3] http://www.medscape.com/viewarticle/821908

[4] http://plasticsurgery.stanford.edu/content/dam/sm/plasticsurgery/documents/education/microsurgery/FlapsSelectedReadings.pdf

[5] http://theraskin.com/

[6] http://www.apligraf.com/patient/what_is_apligraf/what_is_apligraf.html

Modern diabetic wound issues

Diabetic foot wounds are among the most common complications of diabetes, and are some of the more difficult conditions to treat.  In the USA, yearly, approximately 8% of diabetic Medicare beneficiaries have a foot ulcer.  When these occur, 1.8% of these patients will have an amputation. These are further elevated for patients with lower extremity peripheral artery disease.[i]  The costs of diabetic foot ulcerations range from $12,211 for hospitalizations without amputation, to $34,671 for patients requiring an amputation.[ii]

It is fairly simple to understand why prevention of the first wound or amputation is so crucial.  Somewhere between 50-79% of people hospitalized with a diabetic foot infection will be either unable to work, or unemployed after the episode.[iii]  These events, while often not life threatening, (can become so if not treated) can have significant influences on entire households.  This includes children and spouses.

In our practice, we have a comprehensive policy for diabetic foot prevention.  The first and most important step is education.  I often get asked during new diabetic evaluation questions related to when foot loss or lower extremity amputation will occur (as most of these patients have friends or family members who have had an amputation).  My answer is always the same.  While we can’t prevent every amputation, most are probably avoidable with simple steps.  The American College of Foot and Ankle Surgeons has set specific guidelines for diabetic foot care.  These include:

  • Inspect your feet daily
  • Bathe feet in lukewarm, never hot, water
  • Be gentle when bathing your feet.
  • Moisturize your feet but not between your toes.
  • Cut nails carefully.
  • Never treat corns or calluses yourself.
  • Wear clean, dry socks.
  • Consider socks made specifically for patients with diabetes. Wear socks to bed. Shake out your shoes and feel the inside before wearing.
  • Keep your feet warm and dry. Never walk barefoot.
  • Take care of your diabetes.
  • Don’t smoke.
  • Get periodic foot exams. [iv]

In our office, we make sure that all diabetics start out with a yearly diabetic foot examination.  This assumes no known preexisting conditions for example vascular disease, neuropathy, or deformities.  As risk factors increase, so do visit frequency.  The range can be from twice yearly all the way up to weekly.  Our doctors know how to evaluate and treat these problems, and have strategies to prevent wounds.

If you have a wound, all is not lost.  First, make sure you get this checked by a qualified physician as soon as possible. Tomorrow is never advisable.  Second, I always tell patients that this is a 2 step process; first is getting the wound healed, second is keeping the wound healed.  The rate of re-ulceration is reported as high as 35–40% over 3 years, and that increasing to 70% over the 5years after the first wound.[v]  Five-year mortality rates after a diabetic foot ulceration have been reported to be between 43 and 55 percent, and can be as high as 74 percent in patients with lower-extremity amputation.[vi]  Prevention is crucial to longevity of patients with diabetes.

Our internal ulceration and amputation rates are much lower than the average throughout the country.  If you are diabetic, even if you have no complications, get your feet checked today.  It may save your life.  Our doctors offer same day and next day appointments, and we provide night and weekend coverage at several area hospitals.

 

 

 

[i] https://effectivehealthcare.ahrq.gov/topics/diabetes-foot-ulcer-amputation-prevalence/research/

[ii] Barshes 2012; Barshes 2014

[iii] Van Acker K, et al., 2014; Hogg FRA, et al., 2012; GoodridgeD, et al. 2005

[iv] http://www.acfas.org/footankleinfo/diabetic-guidelines.htm

[v] http://www.woundsinternational.com/media/other-resources/_/1097/files/dfj12-4-181-6.pdf

[vi] http://barefoot-science.com/pages/diabetes/

VIDEO: Dr. Daniels’ patient recalls limb-saving treatment provided by We Treat Feet

In Northwest Hospital’s Gala video, a patient of We Treat Feet’s Dr. Mike Daniels recalls the procedure that ended up saving him his foot. The patient had a very serious condition which combined with his diabetes would have required amputation for most patients without the aggressive treatment provided by Dr. Daniels and his colleagues at Northwest Hospital.

Read More

REPORT: Office Visits by Patients With Diabetes Rising Rapidly in United States

Office visits in the United States for diabetes rose 20% from 2005 to 2010, with the largest increase in adults in their mid-20s to mid-40s, according to a new data brief from the Centers for Disease Control and Prevention’s (CDC’s) National Center for Health Statistics (NCHS).

Nearly 29 million people in the United States have diabetes, putting them at risk for other chronic conditions, such as heart disease, eye disease, and stroke, Jill J. Ashman, PhD, and colleagues from the NCHS note in the brief.

On an annual basis, the cost of diabetes in the United States approaches $245 billion, and patients with diabetes have medical expenditures 2.3 times those of patients without diabetes.

The researchers analyzed recent trends in office visits by patients with diabetes using the National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey of visits to nonfederal office-based physicians (excluding anesthesiologists, radiologists, and pathologists).

They found that office-based physician visits by patients with diabetes rose from 94.4 million in 2005 to 113.3 million in 2010 (a 20% increase). Visits by patients with diabetes made up about 11% of all office-based physician visits in 2010.

The number of office visits increased during the study period for all age groups except for those younger than 25 years. The largest percentage increase (34%) occurred in people in the 25- to 44-year age range.

However, the volume of visits was higher for older adults; individuals aged 65 and older made 53.7 million visits in 2010 compared with 2.6 million visits made by those younger than 25.

The researchers did not see any marked change in the rate of office visits by patients with diabetes in any age group during the study period. The highest rate in 2010 was among those aged 65 and older (1380 visits per 1000 persons) and lowest in those younger than 25 (20 visits per 1000).

“Diabetes is not the only health concern for the majority of patients who have it, with 87% of visits being made by patients who have additional chronic conditions,” Dr. Ashman and colleagues say.

Regardless of age, they found that patients with diabetes use “extensive health resources,” making frequent trips to the doctor and often receiving multiple prescriptions.

One of the federal Healthy People 2020 goals is to reduce the disease and economic burden of diabetes. “Continuing to examine office-based physician visits by patients with diabetes is especially important given changes in standards of care that may influence such visits,” Dr. Ashman and colleagues say.

Source: Medscape

Fashionable Footwear – Good for Style, Bad for Foot Health

More than half of Americans suffer from foot problems, and often those problems are directly related to shoes.

But no matter how cute a shoe looks, Orly Avitzur, medical adviser at Consumer Reports, said that having fashionable footwear isn’t worth the health risks.

“Wearing the wrong shoes can lead to lifelong deformities that require surgery to fix,” she said.

According to a new study from the Institute for Preventive Foot Health, uncomfortable and ill-fitting shoes are a serious problem. Shoes that force feet into narrow or pointy toes can cause bunions or hammertoes, where the toes curl unnaturally downward.

But that doesn’t stop women like Trisha Calvo and Jennifer Frost from wearing name brand heels.

“I feel fabulous in them,” Frost said. “You feel fabulous in your shoes…not physically
fabulous in them.”

Studies show that high heels can shorten your Achilles tendon and can trigger planter fasciitis, an inflammation in the soles of the feet. Avitzur recommends foregoing high heels for something more comfortable.

“Opt for a lower heel to take some of the pressure off the ball of your foot,” she said. “Make sure that there is enough room in the toe, and avoid thin-soled shoes that have little or no support.”

But even flat shoes can hurt feet if they lack proper support and cushioning, especially if they’re the wrong size.

One recent study revealed that up to a third of people wear the wrong shoe size, sometimes by up to one-and-a-half sizes. To combat that problem, Consumer Reports recommends measuring your feet each time you buy, especially for people over 40. After that, feet can grow up to half a shoe size every 10 years.

Source:
WRAL

8 Great Suggestions for Diabetic Foot Care

1.) Maintain a blood sugar level of 70 to 130 mg/dL before your meals and less than 180 mg/dL two hours after you’ve started your meal, with a haemoglobin A1C level that is less than 7 percent. This can be achieved through regular exercise, monitoring how often and what you are eating, keeping up with medications prescribed by your doctor, and monitoring your blood sugar as often as is necessary for optimal control.

2.) Never walk barefooted. Seashells, glass, or other ocean debris can cut your skin and cause serious infections without you realizing it. Walking barefoot on a hot pavement or hot sand can also lead to severe burns or infections. Avoid wearing sandals, as sand and other foreign bodies can still get into the sandal. Podiatrist, Cyaandi Dove, advises all her diabetic patients to choose closed shoes over flip-flops and sandals to give their feet maximum protect. She says: “Insects can still have access to your feet and cause problems with bites and other infections. Rather than saying that you should never wear sandals, I would say that you should be very vigilant when you do wear them.”

3.) Be shoe wise. Wearing shoes that are too big or too small can cause blisters or calluses. Measure your feet each time you buy new shoes. It’s is normal for adult feet to change sizes four or five times during your lifetime. Weight fluctuations, changes in the weather, and poor circulation can all alter the shape and size of your foot.

4.) Be sock wise. Choose socks that have no seams. Seams will rub against your skin and cause blisters.

5.) Wash and inspect your feet and shoes daily. Give your feet a daily wash. Inspect your feet before putting on your shoes and once more when you take them off. If you are not flexible enough to see the base of your foot, use a magnifying hand mirror. Shake out your shoes before you put them on and make sure there is no debris that will rub against your feet. Although a tiny grain of sand might not be felt, it could lead to serious infection if it is not treated properly.

6.) Trim toenails. Don’t let your nails get long and overgrown. Trim them straight across, and, if necessary, file down the edges.

7.) Use skin lotion for your feet. As a preventative, Flexitol Heel Balm can reduce the risk of infections and foot ulceration in diabetic patients keeping the skin optimally hydrated. Rub a thin coat of Flexitol Heel Balm on the top and bottom of your feet, but not between the toes. Excess moisture can also lead to fungal infections, so let the balm soak into your skin for a few minutes before putting on socks on covering up your feet.

8.) Visit a podiatrist before and after your vacation. Fungal infections tend to happen a lot more when the weather is heated and increased in moisture. Your feet might also increase in calluses because you have switched to summer footwear. Do not try to remove corns, calluses, or warts on your own. Even over-the-counter products for removing corns and warts may cause burns or damage to your skin that cannot be repaired. Your podiatrist will help you manage minor infections and ensure that they do not lead to serious complications.

Sources: http://www.digitaljournal.com/pr/1282575#ixzz2sMMwFuEF, http://www.diabetes.org.uk/Documents/Reports/State-of-the-Nation-2012.pdf

Ladies! Don’t Let Bunions Give You the Blues!

APMA put out the following notes on bunions – check it out:  Bunions are among the most common type of foot ailment today’s podiatrist treats, especially in women. Studies show that women are anywhere from two to nine times more likely to develop a bunion than men! While your high heels and peep toes are partially to blame, your foot type (passed down through your family) is the true culprit.
Style Squeeze

Click the image above to order a FREE poster for your office.

Here’s the good news! Today’s podiatrist is the true expert when it comes to diagnosing and treating bunions. Podiatrists perform tens of thousands of bunion procedures every year, more than any other medical professional in the United States.

Fortunately, today’s podiatrist is only a click away! Podiatrists are uniquely qualified among medical professionals to treat bunions, based on their education, training, and experience. If you suspect a bunion, visit a podiatrist and beat bunion blues!

Bunion Basics
What exactly is a bunion? Find out in our Bunion Basics tip sheet.

Bunion Blues and Shoes
Are your shoe selections worsening your bunion? Check out our Bunion Blues and Shoes tip sheet to learn more.

Order a FREE Poster for Your Office
Check out this download of a bunions poster – APMA members can get one directly from the APMA e-store

Have More Bunion Questions?
Contact We Treat Feet’s Expert (and Friendly) Staff, they’d be happy to answer any questions you may have!

Source:APMA

Dos and Don’ts for Pedicures!

The APMA put out a great list of important Dos and Don’ts when it comes to pedicures – we’ve highlighted some we thought were most important.  You can also check out the poster released by APMA by clicking here.

Here’s what you should DO when consider a pedicure:

  • If you have diabetes or poor circulation in your feet, consult a podiatrist so he or she can recommend a customized pedicure that both you and your salon can follow for optimal foot health.
  • Schedule your pedicure first thing in the morning. Salon foot baths are typically cleanest earlier in the day. If you’re not a morning person, make sure that the salon filters and cleans the foot bath between clients.
  • Bring your own pedicure utensils to the salon. Bacteria and fungus can move easily from one person to the next if the salon doesn’t use proper sterilization techniques.
  • When eliminating thick, dead skin build-up, also known as calluses, on the heel, ball and sides of the feet, use a pumice stone, foot file or exfoliating scrub. Soak feet in warm water for at least five minutes, then use the stone, scrub, or foot file to gently smooth calluses and other rough patches.
  • When trimming nails, use a toenail clipper with a straight edge to ensure your toenail is cut straight across. Other tools like manicure scissors or fingernail clippers increase the risk of ingrown toenails because of their small, curved shape. See a podiatrist if you have a tendency to develop ingrown toenails.

And here’s what you DON’T DO when consider a pedicure:

  • Resist the urge to shave your legs before receiving a pedicure. Freshly shaven legs or small cuts on your legs may allow bacteria to enter.
  • If you are receiving a pedicure and manicure, don’t use the same tools for both services as bacteria and fungus can transfer between fingers and toes.
  • Although certain salons offer this technique, don’t allow technicians to use a foot razor to remove dead skin. Using a razor can result in permanent damage if used incorrectly and caneasily cause infection if too much skin is removed.
  • Don’t round the edges of your toenails. This type of shape increases the chances that painful ingrown toenails will develop.
  • Emery boards are extremely porous and can trap germs that spread. Since they can’t be sterilized, don’t share nail files with friends and be sure to bring your own to the salon, unless you are sure that the salon replaces them with each customer.
  • Don’t use any sharp tools to clean under nails. Using anything sharp makes it easy to puncture the skin, leaving it vulnerable to infection.
  • Be sure that you don’t leave any moisture between toes. Anything left behind can promote the development of athlete’s foot or a fungal infection.

Source:
APMA

Flatfeet in Children – Cause for Concern?

An article by the American College of Foot and Ankle Surgeons warns that Pediatric Flatfoot, a childhood condition can, if left untreated, result in permanent deformity in adulthood. Flatfoot deformity makes mobility and exercise painful, increasing the risk of reduced cardiovascular health and obesity.

All reasons why it is imperative for parents to keep a close eye on their childrens’ foot development – namely by having them visit a podiatrist at any sign of discomfort.

“Parents never want their child to undergo a surgical procedure,” says Mary Crawford, DPM, FACFAS, an Everett, Washington foot and ankle surgeon, “but uncorrected symptomatic flatfoot can lead to chronic pain and instability as the child ages into adulthood. Children will be on their feet for a long time to come. It’s vital to keep those feet healthy. A foot and ankle surgeon can help parents understand the options – surgical and non-surgical – for treating pediatric flatfoot.”

Not every child with pediatric flatfoot will display symptoms but many will complain of discomfort, tenderness or cramping in the foot, ankle or knee area.  It also makes participating in physical activities difficult, so parents should take note if the child is not participating in these activities with their friends.

So how do doctors diagnose pediatric flatfoot?  The DPM will evaluate the child’s foot in weight bearing and non-weight bearing positions, both in and out of shoes and will also note how the child walks and evaluates the foot’s range of motion.  For further detailed analysis, the physician may order imaging tests such as x-ray, a CT scan, MRI or bone scan.

So moral of the story – don’t mess around if your child appears to have symptoms of pediatric flatfoot as it could have direct, deleterious effects on their future health.

Source:
American College of Foot and Ankle Surgeons

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