At a Glance:
- Diabetes may lead to blood flow issues to the feet as well as nerve damage known as peripheral neuropathy
- The nerve damage makes it easier for the feet to be damaged and the lack of sufficient blood flow may stop a wound from healing normally
- These wounds may become ulcers and the ulcers may become infected
- The infection may lead to tissue death (necrosis) and that in turn may lead to gangrene
- Depending on the severity of the ulcer and the extent of the infection, a doctor or podiatrist may use non-invasive techniques to try and help the wound heal naturally or may have to resort to invasive procedures up to and including amputation
- Around 1.7 million Australians are living with diagnosed diabetes and there may be as many as 425,000 more with an undiagnosed form of the disease
Why are Pain and Ulcers Related to Diabetes?
Feet are, to put it mildly, very important. People spend a huge amount of their life on their feet, and utilise them in some way in a number of activities that are performed every day. Proper care of feet is important for everyone, of any age, but for people with diabetes, diligent foot care is especially important.
Around 1.7 million people in Australia live with some form of diabetes, making it one of the major burdens on the Australian health system and one of the fastest growing chronic conditions in the country. What’s more, a recent survey by the Australian Bureau of Statistics and quoted by Diabetes Australia states that for every four people with a diabetes diagnosis in Australia there may be one person with undiagnosed diabetes.
That means that potentially there are around 425,000 people who may not be doing anything to control their blood sugar levels, leaving them more at risk for problems related to diabetes.
Uncontrolled or poorly controlled diabetes may lead to a number of related health issues all around the body. In the feet, uncontrolled diabetes may lead to nerve damage, known as peripheral neuropathy, as well as limit blood flow.
Neuropathy may cause pain or pins and needles, but in many cases it mutes sensations such as heat, cold and pain. With reduced sensation in the feet, sustaining and failing to notice damage is far easier than in healthy feet. As such, people with peripheral neuropathy in the feet may not notice blisters, cuts and abrasions, burns and the like.
If these wounds go unnoticed it’s far easier for them to worsen and become infected. As diabetes can affect blood flow to extremities. The reduction of blood flow makes it harder for wounds to heal, so infection may become severe or spread. These wounds that can’t heal properly are called ulcers, which often have surface bacteria slowing or preventing healing, leading to deeper, more serious wounds.
A foot ulcer occurs when the skin degrades exposing the more fragile tissue underneath. These ulcers frequently form on weight bearing parts of the foot, such as under the big toes or the balls of the feet or in areas with poor blood supply like the medial ankle bones. Left untreated, ulcers continue to grow and deepen, potentially even exposing bone.
These severe wounds may become necrotic. This means that the tissue dies and cannot be regenerated. This necrosis may lead to gangrene, a more serious form of necrosis. In order to stop the spread of gangrene, the dead tissue must be entirely removed.
In some cases this may lead to the amputation of toes. Very serious cases may require the removal of part of the foot, the whole foot or the lower lower limb below the knee as there may not be enough salvageable tissue to form a functional extremity.
Each year in Australia there are around 4,400 amputations performed in hospitals. Diabetes Australia and Diabetic Foot Australia estimate that around 85% of these amputations could be avoided if correct and diligent foot care was performed.
Symptoms of Diabetic Foot Issues
While the symptoms of diabetic foot issues don’t differ from those of foot issues that may affect anyone, people living with diabetes need to be extremely diligent in looking out for symptoms, scheduling an appointment to see a doctor if any of them arise. Catching a foot problem related to diabetes early may be the difference between a quick recovery and a potential amputation.
One of the first symptoms that you may have a foot ulcer is drainage (clear or yellow fluid, sometimes blood) from the wound that may be visible on a sock, or in extreme cases, the shoe. A major symptom of a serious ulcer is a ring of dark tissue, known as eschar, around the wound.
This is a sign of poor blood flow to the area. This lack of sufficient blood flow may lead to gangrene. If that is the case, in addition to the skin discolouration, the ulcer will typically also have a foul smelling discharge.
Foot and lower limb symptoms that may be due to complications of diabetes include:
- A lack of feeling or muted sensitivity in the feet
- A marked change in skin color - typically involves the darkening of skin but may also include a skin looking white, purple or blue and bloodles
- Loss of hair on toes or legs - poor circulation may lead to the loss of hair. Over time, diabetes-related damage to blood vessels may cause Peripheral Artery Disease (PAD). PAD causes fatty buildups known as plaque to be deposited in the small blood vessels (those that supply the skin and hair follicles) leading to hair loss.
- Numb toes - may feel like they are “asleep” much like when you sleep on your arm
- Pins and needles, tingling or a burning sensation, particularly in the toes
- Slow to heal sores - even if not infected, a sore that is slow to heal may be a sign that you have a problem with blood flow to the area, necessitating special attention
- Swelling in the legs or feet
Many wounds or problems that may not cause too much of an issue for most people may be much more of a problem for people living with diabetes. Risk factors that may lead to infections, necrosis and even gangrene include:
- Athlete’s foot
- Calluses and Corns
- Cracks between toes - cracked skin may be little more than an irritation for many people, but for someone living with diabetes, the soft, often moist skin between toes is ripe for infection
- Breaks in the skin from dryness
- Hammer and Claw Toes
- Ingrown toenails - a person living with diabetes has a higher risk of developing an infection from an ingrown toenail
- Planters Warts
While all people living with diabetes are at risk for foot ulcers, there are some risk factors that may make them even more in danger of developing a foot ulcer, such as:
- Alcohol consumption
- Diabetic Retinopathy
- Heart disease
- Kidney disease
- Poor hygiene (not washing regularly or thoroughly)
- Poorly fitted or poor quality shoes
- Uncut or poorly cut toenails
If you notice any of these symptoms, you should seek medical attention. According to Diabetes Australia, immediate medical attention should be sought if you notice an ulcer, swelling, discolouration, blisters, ingrown toenails, bruising or cuts.
If you notice broken skin between toes, a callus or corn, changes in foot shape, cracked skin or changes in nail colour you should seek medical attention within the week.
Treatment for Diabetic Foot Issues
Before resorting to invasive treatment for diabetic foot problems, doctors will typically attempt to use non-invasive measures aid in natural healing. If you have developed a foot ulcer, a doctor or podiatrist may recommend “off-loading” during treatment. Pressure on an ulcer may make the ulcer expand or the infection worse, so limiting that pressure may be key to treating the wound.
Aside from staying off your feet, there are a number of methods a doctor or podiatrist may use to limit pressure on an ulcer, including the use of special shoes, braces or casts, compression wraps or shoe inserts.
In addition to relieving pressure, the doctor may remove tissue (debridement), and, in the cases of infection, will undertake necessary steps to control the infection.
Depending on the severity of the infection, a number of different approaches or steps may be be required, such as:
- Antibiotics (oral or intravenous depending on severity)
- Enzyme treatments
- Foot baths
- Treated dressings designed to stop bacterial growth
Extra testing may be required to see if the infection has spread to other areas of the foot or the bones.
In cases of gangrene of the toes, rather than resort to surgery, a doctor may instead opt to closely monitor the progress of the gangrene until self-amputation occurs (the toe falls off by itself).
If non-invasive treatments are ineffective or the ulcer/infection/gangrene has progressed too far, the foot will be treated using surgical means. This may mean removal of tissue or bone in the affected areas, amputation of toes, removal of food abnormalities (like bunions or corns) that may be causing pressure ulcers or, in advanced cases, removal of the entire foot.
Rather than go through lengthy non-invasive treatment or potential surgery, maintaining healthy feet and doing what you can to avoid problems that may lead to foot pain, ulcers and related complications is vitally important. Speak to a podiatrist about a full diabetic foot care plan. This plan may include steps such as:
- Regular monitoring of symptoms for change.
- Regular testing of circulation and sensation for early detection of changes.
- Education regarding appropriate self care of feet
- Daily foot inspections - monitoring for cuts, changed in shape or colour, blisters, bruises, ulcers and the like
- Wash and dry feet thoroughly each day - typically using warm, not hot water
- Wear appropriate, well fitting shoes - wearing shoes appropriate for the task at hand that don’t put undue pressure on the foot or rub reduces the chance of sores or blisters
- Avoid walking barefoot - if you have peripheral neuropathy you may not be able to detect damage being done to your feet from burns, punctures, cuts and the like
- Exercise - getting daily exercise may increase blood flow to extremities
- Avoid chemical remedies - many over the counter and home remedies for warts, calluses and corns use harsh, corrosive chemicals that may damage the skin making it easier for an ulcer to form
- Moisturise your feet - keeping the skin on your feet moisturised makes it less likely to crack
- Quit smoking - smoking decreases blood flow to extremities
- Lose weight - being overweight or obese may put more pressure on the feet, making it easier for them to be damaged and making it harder for ulcers to heal. Excess weight may also affect blood pressure and peripheral blood flow
If you are one of the 1 .7 million people in Australia living with diabetes, don’t be afraid to seek medical advice . Small, trivial wounds that would heal normally for many people may become a problem for someone with diabetes, so it’s far better to have something looked at or treated before it becomes a big issue than wait until potentially debilitating damage has been done.
Book an appointment to see a podiatrist and take care of your feet. The fastest and easiest way to search for and book healthcare appointments online is through MyHealth1st.