John Nebitt M.D.
Why the Treatment of Diabetic Ulcers is so Important - Presentation

When you have diabetes, your feet need a little extra care and attention. Diabetes damages the nerve endings and blood vessels in your feet, making you less likely to notice when your feet hurt. Diabetes also interferes with your body's ability to fight infection. As a result, if you develop a minor foot injury, it can become an ulcer (a hole or break in your skin) or develop into a serious infection. With a good daily foot care routine, you can prevent many of these problems.

  • The purpose of this site is to decrease diabetic and peripheral vascular disease lower extremity complications by at least 50% by the use of effective foot care practices. Diabetic and peripheral vascular disease foot care education is extremely important as more than 50,000 lower extremity amputations are performed each year on diabetic patients.
  • Of these amputations, 24% are of the toe, 5.8 % are mid-foot, 38% are below the knee and 21.4% are above the knee
  • A major amputation is required because an untreated ulcer may develop gas gangrene or compromise the local blood flow significantly to cause digital or forefoot necrosis.
    • Unfortunately, the downward spiral of diabetic lower extremity complications and further amputations do not stop there in that:
    • Approximately 20% of people who require below-knee amputations will not heal their surgical wounds and will require further wound revision and above-knee amputation
      Patients with below-knee amputations 5 year rate of the amputation of the other leg is 50%
    • Patient with below-knee amputations 5 year survival rate after the first amputation is about 40%, the major cause of death being cardiovascular (ie. strokes, heart attack, complications associated with the diabetic foot)

Patient Profile

Both insulin and non-insulin dependent diabetics develop foot infections. They are on average 60 years of age and have had their disease for more than 10 years.

It is well known that high blood sugar levels from diabetes over years can:

  • Cause damage to the nerve endings (or peripheral neuropathy) in your feet. That means that you may not feel it when you feet are hurt or injured. Also, if your shoes don't fit properly, you may not feel any discomfort (even a blister). This nerve damage caused by diabetes in some people can lead to deformed feet that may not fit well in standard shoes.
  • Cause damage to the blood vessels (or arterial disease) throughout the body. Damage to the vessels that carry blood to the feet and legs decreases blood flow to the feet. Small cuts, sores and even ingrown toenails take longer to heal and are more likely to become infected because of the decreased blood flow to your feet.
  • Affect your body's ability to fight infection. Even a small cut may become seriously infected because your immune system may not work as well as the immune system of someone who does not have diabetes.

The good news is that the 1993 landmark study Diabetes Control and Complications Trial conclusively showed that keeping blood glucose as normal as possibly significantly slows the onset and progression of nerve and other complications associated with diabetes.

Now that you know what can happen and how it happens, you have to know what to look for and what to do about what you find. We will now outline the physical characteristics of a diabetic neuropathic and a peripheral arterial disease foot. It must be kept in mind that your foot may not have all of these features and may only develop them slowly (if at all) over a long period of time.

Characteristics of a foot affected by diabetes include:

  1. Cocked-up toes
  2. Thinning of the fat pad under the ball of the foot.
  3. Loss in protective sensation (neuropathic) as determined by sensation testing
  4. Cracked dry skin secondary to a decrease in the foot's ability to perspire
  5. Bony foot deformities (Charcot foot abnormalities) can cause new plantar pressure points on the bottom of your foot.

It is important to understand that the diabetic foot takes on this new shape because of a decrease in nerve function in this area and now the foot can be further traumatized by it being forced onto footwear that no longer fit.

Signs that you may have peripheral arterial disease or a decrease in blood flow to your feet include:

  1. Absence of pulses in your foot and a cold foot
  2. Loss of hair and shiny thin skin
  3. Thickened brittle nails
  4. Foot discoloration or redness
  5. Pain in your calfs when you walk that stops when you rest. This is often one of the first symptoms of a decrease in blood flow to your feet.

As one would expect, the combination of foot deformities, loss of protective sensation and the presence of peripheral vascular disease, places one's feet at particularly high risk.

What you can do to stop your loss of life and limb

  1. You must try to stop smoking. The stopping of smoking is extremely important as smoking increases the speed of onset of all of the above-mentioned complications.
  2. You and your health care professionals must take an active role in your diabetic foot care education, the cornerstone being your daily foot care inspection and routine.
  3. You should be categorized according to your "active diabetic foot group" and should follow the guidance given according to your required medical follow-up, foot wear, skin and nail care, job and exercise restrictions.