Chapter 1 – WHAT DOES THE FOOT HAVE TO DO WITH MY DIABETES?

Despite modern advances in diabetes management, foot complications remain a serious issue that can lead to major leg amputations. According to the American Diabetes Association, 20% of all hospital admissions for diabetic patients are related to foot problems, and 50-70% of all non-traumatic amputations in the United States occur in people with diabetes. In fact, about 25% of individuals with diabetes will eventually develop foot complications during their lifetime, and these problems frequently become infected, which can ultimately lead to amputations.

The good news is that most patients can prevent these severe outcomes by becoming knowledgeable about diabetic foot disease. It is essential for each patient to understand the processes behind diabetic foot complications and to take proactive steps. It is the responsibility of the individual patient to learn and understand the processes of diabetic foot disease.

Diabetic patients are particularly susceptible to foot complications due to poor blood circulation—known as Peripheral Vascular Disease or Arterial Insufficiency (see Chapter 3)—and nerve damage, referred to as Peripheral Diabetic Neuropathy (see Chapter 2). The combination of these conditions, along with negligence, can lead to a variety of foot problems, including calluses, ingrown nails, skin lesions, foot ulcers, and ultimately gangrene.

Most foot infections that result in amputation can be traced back to mismanagement or neglect of calluses or poorly treated infections. Diabetic peripheral neuropathy is characterized by a burning sensation, tingling, and a pins-and-needles feeling, which may eventually progress to a complete loss of sensation. When an insensitive foot is subjected to repetitive trauma—whether from foot deformities, inappropriate shoes, chemical burns, or dry skin cracks—it can lead to foot ulcers. Deformities such as contracted toe deformity (hammer toe) and bunions are particularly prone to ulceration due to the pressure and irritation from the shoes (see Chapter 10).

Calluses on the bottom of the foot (see Chapter 6) are subject to constant friction from inappropriate shoes, which can eventually lead to the development of ulcers. These ulcers frequently become infected. The infection destroys surrounding tissue, and the small vessels in the foot become congested, leading to tissue ischemia (gangrene) and, ultimately, amputation.

Vascular disease in the lower extremities of diabetic patients most commonly affects the major arteries below the knee. Over time, atherosclerotic plaques—often up to 80% blockage due to cholesterol-like deposits —can form within these arteries, gradually reducing blood flow to the toes. When this process is combined with neuropathy, the risk of losing a leg becomes very high.

Toenails in diabetic feet can be particularly problematic (see Chapter 5). Reduced blood flow to the nails may cause them to become thick and discolored. Additionally, ingrown toenails that become infected can lead to a slow healing, chronic infection, which may eventually spread to the underlying bone of the toe (refer to Chapter 8). Chronic infections of ingrown toenails can progress to gangrene. For detailed prevention and care strategies, please see Chapter 5.

Diabetic patients with hammertoes and bunions must pay particular attention to their footwear, as shoe irritation on corns and calluses can lead to serious foot infections (see Chapter 10 for diabetic footwear recommendations.)

Diabetic individuals should also pay special attention to their skin, as many conditions that might seem harmless can lead to serious infections (see Chapter 4).

It is the patient's responsibility to take care of their feet and understand that any carelessness or negligence could cost them their leg. A foot infection can lead to amputation, often with devastating psychological effects for both the patient and their loved ones. According to the ADA, 30% of diabetics who have a foot or leg amputation will lose the other foot within three years, and the overall survival rate for diabetics with a leg amputation has dropped to 30%.

HOW CAN YOU PREVENT THESE PROBLEMS?

As mentioned earlier, the greatest responsibility of the patient is to learn about and understand diabetes and its foot complications. Numerous studies have shown that people with diabetes can reduce the risk and severity of complications by 50% or more by maintaining blood sugar levels as close to normal as possible. This can be achieved through intensive therapy—checking your blood sugar four to five times a day and adjusting your insulin dose accordingly. Always discuss any changes to your treatment plan with your physician before making adjustments.

If you have diabetes, it is crucial to see a podiatrist regularly, even before any foot problems worsen. Regular visits to a podiatrist can greatly reduce the risk of foot complications, especially if you notice any disturbances in your feet. Podiatrists are specialized physicians and surgeons who focus exclusively on the medical and surgical care of the foot and ankle. Given the high prevalence of diabetic foot complications, incorporating a podiatrist into your diabetes care team is essential.

Your ability to recognize early signs of diabetic foot conditions and to seek timely medical and surgical intervention can significantly reduce the rate of diabetic foot amputations and improve overall outcomes.