FAQs

Every 30 seconds, there is a leg amputated because of diabetes, somewhere in the world. In India the number of amputations is anywhere between 40,000 to 2 lacs per year. Currently there are more than 7 crore diabetics in India, and this number is ever increasing. Also, the age at which people are catching diabetes is getting younger.

Once a diabetic gets an ulcer on foot, half the patients are dead in 5 years. Prognostically, this is worse than getting breast cancer, colon cancer or prostate cancer. If an amputation is required, only 50% survive 2 years after surgery. The reason for this is that most diabetics already have other complications like heart and kidney and circulation. The good thing is that 85% of all these amputations can be prevented.

An ulcer in foot is an area where skin is broken down. Once this protective layer of skin is broken, infection enters inside and spreads inside. It can involve muscles, tendons, joints and bones. In diabetics, ulcers don't heal well. Most ulcers in diabetics start without any injury from outside and without any pain. The ulcer in a diabetic starts from ‘within out’.

The 3 Main reasons for wounds not healing in diabetics are (1) Repeated high pressure – If you keep walking on the infected foot, it is less likely to heal, for the simple reason that, the whole weight of the body is falling on that area. The more you walk, more is damage and less is healing (2) Deep infection –If infection has gone in deeper areas or areas like bones and joints, it needs proper cleaning or even removal of some part to control infection. Foot has more than hundred compartments. If the infection is not fully removed, it spreads further inside or up the leg. (3) Poor blood flow – Blood not flowing enough can be a reason in some patients (4) Other reasons – Old age, poor immunity, heart disease, kidney disease or any other major health problem has impact on healing.

More than 50 % diabetics are at risk of developing ulcer. This is because 40-50 % diabetics get loss of sensation and approximately 10-20 % diabetics have serious circulation problem. Both

Prolonged uncontrolled diabetes leads to death of long nerves, the one that carry sensation from feet. So sensation in feet and some part of leg may be lost. This is called neuropathy.

There are two main reasons to get foot ulcer and infection in diabetics – reduced sensation and reduced circulation (1) Reduced sensation – Prolonged diabetes results in neuropathy or damage to the nerves that carry sensation of touch and pain from feet. This complication of diabetes is called peripheral neuropathy. Secondly, diabetes itself causes change in shape of foot and skin. This results in high pressure areas in certain parts of foot like heel or beneath the ball of big toe. The affected person keeps walking again and again on these high pressure areas. It is this repeated pressure pressure injury that does the damage. This, combined with loss of pain sensation, keep patient unaware of the ongoing damage and the seriousness of the problem. So, ‘No pain + High pressure points + Repeated pressure = Ulcer and infection’ Also, many injuries like cuts, bruises go unnoticed. In India, it is not uncommon for patient to wait till he develops a bad infection or even a gangrene, and even then doesn't realize how bad the problem is until the leg is amputated, as there is no sensation. (2) Reduced circulation –Longstanding diabetes, damages the blood vessels and blocks them. There is poor blood flowing to the feet. This starts process of some parts of foot dying (gangrene). Also, tiniest of injuries fail to heal. (3) The other reasons are animal or insect bites, high blood sugar, poor immunity, and poor healing of wounds. Also, by this time most patients have high blood pressure, heart disease and kidney problems. All these ailments have effect on wound healing and general health.

o Reduced sensation may start with tingling, numbness, heaviness in legs or a sensation of pins and needles. Sometimes there could be shooting pains or other uncomfortable sensation as the nerves are getting damaged by diabetes. o Thickened skin or callous forms over high pressure points. This is the commonest warning sign before skin breaks and serious ulcer starts. If treated early, it can prevent serious infection. o Any change in colour or appearance of foot should alert a person. One may check other leg for comparison.  Skin may turn red after infection.  Pus collection may show yellow areas.  Purple to black colour can herald circulation problem.  When circulation is poor, a person may get lot of pain and/or one foot may feel colder than other. o Worn out insole- Inside of shoes getting worn out in one area indicates high pressure in that point and may need modification of footwear. o To know more, read ‘Early signs of diabetic foot problem’.

Once patients gets infection, it can spreads to deeper structures like muscles, bones and joints. This can lead to amputations of some parts of the foot or the whole foot, if the infection is not treated in proper manner in right time. Inappropriate footwear, poor vision, lack of education about diabetes and foot care, and not adhering to the treatment advised also worsens the problem.

Depending upon the individual problem, treatment involves many non-surgical and surgical options depending upon the extent of the problem. Some may need a simple change in footwear or a course of antibiotics, or some may need combination of more complex procedures like amputations, debridement, fasciotomy, etc Read “services” for detailed information

Typically, necessary investigations could be (those in bold are usually necessary) (1) To check how much spread of infection is there - Xray, MRI, CT scan (2) Circulation check – Doppler, angiography (3) Nerve sensation – Biothesiometry, nerve conduction studies, MRI scan. (4) Blood tests for checking diabetes, liver, kidney, heart, cholesterol. (5) Bacteria testing – culture and sensitivity (c/s) studies. Read ‘Investigations in Diabetic foot’ for more information.

These may include • VAC or suction therapy • Specialised dressings using growth stimulating medicines • HBOT or high pressure oxygen • Circulation imrovement – using special medicines like prostaglandins or procedure like angioplasty or bypass surgery in legs. • Maggot therapy • Read ‘modern methods in diabetic foot treatment’ for more information.

Each hospital and specialist may have its own protocol, But, a standard protocol may include - • Checking the foot for infection, its spread, circulation, sensation. • Checking general health for diabetes, heart, kidney, etc • Investigation, to confirm above findings about spread and depth of infection, circulation and sensation. (Read more about it in ‘Investigations in diabetic foot’) • Making the patient fit for surgery (This in the least may need admission for 1-2 days and therapies like iv fluids and insulin and improving heart condition). • Planning necessary non-surgical (antibiotics, plaster, dressing, VAC dresing) or surgical treatment (minor or major cleaning/debridement, minor or major amputations). Read more in ‘services’ • Sometimes, specialised procedures like VAC treatment, angioplasty may be required (Read more in special treatments in diabetic foot) • Specialsied plaster and later specialised footwear (Read more in footwear in diabetics) • Regular follow up and tests after healing Read ‘Protocol in treating diabetic foot problem’ for more information.

• Preventive care of diabetic foot is most important at all stages. It includes taking care of the nails, hygiene, skin, moisture, footwear and general health. • Have your feet regularly examined in a foot clinic by an appropriate health professional experienced in foot care. (Once every 6-12 months). • Simple tests in clinic, can diagnose neuropathy (loss of sensation). This gives a lead time of 1-2 years before ulcer develops. If proper footwear is used and proper foot care taken, ulcers can be avoided in more than 85 % of cases. • Keeping good general health, controlling diabetes and controlling the risk factors will be other things on the ‘to do’ list. But if there is an active problem like infection or an ulcer, one may not be able to do walking and similar exercises that need standing on foot. Please read ‘Prevention of foot problems in diabetics’ for detailed information

• Many varieties are available. But, for most, the best footwear should have these 3 properties o Thick soft insole o Broad in front o Covering the whole foot In India, a simple sports shoe of 1 size bigger than your foot size and socks will usually be enough for most people. In certain special condition, one may need specialised shoes. Your diabetic foot doctor should be able to help you. • Specialised shoes include – wedged shoes, customised shoes, insoles made by CAD/CAM technology, air cast shoes, etc Read ‘Footwear in diabetics’ for more information.

A routine checkup of diabetic foot can prevent serious problems in 85% of cases. Mostly this can be done on OPD basis.. It may include - • Any change - You should be clinically examined for infections, corns, thickened skin areas, ulcers, deformities or any other problem. • Sensation or checking for neuropathy – A simple monifilament or other bedside test can check for neuropathy. • Blood flow or circulation – Checking foot pulses and if ecessary a hand-held doppler can test for any circulation problem. • Footwear – Cheking the footwear and any signs of wearing out are important part of examination. A good foot professional/doctor will always check your shoes and comment on them. • Any major deficiency found in these simple tests may warrant further investigation. This should follow advice about footwear. • General health – Diabetes and general health also shold be looked into.