Diabetic Foot – Foot Syndrome, Diabetic Foot, Symptoms, Treatment, Diabetic Foot Syndrome (DFS), Prevention, and Risk Factors for Diabetic Foot

There are currently about 8 million people with diabetes living in Germany. One-third of them have poor circulation in their legs. Approximately one million people with diabetes are at high risk for open wounds or are already suffering from open foot injuries. The problem of “diabetic foot” is widespread. This shows that people with diabetes do not always follow the guidelines for managing their condition.

Diabetic foot primarily occurs in cases of long-standing, poorly controlled diabetes. Consistently high blood sugar levels damage the nerves and blood vessels in the feet. It can also trigger neuropathic pain.

The first signs of impending diabetic foot are usually circulatory and sensory disturbances. The immune system is also weakened. As a result, even the smallest injuries can lead to major inflammation.

There is actually no single “typical” presentation of diabetic foot. As a result, people with diabetes often find it difficult to tell whether they are at risk or not. The clinical picture is extremely varied, ranging from athlete’s foot to large ulcers. About one-quarter of all people with diabetes already have diabetic foot complications at the time of diagnosis by a doctor.

Slow-healing wounds on the foot should always be taken as a warning sign. If a diabetic foot is treated too late, amputation of the foot—or at least some toes—is often a risk. People with diabetes must therefore pay special attention to their foot care.

In addition to poorly controlled blood sugar levels, important risk factors for diabetic foot include, for example,

• nephropathy with reduced pain sensation,
• diabetic ulcers on the feet,
• walking barefoot,
• inappropriate footwear, and
• inadequate or improperly performed foot care.

Patients with diabetic foot very often already have reduced sensation in the affected leg.

There are essentially two forms of diabetic foot. Subsequent treatment depends on the type of diabetic foot.

Neuropathic-infected foot: This form results from insufficient nerve supply and nerve damage. This type accounts for approximately 70% of all cases of diabetic foot. Ischemic-gangrenous foot: This form results from arterial circulatory disorders. Tissue dies off over large areas. 20–30% of patients with a diabetic foot are affected by this form.

The situation becomes more complicated when mixed forms occur. This is the case for up to one-third of people with diabetes. In these individuals, diabetic foot develops due to a combination of polyneuropathy and impaired blood flow to the foot.

The Neuropathic Foot

It all starts with excessively dry skin. This unusual dryness of the foot is a typical early warning sign of a neuropathic foot. Severe calluses and pressure points are another indication of this type of diabetic foot.

At the same time, these symptoms are usually accompanied by numbness. Due to the slow destruction of the nerves caused by diabetes, even deep open ulcers are not painful. Those affected often do not realize they are injured or ignore the wound.

Early education about the health risks should therefore be an important part of treatment for people with diabetes. A thorough foot examination is the only way to reliably identify a neuropathic foot as quickly as possible.

Not all components of the clinical picture need to be present. In summary, the neuropathic diabetic foot is characterized by the following symptoms:

• unusual dryness of the foot as an early warning sign
• painless injuries
• reduced sensitivity
• ulcers on the soles of the feet
• warm feet
• Palpable foot pulses
• Calluses
• Localized fluid retention (edema)
• Secondary infections

To ensure successful healing, the doctor thoroughly cleans the wounds and removes necrotic tissue. To prevent the wound from becoming inflamed, a silver-activated charcoal dressing is often used. Systemic antibiotic therapy also provides additional support.

Depending on the extent of damage to the surrounding tissue, surgical intervention may also be necessary. This may involve removing dead bone tissue or performing minor amputations—that is, amputations just below the ankle.

Ischemic-gangrenous foot

Unlike the neuropathic foot, an ischemic-gangrenous foot is always very painful. Most patients already have peripheral circulatory disorders at the time of their diabetes diagnosis. As a result, the foot is no longer supplied with sufficient oxygen, and the tissue dies.

The ischemic-gangrenous foot is characterized by

• oxygen deprivation resulting from circulatory disorders, as well as
• severe tissue necrosis.

Severe pain, even with minimal exertion, is an early sign of the condition. Ischemic-gangrenous feet frequently affect

• smokers,
• people with coronary heart disease (CHD),
• people with high blood pressure,
• people with “intermittent claudication” (peripheral arterial disease, PAD)

The most significant characteristics are:

• pale, blue-tinged, and cold feet,
• very painful injuries,
• absent foot pulses
• feet with normal sensation,
• extensive tissue loss (necrosis), initially in the toes.

The doctor first conducts a patient interview (medical history) and a physical examination. During this process, the following are typically noted:

• an overheated foot, swelling, pain,
• abnormalities in the shape of the foot,
• protruding bones (e.g., hallux),
• pressure points and even ulcers,
• misalignments of the bones in the foot joints, and
• dislocated joints and displacement of bone fragments

.

Redness around the wound indicates inflammation and must be evaluated through appropriate laboratory tests. X-rays help the doctor examine the foot’s skeletal structure in detail.

The diabetic foot is often characterized by markers of inflammation. In patients with poorly controlled diabetes, elevated blood glucose levels are common. A blood test is therefore an important diagnostic tool.

Diabetic foot syndrome (DFS) must always be treated by an experienced team at a foot clinic. Such a team consists of

• diabetologists,
• vascular specialists (angiologists),
• surgeons,
• radiologists,
• dermatologists, and
• orthopedic shoemakers and
• podiatrists

. In most cases, with their help, it is possible to develop a treatment strategy that can prevent the dreaded amputation.

Amputations resulting from diabetic foot complications have been on the rise recently:

• in 2001: approximately 29,000 amputations,
• in 2003: about 40,000 amputations,
• and the number has now reached 62,000 per year.

Polyneuropathy is generally treated jointly by diabetologists and neurologists.

If even minor misalignments are present without calluses, the treating physician prescribes “diabetes-adapted shoes.” These shoes provide more room for the toes and also feature soft-padded insoles to prevent pressure points.

In cases of misalignment of the foot bones or ulcers, the foot is stabilized within the shoe through additional measures.

For wounds that are slow to heal, a bandage shoe or a special cast may help initially. If the wounds have not healed even after two months, surgical correction of the foot must be considered.

Surgical Corrections

The primary goal of the surgery is to correct the misalignment and thereby eliminate the bone pressure that led to the wound. As with hammertoe surgery, tendons are repositioned in cases of diabetic foot to correct the misalignment.

In cases of particularly advanced deformities and severe inflammation, it is usually necessary to partially remove some bones.

Inflammation is the greatest risk associated with diabetic foot.

Infections Associated with Diabetic Foot Syndrome

Severe, protracted, or frequently recurring infections of the diabetic foot can often only be brought under control through amputation. Nevertheless, in many cases there are other treatments available that are primarily intended to preserve the foot.

Mild infections without tissue loss (necrosis) can be treated by immobilizing the foot and administering antibiotics. If the inflammation progresses, it is necessary to remove the source of infection and, if necessary, amputate parts of the foot.

The later treatment is initiated, the greater the tissue damage will be and the more tissue will need to be removed

To prevent further complications, the patient must be mobilized again very soon after surgery.

To support wound healing, people with diabetes must learn to properly manage their blood sugar levels after a successful surgery. They should also get plenty of exercise.

Following a few simple rules can significantly reduce your risk of developing diabetic foot. The following measures—covering hygiene, preventive care, and daily habits—can lower your personal risk:

• Do not smoke.
• Avoid extreme heat.
• Wear warm socks to prevent cold feet. Do not use hot water bottles or heating pads. Neuropathy may impair your ability to feel heat, putting you at risk of severe burns.
• The inside of your shoes must always be smooth and soft. Check them daily to prevent sores and pressure points.
• Socks should fit well and be comfortable to wear.
• Wearing shoes without socks is a no-no.
• New shoes must always fit comfortably.
• The instep is often the area most affected by improperly tied shoelaces. Do not tie the laces in a crisscross pattern. This reduces pressure on the instep.
• Do not walk barefoot, as the risk of injury is too high.
• Check your feet and the spaces between your toes daily for blisters, cracks, and scrapes. This includes the soles of your feet; a mirror can help.
• Wash your toes daily and dry them thoroughly to prevent fungal infections.
• Applying moisturizer is helpful, but not between the toes.
• Use a thermometer to accurately gauge the water temperature in a foot bath.
• Chemical treatments for calluses or corns are strictly prohibited.
• When trimming your nails, always cut them straight across. Injuries can occur quickly, especially when trimming nails, and you may not notice them due to the neuropathy present in diabetic feet. Foot care should therefore be entrusted to a podiatrist. Make sure to mention that, as a person with diabetes, you suffer from circulatory problems, and have your feet examined regularly by a doctor as well.

Foot injuries in people with diabetes require daily wound monitoring by a doctor. If the injury does not heal or becomes infected, see a doctor immediately.

Diabetes can affect various organs. At a diabetes-specialized clinic, people with diabetes receive comprehensive and competent care. These clinics bring together the necessary expertise to support you with in-depth knowledge and, if necessary, refer you to other specialists.

Chronic wounds and other deformities of the feet can be serious complications of diabetes mellitus. About one-quarter of all people with diabetes develop a foot ulcer at some point in their lives. Even today, there is a common misconception that such ulcers will never heal. In fact, it is true that they take longer to heal and complications can sometimes arise.

With optimal treatment and the use of all treatment options available today, a “diabetic foot” is curable. This may even apply to wounds that have been present for years.

However, success also depends on close interdisciplinary collaboration among the medical team.