Healthcare Guide to Diabetes and Your Feet 3 Ways to Prevent a Foot Wound 8-Step Comprehensive Foot Exam 4 Serious Footcare Mistakes Diabetics Commonly Make
4 Questions to Ask Your Podiatrist Benefits of a Personalized Foot Exam
By Dr. Donald Pelto
Contents 3 Ways to Prevent a Foot Wound ........................................ 2 8-Step Comprehensive Diabetic Foot Exam ...................... 6 4 Serious Footcare Mistakes of Diabetes .......................... 12 4 Questions to Ask Your Podiatrist ................................... 16 Benefits of a Personalized Foot Exam ............................... 20 About Central Massachusetts Podiatry ............................ 21
Copyright ÂŠ 2012, Dr. Donald Pelto All Rights Reserved
Practical Guidance for a Healthier Life as a Diabetic Taking care of your feet when you have diabetes isn’t easy, because you are bombarded with misleading information, confusing terms, bad information from unqualified websites, or fearful stories from your friends and family. How do you find accurate, trustworthy information about diabetes and how it can affect your feet? Start by reading this healthcare guide. In this fact-filled booklet, you’ll discover: • 3 ways to prevent a possibly serious foot wound. • 8 steps to performing a comprehensive diabetic foot exam. • 4 common and potentially deadly mistakes you can make when you have diabetes. • 4 questions to ask your podiatrist if you have diabetes. I wrote this guide to help you better understand the complexities and the problems you can experience as a diabetic. This information can help you make informed, intelligent decisions. I have dedicated myself to educating my patients about diabetes, treating them and helping them avoid the mistakes many of my patients have experienced.
To your health! Dr. Donald Pelto Central Massachusetts Podiatry
3 Ways to Prevent a Foot Wound If you have diabetes, you have a greater risk of developing a foot wound called an ulceration. Wounds of this kind typically begin as a blister on the bottom of your foot. They can become infected and, if the infection is serious, lead to loosing a portion of your toe or even your leg. Here are the easiest and most effective ways you can prevent an ulceration. 1. Examine Your Feet Daily I cannot emphasize enough the importance of self-examination of your feet, both on the tops and the bottoms, and between the toes. A mirror can be helpful, but if you are unable to see all sides of your feet, have a loved one help. Anything you find that appears abnormal or strangelooking should be evaluated by a professional, such as dampness between the toes, a new callus, a wound or an ingrown toenail. 2. Wear Diabetic Shoes Diabetic shoes are specially designed to help diabetics avoid ulcerations, which, as weâ€™ve seen, can lead to very serious medical problems. Medicare and most medical insurance provide coverage for this kind of shoe. For insurance companies, this coverage can save them the thousands of dollars that treatment of ulcerations can ultimately cost. And an amputation is 10 to 20 times more expensive than treating the wound in the first place. 2
Who can get diabetic shoes? Generally, diabetes by itself is not enough. You must have certain risk factors, such as: Poor Blood Flow Swelling or lack of a pulse in your feet can be a sign of poor circulation. Hereâ€™s a simple test. Press on the tip of your big toe. If the spot you pressed on becomes white or blanches, and then quickly returns to its natural pink color, your circulation is probably normal. If you have poor blood flow, you may need a specialized exam by a physician. Here we use blood pressure cuffs on different areas of your leg to determine the quality of your blood. Foot Deformity Foot deformities often call for wearing diabetic shoes. No one likes being considered deformed, but this is merely a technical term for any type of foot or bone abnormality that can cause rubbing in your shoe. This can cause blistering and lead to very serious problems. Extra-depth or diabetic shoes can help. Typically, bony prominences, such as bunions, hammer toes, longer toes or a collapsing foot arch, can be at work here. These foot deformities generally are sufficient for insurance providers to pay for diabetic shoes.
Poor Feeling If your sense of feeling – or touch – on the bottom of your feet is compromised, you are at greater risk for stepping on a foreign object that can penetrate your skin. Also, you might not know you are scuffing the bottoms of your feet, which can produce a wound or callus without you knowing it. We can test the feeling on your feet using a 10-gram monofilament, a thin, plastic wire with which we gently poke different areas on the bottom of each foot. If you are unable to feel the pokes in uncalloused areas of skin, you probably have some level of neuropathy (poor feeling), which qualifies you to obtain diabetic shoes. Previous Wound or Amputation If you have had a wound or even needed a partial amputation of a toe, you are at greater risk for developing other problems in the future. This probably indicates that you have some or all of the conditions mentioned above as well. Usually a foot wound is not caused by one isolated problem, rather by a combination of problems that led to a wound or amputation. These are the top health risks that qualify you for diabetic shoes. Other factors can be involved, but most people who have the above conditions would qualify for diabetic shoes. 3. Get Professional Care for Your Calluses If you develop a callus on the bottom of your foot or the sides of your toes, it can develop into a wound quite easily. The proper treatment for calluses is trimming them with a specialized instrument. This should never be done at home on your own. Only a podiatrist should trim your calluses. 4
For mild calluses on the bottom of your foot, specialized callus creams and pumice stones can help. A word of warning: Do not use “callus removers”! They contain a strong acid. The acid is not able to determine what is normal skin and what is the thickened skin of a callus. And it cannot determine how deep to penetrate your skin. If you have poor blood flow or poor feeling and use these treatments, they very commonly cause wounds. Instead, lighter and safer creams are available that can reduce some of the callus. But if the callus seems to be getting thicker, consult a podiatrist about proper treatment.
8-Step Comprehensive Diabetic Foot Exam You are wise to have your podiatrist perform a comprehensive diabetic foot examination at least once a year. This exam is more detailed than those performed by your primary care physician (PCP) or your endocrinologist. This exam is used to assist your doctors, much the same way an eye doctor’s exam is shared with your PCP. Depending on your risk factors, your podiatrist may need to conduct this exam more frequently. Risk Factors Affecting Frequency of Exam • No neuropathy – yearly • Neuropathy – semi-annual • Neuropathy, poor feeling and/or foot deformity – quarterly • Previous ulcer or amputation – every two months or more frequently The exam is an eight-step assessment of your skin, blood flow, nerves, past medical history and risk factors that could lead to serious problems, including amputation. Let’s look at each step in more detail. Step 1. Review Your Medical History Like most medical exams, we need basic information, including: • Name of doctor supervising diabetes management. This can be your primary care physician, internist or endocrinologist. 6
• Date of last palliative foot care. When was your last foot-care appointment? Depending on your symptoms and risk factors, this should be performed every twoto-three months. • Past medical history. What other health conditions do you have? • Medications. Are you on any new medications? Have you switched any medications? What type of insulin do you take? What diabetes medications do you take? • Last Fasting Blood Sugar (FBS) results. This is a blood sample taken and sent to the laboratory after you have not eaten in the previous 8–12 hours. FBS is a more reliable value than that obtained by a simple finder stick and your own blood glucose tester. • Last Hemoglobin A1c (HbA1c). This is a blood sample that is taken usually every three months by your endocrinologist or primary care physician. It indicates your blood sugar over the last three months, not the single moment in time a finger stick tests. It is a better gauge of how your blood sugar has been doing. • Estimated duration of diabetes. How long have you had diabetes? If not properly managed, the longer you’ve had diabetes, the higher the risk of complications. • Activity level. What and how much exercise do you do? 7
After we review this information, we can make recommendations as needed, focusing especially on the type and level of your physical exercise. For example, we’ll look at what kind of exercise is safe for you as a diabetic, whether that may be walking or other physical activities. Step 2. Orthopedic (Bone Structure Evaluation) First, we evaluate your bone structure. We look for any bones that are more prominent on your feet as well as hammer toes or other curved or bent toe structures. Equally telling are bony prominences, which can cause shoe rubbing and ulcerations on the bottom of your foot. One area of specific concern is Charcot foot, a potentially severe condition in which the arch of your foot collapses. Charcot foot can be mistaken for an infection and may lead to an ulceration. Certainly you should consider special footwear at a minimum. Step 3. Dermatological (Skin Evaluation) The next phase is to look at the skin on your feet to see if there are any areas of callused skin, cuts or dry skin. It is important to see if you have any athlete’s foot or thickened ingrown nails. Talk to your doctor if you have had a foot infection in the past or if you have ever had gangrene on your foot. An essential part of examining your feet is to look between your toes and note the temperature on your feet.
Step 4. Neurological (Nerve or Feeling Evaluation) This exam tests the proprioceptive (nerve) sensations of your feet, including vibration and light touch, and distinguishing between sharp and dull feeling. We use a special instrument to check how well you perceive these sensations. It’s called a SemmesWeinstein, a 10-gram piece of monofilament plastic wire. We touch its end to different areas on the bottom of your foot. If you are unable to sense touch to any of these areas, you have lost what’s called “protective sensation.” This means you are at high risk of developing a foot wound, which may lead to more serious problems and ultimately to amputation. Without protective sensation, you might step on something dangerous without knowing it and possibly cause serious problems for your feet. Step 5. Vascular (Blood Flow Evaluation) Next we determine how well your blood flows – your circulation. We examine your blood flow in your pulse on the tops and sides of your feet. We also look for swelling in your feet. At home you can perform an easy test yourself. Simply push on the tip of your big toe. The toe’s natural pinkish color will turn white. If the pink returns in less than three seconds, you can rest assured that your circulation is not a problem. Poor circulation signals the need for other, more formal exams by your podiatrist. 9
Step 6. Footwear The final step in the exam looks at what you wear on your feet. A shoe exam is very important. Do you look at your shoes before you put them on? If you don’t, you may be at greater risk for getting a cut or wound on your foot. Often small items – sometimes sharp or abrasive – can fall into your shoe. If you don’t feel them, because of the problems discussed above, you may develop bigger problems down the road. We also look at the type of shoes you wear to see if they are appropriate for you as a diabetic. Step 7. Risk Factors We then compare the results of your examination with those of many other patients. If you were recently diagnosed with diabetes and have no risk factors, yearly exams are generally sufficient. But if your risk factors intensify, such as you start to lose feeling or have a pulse that cannot be felt with your fingers, we will recommend more frequent exams. We’re confident you’d agree that more frequent exams are far less inconvenient than developing a foot wound, infection or worse.
Step 8. Education and Counseling Finally, we spend considerable time explaining the risk factors of diabetes and the vital importance of controlling your blood sugar. We review the dangers of neuropathy and explain the findings of your comprehensive foot examination. Most important, we teach you how to do a daily self-examination of your feet â€“ the best thing you can do to prevent an amputation. If you have not had a comprehensive foot examination, it is wise to contact your podiatrist today to schedule one.
4 Serious Footcare Mistakes of Diabetes Mistakes are common in life, and we all make them. All mistakes have consequences, sometimes minimal but sometimes quite severe. In treating hundreds of individuals with diabetes, I have found that many make mistakes in their care. Some mistakes, however, can be tragic. Unattended, the more severe the mistake, the greater the risk of foot wounds, amputation or even death. Common mistakes in how you take care of yourself may seem inconsequential at the moment, but in time they may have life-threatening consequences. Diabetes resembles a forest during a drought: A small flame – even a spark – can fuel a forest fire. Similarly, a small cut or one self-care mistake can end up taking a limb or even your life. Mistake #1. Trimming Your Own Calluses We strongly advise not trimming your own calluses. If your sense of touch is a problem, or if you try to use an improper trimmer, you can actually cut past the callus and into your skin. That cut can be slow to heal or may even become infected. The best treatment is to have your podiatrist trim your calluses regularly. Some commercially available callus creams can reduce the hardness of your skin, but stay away from any acid to remove foot calluses. And try to eliminate the cause of the calluses. Are you walking too much with improper shoes? Are your shoes too tight and rubbing? Is there excessive friction on 12
the bottom of your foot? If the calluses are on the bottom of the foot, you should look into footwear designed to reduce the friction on the bottom of your foot. In many cases, your health insurance will pay for these shoes. Mistake #2. Thinking You Have a Foot Problem Only if it Hurts You probably only go to the doctor if you feel sick or if something hurts. Unfortunately, that’s not the way it works with your feet. If you only recently have been diagnosed as having diabetes and you have lost some feeling, your foot may be injured, but you may not feel pain. Don’t wait for pain before you go to the doctor to have a foot evaluation. Check your feet daily or have someone else check them. If you can’t see the bottom of your feet, try using a mirror. If you see something during your daily foot exam that doesn’t look right, see your doctor immediately. As mentioned above, routine foot exams should be done based on your risk factors. Mistake #3. Treating Your Own Ingrown Toenails Due to a lack of pain sensation, people with diabetes can develop ingrown toenails and not feel them. If your nails are thick due to a fungal infection called onychomycosis, you may be more likely to develop ingrown toenails. If you see an ingrown toenail, you will notice the side 13
of your toenail growing into the skin. At times, you may see yellow or white puss, and your toe may or may not be red. Many times it will not be painful, either. The best way to determine if you have an ingrown toenail is to look at your toes or have someone else look at them. If your nails can grow past your skin without difficulty and do not creep into the edge of the skin, you are probably okay. But if your nails grow into the edge of the skin and if you find yourself digging out the edge of your nails when you trim them, you should see a podiatrist. The best way to prevent an ingrown toenail is to let the nail grow forward past the skin and then trim it straight across. Don’t trim it to the edges. Also, many people with diabetes see their podiatrist for nail care to prevent the occurrence of ingrown toenails. Healthier diabetics may even be able to have a procedure to kill the root of the nail to prevent ingrown nails from reoccurring. This is not for everyone, and you should ask you podiatrist if it is an option for you. Mistake #4. Wearing Worn-out or Improper Shoes People in general tend to wear their oldest shoes for the hardest, dirtiest work they do. Unless it’s your job, when you’re gardening or doing construction work, you tend to wear your oldest shoes. For diabetics, however, wearing old, worn shoes at any time can cause serious problems. First of all, your shoe size may change over time and as you age. A shoe that fit you five or 10 years ago now may not fit. And leather can harden over time. A shoe that used to stretch enough for comfort can become hardened an develop places that rub excessively on your foot. 14
Therefore, diabetic shoes are often your best option. But if you wear regular shoes, make sure they are shoes you’re used to wearing. All shoes you wear should be comfortable from the day you buy them. Inspect your feet every few hours when you buy new shoes to see if there’s rubbing (blisters or red marks) or pain. If you experience any of this, you should return them. Please get rid of these shoes or bring them to me, and I will buy them from you! Inexpensive shoes may save you money initially, but if they rub you the wrong way – literally – they can cause a sore on your foot. Bad news. Don’t wear shoes that don’t fit!
4 Questions to Ask Your Podiatrist Question #1. Why are my feet tingling or burning? Tingling and burning are signs of neuropathy, or nerve damage. You need to know from your doctor if you have neuropathy, if your sense of feeling is good, poor or borderline. If you have borderline neuropathy, your podiatrist should evaluate your feet at least yearly. Neuropathy resembles a failing light bulb: One day the light is working well; the next thing you know it is starting to flicker. Finally it goes out. You never know when the light will go out, and you never know when your neuropathy will become worse. If you have painful neuropathy on your feet, medication is available. Ask your doctor if this can help. As well, topical medications may relieve some of the burning, tingling pains on your foot. The tingling and burning are signs that the nerves in your feet are dying. If the pain disappears, that means the nerves have stopped working. Therefore, painful neuropathy in your feet is better than no pain and no feeling. Question #2. How is my blood flow? You need to know how well blood is circulating in your feet. Poor circulation signals the need for at least one of the following exams: â€˘ Ankle brachial index. Here blood-pressure cuffs are placed on your legs to determine if there are any blockages in your legs. See photo on page 17. 16
• MRA (magnetic resonance arteriogram). This more advanced exam determines exactly where the blockages are in your arteries. This exam is usually preformed by the vascular specialist. Even though you have poor blood flow, you may or may not feel anything. Many people do not realize they have poor circulation until they develop a sore on their foot that’s slow or unable to heal. Often, people with poor blood flow to their feet feel pain in the back of their calves or in their buttock area after walking a certain distance. For example, if you walk a block, but have to stop to rest, and then can walk another block, it’s called intermittent claudication. That’s a sign of poor circulation in your legs. As your blood flow becomes worse, you may have pain while just standing or resting in bed. These more severe symptoms can make it difficult or even impossible for you to walk. Sometimes poor blood flow pain can even be masked as a pain in your back. If you have concerns about your blood flow, you should make an appointment with a vascular specialist.
Question #3. Do I qualify for diabetic shoes? If your healthcare insurer will pay for diabetic shoes, I recommend getting them. To qualify for this healthcare benefit, you need to have risk factors. These include poor blood flow, poor feeling in the foot, or foot deformities. If you
have one or more of these symptoms, normally your insurance plan will pay for a pair of diabetic shoes every year to prevent the complications of diabetes. I know many of you think diabetic shoes are ugly! That may have been accurate at one time, but shoe companies have come to realize that competition leads them to offer products that are both more attractive and good for you. No one wants to wear a Frankenstein-looking shoe. Many fashionable diabetic shoes are now available, bearing popular brand names like New Balance and Hush Puppies. You may find that shoes with a Velcro or stretch closure are easier to get on and fit you better, especially if your feet are very swollen or you canâ€™t easily reach your feet.
Question #4. What should I do if I have a foot problem? Many diabetics experience some type of emergency during their lifetime due to blood sugar, foot or other health condition. It is important to find a trustworthy group of doctors to help if problems arise. Your doctor should be able to see you the same day if you have a foot problem. If not, go to your local Emergency Room. If you have diabetes, consider the following to be an emergency: • A cut or wound on your foot • A painful ingrown toenail with infection • Redness or streaking on your skin with infection • Feeling pain in your foot when it usually does not have any feeling • Symptoms of fever, nausea and vomiting If you have any of these conditions, you need to be seen within 12 to 24 hours. Be aware that you may not be able to see your feet from all sides and that poor feeling on your feet is a sure sign of a problem. Seek help from a loved one or friend. If found too late, you risk a complication or infection on your foot, which sadly can lead to an amputation.
Next Steps We hope you have found this Healthcare Guide to Diabetes and Your Feet helpful. It tries to answer the question, “Why is proper foot care so important for a diabetic?” If you have found this booklet informative, please pass it on to a friend or loved one who suffers from diabetes. Learning how to take care of your feet is one of your strongest defenses against the risks of diabetes. If you do not currently have a podiatrist, contact the American Podiatric Medical Association (www.apma.org) to find one close by. If you live in Worcester County or beyond, you are certainly welcome in our office.
Get Your Comprehensive Diabetic Foot Exam and Personalized Recommendations Preventive foot care is paramount for preventing foot wounds or amputations to you or a loved one. Please see a qualified podiatrist who specializes in diabetic foot care. If you choose our office, we will perform an initial comprehensive foot exam and give you personalized recommendations. These recommendations will be in the form of a diabetic foot audit, explaining the exam, what’s in it and any risk factors you have. We will share our recommendations with your primary care physician (PCP), endocrinologist, eye doctor and podiatrist. We’ll also discuss types of shoes you may need to 20
have and any types of nerve or circulation studies that are recommended. Your podiatrist should perform a comprehensive diabetic foot exam at least once a year. Be aware that simply having your calluses and nails trimmed is not the same as a comprehensive diabetic foot exam (see â€œ8-Step Comprehensive Diabetic Foot Examâ€? on page 6).
About Central Massachusetts Podiatry Central Massachusetts Podiatry is a full-service footcare medical practice. Our doctors are skilled in all aspects of foot care, both clinically and surgically, with special emphasis on the needs of patients with diabetes. Drs. Feldman and Pelto and their staff are dedicated to understanding each patientâ€™s podiatric concerns and providing a complete diagnosis and treatment plan.
Neil J. Feldman, DPM
Donald Pelto, PDM
More Helpful Resources To listen to a free recorded summary of this booklet, phone 641.715.3800 /Access Code 32299# / Message 2. Smart phone users can scan the QR code to link to an order form for this free booklet. Or visit www.diabetesfootbook.com. American Diabetes Association www.diabetes.org Diabetic Shoe Information www.safestep.org New England Amputee Association www.newenglandamputeeassociation.com American Podiatric Medical Association www.apma.org
Dr. Neil J. Feldman Dr. Donald Pelto
299 Lincoln Street, Suite 202 Worcester, MA 01605 508.757.4003 www.worcesterfootcare.com
Helpful information about diabetes and your feet