Diabetes (Lower Limb Related Subjects Only)

Diabetes mellitus is now a major global public health problem. The incidence and prevalence of diabetes is escalating around the world, especially in developing and newly industrialized nations. The World Health Organization (WHO) classification recognizes 2 major clinical forms, insulin-dependent diabetes mellitus (IDDM) and non-insulin dependent diabetes mellitus (NIDDM) NIDDM (or Type 2 diabetes)

Vascular Disease

Cardiovascular disease is a serious, long-term complication of diabetes. Uncontrolled blood sugars damage blood vessels throughout the body by making the vascular walls thicker. Additionally, people with diabetes are more prone to high cholesterol levels. Cholesterol, or fat, can block major arteries and lead to heart disease. Patients are treated with the mainstay of diabetes management: controlling blood sugar levels, eating properly, exercising often, stop smoking and taking diabetes medications if these are indicated for you. Smoking is a major problem amongst diabetics Nicotine constricts blood vessels, thus compromising an already damaged vascular system.

Diabetics, especially Type II suffer damage to large and small blood vessels, including vessels that supply the heart and brain. Diabetics are  more likely to have heart disease or suffer a stroke. The more advanced your age the more at risk you are from stroke. Your doctor may also prescribe cholesterol-lowering drugs to control the amount of fat (lipids) in your blood and blood pressure medication to keep blood pressure within a normal range. (High blood pressure makes the heart work harder and damages the inner walls of arteries where cholesterol can build up.)
 

It is important that diabetic’s pulses are checked this enables a Podiatrist to monitor the blood supply to the feet. A healthy blood supply means a healthy foot, which can fight infection. A special instrument called a Doppler enables a Podiatrist to listen to the pulses within the feet. A Podiatrist will use an inflatable cuff around the ankle and take the blood pressure; this procedure will also be carried out with the arm. A special value will be calculated called the Ankle Brachial Pressure Index, this value enables a Podiatrist to gauge how healthy diabetics arteries and blood supply are within the foot.

Nerve Damage (NEUROPATHY)

High blood sugar levels (Hyperglycemia) can damage nerves and small blood vessels. Unfortunately nothing can rejuvenate or replace nerves that have been damaged or have died because of diabetes. Studies of diabetic peripheral neuropathy have found that hyperglycemia leads to an increase in the levels of Sorbitol and fructose in the nerves People with diabetes are prone to ulceration and gangrene of the lower limb, which may increase the risk of amputation. Nerve damage can be tested by using tuning forks, monofilaments, and even something as simple as cotton wool!

Cotton Wool	Monofilaments	Tuning Fork

Diabetics may suffer from nerve damage, which can result in a sense of numbness and tingling typically occurring in the hands and feet, and or affect the body's control of blood pressure, sexual function (impotence), heart rate, bladder and bowel function. You may be prescribed drugs to help the bladder empty urine and an antibiotic to keep infection under control. Your doctor may also suggest that you take pain relievers such as aspirin or ibuprofen on a regular schedule throughout the day instead of when the pain is at its worse

Foot Ulcers The nerves that go to the feet can be damaged by years of high blood glucose levels. Lack of sensation in the foot makes a foot injury more likely. If blood flow is also reduced, healing is more difficult. In severe cases, sores may never heal, leading to gangrene and amputation. A foot ulcer can begin with a callus or corn that becomes thick over time and breaks down, leaving an open sore. Untreated, the wound can become infected and enlarged. The infection may also travel deeper into your foot. Always see your Podiatrist if you have cracked skin or an open sore on your foot.

Treatment will depend on the ulcer itself. You may have an x-ray taken of your foot to determine if there is an infection in the bone or if a foreign body has lodged in the tissue. If the wound is deep, this may require surgery in the hospital. You may also be prescribed antibiotics. During treatment for an ulcer, you will need to keep off of your foot. You may also need to wear special insoles or shoes to allow healing to take place.

Total Contact Casts Provide good pressure relief for ulcers. Provide stability for Charcot joints. Effective for use on “non-compliant” patients who might otherwise remove the splint and not wear anything on their foot. Elderly patients may by unstable during walking. Not good in damp environments. Avoid the bath and shower.

Pneumatic Walkers Light and easy to keep clean. Patients generally prefer them to the plaster cast. Can be removed for bathing and sleeping. Good for active Charcot feet. More suitable for frequent dressing changes. Suitable for vascular patients and where swelling is present. Cheaper than Total Contact Casts Disadvantages No good for non-compliant patients No good for over-size patients

Amputations

Diabetes is the most frequent cause of non-traumatic, lower-limb amputations. More than 56,000 diabetics have amputations each year. It is a result of both vascular and neurological disease processes.

Damage to blood vessels can impair delivery of oxygen and nutrients to the limb. Loss of pain sensation due to nerve damage often allows small injuries and infections to go unnoticed. This combination can lead to ulcer, infections and gangrene. Good shoes and meticulous inspection of the feet and toenails on a daily basis (with a good light and mirror if necessary) can detect the earliest signs and is one of the best defences. Older adults are more likely to develop the complications that lead to amputation.
 

Increased risk of infection

High circulating blood sugar levels reduce immune function, allowing infections to occur more easily and last longer in those with diabetes. Tuberculosis is one of the classic infections related to diabetes. Bacterial skin infections and yeast infections (oral thrush, vaginal yeast, fungal infections of the groin, feet, armpits, and under the breasts) are also common. Bacteria can infect diabetic foot ulcers, and can then travel inward and infect the bone.
 

Hints and Tips for Diabetics

Left is a picture of a typical lady's Court shoe. A plaster cast has been taken of the owner's foot. In this second picture you can see that trying to place the plaster cast in the shoe is impossible. Of course, with a real foot the foot can be squashed into the shoe but it is not good for diabetics. Slip-on shoes like these are more likely to cause callous formation and press on the toenails, which may predispose towards in-growing nails. As we have already highlighted within these pages infection is bad for a diabetic. A better shoe is the soft-topped lace up shoe with plenty of room in the toe-box. Lace up shoes have the advantage that they hold the foot more firmly into the heel of the shoe and do not allow the foot to slide about in the shoe the way slip-ons do. There is less likelihood of getting callous and in-growing toenails with lace up shoes.

It is always a good idea to get diabetics to check the inside of their shoes every day to see that there are no stones or other sharp objects inside which could injure the foot. Watch out for torn linings in shoes. They can so easily cause blisters to form. Shoes like this should be discarded and replaced with new ones. Socks are important. Compare the walking socks shown here. Notice the large seam on the one that has been turned inside out. This can stop unwanted blister and infections. Many diabetics nowadays wear their conventional socks inside out to prevent the seam rubbing on their toes.

This is by no means a comprehensive lists of all the complications linked to diabetes we have tried to give an overview of the majority of complications which can effect the lower limb.