Perhaps you have heard about the “team approach” to treating diabetes. You may be interested in putting together a team for your foot care. Who should be on this team? How often should you see them and what should you expect?
The most important member of the team is YOU. You need to practice good foot hygiene, wear your prescribed shoes and inserts, and in general take charge of your own foot health. You need to assemble your team and help them to help you.
A podiatrist is a foot and ankle specialist who you should see at least once a year. If you have foot problems, such as poor circulation, nerve problems, wounds, or deformities you will need more frequent visits. You can see a podiatrist for routine foot care if you are unable to reach or see your feet. Podiatrists are doctors of podiatric medicine (DPM) and, in most states, diagnose and treat conditions of the feet and ankles. They perform routine foot care, such as toenail trimming, callus removal, and treatment of ingrown toenails, and they perform foot surgery on bones and soft tissue, such as bunion or hammertoe surgery. If necessary, a podiatrist can operate on infected bones and do amputations (some orthopedists do foot surgery as well). Podiatrists study how your feet and legs work when you move and walk (biomechanics). Podiatrists can identify bone and joint deformities that put unusual pressure on the skin of your feet. They can design insoles or braces to help your feet work normally and order special footwear if you need it. Podiatrists are trained in the treatment of the diabetic foot, including the treatment of wounds and infections. Your podiatrist will do a thorough history and exam and should treat any current problems and advise you about preventing future foot issues. He/she should suggest changes in shoes and socks. You should call your podiatrist immediately if you see any changes in your feet.
Your podiatrist should work closely with your primary health care provider (PCP). In fact, you may already have had a PCP before you chose your podiatrist. Your PCP is an excellent person to ask for a referral to a podiatrist or any medical specialist. Your PCP is the go-to person for any medical problems you may have. Your PCP and podiatrist may suggest these other members of your team:
• Vascular surgeons specialize in surgery on blood vessels and can help restore circulation to your feet. If your feet are cold or you notice your feet looking red or blue you may have poor circulation and require the expertise of a vascular surgeon. Vascular surgeons often help heal wounds and prevent gangrene and amputations.
• A neurologist may join the team if you have neuropathy (numbness or pain due to abnormal nerve function). The neurologist may perform nerve testing and prescribe medications to decrease pain or numbness.
• A physiatrist (a physician specializing in rehabilitation medicine) and a physical or occupational therapist may be consulted if you need rehabilitation. Physiatrists may also test nerves and help treat neuropathy or chronic pain.
• A pedorthist is a professional who fits shoes and insoles for people with foot problems. Pedorthists do not diagnose or prescribe care; they should follow the advice of your podiatrist or primary care physicians. When you visit a pedorthist make sure you have your doctor’s prescription or recommendation with you.
• A certified diabetes educator (CDE) can help teach you how to care for your feet.
• A nutritionist or registered dietician (RD) can help you with your diet plan to assist in your efforts to control your diabetes. Good control may help prevent complications such as peripheral neuropathy.
• An endocrinologist can help with your diabetes management. Good control of your diabetes may be able to prevent complications such as diabetic neuropathy.
Your family members who help you care for your feet at home are also part of your health care team. Family members or friends can be especially important if you cannot see your feet to examine them, or if you cannot reach your feet to clean or treat them.
Have a complete foot examination at least once a year. During this exam, your health care provider or podiatrist will look for any changes in shape (deformity) that alter the way you walk and bear weight on the foot. He or she will also check for loss of feeling by pressing a thin plastic wire that looks like a piece of fishing line, called a monofilament, against the soles of your feet or by holding a vibrating tuning fork against the base of your big toe. The provider will check your circulation and examine your skin, especially between your toes and under the metatarsal heads (the bones in the ball of your foot). If you can’t examine your own feet or if you have foot problems or nerve damage, have your feet checked more often, probably at every visit to your health care provider.
The following are warning signs. You should have your feet checked immediately if you have any of these symptoms.
• pain, redness, swelling, or increased warmth
• a change in the size or shape of the foot or ankle
• pain in the legs at rest or while walking
• tingling or numbness in the feet
• open sores (with or without drainage), no matter how small
• nonhealing wounds
• ingrown toenails
• corns or calluses with skin discoloration
• unexplained high blood glucose levels
About 60% to 70% of people with diabetes have mild to severe forms of nervous system damage. The results of this damage can include impaired sensation or pain, muscle weakness in the feet or hands, slowed digestion of food in the stomach, carpal tunnel syndrome, erectile dysfunction, or other nerve problems. Almost 30% of people with diabetes over the age of 40 have impaired sensation in the feet (i.e., at least one area that lacks feeling). Severe forms of diabetic nerve disease are a major contributing cause of lower-extremity amputations.
Peripheral neuropathy is the name for damage to sensory, motor, and autonomic nerves. Motor and sensory nerves help you move and feel the world around you. In the feet, autonomic nerves control perspiration. Autonomic neuropathy may result in dry, cracked skin. “Peripheral” means at the edges or away from the center, or away from the brain and spinal cord. In this case, the feet are farthest from the center of the body. “Neuro” means nerves and “pathy” means “a disorder of.” Because the longest nerves are usually affected first, symptoms such as tingling, burning, or numbness appear first in the feet and hands.
You can think of the nervous system like the electrical system in your house. The wires to the lights and appliances are the peripheral nerves, and the fuse box and the main electric cable are the central nervous system (the brain and spinal cord). When motor nerves are damaged, muscles in your foot can become weak and allow the shape of the foot to change. Toes can curl up, and the fat pad on the bottom of the foot can shift so that it no longer protects the skin on the bottom of the foot. Bones can get very close to the skin and can cause calluses. The sensory nerve damage prevents you from feeling pain, so a callus can become an ulcer without you being aware of it. Autonomic nerve problems can cause dryness of the skin.
While it is not yet known how diabetes causes nerve damage, it is likely that higher than normal blood glucose levels are part of the cause. Keeping your blood glucose levels close to normal can lower your chances of developing neuropathy. People with high blood glucose levels are more likely to have neuropathy, and the longer a person has diabetes, the more likely he or she is to experience this complication. Researchers are working to better understand the causes of neuropathy and