Diabetic Foot

Diabetes is the most common non-communicable metabolic disease. Generally classified as Type 1 (insulin deficient) & Type 2 (insulin resistant) Diabetes Mellitus, it is primarily measured by the amount of blood glucose present. The disease is managed by medications including insulin, lifestyle modifications, diet and exercise.  If neglected, Diabetes can cause several complications.

One of the most difficult to treat complications of diabetes Mellitus is Diabetic Foot. Prolonged hyperglycemia coupled with extrinsic risk factors like lack of awareness and illiteracy, social practices such as walking barefoot, poor dietary control, poor hygiene and personal care, poor medical attention and improper footwear can lead to a Diabetic Foot Syndrome.

Prolonged hyperglycemia leads to polyneuropathy (diabetic peripheral neuropathy (DPN)), peripheral arterial disease (PAD) and musculoskeletal changes. Increase in plantar pressure ultimately surges the risk for Diabetic Foot Ulcer (DFU). DFU progression can finally lead to amputation. Worldwide, women show lower prevalence of DFU than men. In Asia, the DFU prevalence was noted at 5.5% amongst diabetics.

Diabetic Peripheral Neuropathy (DPN)

Prolonged hyperglycemia causes damage to the nerves in the entire body - neuropathy of the autonomic, motor and sensory nerves. The patient may present symmetrical distal limb symptoms like loss of pain and temperature sensation, loss of protective sensation (LOPS), reduced vibration threshold, etc. which prevents the patient from realizing presence of puncture wounds and blunt injuries. Autonomic neuropathy causes loss of regulation of skin temperature and blood flow, increasing the susceptibility to fungal infections. Also dryness can cause fissures. Motor neuropathy causes muscle atrophy that in turn results in deformities. Deformities can increase plantar pressure in different foot regions. Studies have also suggested that people with diabetes present higher plantar pressure and peripheral neuropathy in comparison to normal individuals. 

Pathophysiology 

Charcot Foot 

Also called acute charcot osteoarthropathy, a trio of bony destruction, bone resorption and deformity followed by degeneration of bones and joints, finally presents  as Rocker-Bottom foot. The main factor for developing a Charcot foot is recurrent low-grade stress to the joints and bones along with neuropathy. If the elevated skin temperature is ≥ 2° in comparison to the same site on the other foot, it indicates a Charcot foot. The Charcot foot follows a process through which the degeneration and healing transpire which is described in the table5 below. 

Assessment of DFU

A proper assessment will enable the clinician to assess the risk of DFU as well as progression or management of diabetic foot patient3. A complete assesment includes medical history including specific diabetic and foot related history and complaints; observing gait, examine skin for high temperature, discoloration of the skin, foot deformities such as hammer toes, hallux valgus, charcot; neurological examination including sensory perception, nerve stimulation, response to vibration; vascular examination including pulse at dorsal and tibial arteries, blood pressure; musculoskeletal evaluation including plantar pressure.

Normal plantar pressure
Loss of protective sensation (LOPS)
LOPS + high pressure or poor circulation
H/o ulceration, amputation or neuropathic fracture

Low risk
Moderate risk
High risk
Very high risk

Disease Progression 

The development of Diabetic Foot is a gradual process. Chronic hyperglycemia, poor care and repeated trauma to the foot can kick start Diabetic Foot Ulceration. Although neuropathy and increased plantar pressure can be seen even before obvious signs of Diabetes or Diabetic Foot are seen, it is important to understand the current status of the foot as well as assess the risk of diabetic foot. DFU, once occurred is difficult to treat and bringing awareness and preventing it, is essential.

Clinician’s Role in Detection and Treatment of Diabetic Foot

Primarily, in India, medical professionals are rarely concerned about the foot and often disregard Diabetic Foot as a major complication of Diabetes Mellitus. The number of trained and certified professionals who look at DFU is also very low. This therefore requires a more patient centric and multidisciplinary approach to patient education, detection, treatment and counseling of Diabetics. Physicians & surgeons, diagnostic centers, physiotherapists, dieticians, physical trainers can all diligently examine Diabetics and their feet and contribute towards the care and prevention of DFU.

Diabetic Foot Treatment

The early signs of Diabetic Foot need to be assessed and suitable recommendations to be given. Most of the treatments are preventative in nature – personal habits and care, proper diet and blood glucose management, choice of footwear and prevention of injury. An important recommendation based on a detailed musculoskeletal examination is the use of supportive and corrective insoles and footwear, custom recommended and fitted for each patient. Also immediate medical attention must be given to any injury, to prevent infection even if very superficial. In the event of a full-blown Diabetic Foot Ulcer, the treatments are aggressive which include harsh local and systemic antibiotics, wound drainage systems and many a times also require amputations if ulcer becomes gangrenous.

1. International Diabetes Federation. IDF Diabetes Atlas, 8th edn. Brussels, Belgium: international Diabetes Federation, 2017. http://www.diabetesatlas.org
 

2. Pengzi Zang, et al. Global Epidemiology of Diabetic Foot Ulceration: a Systematic Review and Meta-analysis. Journal Annals of Medicine, 2017: Volume 42, Issue 2: page106-116.  http://doi.org/10.1080/0753890.2016.1231932
 

3. International Diabetes Federation. Clinical Practice Recommendations on Diabetic Foot: A guideline for healthcare professionals : International Diabetes Fedaration, 2017

4. Gendla Kiran Kumar, Caren D Souza and Erel Al Diaz. Incidence and Cause of Lower-limb Amputations in a Tertiary Care Center: Evaluation of Medical Records in a Period of 2 Years. International Journal of Surgery Science, 2018; 2(3): 16-19
 

5. Andrew J. Rosenbaum, John A. DiPreta. Classification in Brief: Eichenholtz Classification of Charcot Arthopathy. Clinical Orthopaedics and Related Research, 2014; 
doi 10.1007/s11999-014-4059-y

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