Foot complications associated with diabetes are becoming more prevalent. It is important to understand the signs and symptoms of foot complications, and educate patients of good care, in order to prevent hospitalisation, ongoing morbidity and risk of amputation.
Peripheral neuropathy and/or peripheral arterial disease (PAD) are causative factors in diabetic foot ulcers (DFUs), which can be complicated by acute or chronic infection of soft tissue or bone. DFUs can be difficult to manage due to a host of issues including plantar pressures, patient compliance and complex medical histories, which may prevent ‘gold standard’ treatment.
Peripheral neuropathy can be a common side effect for patients with diabetes. This can cause loss of protective sensation and paraesthesias. Injuries can go unnoticed and untreated for some time if the patient is unable to feel the problem, causing DFUs.
PAD can cause a number of issues in the foot. A patient with PAD will have delayed wound healing (or no wound healing), leading to higher risks of infection. Severe PAD can cause pain in those with loss of protective sensation. PAD can lead to DFUs and amputations of digits and limbs.
Increased plantar pressures from foot deformities, such as HAV (bunions), claw or hammer toes and arthritis, are a leading cause of plantar DFUs. Sites that are prone to callous and corns are areas that are more likely to break down to a pressure ulcer.
Inappropriate footwear is a high cause of DFUs. Most pressure ulcers will begin as blisters, and poorly fitting footwear can easily cause damage to a neuropathic foot. Footwear education is extremely important to prevent injury.
Charcot’s neurarthropathy (CN) is a rare condition that, when in its active phase, occurs in clients with good arterial supply, but who also have peripheral neuropathy. Symptoms of acute CN include a red, hot, swollen foot. Pain can also be reported. When not managed appropriately, non-reversible deformity of the foot will occur. Patients with acute CN should be referred to a high risk foot clinic immediately for management. In chronic presentation, the classic rockerbottom foot type is seen, showing collapse of soft tissue and joints of the foot.
Those with reduced vision are at higher risk of foot complications, as it is more difficult to identify and manage foot problems.
Reduced immune response
Those patients who have had diabetes for longer periods, who may have poorly controlled BGLs or brittle diabetes, will high higher risk of immune complications. This can make the management of DFUs, and infections, quite difficult, and can cause secondary chronic conditions to complicate their health further.
Those with diabetes are at higher risk of cardiovascular disease, and suffer heart attack and stroke. These issues can further complicate the management of diabetic foot ulcers, and can be fatal in their own right. Arterial disease of the abdomen and upper leg can affect the lower limb, eventually causing PAD.
Diabetes is one of the highest causes of chronic renal disease, and dialysis. Not only does it affect wound healing, but the patient’s general health can deteriorate markedly. Medication needs to be strongly monitored to ensure it doesn’t cause further damage to the kidneys.
Patients with diabetes — and indeed any chronic disease — are more prone to depression than the general population. This can cause many issues, not only for the patient’s mental health, but also in compliance to managing their general health and associated complications.
It is important that patients with diabetes are well educated to prevent or manage complications to the foot. It is recommended that any patient with diabetes is assessed by a podiatrist on an annual basis.