You are diabetic and you want to know how to prevent amputation. Most diabetics, whether you are the healthiest diabetic with well controlled blood sugars or the worst non-compliant diabetic patient with daily sugars in the 400's, the thought of limb loss/amputation has crossed your mind. Even if it was a brief thought and then gone, you have heard the statistics and know that it is a risk a diabetic patient can face. If you are diabetic and have never given this a thought, this article is also for you, as there is a percentage of diabetic patients that just hide there head in the sand hoping all will be well, as long as they do not acknowledge the possibility.
"In the United States every 17 seconds someone is diagnosed with diabetes, and everyday 230 Americans with diabetes will suffer an amputation. Throughout the world every 30 seconds a limb is amputated. 85% of these amputations were the result of a diabetic foot ulcer."(Mary Caffrey, AJMC December2018) These numbers are staggering and are the reason you, as a diabetic, can not help to have thought about limb loss at least once in your lifetime. We all know someone who has suffered an amputation an aunt, uncle or grandparent. This article is for you. We want to provide you with some really simple tools on how to prevent amputation in the diabetic foot. We also want to explain a little first on why these things happen.
Need to start here, first and foremost, poor blood sugars for long periods of time will wreak havoc on your body. Your feet get basically punished after periods of high blood sugars. I have decided to explain this in the simplest way possible because I want you, the patient, to understand. I do not mean this in a condescending way, but far too often us doctors do not make thing simple to understand, and since limb loss is at stake, simple is good. When your body is experiencing high blood sugars, your body wants to help them go down as quickly as possible. Your body does this by activating the polyol pathway. The polyol pathway is way to convert the high sugar to a normal or less high glucose level. When this process happens your bodies nerves and arteries can be effected. The nerves over time, if your sugars continue to be high, will stop working correctly. You may begin to experience numbness, tingling, shooting pain or, what I consider to be the worst, lack of protective threshold. All of this combined is what we refer to distal symmetric polyneuropathy. Distal just means your extremities far away from your heart, like your hands and feet. Symmetric means both sides of your body are effected. Polyneuropathy means many types of ways the nerves can be effected and present different symptoms like the burning, tingling, ect.
We all have heard the term neuropathy when it comes to diabetics. As mentioned above, the diabetic neuropathy can effect your nerves in many ways, but the best predictor for determining limb loss is your protective threshold. Protective threshold is when the nerves are so damaged you can not feel the pain or pressure on your feet(again, this is just a simplification of what this means). When patients lose their protective threshold they are at the highest risk for limb loss. It is possible when this happens that a patient can step on, for example, a rusty nail, have it stuck in their foot for days and walk around on it and not even feel it. This is inconceivable to those of us who have all of our sensation intact, but all too real for patients who no longer have their protective threshold intact. I tell all of my patients with no sensation that they are one happy event away from an amputation. The example I always give is a wedding. You can put on your best looking pair of shoes, not feel they are too tight and wear them for the 10 hours you may be away from home. Then you get home and notice blisters that when popped are to the bone. It seems far fetched, but again these things happen on a daily basis for people with no sensation.
In a more insidious, and actually a more common way lack of protective threshold effects people with diabetes, patients will present to the office with calluses with what they say have dark spots that concerned them and that is why they came into the office.
In the picture above, this patient started with a callus, they could not feel the callus and over time as the callus got bigger and harder it started to damage the tissue under the callus and a wound or open area formed under this callus. These patients can not feel the pain that a person with normal sensation would feel long before blood under the skin formed. Most patients will not even notice something like this until they see blood on their sock. When I see a patient like this in the office, I spend a great deal of time before I clean this area up. I explain to the patient that under that blood filled callus there is going to be an open area or what we call an ulcer. If not treated correctly this can easily go on to a toe amputation.If the patient has good blood flow and can follow simple directions that can be completely avoided in almost all cases.
I always find this a little difficult to explain to my patients who are diabetic. One of the reasons that it is difficult to explain, in my opinion, is because a lot of people who are type 2 diabetics also have peripheral arterial disease due to diet and life style choices. But the nerves can be affected by high blood sugars that cause the nerves that innervate the muscles in the extremity get damaged as well. This is called motor neuropathy.
The easiest and most simple way to describe this, how our arteries are effected by bad diet versus high blood sugars, is by looking the two arteries above. If you are a smoker and eat lots of cheesburgers, over-processed foods and in general over consume what is bad for you to eat, your artery will look like the lower artery. Plaques will develop in the artery making it difficult for blood to get where it needs to be. If you are diabetic and you eat really healthy, these plaques do not necessarily have to build up in your arteries. But if your blood sugars are out of control for some reason, the pink muscle layer in the pictures above stop working and pumping the blood where it needs to go. This is because the nerves that send the signals for the muscle to contract in the artery are non functional in severe diabetic peripheral neuropathy.
The reason I go into detail above about your nerves and your arteries is so you have an understanding of what it going on with your body. Preventing amputation really hinges on you understanding how your nerves and arteries are affected with diabetes. Below are the simplest to more complex ways, depending on where you are with your foot health, to prevent an amputation.
If there is one thing you take from this article that you listen to, I hope it is never go barefoot. This seems so simple and can not be a real answer you think. But seriously, the number one reason I have to admit a patient to the hospital and perform surgery to clean out infection in the foot or ankle in the operating room is because the person was walking barefoot stepped on something and did not feel it. I have seen legos, dry pasta, insulin needles, rocks and all other crazy objects embedded in peoples feet and they had no clue that was happening. I also have had patients just run out to the driveway to tell their wife something else they need from the store. The stand on the hot pavement return to the house only to discover full thickness burns on their feet just from standing on the hot pavement to long. Since they could not feel the heat there was no trigger to move. If it was me I would be jumping up and down yelling,"owie!" If they just had a shoe on, socks do not count, they could have avoided such a misfortune. Have a dedicated house shoe, just make sure it has a rubber sole.
You need to get into the habit of taking your shoes off at night and inspecting your feet. What are you looking for? You are looking for anything that is not normal and if you are checking your feet daily you will understand what I mean. One day you take your shoes off and you have a new red or blue spot. If it wasn't there yesterday get into see your podiatrist. It is really simple things like this that prevent amputation. Most people do not know if they have their protective threshold intact, so using pain as an indicator to have something checked out on your feet is a really bad idea. Some patients say, "I can not reach my feet." Then you have two options: get a mirror or be nice to the people you live with and they will return the favor and check your feet for you.
You discover an open area on your daily foot checks and think, it's nothing. Get in to see your podiatrist! We will assess if you have the blood flow to heal the wound. Yes it is a total pain in the butt. If the wound has been present for an extended duration and you are not improving there are so many little things and big things that may be causing this. Sometimes something as simple as taking a pad to take pressure off the area can make a huge difference in combination with different topical wound care regimens. Other times we need to coordinate with a vascular surgeon, the blood flow has to be good to heal and there are procedures that can be done to improve your outcome and prevent amputation.
This is a very important relationship to establish when you are diabetic. If you have any sensation issues, you should see them quarterly to check your feet and make sure you are not developing and problem spots, like the blood under the callus picture. Each visit your podiatrist will take time to check your pulses and evaluate your sensation. In our office, Dr. Henne and I (Dr. McGowan) see and treat all of our diabetic patients ourselves. We do not believe that a physician extender like a medical assistant should be tinkering with your feet. Plus, this is one of our favorite group of patients to treat, we get to know these patients over the years and have a vested interest in keeping them on their feet. If your sensation is very poor and you are develpoing callus in places on the bottom of your feet we may recommend diabetic shoes. This usually entails us giving you the prescription and sending you to an orthotists to get casted and fitted for inserts and shoes.
If you don't have a foot doctor and live in Central Florida click our picture below to make a new patient appointment.