Getting regular foot risk assessments are as important as getting regular eye examinations in people with diabetes. An assessment is a great preventative tool.
Most foot problems are preventable provided they are identified early, treated appropriately and when people are educated to avoid problems.
The first assessment creates a baseline, results thereafter are then compared to note any changes.Normally these assessments are conducted once every 12 months. This duration may be shorter depending on your risk status. This article covers how diabetes affects the feet and details what a foot risk assessment involves.
What is Diabetes?
Diabetes is a medical condition with associated high levels of sugar in the blood. Someone who has diabetes means their body can’t maintain healthy levels of glucose in the blood. Glucose is a form of sugar which is the main source of energy for our bodies. Insulin converts sugar to energy. In type I diabetes, the cells that release insulin are destroyed and the production of insulin declines. In type II diabetes the body isn’t able to use insulin the right way, meaning less sugar is converted to energy resulting in less sugar being removed from the blood.
Gestational diabetes is diagnosed during pregnancy when your body cannot cope with the extra demand for insulin production resulting in high blood glucose levels.Unhealthy levels of glucose in the blood can lead to long term and short term health complications. Foot damage is a long term complication.
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How does Diabetes Affect your Feet?
The main two ways diabetes affects your feet in through the nerve and blood supply. Not everyone with diabetes will experience these changes. Those with long standing and poorly managed diabetes are at most risk of damage. The nerves in your feet let you know if there is a problem e.g. if you have a cut or graze it is the superficial nerves that message your brain saying there is a problem or if there is a rock in your shoe is it the sensation nerves that inform you. If you lack this sensation it is a sign of nerve damage which is called peripheral neuropathy. Being unable to detect foot injuries like simple blisters or bunions can cause major problems if left unattended, especially if your circulation is impaired.
Blood flow is required to keep your feet healthy. Poor circulation is called peripheral vascular disease. If there is inadequate blood supply getting to your feet broken skin will have longer healing times. Diabetes affects the small, medium and large blood vessels. If the blood glucose levels are high, sugar-based complexes build up in the small blood vessel walls, decreasing blood flow through them.If these cuts, grazes or foreign objects in your skin go unnoticed they can develop into a wound. Furthermore, if the wound if left unattended it can become infected. Poor circulation will delay healing. In some cases the wound doesn’t have enough blood supply to heal and in worse case scenarios amputation is indicated.
What are the Symptoms of Diabetes Affecting My feet?
If your diabetes isn’t well managed, symptoms and signs of nerve and circulation impairment include:
- Dry, flaky skin
- Numbness, burning or pins and needles
- Altered sensation when touching your feet
- Decreased hair and nail growth
- A pale blue colour to the skin of your legs (applies to lighter skinned people)
- A break in the skin takes longer to heal
- Pain in the back of the leg/calf muscle when walking
What Does a Foot Risk Assessment involve?
The first part of the assessment is to get background information about your risk of cardiovascular/heart/blood vessel complications and your current control of diabetes. Some questions that will be asked include:
1. How many years you have had diabetes for?
2. Do you smoke?
3. Do you exercise?
4. Do you have high blood pressure or high cholesterol levels or are you medicated for these?
5. Do you check for blood glucose/sugar levels at home? If so what numbers are you recording?
Other areas of assessment are nerves, circulation, footwear, foot shape, walking pattern and skin and toenail conditions.
Nerve Supply to the Feet
You will be asked if you have numbness, burning, pins and needles or sharp pain in your feet. These can be signs of nerve damage as a result of diabetes.
A reflex hammer and tuning fork will be used to assess your reflexes and deep nerve sensation, respectively.
An important test is your ability to detect 10 grams of pressure. If you can’t detect the fine pin point pressure points you have loss of protective sensation. Sensation loss that starts at your toes is called ‘peripheral sensory neuropathy’. This means that cuts in your skin or deep calluses may go undetected. These can contribute to serious complications such as wounds/ulceration and amputation.
There is no cure for peripheral sensory neuropathy; you can only prevent future damage. There are some medications and creams that can help with pain associated with this type of neuropathy.
There are two main pulses in the foot/ankle, some people have three depending on their anatomy. Pulses are palpated to see if they are strong or diminished.
An ultrasound is conducted on the arterial flow to hear how the blood is flowing to your feet. This is called a Doppler ultrasound and we can listen and hear if the blood flow is irregular, regular, sluggish, slow or rapid.
As the ultrasound is happening, blood pressure is taken in your ankles and arm, the numbers are compared to quantitatively determine if you have impaired circulation or not.
Other clues to tell you if you are getting enough blood to your feet are a healthy pink colour as opposed to a bluish tinge and if you have nail and hair growth. You need blood to supply nutrients for nail and hair to grow, so if your nails grow extremely slow that is indicative that there is a lack of nutrients and blood getting to your toes.
Some people have symptoms of poor circulation, for example pain in the back of the leg/calf muscle during walking that resolves with rest. The increased blood demand of walking is not meet at the calf muscle and pain results. Treatment options exist but early diagnosis is important to prevent/delay surgery.
So far, we have discussed the blood getting to the feet, but what about the blood travelling from the feet to the heart? Veins return blood back to the heart and signs of problems with the veins include spider veins, varicose veins, red-brown deposits on the skin and leg swelling. Compression stockings can assist with return blood supply and your podiatrist will recommend these if they are required. Varicose veins are a result of vein damage as seen below.
Your shoes should be comfortable, accommodating and supportive. Comfort is achieved through good cushioning without rough seams and edges pressing into your skin. An accommodating shoe is the right length, width and depth for your feet. Some people have quite wide feet and need extra depth and extra width footwear that can be purchased through specialist footwear stores. A podiatrist can suggest shoe stores that have shoes to meet your foot shape.
An example of a shoe for a wide foot or a foot with hammer toes. The material on the upper will stretch to accommodate bony prominences.
Abnormal foot shapes contribute to high pressure areas and friction areas. Excessive pressure placed on the skin can result in calluses and corns. Blisters are a result of friction. Corns, calluses and blisters predispose the skin to pain, infection and ulceration. Your feet will be checked for bunions, hammer toes, claw toes and other lumps and bumps.
Other terms used when assessing walking and/or running are gait analysis and biomechanical assessment. During the assessment who will be asked to walk the length of the corridor several times. Certain gait patterns predisposed your feet and lower limbs to injury. Very high arched feet, flat feet and limb length difference are examples of conditions that need attention. Treatment may include recommending certain types of shoes, orthotic therapy (special inserts in your shoes), heel raises or wedges and at home exercises.
Skin and Toenails
The skin of the foot and ankle are inspected for blisters, cuts, cracked skin or anything else that could allow bacteria entry to your body. Calluses and corns are noted as they are evidence of a high pressure area. Very thick calluses and deep corns place your skin at risk of ulceration. Toenails are checked for abnormalities such as toenail fungus. It is estimated that 1/3 of people with diabetes will have fungal toenails in their lifetime.
Unfortunately, it is extremely rare that a fungal toenail will resolve itself. Treatment is required to prevent the spread to other people and to the skin causing tinea/athlete’s foot and to decrease the risk of ingrown toenails and permanent damage to the nail. Serious complications of fungal toenails are a serious bacterial infection called cellulitis and ulceration under the toenail due to the pressure placed on the underlying nail bed.
1. What Happens After the Assessment is Complete?
Your podiatrist will inform you of your foot risk status. There are 3 categories; low, intermediate and high. The level of foot risk is determined by assessment findings. A high status means the feet and lower limbs are at a high level of risk of diabetes related complications such as ulcers, infection and amputation. In saying that, a high foot risk status doesn’t mean these complications will occur, it means further precautions must be taken to prevent these complications. Your podiatrist will discuss in detail what needs to be done in your circumstances, in summary they include:
- Inspect your feet every day checking for cuts, grazes and foreign objects. The use of a mirror can help to inspect hard to see areas.
- Apply first aid to any cuts, grazes or blisters
- See your podiatrist immediately if a skin abrasion hasn’t healed in 2 weeks or you find a red, swollen area
- Check the insides of your shoes for rough edges and exposed tacks and remove any foreign objects
- Keep your feet clean and dry
- Avoid barefoot walking
- Wear supportive footwear that accommodates your foot type
- A daily foot check with a mirror
- To prevent damage to the nerves and blood supply to the feet remember to:
- Maintain acceptable blood sugar levels, blood pressure and cholesterol levels
- Limit alcohol consumption
- Don’t smoke
- Exercise regularly
- Enjoy eating a healthy balanced diet
2. What Do I Need to Bring?
- Shoes that you wear regularly: work shoes, runners
- Medication list if you have one
- .Year of diabetes diagnosis
- A recent record of blood glucose levels
- A GP referral but only if you have been given one
3. Do I need a Referral?
A referral is not required. If you have a GP referral for your Diabetes, you may be able to qualify for rebates through Medicare.
4. How much does the Appointment cost?
Appointment fees apply. Please contact Sport & Spinal Physiotherapy on (02) 6262 4464 for current fees. If you have a Medicare referral for podiatry from your general practitioner, a rebate of $52.95 applies.
5. How Long Will the Appointment Take?
Even though the assessment is thorough and involves multiple areas of investigation, most appointments are completed in 30 minutes. After this a report is written to your GP
An assessment is a great preventative tool! You can prevent most foot problems provided they are identified early and treated appropriately. At Sport & Spinal Physiotherapy, we currently have a special on our Diabetes Foot Assessment – saving you $30!
Call us today on 6262 4464!