FOOT LESIONS IN PATIENTS WITH DIABETES MELLITUS

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The Heel

The heel of the diabetic patient is particularly vulnerable to trauma. When the diabetic patient is restricted to bed rest for any length of time, such as when hospitalized, particular attention must be paid to the heel. Because of the loss of sensation, the patient tends to keep the heels in the same position. This can result in pressure necrosis to the heel and or to the lateral portion of the ankle, causing the skin to break down. Infection and gangrene can follow. Bed-confined patients

DIABETIC FOOT ULCERS

Ulcers occur on the diabetic foot because of repetitive stress on insensitive feet. When repetitive stress continues, the foot develops hot spots, callous buildup, pressure necrosis, and, ultimately, ulceration. Ulceration occurs most often at the site of the maximum pressure and excessive callus build-up, usually over the metatarsal heads, especially the first, and on the plantar surface of the hallux. Patients in whom ulcers develop have increased foot pressures.10, 63 Increased pressure,

POST-TREATMENT OF HEALED DIABETIC FOOT ULCERS

Even when the diabetic foot ulcer has healed, treatment is not complete. The underlying etiologies responsible for the ulcer, such as foot deformity, calluses, and increased pressure, are still present. In addition, scar tissue from previously healed ulcers is not strong tissue and is, thus, vulnerable to the shearing forces of walking. Special measures are necessary to protect the vulnerable sites of previous ulceration. These include education of the patient in walking, for example, taking

EXERCISE AND THE DIABETIC FOOT

Exercise is an important modality in the management of diabetes. However, in patients with peripheral arterial disease and peripheral neuropathy, weight-bearing exercises, such as jogging, prolonged walking, treadmill, and step exercises, may need to be curtailed or avoided. The presence of an active foot ulcer is an absolute contraindication for weight-bearing exercise. Patients who have a healed ulcer must take special precautions with weight-bearing exercise. Patients with peripheral

TEAMWORK

Management of the many problems affecting the foot can be extremely complicated. Therefore, action to prevent foot lesions, to heal ulcers should they occur, and to save the foot and not amputate it requires the expertise and interaction of many medical and surgical disciplines, including the following:

  • Primary physician

  • Endocrinologist

  • Diabetologist

  • Podiatrist

  • Nurse educator

  • Physician's assistant

  • Enterostomal nurse

  • Infectious disease specialist

  • Neurologist

  • Vascular surgeon

  • Orthopedist

  • Physiatrist

FOOT INSPECTION

One of the most important but often neglected steps in saving the diabetic foot is removal of the shoes and socks for inspection of the feet, including looking between the toes. This should be done at every visit. Because many of these patients have insensate feet, they frequently are unaware of limb-threatening lesions. Despite the importance and simplicity of this examination, only a small percentage of patients' feet are routinely examined.3, 14 For example, before the institution of a

PATIENT EDUCATION

The most important step in saving the foot and leg is patient education. Despite current knowledge, we cannot totally prevent peripheral arterial disease and peripheral neuropathy. However, the patient can be educated in proper foot care and can learn how to prevent injury and detect lesions.

At the time of the office visit and while the shoes and socks of the patient are off, the nurse, physician, or both should review recommendations for foot care with the patient Table 3). A successful

SUMMARY

Diabetic foot ulcers are common. If treatment is delayed or is inappropriate, the lesions can become infected, resulting in gangrene and amputation. Physicians and clinics that perform aggressive therapy for these ulcers, provide revascularization when indicated, practice a team approach, suggest the use of therapeutics shoes, and repeatedly educate patients in foot care have reduced their amputation rates by 50% or greater.2, 15 Goals of the United States Department of Health for the year 2000

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    From the Endocrinology, Diabetes, and Metabolism Clinic, Washington University School of Medicine, St. Louis, Missouri

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    Copyright © 1996 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.