by Ann S. Williams, PhD, RN, CDE
One of the more dramatic and fearsome complications of diabetes is amputation
of a lower limb: A foot, a leg or a toe. Many people can remember older relatives
who had an amputation from diabetes and the difficulties they faced. Sadly,
in the U.S., there are about 80,000 lower-limb amputations per year as a complication
Fortunately, amputation is also one of the more preventable complications. Foot surgeons estimate that up to 85% of all diabetes-related amputations can be prevented. Taking care of your feet is not difficult and does not require expensive equipment, extraordinary skills, or much time. Preventing amputation will be well worth any effort you make.
Why do amputations happen in people with long-term diabetes?
People who have had diabetes for more than ten or fifteen years are most at risk of amputations as they result more commonly if you have not kept your blood sugar, blood pressure, and cholesterol in control over time. Because your feet are farthest away from your brain, diminished blood flow may affect them first, often damaging blood vessels and nerves. In these cases, blood vessels in your legs become narrower, so blood does not flow adequately through the lower legs and feet. Your skin becomes dry and thin, and your muscles, bones and joints weaken. These conditions also damage nerves in the feet which eventually become insensitive. The combination of damaged blood vessels and damaged nerves can produce disastrous results.
Let’s say your toenails are thick and when you cut them you accidentally nick the skin on the toe. Or, you have athlete’s foot and there is a small crack between your toes. You may simply have a blister. If you cannot sense your feet, you may not be aware of these wounds. Now, small wounds won’t bleed much, but an opening in the skin can become infected. If your nerves were working well, it would hurt. But they aren’t, and you don’t notice.
Your blood vessels are too narrow to allow enough flow of blood around the
foot wound. Therefore, not enough white blood cells can get there to fight the
infection, and not enough food and oxygen are arriving to help the cells heal
So it heals very slowly and the infection gets worse.
Now you have a physical stressor on the body (infection) which drives blood sugar even higher. This, in turn, causes white blood cells to become less effective at their job: fighting infection. The infection spreads and moves deeper into your foot. Your blood sugar surges higher again, and so on in a spiral of worsening damage.
By the time you notice that anything is wrong on your foot, deep infection may have ravaged a large area. Sometimes you can be treated with antibiotics given directly into the blood stream (intravenous, or I.V., antibiotics) but a deep, well-established infection may require amputation of the foot or lower leg.
It’s far better to prevent this situation than to try to heal a pervasive infection.
Six Simple Steps to Prevent Infection and Amputation
1. Keep your whole body healthy: maintain your blood sugar, blood pressure, and cholesterol as close to normal as you can.
You need to know how to manage your diabetes. If you have never received a complete diabetes education class, take one. You will also need to see your doctor regularly to have lab tests that are not done at home, and to discuss with your doctor whether you need any changes in medications.
Do not smoke. If you do not smoke, congratulations! You are already doing something very important right. If you do smoke, you need to know that smoking causes the blood vessels to contract, so less blood gets through. Smoking makes poor circulation worse. Along with damaging your heart and lungs and causing cancer, smoking increases your risk of having an amputation. Make a plan to quit smoking and then carry it out.
2. Keep your feet clean. Wash your feet every day, whether they seem to need it or not. The cleaner your feet are the less likely you are to get an infection if you do have a small cut. Wash carefully between the toes because that is where athlete’s foot usually starts.
After washing, dry your feet thoroughly. Dry between all of your toes to help prevent athlete’s foot. If your skin is thin and fragile, use a soft towel to gently pat your feet dry, rather than rubbing them.
3. If your skin is dry, use a lotion or cream for moisturizing.
Dry skin on the feet is not only uncomfortable, it can also be dangerous. Very dry skin can crack and the crack can be an opening for infection.
Many special foot care lotions and creams for diabetics are sold over the counter. These can be quite helpful for keeping the skin soft and flexible. If your skin is extremely dry, over-the-counter creams and lotions may not be enough. Prescription foot creams are available for people with this problem. Consult with your podiatrist or doctor.
One particular caution about using creams and lotions on your feet: Be careful to keep the area between your toes free of lotions and creams. Keep that area dry. Remember, this is where athlete’s foot often begins. Spread the cream or lotion on the top and bottom of your foot, but avoid the area between your toes.
4. Check your feet every day. Look for blisters, cuts, scratches, corns, calluses, and any changes from the previous day.
If you have good eyesight, simply look at the entire surface of your feet, including the bottoms and between the toes. It can be difficult to get the foot into a good position. If you have trouble seeing the bottom of your feet, use a mirror and good lighting.
If you have low vision, a telescoping self-examination mirror might help you. This is a two-sided, shatter-resistant mirror, with one side having no magnification and the other side having 2X magnification. The handle expands from 6 inches to 18 inches. This mirror is manufactured by MedPort and is available through many local pharmacies and mail order supply companies. When used with good lighting, this tool may help some people who have low vision to inspect their feet thoroughly.
If you can see only a little or not at all, you can still inspect your own feet using your senses of touch and smell. First, when you remove your shoes and socks, notice the smell of your feet. Many people’s feet do not smell very good, but they should not smell really foul! An exceptionally bad smell can indicate an infection. In fact, sometimes the feet begin to smell bad a day or two before there is any other sign of infection.
Next, check your feet with your fingers. The balls of your fingers are most sensitive to changes in texture and shape, so with your fingers you are checking for small cuts, corns, calluses, swelling, and any change in the shape of your foot.
Use a systematic way of going over the entire surface of your feet, one at a time. For example, begin by feeling the top, bottom, and sides of the big toe. Pay special attention to the nail bed. Then move on to the next toe. Feel all the toes, then the outer edge of the foot, the heel, and the inner edge of the foot. Then feel the entire bottom of the foot and the entire top of the foot.
After checking with your fingers, turn your hand over and check the top, bottom,
and sides of the foot with the back of your hand. This part of your hand is
more sensitive to temperature changes and will allow you to feel any especially
A warm spot is likely to be inflamed, which may signal an infection.
If you smell or feel anything unusual on your feet, you should discuss it with your podiatrist or doctor. See Step #6 below!
5. Protect your feet from injury. Always wear shoes or protective slippers, even inside your house, especially if your feet are even a little numb. Consider that if you step on a paperclip, and you have bare feet or are wearing only socks, your foot can be injured. Wear something that has a thick enough sole that something sharp on your floor could not go through it.
Wear shoes that fit you well, protect your whole foot, and are made of materials that ventilate well. Don’t buy shoes in the wrong size, thinking you’ll break them in. And it’s best not to wear open-toed shoes, or shoes made of manmade materials that trap the moisture inside the shoe.
Check the inside of your shoes with your hands before putting them on. Small things can sometimes fall into shoes. If your feet are numb, you may not feel them. For example, I know people with numb feet who have walked all day with pins, Lego blocks, or cat toys in their shoes without knowing it. All three of these people had wounds on their feet at the end of the day that could have been avoided if they had routinely checked the inside of their shoes before putting them on.
Always wear socks or stockings made of an absorbent material inside your shoes. Cut or file your toenail following the natural curve of the nail, leaving about 1/8 to 1/4 inch of nail beyond the nail bed. Don’t try to cut the sides of the nail down into the nail bed as this can lead to ingrown toenails. If you have low vision or blindness, especially if your toenails are thick, consider having your toenails cut regularly by a podiatrist. Medicare and most private insurance cover such services for people with visual impairment. This has the extra advantage of having a health care professional who knows your feet examining them regularly.
If you develop corns or calluses, see a podiatrist to have them removed safely. Do not try this at home! It’s too risky to do “bathroom surgery” on a diabetic foot.
6. If you notice anything unusual about your feet, call your podiatrist or doctor right away!
No problem on a diabetic foot is a small problem. Many people think they are bothering their doctors if they call about what seems like a minor concern. Doctors and podiatrists would rather see a problem on a diabetic foot while it can be healed—you are not bothering them! Remember, if you wait until a problem has become big, it could take a lot of time, effort, and antibiotics to heal it—if it can be healed at all.
The bad news at the beginning of this article is that 85% of the diabetic amputations in the U.S. could be prevented. But that is also good news. With careful foot care, it is very likely that you will be able to prevent an amputation from happening to you. The power to prevent amputation is, quite literally, in your hands.