Common Disorders
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Did you know the foot has 28 bones, 37 joints, 107 ligaments, 19 muscles, and numerous tendons? These parts all work together to allow the foot to move in a variety of ways while balancing your weight and propelling you forward or backward on even or uneven surfaces. It is no wonder that most Americans will experience a foot problem that will require the care of a specialist at one point or another in their lifetime.

Ulcerations, infections and gangrene are the most common foot and ankle problems that the patient with diabetes must face. As a result, thousands of diabetic patients require amputations each year. Foot infections are the most common reason for hospitalization of diabetic patients. Ulcerations of the feet may take months or even years to heal. It takes 20 times more energy to heal a wound than to maintain a health foot.

There are two major causes of foot problems in diabetes:

  1. Nerve Damage (neuropathy): This causes loss of feeling in the foot, which normally protects the foot from injury. The protective sensations of sharp/dull, hot /cold, pressure and vibration become altered or lost completely. Furthermore, nerve damage causes toe deformities, collapse of the arch, and dry skin. These problems may result in foot ulcers and infections, which may progress rapidly to gangrene and amputation. However: Daily foot care and regular visits to the podiatrist can prevent ulcerations and infections.
  2. Loss of circulation (angiopathy): Poor circulation may be difficult to treat. If circulation is poor gangrene and amputation may be unavoidable. Cigarette smoking should be avoided. Smoking can significantly reduce the circulation to the feet significantly. There are certain medications available for improving circulation (Trental) and by-pass surgery may be necessary to improve circulation to the feet. Chelation therapy is an alternative form of treatment for circulatory problems that is not well recognized by the medical community at large. Daily foot care and regular visits to the podiatrist can often prevent or delay the need for amputation.

Do the Following to Protect Your Feet

The Charcot foot is a non-infective, destructive type of arthritis that affects between 1-2.5% of diabetics. The incidence of this arthritic process has increased recently due to patients with diabetes mellitus living longer. There is an equal distribution among males and females. The average age of patients developing a Charcot foot is 40 years. 30% of patients develop a Charcot foot in both feet and/or ankles. This form of arthritis can develop suddenly and without pain. In a very short period of time the bones in the foot and/or ankle can spontaneously fracture and fragment.

The final result in the development of a diabetic Charcot foot is severe foot deformity. These deformities may result in difficulty wearing standard footgear. As the deformity progresses the foot takes on the appearance of a "rocker bottom". As the arch of the foot collapses areas of pressure develop on the bottom of the foot that are prone to developing open sores or ulcerations. Loss of ankle stability may occur to such an extent that the patient may not be able to walk without the use of a brace. The vast majority of these deformities can be treated with non-operative care. New advances in technology and the development of new forms of lower extremity braces and splints have provided a wider range of treatment alternatives that are very effective in managing the Charcot foot.

This is an "Ask the Doctor Question" and the response. We felt that this question and answer was informative.

Question:

I would like to know how the cells in the body react when someone has diabetes and how is this different from someone who does not have diabetes?

Answer:

Malignant Melanoma

Pigmented lesions should always be inspected and observed. Most pigmented areas are nothing but freckles and moles. However a potentially deadly pigmented lesion that can occur on the foot and lower extremity is Malignant MelanomaA physician should evaluate any pigmented lesion that suddenly occurs or a pigmented lesion that starts to change its appearance. These changes are usually subtle and may consist of increased size and depth of color, onset of bleeding, seepage of clear fluid, tumor formation, ulceration and formation of satellite pigmented lesions. The color is usually not uniform but is likely to be scattered irregularity, being brown, bluish black or black. An increase in pigmentation may precede enlargement of the lesion by several months. Although any part of the body may be affected, the most frequent site is the foot, then in order of frequency, the remainder of the lower extremity, head and neck, abdomen, arms and back. Malignant melanoma may also form under the nails of the feet and hands. The thumb and big toe are more commonly affected than the other nails. Quite often the adjacent skin to the nail is ulcerated. Usually a fungal infection is suspected and antifungal treatment may be administered for months before the true nature of the lesion is discovered. A black malignant melanoma of the toe can also be mistaken for  Overall, the incidence of malignant melanoma is quite low.

Circulation disorders includes a large number of different problems with one thing in common, they result in poor blood flow. Specifically, the term peripheral vascular disease refers to blood flow impairment into the feet and legs (although it could include the arms and hands as well).

Blood is circulated throughout the human body by the strong, muscular pump called the heart. With each heartbeat, blood is pushed along through blood vessels called arteries that carry the oxygen and nutrient rich blood to all parts of the body including the legs and the feet. The individual cells in the body take up the oxygen and nutrients. Then a second set of blood vessels known as veins carry the oxygen depleted blood back to the heart and lungs to get more oxygen, and again be pumped throughout the body. Peripheral vascular disease may refer to arterial inflow disorders, (arterial insufficiency) or venous outflow disorders (venous insufficiency).

This is a question and answer that we felt was worth sharing.

Question:

I am age 67 and have been a diabetic since the age of 50. Insulin dependent for the last 5 yrs. My feet often have hard calluses on them which I have had trimmed by a podiatrist. Unfortunately, this has led to severe infection and have lost my big toe because of this. At the moment I am again battling an infection. I am wondering what is the alternative to trimming a callus. I understand Vitamin C is good for healing. Do you have any info on this? I would be greatful for any advice you could give me.

Answer:

Callus build up on the foot is due to abnormal pressure and friction as you stand and walk. It is important that the callus not get to thick or the skin under the callus can break down and cause an ulceration. It is not uncommon for me, when treating a diabetic patient with calluses on the feet, to trim a callus and find an ulcer under the callus. If the callus is not trimmed, then the infection can progress into the bone or deep into the foot. Good nutrition and vitamin supplements will help with healing but the most important issue is adequate blood flow. If you have bad circulation ask your doctor about hyperbaric oxygen treatment.

You should also discuss with your doctor about obtaining a diabetic shoe and molded insole to protect your foot.

Peripheral Neuropathy is a nerve condition that affects the arms, hands, legs, and feet. The most common form of peripheral neuropathy is due to diabetes.

Diabetic Peripheral Neuropathy

People with diabetes have an abnormal elevation of their blood sugar, and lack adequate insulin to metabolize the blood sugar. As a consequence, the blood glucose (sugar) abnormally enters certain nerve tissue and damages the nerve. This can occur in any type of diabetes. It does not matter if the patient is on insulin, is taking pills, or is diet controlled. The nerve damage that occurs is considered to be permanent.

As the nerve damage occurs, the protective sensations are affected. These include a person's ability to determine the difference between sharp and dull, hot and cold, pressure differences, and vibration. These senses become dulled and/or altered. The process begins as a burning sensation in the toes and progresses up the foot in a ""stocking distribution"". As the condition progresses, the feet become more and more numb. Some people will feel as though a pair of socks on their feet, when in fact they do not. Other patients will describe the feeling of walking on cotton, or a water-filled cushion. Some patients complain of their feet burn at night, making it difficult to sleep. The feet may also feel like they are cold, however, to the touch, they have normal skin temperature. Diabetic peripheral neuropathy is not reversible. The progression of the condition can be slowed or halted by maintaining normal blood glucose levels.

Gangrene of the skin is associated with the loss of blood supply of a particular area. In some instances, it is caused by bacterial infection of an open sore or ulceration. The most common form of gangrene develops in the feet of people with diabetes who also have associated loss of circulation in the feet and toes. Any person with poor circulation can develop gangrene. A sudden onset of pain in the feet or legs associated with a decrease in skin temperature, and color changes to the skin of the feet is a strong indication that there has been a sudden blockage of blood flow to the legs. This condition needs immediate medical attention. People who have diabetes may not experience pain associated with such an event because of a condition called diabetic neuropathy. Diabetic neuropathy affects the nerves of the feet and legs causing a diminished ability to perceive pain, excessive heat, cold, vibration, or excessive pressure. This condition places people who have diabetes at greater risk of injury from any source without their being aware of it. For instance, a patient with diabetes can develop an ingrown toenail, and if they also have diabetic neuropathy, they may not experience the same level of pain as someone without the neuropathy. As a consequence the ingrown toenail can worsen, and become infected without providing the warning signs of pain. If the person with diabetes also has poor circulation, the infection can lead to gangrene of the toe. This situation can ultimately lead to the amputation of the toe, foot, or leg, depending upon how bad the circulation is in the leg.

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