Diabetes can affect every organ, but if there’s one part of the body that is particularly vulnerable, it is the feet. Surprisingly, though, foot care is often ignored by diabetics and non-diabetics alike.
“Nearly 62 million Indians suffer from diabetes. What is startling is the little-known fact that 100,000 diabetics unnecessarily lose their legs in amputations every year,” says A.P.S. Suri, diabetic foot surgeon and founding president, Indian Podiatry Association, New Delhi. Dr Suri also heads the podiatry department at Fortis C-DOC and is the director of the Diabetic Foot Care and Wound Care Centre, Delhi. A survey of type 2 diabetics in Puducherry, published in 2014 in the Indian Journal Of Endocrinology, found that only 54% of the respondents were aware that diabetes could lead to reduced foot sensation and foot ulcers, and only 22% of diabetic patients had their feet examined regularly by a health worker or doctor.
Why are the feet so vulnerable?
If blood sugar remains high for years and diabetes is not treated effectively, it can damage the feet in two ways, says Sanjay Kala, national secretary, Indian Podiatry Association, and head of surgery at the GSVM Medical College in Kanpur. “Firstly, the high glucose levels in your blood weaken nerves. Secondly, it creates vascular problems. Circulation and blood supply to the feet is diminished. This is because high glucose levels tend to clog the arteries of the feet in the same way that it affects the heart arteries.”
As a result of poor circulation and nerve damage, diabetics often experience a complete loss of sensation in their feet, developing a condition called neuropathy.
“Diabetic neuropathy occurs gradually over a period of 8-10 years after one is first diagnosed as a diabetic. That’s why an early diagnosis (of diabetes) is important. And an adequate foot-care routine must follow,” says Dr Kala.
Greater risk of injury, wounds and infection
If a diabetic injures his/her feet, infection sets in much faster than it would in a non-diabetic person. It also takes a longer time to heal. “It can take double the time normal recovery would. Such infections tend to be much more painful in comparison to those sustained by a non-diabetic,” says C.H. Sunil Kumar, consultant diabetologist at the Apollo Sugar Clinic in Hyderabad. Any wound you sustain tends to infect the bone directly, heightening the risk of amputation, he says.
Due to the lack of feeling in their feet, diabetics can put themselves at risk of injury unknowingly. “I’ve treated patients for burn injuries after they’ve walked barefoot for hours in temples and on hot scalding surfaces without realizing it,” says Dr Suri. “Such patients can also sustain injuries from glass shards and other sharp objects. Even if a pebble were to get into their footwear, they can’t feel it. They’re completely numb.”
Sometimes, an infection sustained this way never heals, leading to gangrene. “Gangrene can cause a great deal of pain and discomfort. At this stage, there is a greater possibility of amputation,” says Dr Suri. That is why any sore or festering wound in your feet needs immediate attention.
Creation of high-pressure zones
Not all diabetics whose feet are infected go on to develop gangrene. Nerve damage over time, however, can change the shape of the feet, creating “high-pressure zones”.
“We call it the abnormal biomechanics of the foot,” says Dr Kala. “Our feet have natural arches that support our weight. However, when a diabetic experiences foot problems, there is a thickening of skin on the feet. Moisture is lost and calluses develop quickly. This not only changes the shape of the foot, but also creates zones on the feet where the pressure from having to bear the body weight is intense.”
High-pressure zones can affect your balance and weaken your feet. This is why diabetic footwear—often custom-made to help nullify the debilitating effects these high-pressure zones create—helps.
Foot hygiene then is important, and closed shoes are an absolute no-no. Dr Sunil Kumar says, “Closed shoes trap water and keep the feet damp, which is an open invitation for bacteria and fungi to settle and multiply.” Walking barefoot can be a problem too. Diabetics with foot problems must wear socks at all times, even indoors, because they offer a degree of protection, especially against sharp objects and burns, suggests Dr Suri.
Pay even greater attention to foot hygiene during the monsoon. “Cleanse and dry feet thoroughly after exposure to rainwater. Soap and water is enough to do the job. However, if one wants to go the extra mile, soda or vinegar mixed in water will do the trick,” says Dr Sunil Kumar. Keep the toenails short; long nails are prone to collecting dirt, turning them into a breeding ground for bacteria.
Keeping your feet free of cracks is important because fissures could give germs access, says Dr Kala. Removing hardened skin with blades or sharp scrubs can only put you at greater risk of infection. Frequent pedicures help and it’s more practical for diabetics to do this at home.
If you’re a diabetic, regular visits to a podiatrist are essential. If your feet are already infected, your physician will prescribe pills or topical creams, depending on the severity of the problem, to help prevent the infection from spreading further.
The latest treatments for a diabetic foot
Autologous stem cell therapy
Stem cells are extracted from the patient’s own blood marrow. These are then injected into the leg to heal wounds. The healing occurs over two-three weeks. The treatment costs around Rs50,000. “This is one of the new-age treatments which has been most promising,” says Dr C.H. Sunil Kumar. “The good news is that there are no known side effects. Yet, we need more research.”
A special unit is fitted to the patient’s foot and the person is sent home. The machine creates suction on the leg wounds and the accumulated pus is drained into a canister over five-six days. “Patients are still mobile and this helps heal the wound faster,” says Dr A.P.S. Suri.
PRP (Platelet-rich plasma) injections
Platelets, a component of white blood cells, are extracted from the patient’s blood. These are injected into the patient’s wound. In 10-15 days, the colour of the wound changes from black/yellow to red, and it then heals.
Where is treatment available?
There are very few hospitals in the country that offer these treatments. Here’s a handy list.
■ Diabetic Footcare Centre, G-191, Naraina Vihar, New Delhi (43094656).
■ Fortis C-DOC, B-16, Chirag Enclave, New Delhi (491011222).
■ Amrita Institute of Medical Sciences and Hospital, Ponekkara, Kochi, Kerala (0484-4001234).
■ GSVM Medical College, Kanpur, Uttar Pradesh (0512-2535483).
When diabetes patients choose footwear off the rack, they invariably choose a size that is much too small for them. “This is because the only feeling they have in their feet is that of compression,” says Dr A.P.S.Suri.
Wearing severely restrictive footwear can cause injuries and lead to complications. Specialized footwear, ideally one size bigger, is recommended for diabetics.
Diabetic footwear has sufficient padding on the sides and the shoes are crafted from soft leather. Often, ink impressions are taken of the feet. A doctor examines which areas of the feet are under greater pressure (these usually show up as darker impressions). Based on this, footwear can be custom-made keeping in mind the vulnerable areas of the foot.
Custom-made footwear can cost Rs.2,000-3,000. Diabetic footwear that you can buy off the shelf isn’t as effective, but it is still better than normal footwear. This can cost Rs.300-500 and is available in hospitals across the country.