Appendix
E: Foot Care for Diabetics /
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Although it is
not directly related to the normalization of blood
sugars, I have included this short but important section
on foot care because of the constant danger diabetes
poses.
The incidence of limb-threatening
ulcerations in diabetics is very high, affecting about
one in seven patients. Nonhealing "diabetic"
ulcerations are the major cause of leg, foot, and
toe amputations in this country, after traumatic injuries
such as motor vehicle accidents. These ulcerations
do not occur spontaneously; they are always preceded
by gradual or sudden injury to the skin by some external
factor. Preventing such injuries can prevent their
sad consequences.
Virtually all diabetics
who have experienced ongoing higher-than-normal blood
sugars for more than five years suffer some loss of
sensitivity to pain, pressure, and temperature in
their feet. This is because elevated blood sugars
injure and can eventually destroy all sensory nerves
in the feet. Furthermore, the nerves that control
the shape of the foot are likewise injured, with a
resultant deformity that includes "claw"
or "hammer" toes, high arch, and prominent
bones at the bases of the toes on the underside of
the foot. The nerves that stimulate perspiration in
the feet are also affected. This results in the classic
dry, often cracked skin that we see on diabetic feet.
Dry skin is both more easily damaged and slower to
heal than is normal moist skin, and cracks permit
entry of infectious bacteria.
Elevated blood sugar also
causes impairment of circulation in the arteries of
the legs, as well as in the arteries and small capillary
blood vessels that supply the skin of the feet. In
order to heal, injured skin can require fifty times
the blood flow of normal skin. If this increase in
flow is unavailable, the injury will deteriorate,
becoming gangrenous, and facilitate an infection that
spreads up the leg. This infection may not respond
to antibiotics.
Blood circulation to the
normal foot can readily increase one hundredfold,
if necessary, in order to conduct the heat of warm
objects away from the skin. Impaired circulation may
make this impossible, and the resultant burn may not
even cause pain.
A deformed foot with bony
prominences (knuckles of toes, tips of toes, heels,
and bases of toes at soles) may be continually rubbed
or pressed by shoes. This foot is frequently unable
to perceive the extent of such pressure and may not
heal readily if injured. It can be burned at relatively
low temperatures.
The following guidelines
are therefore essential for all diabetics, to prevent
foot injury and the potentially grave consequences
that may ensue:
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