Yesterday James came into my office because he just found out that he had just been diagnosed with diabetes. His doctor said that he needed to get a diabetic foot check. First thing I asked James was if he’d ever known anybody who have a diabetic foot amputation. He said that yes he did have a cousin who had lost his lead to diabetes. He also said that his cousin had died shortly after the operation. When asked what happened he didn’t seem to recall any of the specifics surrounding the event. Asked if he knew how diabetes can cause an amputation. He said he had no idea.
Shouldn’t every diabetic know the details so that amputations could be prevented?
There are basically two groups of patients when it comes to understanding of diabetic foot problems. One group are ready fully understands all of the risks to their feet related to diabetes, but this is very rare. The much larger group of people have no clue how all of this happens. With every one of these folks I feel that the one goal is to get them to understand that diabetic foot problems are optional.
Diabetes can be a very difficult disease to learn to live with. Next thing you know, your doctor is telling you that you have to start exercising, he’s telling you what you can and cannot eat, and he is also telling you to have a heart attack. Then you are at home learning about blood sugar monitoring, taking medicine, pricking your finger every day. People will say, “Now I gotta think about my feet too? Seems like such a hassle.”
And it is.
But the good news in all of this is that everything bad that can happen to you because of diabetes is preventable. Everything. All it takes is a little learning, a little lifestyle change, and little daily effort. The goal is to get you to understand the basics of how diabetes can affect your feet…So you can take action and do something about it.
When you have diabetes you have three main problems, all working together and conspiring against you, that can lead to a diabetic foot amputation. It involves your nerves, blood flow and immune system.
When your blood sugar is high, there is a chemical reaction that directly damages the ends of the longest nerves in your body. The longest ones start in your back (where they exit the spine) and head all the way down to the toes in one long piece. Because the ends get damaged first, any nerve damage starts in the toes and gradually creeps up the foot toward the ankles.
It is always damaged at the same level in both feet. For example, if you have nerve damage (neuropathy) at the ball of the foot, the nerve damage is only in the toes. In this case the part of the foot around healed ankle and arch might be just fine.
Diabetic nerve damage makes it very difficult for someone to tell if they’re starting to develop a blister, cut, or even an infection. This can put them in a very high risk for developing serious problems. It is deceptive because you might be able to feel other things like the position of your feet, shoes and socks squeezing, but not a blister, cut or sore.
The second problem is the circulation or blood flow in the feet and legs. The arteries get clogged faster when you have diabetes. If you take two people who are identical, except one is diabetic, the one who is diabetic is four times more likely to have a heart attack. That is because of the increased rate of clogging up those arteries through the process called atherosclerosis. But this process happens everywhere, not just the heart. The blood vessels to the legs get plugged up too. Then, when you get a sore it takes longer to heal. It is also harder for your infection fighting white blood cells to get down there.
The last problem is your immune system. When your blood sugar is high, the white blood cells (called macrophages) have a hard to time fighting off those nasty bacteria. The white macrophages find bacteria through a process called chemotaxis. It is like following a trail of chemicals to its source. This is not very effective when the blood sugar is elevated. In effect, the macrophages are lost in the dark, simply bumping around, hoping stumble into some bacteria to kill. Very inefficient and not very effective.
Even if the white blood cells to find bacteria, they still have a problem. The high blood sugar prevents them from eating the bacteria. The process where the white blood cells engulf the bacteria (called phagocytosis) is essentially disabled. So they bump up against they bacteria, but can’t do anything. Imagine a great white shark with his mouth wired shut trying to eat a smaller fish for dinner. Because of all of this, the immune system is ineffective, the bacteria continue to grow and the infection quickly gets out of hand.
So a diabetic amputation goes something like this. If you start a walking program to help control your diabetes, but you have a little nerve damage, he may not be able to field blister starting to develop. If you keep walking the blister conversed. Just like that, you have an open sore. Your blood flow is a little sluggish and it takes a long time to heal. Then it gets infected while it is trying to heal. If your blood sugar is high, all of those sharks are wandering around in the dark, mouths wired shut, and the infection spreads.
If it spreads enough, one of the foot bones gets infected. And a bone infection is the kiss of death for the diabetic foot. The most consistently effective method of treatment for a diabetic bone infection (called oseomyelits) is to take out the infected bone. And that is where the amputation begins.
The moral of the story is watch your blood sugar, and your nerve damage will never get any worse. If you walk 30 minutes a day, fives days a week, your blood flow will never get any worse. If you develop any diabetic peripheral neuropathy, it is important that you are closely monitored and evaluated by someone who is an expert in the treatment of diabetic foot problems. If you ever get any open sore, blister or ingrown toenail it is an emergency…no joke. Get that foot checked out or it might get chopped off!
Dr Christopher Segler