Monday, May 20, 2024

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If you’re looking for a simple easy-to-understand guide to learning about diabetic foot ulcers and how to manage them you’ve come to the right place!

Let’s dive in…

What Exactly Is a Diabetic Foot Ulcer?

A diabetic foot ulcer is an opening or sore that can develop on the bottom of your foot. It occurs due to repetitive pressure and is oftentimes seen in patients who have diabetic neuropathy.

The Centers for Disease Control and Prevention (CDC) has recently released its 2022 National Diabetes Statistics Report. This report states that “130 million adults are living with diabetes in the United States.”

When you have diabetes, elevated blood sugar levels can lead to neuropathy. Neuropathy is a lack of sensation or complete absence of sensation in the feet. If you have neuropathy, you may also experience burning, tingling, or a feeling that your feet may be “asleep.” 

People may also describe their neuropathy symptoms as feeling like they still have socks on their feet when in fact they don’t. They may also feel a “leathery” feeling on the bottoms of their feet. 

If you have difficulty feeling sensation on the bottoms of your feet, then you may be more likely to develop a foot ulceration.

A person with complete sensation in their feet can generally feel pain if they develop a blister, or step on something. Unfortunately, in diabetics, this is not always the case. 

Other Causes of Diabetic Foot Ulcers

  • Foot deformities

When you have neuropathy, you may experience muscle weakness. You may also suffer from balance issues. This can alter how you walk and lead to worsening foot abnormalities.

normal arch high arch and flat farch

For instance, if you have a severe flatfoot, high-arched foot, or even a rocker-bottom type foot, this may cause excessive pressure on specific areas of the foot. These pressure points can develop into ulceration. 

  • Poor-fitting shoe gear or socks

If you have neuropathy in your feet, even the slightest change in your shoes and socks can have an impact on whether you develop a diabetic foot ulcer.

A shoe that may be too tight or too loose can cause you to develop blisters. 

Read more about how bad shoes can cause foot pain in this supplemental article.

Even a pair of socks that have thick seams in them may irritate your skin and cause you to develop a diabetic foot ulcer. 

  • Improper trimming of your toenails

When you have neuropathy in your toes, it can be hard to properly trim your toenails. You can inadvertently cause an ulceration when you nick your skin while trying to trim your toenails.

If you cannot see a medical professional to help you trim your toenails, you should focus on trimming your nails straight across. This will help avoid an ingrown toenail from forming. Also, make sure you trim your nails slowly.

You can read more about how to trim your nails and nail surgeries in this article about ingrown toenails.

Who Is at Higher Risk for Developing Diabetic Foot Ulcers?

  • People who have poorly-controlled blood sugar levels

The more poorly-controlled your blood sugar levels are, the higher your risk is for developing neuropathy and other complications. Some of the other complications that can result from elevated blood sugar levels include kidney disease, eye disease, and heart disease.

  • Diabetics with neuropathy

If you already have numbness in your feet, you are at higher risk of developing a diabetic foot ulcer. Simply put, if you have complete numbness, it is easy to step on a piece of glass or develop a blister without even realizing it. This can lead to not only ulceration, but infection.

To learn more about nerve pain check out the Ultimate Guide To Nerve Pain In the Foot.

  • People who are obese

Every extra pound that we carry can cause more weight to be placed on our feet. In people who have neuropathy, even a little bit of extra weight can place them at a higher risk for developing a diabetic foot ulcer. 

  • People who suffer from peripheral vascular disease

When your blood sugar levels are elevated for a long time, it can affect your vascular system. This will decrease blood flow to your feet. This can delay wound healing in the foot.

Smoking can also prevent wound healing due to its impact on the vascular system. 

  • People who have autonomic neuropathy

Elevated blood sugar levels can also cause changes in your skin. Your skin may dry out more than the average person. When it comes to the foot, this can be problematic. 

The skin on the bottoms of our feet (especially our heels) is usually very thick. If the skin dries out too much, you may develop fissures in your feet.

picture of heel fissures

If you have fissures and neuropathy, you may not notice if the fissure becomes deeper. The deep fissure will form an ulceration, and places you at a higher risk for developing an infection.

Read more about how to treat cracked heels in this supplemental article.

How You Can Tell If You Have a Diabetic Foot Ulcer

Believe it or not, it may not be immediately obvious that you have developed a diabetic foot ulcer. 

study performed in Germany by Brenda Bongaerts in 2013 indicated that more than 90% of people with peripheral neuropathy were unaware they had it.

Here are some tips on what to look out for: 

  • Check to see if there is bloody drainage on your carpet, socks/shoes. If you develop an open sore in your foot, it will usually drain
  • Keep an eye out for dry skin on your feet. Check to make sure your foot fissures aren’t getting deeperThis may result in a full-thickness ulceration which can lead to infection. 
  • Check for odor in your foot. When a diabetic ulceration becomes infected, the ulceration can emit a strong odor due to bacteria. This can signal to you that something may be wrong.
  • If you are increasing your activity or recently changed your shoes and socks, make sure to check the bottoms of your feet for any blisters. If you develop a blister, contact your doctor. 
  • Check for skin discoloration. Is there a toe that may be turning blue or black? If so, this can be a sign of poor blood flow to the foot. If the skin turns completely black, it is called gangrene. This requires prompt attention.

How Are Diabetic Foot Ulcers Treated?

So you have a diabetic foot ulcer, now what? You will need to see your foot doctor to establish a plan of care moving forward. It’s so important to receive regular care for diabetic foot ulcerations. The goal is to help you heal the ulceration as soon as possible. 

Chronic open ulcerations are more likely to get infected. Skin infection can easily turn into a bone infection (osteomyelitis) over time. If you develop a bone infection, you may be at risk for amputation. 

Treatment for Diabetic Foot Ulcers

  • Debridement

Your doctor will use a scalpel to trim away the unhealthy tissue and callus from the ulceration. This should leave a clean, bleeding base at the site of the ulceration. This procedure is usually not painful, as most patients have neuropathy in their feet.

Your doctor may use wound care products in the form of creams, gels, and dressings to help try to heal your ulcer. Regular debridement and removal of dead tissue are necessary to ensure that your ulcer will heal. 

Debridement of your ulcer will also allow your doctor to examine the ulcer. 

What your doctor may be checking for: 

-How deep is the ulceration?

Does the ulceration base appear healthy?

Is the ulceration infected?

-Is there pus at the ulcer site that is tracking to another part of the foot? (this confirms that the infection has spread)

-Does the ulcer probe to the bone? If the bone is visible, there is a higher chance that an underlying bone infection may be present.

Your doctor will also advise you on how to perform wound care at home between office visits. 

Wound care dressings instructions will vary depending on the type of ulcer, ulcer drainage, and whether there is infection.

Your doctor may also recommend advanced wound care treatment. One of which is hyperbaric oxygen therapy. The hyperbaric oxygen chamber provides an oxygen-rich environment that allows cells to provide oxygen to the wound, thus helping the wound heal faster.

  • Blood flow

Your doctor will want to check your blood flow in the foot by checking your foot pulses. If you don’t have palpable foot pulses, your doctor may order additional testing to evaluate your blood flow. 

  • Sensation

The level of neuropathy must be tested. Your doctor may use a Semmes-Weinstein Monofilament Wire to check sensation in different areas of your feet.

The Semmes-Weinstein Monofilament wire is a device that consists of a nylon filament mounted on a holder. It will bend at 10 grams force. You should be able to feel the wire when tested. If you have difficulty feeling the wire against your foot, you may have neuropathy. This is just one common way that neuropathy is tested.

It’s important to understand that neuropathy can manifest in so many different ways. Some people feel burning, some feel tingling, some can’t tell the difference between hot and cold sensations, and some feel complete numbness in their feet. Occasionally, people may also complain of itchy skin.

Unfortunately, there is no cure for diabetic neuropathy. However, if you experience pain secondary to neuropathy, you can speak to your doctor about nerve pain medications that are available to keep you comfortable.

If you suffer from balance issues, you may benefit from physical therapy to help improve your balance and decrease your risk for falls.

  • Offloading

As I stated previously, your foot structure can cause you to place excessive pressure in certain areas. Your doctor will want to examine your shoes, inserts, and socks to see if anything is aggravating your foot and causing excess pressure. 

Wounds can be offloaded directly using pre-made offloading pads.

plantar offloading pads

Diabetic shoes and diabetic inserts are beneficial as well. They are designed to accommodate diabetic patients’ feet.

Diabetic plastazote inserts, in particular, are designed to absorb shock and reduce friction, thus lowering the risk for ulceration. 

Your doctor may also be able to prescribe a custom diabetic orthotic that can help offload your ulcer appropriately. 

Your doctor may also suggest you wear a surgical cast shoe to keep pressure away from your ulcer. 

There are many different kinds of cast shoes that serve different purposes. Say for instance you have a pressure sore on the bottom of your forefoot.

You will want to get a forefoot offloading cast shoe. This will help offload the sore when walking.

The bottom line is that if you remove pressure from the ulceration when walking, it can help the ulceration heal faster. 

  • Imaging
James Heilman, MD, CC BY-SA 4.0, via Wikimedia Commons

If you have a diabetic foot ulcer, your doctor may recommend an x-ray. Since diabetic ulcers can cause bone infection, it’s important to get an x-ray to visualize the bone.

Your doctor may also order an MRI, CT scan, or bone scan. These advanced imaging modalities will provide detailed images that can show if there is an abscess, bone infection, and the extent of infection. This is important for surgical planning.

If your doctor suspects you may have peripheral vascular disease, he/she may order arterial testing to determine your blood supply to the foot. These are usually noninvasive tests that will tell the doctor if there is a blockage of blood supply to the foot. 

If you have a poor blood supply to the foot, your doctor may send you to a Vascular surgeon for a workup and possible surgery to improve blood flow to the foot. This would in turn allow the ulcer to heal better. 

  • Antibiotics

If your diabetic foot ulcer becomes infected, you may need antibiotic pills or IV antibiotics, depending on the extent of the infection. Your doctor may refer you to an Infectious Disease specialist for recommendations regarding antibiotics. 

Managing diabetic foot ulcerations is a team effort. It’s not unusual to have many different doctors involved in your care. These specialists include your family doctor, your Podiatrist, an Endocrinologist, an Infectious Disease doctor, and a Vascular surgeon.

  • Surgery

At times, there may be something directly that is causing the ulceration. For instance, if you have a hammertoe that is constantly rubbing against all your shoes and causing a sore, your doctor may perform hammertoe surgery to straighten the toe. This would allow for the ulceration to heal. 

If your ulceration becomes severely infected, you may need to undergo emergent surgery. This would require an incision and drainage surgery to remove pus and dead tissue. If there is an underlying bone infection, an amputation may be required. 

  • Management of Blood Glucose Levels
testing blood sugar levels

Your doctor may suggest you work closely with an Endocrinologist and Nutritionist to help you manage your blood sugar levels. There are also Diabetes Support Groups that you can join in person or online. Just type in “Diabetes support group near me”, and there are a plethora of options.

How Long Will It Take for a Diabetic Foot Ulcer to Heal?

Even when a diabetic ulcer is treated appropriately, it can take weeks if not months to heal. This is due to many different factors, including but not limited to:

  • Age of patient: Young people, in general, tend to heal wounds faster.
  • Weight-bearing status of the patient: If you can stay off your foot, the more likely it will heal faster.
  • Vascular status of the patient: Absence of blood flow can hinder wound healing as wounds require blood supply to heal.
  • Nutritional status: Poor nutrition may hinder ulcer healing.
  • The extent of neuropathy: A person who is completely neuropathic may have difficulty healing their ulcer compared to a person with full sensation in their feet.
  • Smoking history: Smoking has been proven to hinder both wound and bone healing. Non-smokers may heal wounds faster as a result of this.
  • Prior history of foot ulceration: If you have had a foot ulcer before, you are at higher risk for developing a foot ulcer again in the same area. This can make it more difficult to heal the recurring ulcer, as the skin is very vulnerable.

As you can see, these are just some of the reasons why wound healing may be delayed.

Rest easy knowing that if your ulcer healing seems delayed, your healthcare provider will likely change your course of treatment

What You Can Do To Prevent Diabetic Foot Ulcers

  • Check your feet daily

I can’t tell you how many people don’t check the bottoms of their feet daily. It is so important to make sure you check the bottoms of your feet daily to make sure you didn’t accidentally step on something. 

If you cannot reach down to check the bottoms of your feet, you can place a mirror against a wall and use it to check the bottoms of your feet. If you see a draining open wound, make sure to call your provider.

  • Maintain your blood glucose levels
picture of fruits and juices

If you struggle to maintain your blood glucose levels, talk to your doctor sooner than later to find out your options. Perhaps some of your medications can be changed. Perhaps you can speak to a Nutritionist for dietary recommendations. 

  • Wear appropriately fitted shoes, inserts, and socks

You can visit your local foot doctor to inquire about footgear recommendations for your unique foot structure. If you cannot see a foot doctor, you can try getting recommendations at your local shoe store. 

Make sure your shoes are supportive and breathable. It helps to buy shoes that are easily adjustable. Such shoes usually have Velcro straps or laces. 

Avoid wearing open-toe shoes, and shoes that may cause you to put excess pressure on one area.

An example of this would be wearing high heels. High heels cause excess pressure to be placed on the ball of your foot. This may cause an ulcer to form if you are neuropathic.

  • Reduce smoking and drinking alcohol
cigarette smoke

Anything that puts you at a higher risk for neuropathy and poor blood flow should be reduced or avoided altogether.

  • If you do develop a blister or wound, contact your doctor immediately

Oftentimes, people will treat cuts and blisters themselves. Diabetics should be careful not to do this if possible. Even things like hot soaks can irritate the skin. Also, any harsh topical products like peroxide should be avoided.

If you develop ulceration, you can gently cleanse the area, and apply antibiotic ointment onto the area, along with a dry dressing. Then contact your doctor. 

In Conclusion

Diabetic foot ulcerations, although frustrating, can be preventable and treatable. It’s important to catch the ulceration early and seek help immediately if it occurs. 

Regular foot exams performed by you and your doctor are very important and necessary. Even after you heal an ulcer, it is important to continue preventive measures to make sure it doesn’t return. 

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Related articles:

Incision and Drainage of Foot: What a Foot Abscess Drainage Entails

Actionable Solutions For Foot Problems From Diabetes

Diabetic Neuropathy in the feet- A Simple Treatment Guide

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Vaishnavi Bawa
Dr. Vaishnavi Bawa is a Podiatrist who specializes in treating foot and ankle pathology. LifesLittleSteps mission is to educate the public about foot health in an easy-to-understand manner using evidence-based medicine.
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