The diabetes foot
Despite efforts to control their disease and maintain a normal glycemic state, most persons with diabetes eventually develop one or more secondary complications of the disease. These complications may be somewhat subtle in onset and slow in progression; however they account for the high rates of morbidity and mortality. While the specific mechanisms involved remain areas of debate and research activity, most secondary complications are vascular or neural in nature.
Vascular complications may involve atherosclerotic-like lesions in the large blood vessels or impaired function in the microcirculation. Damage to the basement membrane of capillaries in the eye (diabetes retinopathy) or kidney (diabetes nephropathy) is commonly seen. Although there is no satisfactory direct treatment for diabetes vascular disease, its progression is often monitored closed as an indirect indicator of the overall diabetes state.
Diabetes neuropathy typically involves symmetric sensory loss in the distal lower extremities or autonomic neuropathy, leading to impotence, GI dysfunction, or anhidrosis (lack of sweating) in the lower extremities. The diabetic foot is an example of several complicating factors exacerbating one another. About 50% to 70% of nontraumatic amputations in the United States each year are due to diabetes. Breakdown of the foot in persons who are diabetes is commonly due to a combination of neuropathy, vascular impairment, and infection. In a typical scenario, small lesions on the foot result from dryness of the skin due to a combination of neural and vascular complications. Impairments is sensory nerve function may result in these small lesions going unnoticed by the patient until a severe infection or gangrene has become well established.
Loss of the affected foot or limb often can be avoided with the patient and physician education. The focus in managing patients with diabetes is the maintenance of normal blood glucose levels; avoiding primary complications, such as diabetes ketoacidosis or hyperosmolar coma; and initial secondary complications, such as diabetic retinopathy. There is an increasing awareness of the importance of assessing the feet of a diabetic patient at each visit. The results of one study show that the likehood of amputation is reduced by half if patients with diabetes simply remove their shoes for foot inspection during every outpatient clinic visit. Therefore, while the underlying physiological mechanisms of the problem may be complex, the problem can be relatively easily avoided.
References:
- Medical physiology, Lippincott Williams & Wilkins 3rd edi.
- Harrison’s Principles of Internal Medicine, 17th edition.
- Davidson’s Principles and Practice of Medicine, 20th Edition
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