This section is for everyone. You must treat your tootsies like little babies. You must be constantly vigilant that they are safe and warm but not too hot. Just like you would call your mum you must call your doc at any sign of anything that looks wrong.

Nerve damage to the feet due to the effects of high blood sugars takes between 5-20 years to become evident from diagnosis for most diabetics. Lack of sensation makes your feet more vulnerable from things that you may not even feel like tight shoes or a little gravel in the shoe. High blood sugars provide a nice growing medium for bacteria. Blood vessel damage to the area supplying the feet make injuries take much longer to heal in diabetics.

Dr Bernstein runs a specialist wound clinic for diabetics and has studied the causes of injury which have led to amputations. His book Diabetes Solution has a long list of dos and don’ts some of which you may know and others which you may not. I have not included every tip but would encourage you to buy the book and follow them.

Some tips are:

• Buy your shoes late in the day and make sure they do not pinch.

• Before putting on your shoes shake them out and make sure the linings are smooth.

• Have at least two pairs of shoes that you alternate every few days.

• Examine your feet for any injury or undue redness every day or get someone else to.

• Apply vegetable or animal oil every day to keep the skin soft eg olive or almond oil.

• Don’t smoke.

• Keep your feet away from direct heat and avoid overly hot or prolonged baths.

• Wear warm socks when it is cold.

• Avoid beta blockers if you have dry feet.

• Don’t file down or shave callouses or corns. These are natures way to protect you from abnormal pressure. Get appropriate insoles, padding or bigger shoes. A specialist podiatrist or biomechanical evaluation may be required for this.

• Get someone who can see what they are doing to trim your toenails if your vision is poor or not that flexible. Get a podiatrist to teach you how to care for your feet and nails.

• See an experienced nurse or doctor if you get any foot injury right away. It can be a disaster if infection gets hold. You may require high dose antibiotics, dressings and even hospital admission.

Ayrshire and Arran Health Board Podiatry Service have some additional information on foot care.

Washing your feet:

Wash feet every day but avoid keeping them in water for any longer than necessary.

If you intend to cut your toenails keep them in water for up to five minutes to let the nails soften.

Dry carefully between the toes.

If you have sweaty feet apply a light dusting of talc.

Footwear Advice:

Have your feet measured for length and width.

Everyday walking or working shoes should have:

Heels no higher than 3.5 cm or 1.5 inches.

Have lacing, buckles or velcro to hold the foot securely and prevent unnecessary movement.

The toe should be round or square.

Uppers should be made of a breathable material such as leather.

Soles should be thick and cushioning not thin and unyielding.

High heeled, pointed toe shoes, mules or strappy sandals are best avoided. If you want to wear them for a special event keep them to short periods. Don’t have  sandals that have thongs between the toes.

Ensure your socks fit well. Change your socks once or twice a day and throw out any that are too small or which have holes. Don’t darn the darned things. Get rid of them!

Measuring your feet:

Your feet should be measured from the heel to the tip of your longest toe. For some people this is the second toe not the big toe. Congratulations if this is you. The Ancient Greeks regarded this as a sign of beauty.

You can check the length of your shoe by standing bare foot on a piece of thin cardboard and marking the place reached by the longest toe. Then place a thin strip of this into the shoe. There should be a one centimeter gap between the end of the cardboard and the heel of the shoe.

Your shoe width should match your foot width.

If you have a diabetic foot ulcer:

If your foot swells, changes colour or becomes more painful you must seek prompt medical attention. This means the out of hours or accident and emergency services if your doctor’s office is shut.

Podiatrists usually need to look at your feet very regularly and change dressings. You may be advised to shower or bathe less frequently and may need to stay off the foot more than usual. For some daily tasks you could be advised to sit instead of stand.

Healing will be more difficult if your blood sugar control is poor, you don’t rest the foot as advised, your footwear is not suitable, you forget to take medication as prescribed, you miss appointments, you interfere with dressings, or you continue to smoke.

Ulcers heal best when they are not taking your physical weight. Rest, elevation, special shoes, orthotic devices, crutches, zimmers, wheelchairs or plaster casts may  be required at one time or another.

If you or a carer has been trained to do so, you may find that doing your own dressings is more convenient. A key component of this is knowing when and how you need help. There is always a risk that a serious foot infection can develop.

The most important factors in healing foot ulcers are achieving normal blood sugars and avoiding unnecessary pressure.

Antibiotics:

If you are prescribed antibotics you must take them. For most diabetics the courses of treatment will involve several different antibiotics at much higher doses and for much longer than the equivalent infection in a fit non diabetic person.

One estimate is that it takes 50 times the amount of blood to heal a diabetic ulcer than a non diabetic ulcer.

Certain organisms found in probiotic drinks have been found to reduce the chances of getting diarrhea or diarrhea from a serious bacterial strain such as Clostridium difficle. The names of some of these probiotics are Lactobaccillus casei, L bulgaricus and Streptococcus thermophilus. Some commercially available yogurt drinks have probiotic organisms in them. It may be worth your while speaking to your doctor about taking such a preparation if you need a prolonged course of antibiotics. Remember to look out for any extra carbohydrate in the preparations. Sugar is often added to make them more palatable.

Typical antibiotic regimes:

Superficial ulcers:

Co-amoxiclav aka Augmentin 625mg three times a day.

or

Ciprofloxacin aka Ciproxin 500mg twice a day.

For 10-14 days.

Deep Ulcers

Clindamycin aka Dalacin 150 or 300mg four times a day.
and
Co-amoxiclav aka Augmentin 625mg three times a day.
and
Metronidazole aka Flagyl 400mg three times a day.

Duration of triple therapy depends on the severity of the ulcer but generally should be considered for six weeks.

Deep ulcer plus active cellulitis (skin infection):

Give the same sort of triple therapy regime but also add intravenous antibiotics. This could be Augmentin and Metronidazole. The choice of antibiotic is guided by the patients sensitivity and a medical microbiologist can help to choose the most effective regime.

For patients with penicillin allergy Erythromycin 500mg four times a day or Clarithromycin 500mg twice a day can be substituted.

A medical microbiologist will need to be consulted if the wound does not heal or there is active infection in the skin or bone.

Flucloxacillin is a typical penicillin which is used in non diabetics with soft tissue infections. In diabetic ulcers it simply cannot kill the range of bacteria that are likely to be present and so must not be used as a single agent.

Antibiotics can have nasty side effects such as diarrhea, stomach upsets, rashes, the growth of other pathogenic bacteria and liver and blood disturbances. They are given to you in the hope that a foot ulcer can be successfully treated before an amputation is required. If you are not able to take them as prescribed it is extremely important that you discuss this fully with your doctor so that alternatives or medication to counteract the worst of the side effects can be arranged for you.

The old saying, “An ounce of prevention is worth a pound of cure” has never been more apt when it comes to foot care for diabetics.

Please strive for normal blood sugars and be extra respectful and vigilant when looking after your precious feet.

Quick Quiz:
1. Regarding your shoes you should do one of these…
a Wear the same pair every day to make the leather softer.
b Buy shoes early in the day when your feet are less smelly.
c Buy shoes late in the day when your feet are more swollen.
d Buy shoes from the internet or from a catalogue to save walking around shops.

2. Nerve damage causes one of these…
a The feet become more sensitive to pain.
b Bacteria and fungus grow between the toes.
c The feet become abnormally sweaty.
d The feet become less sensitive to pain.

3. You should do three of these things to maintain foot health. What one should you avoid?
a Examine them every day using a mirror if necessary.
b Get corns and callouses regularly paired by a podiatrist.
c Rub animal or vegetable oil into the feet daily to keep skin supple.
d See an experienced doctor or nurse immediately if you get a foot injury or infection.

Have you got it?
1. C is true. Dr Bernstein gives comprehensive advice in his book Diabetes Solution about foot care that you may not hear from your diabetic clinic. Neuropathy can develop within five years for type ones and is often present at diagnosis for type twos as they may have been unaware of having the condition for years.

2. D is correct. It is a sad thing but despite the fact that neuropathy pain can become so intense that it needs opiate and anti-epleptic medications to control it, high blood sugars cause the nerves to be less sensitive to touch and external trauma that would cause pain in a non diabetic person’s foot. Bits of gravel, a seam from a sock and simply overtight shoes can cause friction damage that may go unnoticed unless you make the effort to troubleshoot every day.

3. ACD are the right things to do. Removing or paring callouses can increase your risk of infection and therefore amputation. The callous is a sign of too much pressure on that part of the foot. It is much better to PREVENT the possibility of amputation by leaving the callous alone and taking steps to change your footware or insoles so that it gradually goes itself.

Reference Info:
Most of the information in this section has been obtained from Dr. Bernstein’s Diabetes Solution: The Complete Guide to Achieving Normal Blood Sugars

Where to Next?
Everyone needs to have a good time every so often. A diabetic person’s feet need special care on a regular basis. So you all know exactly how to make your tootsies happy little babies please go to the How To: Give Your Feet a Pedicure section next.