Initial stage of diabetic foot: causes, symptoms and treatment

Description of diabetic foot syndrome, why it occurs in patients with diabetes. Frequent symptoms and causes of the disease are listed. The most effective methods of treatment and prevention.

Diabetic foot is a pathology that develops against the background of diabetes mellitus and is considered one of its most unpleasant complications. The disease manifests itself in damage to the blood vessels and nerve endings of the legs. Most often, this is the reason for limb amputation.

Differential diagnosis

Treatment of diabetic foot depends on its type and mechanism of development. Features of the neuropathic form are as follows:

• the skin of the legs is red;
• significant deformation of the feet (the toes become hook-shaped, the heads of the bones protrude, “Charcot’s foot” appears);
• bilateral swelling occurs, which can serve as a manifestation of pathology of the heart and kidneys;
• the structure and color of the nail plate changes, especially with fungal infection;
• in places of significant pressure, pronounced hyperkeratoses (skin growths that tend to peel off);
• ulcers are localized on the plantar side;
• arterial pulsation is preserved;
• the skin is dry and thinned.

Neuropathy and angiopathy are two main factors in the development of diabetic foot syndrome

The ischemic form of pathology is characterized by the following manifestations:

• bluish skin;
• there is no deformation of the legs;
• swelling is insignificant, appears if a secondary infection occurs;
• the structure and color of the nail plates change;
• pronounced growths around ulcerative defects in places of greatest pressure;
• the presence of areas of necrosis;
• arterial pulsation is sharply reduced, and in critical condition is completely absent;
• feet are cold to the touch.

Classification

Neuropathic form - impaired sensitivity of the feet like stockings or socks, dry skin, small cracks are possible. Nerve damage is a common complication of diabetes mellitus, sensitivity disorders occur in the feet, up to its complete loss, damage to the motor nerves leads to muscle atrophy. In the neuropathic form, some patients do not feel injury, temperature, skin punctures and receive injuries that can lead to infection.

Osteopathic form - destruction of bones and joints leading to foot deformation, the formation of trophic ulcers and skin damage. Poor circulation weakens bones, and can cause the bones and joints in the foot and ankle to deteriorate. Weakness of the ligamentous apparatus leads to multiple dislocations of the bones of the foot and its deformation. Bone destruction and pathological fractures are not accompanied by pain symptoms and can occur unnoticed by the patient, up to perforation of the skin by a bone fragment. In such cases, purulent complications and wet gangrene develop unnoticed.

The ischemic form is a violation of the blood supply to the foot with the formation of trophic ulcers and dry gangrene. It develops when blood flow is blocked due to plaque blocking the arteries. Against the background of ischemia, dry necrosis of the fingers or feet is observed, easily turning into wet gangrene. The most dangerous thing with diabetes is that, in conditions of decreased sensitivity, the patient may not pay attention to the appearance of trophic ulcers and necrosis and progress his disease to diabetic phlegmon.

Diabetic phlegmon and gangrene are severe purulent destruction of the soft tissues and bones of the foot against the background of impaired blood circulation. Cellulitis can develop with preserved vascular patency, and gangrene only with blockage of the arteries of the leg. The causes of phlegmon and gangrene are different, but the result is usually the same - amputation. Only timely specialized surgical care can count on the preservation of the supporting limb. The frequent appearance of purulent and putrefactive infections is associated with impaired immunity, characteristic of patients with diabetes; in the neuropathic form, attention to injuries is reduced, and the infection easily enters the subcutaneous tissue, causing the development of diabetic phlegmon. Phlegmon is a purulent melting of soft tissue. It can be caused by various microbes, but the most dangerous are the causative agents of gas gangrene. Infection in diabetes quickly leads to intoxication and sepsis. With the development of sepsis, the patient's general condition sharply worsens, liver and kidney dysfunctions are noted, and severe pneumonia often develops. In the absence of a timely diagnosis and proper treatment, the prognosis for life is extremely unfavorable.

Also in the classification there is a mixed form of diabetic foot, which gives a variety of symptoms and requires appropriate treatment.

Patient management tactics

Several specialists treat diabetic foot: therapist, endocrinologist, angiosurgeon, podiatrist. The therapist (or family doctor) is engaged in the primary diagnosis of diabetic foot syndrome, determining the patient’s management tactics, and referring for consultation to specialists. The endocrinologist has the same functions. In addition, this doctor deals with the underlying disease.

An angiosurgeon specializes in vascular pathology, carries out measures to restore blood supply, and in critical situations deals with amputation. A podiatrist is a doctor whose work includes foot care, treatment of diabetic feet, treatment of ingrown toenails, etc.

Treatment of diabetic foot is based on four main points:

• Achieving diabetes compensation.
• Proper foot care to avoid complications.
• Drug therapy.
• Non-drug methods.

Compensation for the underlying disease

Hyperglycemia is the trigger for the development of all known complications of diabetes mellitus. Maintaining blood sugar levels within acceptable limits prevents the progression of damage to blood vessels and nerves, which is the basis for the development of diabetic foot.

Based on the results of diagnostic research methods, the endocrinologist determines the effectiveness of an insulin therapy regimen or taking glucose-lowering drugs (depending on the type of underlying disease). If necessary, a correction is made, one drug is replaced by another or an additional drug is added.

Self-monitoring of blood sugar levels is an important preventive measure for diabetic foot

Important! It is necessary to achieve blood sugar levels no higher than 6 mmol/l, and glycosylated hemoglobin (HbA1c) no more than 6.5%.

Foot care

All diabetics should follow proper foot care to prevent complications or slow their progression. The severity of implementation depends on how much the patient’s sensitivity level is affected. For example, a patient with normal sensitivity levels can trim his toenails with scissors, but those with impaired sensitivity can only file them.

Expert advice on foot care is as follows:

Why do your legs hurt with diabetes?

1. Choosing the right shoes. Orthopedic models or those made according to the patient’s individual parameters can be used. It is possible to use coracoid toe correctors, bursoprotectors that protect the interdigital spaces, and orthopedic insoles.
2. Timely removal of calluses. It is not recommended to open blisters on your own; it is advisable to entrust this procedure to a doctor.
3. Elimination of thickening of nail plates. If this condition is caused by a fungus, it is advisable to carry out antifungal treatment. Other reasons require constant filing of the top of the nail.
4. Getting rid of dry skin and cracks. An emollient cream or antifungal treatment is used (depending on the etiological factor).

Treatment of diabetic foot syndrome

All complications of diabetes are potentially dangerous and require mandatory therapy. Treatment of diabetic foot should be comprehensive.

Treatment of trophic ulcers with good blood flow in the limb:

• Careful treatment of the ulcer
• Unloading the limb
• Antibacterial therapy to suppress infection
• Compensation for diabetes mellitus
• Rejection of bad habits
• Treatment of concomitant diseases that prevent ulcer healing.

Treatment of trophic ulcers with impaired blood flow (neuroischemic form of diabetic foot):

• All of the above points
• Restoring blood flow

Treatment of deep trophic ulcers with tissue necrosis:

• Surgery
• If there is no effect - amputation

Treatment of trophic ulcers

After examination and examination, the doctor removes tissue that has lost viability. As a result, the spread of infection is stopped. After mechanical cleansing, it is necessary to rinse the entire surface of the ulcer. Under no circumstances should treatment with brilliant green, iodine or other alcohol solutions, which further damage the skin, be allowed. For rinsing, use saline solution or mild antiseptics. If, during wound treatment, the doctor detects signs of excess pressure, he may prescribe unloading of the sore limb.

Unloading the limb

The key to successful treatment of an ulcer is the complete removal of the load on the wound surface. This important condition is often not met, since the pain sensitivity of the leg is reduced and the patient is able to lean on the sore leg. As a result, all treatment turns out to be ineffective.

• for leg ulcers, it is necessary to reduce the time spent in an upright position
• for wounds on the dorsum of the foot, you should wear street shoes less often. It is allowed to wear soft house shoes.
• for ulcers on the supporting surface of one foot, unloading devices are used (immobilizing unloading bandage on the lower leg and foot). Contraindications to wearing such a device are deep tissue infection and severe limb ischemia. We must not forget that orthopedic shoes, suitable for prevention, are not suitable for unloading the foot.

Infection suppression

Healing of trophic ulcers and other defects is possible only after the infectious process has subsided. Washing the wound with antiseptics is not enough; long-term systemic antibiotic therapy is necessary for cure. In the neuropathic form of DFS, antimicrobial agents are used in half of the patients, and in the ischemic form, such drugs are necessary for everyone.

Glucose compensation

A significant increase in blood glucose levels causes the appearance of new trophic ulcers and complicates the healing of existing ones due to nerve damage. With the right glucose-lowering medications, insulin pumps or insulin doses, diabetes can be controlled, reducing the risk of diabetic foot to a minimum.

Rejection of bad habits

Smoking increases the risk of atherosclerosis of the vessels of the leg, reducing the chances of saving the limb. Alcohol abuse causes alcoholic neuropathy, which, together with diabetic nerve damage, leads to trophic ulcers. In addition, drinking alcohol eliminates stable compensation of carbohydrate metabolism, as a result, glucose levels in drinking patients are constantly elevated.

Treatment of concomitant diseases

Many diseases and conditions, unpleasant in themselves, become dangerous with diabetes. They slow down the healing of trophic ulcers, increasing the risk of gangrene and foot amputation. The most undesirable companions of diabetes include:

• anemia
• unbalanced and insufficient nutrition
• chronic renal failure
• liver diseases
• malignant neoplasms
• therapy with hormones and cytostatics
• depressive state

In the conditions described above, treatment of diabetic foot syndrome should be especially careful.

Restoring blood flow in the lower extremities

In the neuroischemic form of diabetic foot syndrome, blood flow is so impaired that healing of even the smallest ulcer becomes impossible. The result of this process sooner or later is amputation. Therefore, the only way to save the limb is to restore vascular patency. Drug restoration of blood flow in the legs is often ineffective, so for arterial insufficiency, surgical methods are usually used: bypass surgery and intravascular operations.

Surgical treatment of purulent-necrotic processes

• cleansing and draining deep ulcers. In case of a deep ulcer, a drainage is placed at its bottom, through which the outflow of secretions occurs. This improves healing.
• removal of non-viable bones (for osteomyelitis, for example)
• plastic surgery for extensive wound defects. Replacing damaged skin with artificial skin is widely used.
• amputations (depending on the level of damage they can be small or high)

Amputation of a limb is a last resort measure used when the patient’s general condition is severe or other treatment methods have failed. After amputation, restorative treatment and compensation for diabetes mellitus are necessary for better healing of the stump.

Drug treatment

Standards for the use of drugs for the treatment of diabetic foot have two main directions that can be used in combination. This includes means to improve metabolic processes in nervous tissue and the use of medications to eliminate symptoms in the form of pain and sensory disturbances.

Drugs affecting metabolism

Widely used groups of medications are alpha-lipoic acid derivatives and B-series vitamins. Other drugs have been prescribed in the past, but none of them have proven their effectiveness. “Metabolic” drugs can slow down the progression of the neuropathic form of pathology and reduce the severity of symptoms.

Alpha lipoic acid (Berlition, Thiogamma, Espa-Lipon) has the following properties:

• binds and removes free radicals;
• improves blood flow through the epineural vessels (those that nourish the nerves);
• restores the deficiency of cellular enzymes;
• increases the speed of spread of excitability along nerve fibers.

Thiogamma is a derivative of alpha-lipoic (thioctic) acid that eliminates the symptoms of diabetic foot syndrome

The amount of B vitamins in the blood in diabetes mellitus is sharply reduced. This is due to their intensive excretion in urine. Conventional vitamin-based single preparations are water-soluble and poorly penetrate the blood-brain barrier. To solve this issue, Neuromultivit, Milgamma, and Benfotiamine were created.

Symptomatic treatment

This therapy is not used in all patients, since the pain of the initial stage is later replaced by a complete absence of pain and a sharp decrease in all types of sensitivity.

Important! Conventional analgesics and anti-inflammatory drugs are ineffective in eliminating pain.

Patients with pronounced manifestations of pathology are treated with antidepressants (Amitriptyline, Imipramine) and anticonvulsants (Carbamazepine, Tegretol, Phenytoin). Both groups are not used if the patient has glaucoma, since they can affect intraocular pressure.

At the moment, the following are also widely used:

• Gabapentin is an anticonvulsant that can suppress neuropathic pain syndrome. Side effects are practically uncharacteristic. Dizziness, mild nausea, and drowsiness may occur.
• Pregabalin also belongs to the group of anticonvulsants and has a mechanism of action similar to Gabapentin.
• Duloxetine is an antidepressant with central action. Caution should be used in diabetics who have glaucoma and suicidal thoughts due to pathology of the nervous system.

Diagnosis of diabetic foot syndrome

At the first signs of trouble, a patient with diabetes should consult a specialist and describe in detail the symptoms associated with diabetic foot. Ideally, there is a “Diabetic Foot” office in the city with a competent podiatrist. If this is not the case, you can contact a therapist, surgeon or endocrinologist. An examination will be performed to make a diagnosis.

Innovation

New in the treatment of diabetic foot syndrome, Eberprot-P is a Cuban drug that is a recombinant growth factor of epidermal cells. This unique medication is designed for the fastest possible regeneration of cells in the area of ​​the ulcer; it is injected directly along the edges of the wound, changing the needle after each puncture.

Eberprot-P is a product for local injections that are injected into areas of ulcerative defects

Cuban doctors suggest that the product reduces the number of necessary sanitation procedures, reduces the risk of amputation, and promotes rapid healing of ulcers. In Cuba, Eberprot-P is provided to patients free of charge. In other countries, its price rises to several thousand dollars.

Symptoms and signs

The main symptom of diabetic foot is leg ulcers that take a long time to heal. If harmful bacteria multiply in them, then these ulcers look truly scary to an unfamiliar person. If left untreated, the infection can cause gangrene. Amputation of a finger, foot, or entire leg will be required. Otherwise, the patient may die from intoxication. In addition to ulcers, signs of diabetic foot may include:

• calluses;
• fungal infections of the nails and skin of the feet;
• crooked fingers;
• ingrown nails;
• cracks in the skin.

Sometimes there is pain due to the fact that the shoes are not chosen correctly and are not designed for swelling of the feet.

What do leg ulcers look like in diabetes?

Impaired blood circulation due to atherosclerosis can cause attacks of pain called intermittent claudication. If you are worried about leg pain, read about pain medications here. However, in most cases, the patient has lost pain sensitivity due to diabetic neuropathy. Redness and swelling are signs of infection or skin rubbing from unsuitable shoes. It even happens that the temperature of the infected area of ​​the foot to the touch is 2 or more degrees higher than that of the surrounding tissues. Blood poisoning can cause fever or chills.

Restoration of blood circulation

Includes constant control over body weight, reducing it if it is overweight, giving up bad habits, and maintaining optimal blood pressure levels. In the treatment of arterial hypertension, ACE inhibitors (Lisinopril, Captopril) and calcium antagonists (Verapamil, Nifedipine) are used due to the lack of their interference with metabolic processes. The use of thiazide diuretics (Hydrochlorothiazide) also showed a positive effect.

The next stage is normalization of the lipid profile. Studies have shown that diet alone is not able to have the necessary effect on blood cholesterol levels in diabetics. Medications are prescribed in parallel with diet therapy. Statins (Simvastatin, Lovastatin) are used for this purpose.

Antiplatelet agents

Small doses of Acetylsalicylic acid can reduce the risk of developing gangrene in patients with diabetic foot syndrome. If there are contraindications to its use, Clopidogrel and Zilt are prescribed.

Complications

The extreme and most dangerous stage of DFS is the development of gangrene of the foot. Diabetic foot is the leading cause of non-traumatic amputation in peacetime. Every year in Russia 70,000 amputations are performed for diabetic gangrene.

Diabetic gangrene often occurs with an associated anaerobic infection. With this outcome, the damaged tissues die, and the blood and healthy tissues become infected. The disease develops very quickly, often leading to death.

Trophic ulcers are another complication, most often found on the sole or big toe. They can also form on the sides of the foot from poorly fitting shoes. If left untreated, they can lead to serious infections. The classification of complications of diabetes includes trophic changes in the skin of the foot.

Surgical interventions

Against the background of diabetic foot syndrome, surgical operations can have several goals: restoration of blood supply to a particular area, emergency removal of the lower limb in case of critical indicators of purulent-necrotic processes, and orthopedic correction.

Basic methods of surgical reconstruction:

• Bypass surgery (aortofemoral, iliofemoral, femorofemoral, femoropopliteal) is a commonly used intervention that allows the creation of a bypass for blood.
• Balloon angioplasty is a mechanical “inflation” of the affected area of ​​the artery, restoring blood flow. It can be performed as a separate operation or combined with the placement of a stent (a device that keeps the repaired area from narrowing again).
• Sympathectomy is an intervention in which several lumbar ganglia responsible for regulating vascular tone are removed.

Balloon angioplasty is a method of increasing the lumen of the affected artery

Amputation is the removal of non-viable tissue along with articular and bone elements. The height of the intervention is determined by the angiosurgeon. Orthopedic correction is represented by arthrodesis of the ankle joint, plastic surgery of the Achilles tendon.

Foot care for diabetes

Above we describe in detail how to choose orthopedic shoes and socks and how to lubricate your feet. And here is important additional information about foot care that was not included in the previous sections.

The main rule: do not remove calluses under any circumstances! Do not allow your podiatrist, pedicurist, or anyone else to do this. Calluses are a natural and effective defense against excess pressure on areas of the feet. Their appearance signals that you need orthopedic shoes. After removing calluses, wounds remain, from which trophic ulcers often form.

Quit smoking if you haven't already. Avoid secondhand smoke. People with diabetic neuropathy should not walk barefoot to reduce the risk of ulcers and other foot injuries. When you recover from neuropathy, restore sensitivity in your feet, and then you will walk barefoot. Until then, it’s impossible.

Foot care for diabetes

You need to carefully examine your feet every day, paying attention to any changes, and even more so, damage. You should be concerned about blisters, cracks, calluses, traces of minor subcutaneous hemorrhages, and even more so, ulcers and wounds. Don't forget to check the skin between your toes. If necessary, use a mirror to look at everything carefully. Don't hesitate to see a doctor quickly if the condition of your feet worsens.

Baths and other water treatments

Do not immerse your feet in water for more than 3-4 minutes, even if your doctor recommends it. Don't take any baths. Avoid prolonged skin contact with water to avoid unnecessary risk of damage. Turn on the water, check its temperature with an alcohol thermometer, get in, quickly wash and get out. Don't lie in the bathroom. If you like to swim in the pool, it is advisable to lubricate your feet with Vaseline before diving into the water.

Avoid open flames and objects that can cause burns. Keep your feet and hands away from radiators and radiators. You need an alcohol thermometer. Use it to check the temperature of the bathroom before you get into it. Moreover, this temperature should not be higher than 34 ℃. Because any higher temperature can cause burns in people who have poor circulation. Do not check the temperature with your foot or hand. Use an alcohol thermometer for this.

Hypothermia of the feet is almost as serious a danger as a burn. Don't stay out in the cold for more than 20 minutes at a time. Choose warm and comfortable socks carefully. Every few years, it is advisable to undergo a medical examination to determine how severely the blood circulation in the legs is impaired. If you keep your blood sugar consistently normal using Dr. Bernstein's methods, it will gradually return to normal.

Do not apply adhesive tape, tape, or any other type of adhesive tape to your skin. Because there may be damage left after you remove them. Do not apply hydrogen peroxide, iodine in alcohol, salicylic acid, or callus preparations to your skin. Do not use the listed disinfectants. Because they cause burns and inhibit the healing of damage.

Treatment of ulcerative and purulent-necrotic lesions

Local interventions involve removal of necrosis, revision of the ulcerative defect, excision of corns along the edges, washing the wound and applying bandages. “Dead” tissue requires removal because it is considered an optimal environment for infection to multiply. The process can occur using a scalpel, scissors, a Volkmann spoon, dressings with proteolytic enzymes or hydrogels. Be sure to inspect the wound using a button probe, since even a seemingly small defect may turn out to be a fistula.

Important! Hyperkeratosis (thickening of the skin) appears along the edges of the wound, which must be excised. This will reduce pressure on the ulcer when walking.

Excision of corns along the edges of the defect - a stage in the treatment of ulcers in diabetic feet

Washing the wound reduces the amount of pathogenic microflora on its surface. Rinsing with a stream of solution using a syringe and needle has shown effectiveness. It is known that brilliant green, iodine, potassium permanganate solution and Rivanol are contraindicated for the treatment of ulcerative defects. Hydrogen peroxide can only be used during the cleansing stage, when purulent contents and blood clots are present.

Washing the ulcer can be done:

• saline solution;
• Miramistin;
• Chlorhexidine;
• Dioxidine.

After the procedure, the wound must be covered with a dressing. If gauze is used for this purpose, it must be soaked in ointment to prevent drying to the defect. It is possible to prescribe antimicrobial agents (Betadine, Argosulfan), antibiotics (Levomekol ointment), recovery stimulants (Becaplermin gel), proteolytic agents (Chymotrypsin, Iruksol ointment).

Folk remedies

No herbal folk remedies for diabetic foot help, nor do animal products. On the Internet you can find recommendations for making baths and poultices for affected feet using the following products:

• mustard seeds;
• clove oil;
• bird cherry decoction;
• other common and exotic plants.

Stay away from these quack drugs. Traditional recipes for diabetes and its complications are a trap.

While the patient is losing precious time, he may develop gangrene. It will lead to amputation or death. Many patients are looking for some miracle Cuban drug that will quickly and easily cure diabetic foot. Such a magical medicine does not exist in nature. You need to urgently consult a qualified doctor. If you're lucky, you'll be able to avoid amputation.

Some diabetics make foot baths with baking soda at home. However, baking soda is not a suitable means to disinfect and soften the skin. Instead of taking baths, you need to protect your feet from excessive contact with water. Because after prolonged exposure to water, the skin is most vulnerable to damage.

They definitely don’t help with diabetic foot:

• sodium thiosulfate;
• shock wave therapy.

At the expense of diabetics who are fond of folk remedies, surgeons carry out their plan for amputations. Specialists who treat kidney and vision complications of diabetes are also not idle. Don't do anything stupid. Learn and use a step-by-step treatment plan for type 2 diabetes or a type 1 diabetes management program. Keep your blood sugar normal with a low-carb diet.

Unloading the limb

No matter how effective modern drugs are, as long as the patient steps on the wound, it cannot be expected to heal. If the ulcer is localized in the lower leg or dorsum, there is no need for additional unloading devices. When placed on a supporting surface, a special bandage made of polymer materials or a half shoe is used. As a rule, the fingers are left open.

Important! The average rate of healing of ulcers that have existed for years against the background of the unloading method is 90 days.

A boot is one of the ways to relieve a sore leg

Treatment

Treatment of diabetic foot is carried out in several areas:

• control of glucose metabolism;
• surgical treatment of the wound;
• taking antibiotics;
• unloading the affected area when walking;
• daily inspection, compliance with foot care rules.

Some of the necessary steps can only be performed in specialized medical centers, but the main treatment is at home. Obviously, you need to try to bring your glucose levels as close to normal as possible. Read the article “How to lower blood sugar” for more information. If there is an infected wound, surgical debridement is usually required. You cannot limit yourself to taking antibiotics without the participation of a surgeon. He must remove all non-viable tissue. Patients are taught daily inspection and care of the wound until it is completely healed. This is done by specialists who work in diabetic foot clinics.

Cure from diabetic foot is possible if you are not lazy

Many different types of bacteria can cause infected foot wounds and ulcers. First, tests are used to determine which microbes are causing problems, and then antibiotics are prescribed that are effective against them. Universal broad-spectrum drugs help in no more than 50-60% of cases. This page does not contain detailed information about antibiotics to discourage patients from self-medicating with them. The worst thing is if a diabetic is attacked by bacteria that have developed resistance to modern drugs.

Wet gangrene, phlegmon, deep abscesses are serious complications that threaten the life or safety of the patient’s limb. To treat them, antibiotics usually have to be administered through injections in a hospital setting. Success depends on how conscientiously the surgical treatment of the wound is carried out. In milder cases, antibiotic tablets are taken at home to treat diabetic foot. The doctor must carefully adjust their doses, taking into account the fact that a diabetic may have kidney complications.

Immobilizing unloading bandage

It is very important to relieve the affected area of ​​the foot. You need to try to distribute the pressure that occurs when walking more evenly. A healthy person with a foot injury limps, trying not to step on the wound to avoid pain. However, many diabetics do not feel this pain due to neuropathy. They step on wounds when walking. This causes additional injury and blocks healing. It can drag on for many months or even years.

Unloading of the affected leg can be achieved with the help of a professional bandage made of polymer materials. This bandage is called an immobilizing bandage. Do not confuse this with an antibacterial dressing that is applied to a wound. For details, contact specialized centers that treat diabetic feet. Orthopedic shoes are good for prevention, but they are no longer enough to treat advanced cases. Ask if it is possible to provide the patient with a special unloading bandage.

Treatment at home consists of following foot care rules, recommendations for unloading the affected foot, and achieving and maintaining normal blood sugar. Due to a depressed mental state, many patients do not want to conscientiously follow the regimen and neglect to perform the necessary procedures. Relatives of a diabetic and the patient himself should think about solving this problem.

Which doctor treats this problem?

A specialist in foot problems is called a podiatrist. He should not be confused with a pediatrician. The main thing you must learn is: don't let him remove calluses! Because after their removal, wounds remain that become a haven for harmful bacteria. Removing calluses often leads to gangrene. It should not be done under any circumstances. In addition to the podiatrist, the participation of a surgeon and an orthopedist may be necessary. The main role in treatment should be played by an endocrinologist who helps the patient maintain normal blood sugar. In practice, diabetics need to independently control their glucose metabolism, without relying on the help of doctors.

Can diabetic foot be cured?

If gangrene has not yet developed and there has been no amputation, then diabetic foot can, in principle, be completely cured. However, it is not easy. It is necessary to lower blood sugar to normal and keep it stable within the range of 3.9-5.5 mmol/l, as in healthy people. To do this, you should switch to a low-carb diet and take the time to inject insulin in precisely calculated doses in addition to a healthy diet. Read more about the step-by-step treatment plan for type 2 diabetes or the type 1 diabetes control program.

You need to learn to accurately calculate insulin dosages and follow the regimen every day, making no exceptions on weekends and holidays. However, the time and effort put in will pay off. Because normal blood glucose levels protect not only from diabetic foot, but also from all other complications.

Treatment of diabetes with insulin - where to start:

Types of insulin: how to choose drugs Long insulin for injections at night and in the morning Calculation of the dose of rapid insulin before meals Insulin administration: where and how to inject correctly

No diet other than a low-carbohydrate diet allows diabetics to maintain stable, normal sugar levels without spikes. There are no miracle pills, bandages or physical therapy treatments that can cure a diabetic's foot problems without adopting a healthy lifestyle.

The main cause of diabetic foot is neuropathy, a loss of sensitivity in nerve fibers. This complication is completely reversible. After several months of maintaining stable, normal blood sugar, the nerves gradually recover. Atherosclerotic plaques that have managed to form in the vessels will no longer disappear. However, you can slow down their growth and improve blood circulation in the legs. Sensitivity is restored and skin lesions that have been bothering you for a long time are healed.

How long do people live with diabetic foot?

Diabetics who are not lazy to keep their sugar consistently normal live to a ripe old age, like healthy people. However, patients who try folk remedies to treat infected wounds on their legs, instead of urgently consulting a doctor, quickly die.

The prognosis depends on the length of diabetes, the severity of complications that have already developed, and most importantly, on the patient’s motivation. As they say, if a person truly wants to live, then medicine is powerless... Dr. Bernstein’s methods, which are promoted by the Endocrin-Patient.Com website, work wonders. Except in advanced cases, when diabetic kidney damage has already passed the point of no return.

How long do people live after leg amputation due to diabetes?

How long they live after leg amputation depends primarily on the patient’s motivation. In principle, an amputated leg does not really interfere with leading a full life. Kidney failure or blindness caused by diabetes are much more serious complications. You can live to a ripe old age using a step-by-step treatment plan for type 2 diabetes or a type 1 diabetes management program. Read about who Dr. Bernstein is and be inspired by his example.

Can diabetic foot be treated without amputation?

Whether it is possible to cure a diabetic foot without amputation depends on at what stage of the disease the patient seriously decided to take up his treatment. As a rule, it is not possible to do without amputation. If gangrene has already begun, refusal of surgical treatment will lead to death from intoxication of the body.

Only a qualified and experienced surgeon should make the decision. In this case, it is impossible to do without consulting a doctor. Do not try to solve the problem of an infected, rotting diabetic foot while sitting at home, following recommendations from the Internet. It was necessary in time, at the prevention stage, to follow the foot care rules described below on this page.

What kind of shoes does the patient need?

Choose soft and comfortable orthopedic shoes, regardless of their non-standard appearance. Under no circumstances should shoes rub, squeeze the foot, or interfere with blood flow. You should buy or order it not in the morning, but in the afternoon, late in the evening, when the leg size is at its maximum during the day. Shoes should be comfortable from the first try on. It shouldn't require breaking in. Sandals that have a strap between the toes should not be worn.

Shoes to prevent foot damage

Inspect your shoes daily to see if there are any pebbles or other foreign objects, protruding nails, or any abrasions or compactions. If necessary, contact your shoemaker immediately to correct the problem. Don't wait until your foot gets damaged and you have to deal with it to heal. You need to have at least two pairs of comfortable, suitable shoes and alternate them every other day, rather than wearing the same pair every day.

Socks also need to be given attention. Not ordinary socks will suit you, but special ones that do not compress the blood vessels with elastic bands. They should be the right size, not too big. You should not wear socks with holes to avoid damaging your feet. For diabetics who have poor circulation in their legs, socks are an important means of protection against freezing during the cold season. Thus, you need to carefully select socks, not using the first ones you come across or the cheapest ones.

What ointments to use for diabetic foot?

If the skin on your leg is dry, it needs to be lubricated to prevent it from cracking. Olive or any other vegetable oil is suitable for this, as well as animal fats and lanolin. It’s not bad if the ointment or cream contains vitamin E. It is better not to use mineral oil, petroleum jelly and other petroleum products. Because they are not absorbed.

It is important to lubricate the skin after prolonged water procedures. Because at this time she is especially vulnerable to damage. In general, it is better to avoid long-term water procedures. This is discussed in more detail below in the list of foot care rules. Don't expect that lubricating a wound or ulcer will protect you from infection or cure diabetic foot syndrome. Such a magical miraculous ointment or cream does not yet exist in nature.

Fighting infection

Indications for antibiotics:

• wound with signs of infection;
• ischemic necrosis;
• a long-term, large defect with a high risk of infection.

The choice of drug is based on the results of bacterial culture and determination of the sensitivity of microorganisms. Preference is given to penicillins (Amoxiclav), cephalosporins (Ceftriaxone, Cefepime), fluoroquinolones (Ofloxacin, Ciprofloxacin), aminoglycosides (Amikacin, Gentamicin).

Antibiotics are taken orally and administered parenterally. The duration of treatment depends on the patient's condition. Milder forms require the drug to be prescribed for 10-14 days, severe forms require a month or more.

How does SDS develop?

Expert opinion

Guseva Yulia Alexandrova

Specialized endocrinologist

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It all depends on the degree of compensation for diabetes. By keeping sugar at the level of acceptable norms and following all the instructions, you can prevent diabetes from destroying the body for a long time, but it does not disappear anywhere and sooner or later it will begin to actively remind itself.

The pathogenesis of the formation of diabetic foot is due to three main reasons:

• Diabetic neuropathy is the most common complication of diabetes;
• Damage to the blood vessels of the lower extremities;
• Infection, which usually always accompanies the first two factors.

The predominance of certain disorders: either the clinical picture of neuropathy, or changes in the peripheral blood flow, determines the symptoms of diabetic foot, which represent 3 forms of the pathological process. Thus, we distinguish:

1. Neuropathic variant, which is characterized by damage to the nervous system, both somatic and autonomic. The classification of neuropathy in diabetes is quite extensive, but the main driving force for the development of DFS is considered to be a decrease in the conductivity of nerve impulses in sensory and motor peripheral nerves, as well as a violation of all types of sensitivity (vibration, tactile, thermal). Neuropathy, as a sign of diabetic foot, can occur in three scenarios:
   diabetic foot ulcer,
2. osteoarthropathy with the formation of Charcot joint,
3. neuropathic edema;
4. Ischemic type , developing as a result of atherosclerotic changes in the walls of the arterial vessels of the legs and leading to disruption of the main blood flow;
5. Neuroischemic or mixed form, including signs of both neuropathies and ischemic lesions caused by pathological processes affecting the nervous system and the main vascular bed.

Expert opinion

Guseva Yulia Alexandrova

Specialized endocrinologist

Ask a Question

Isolated forms, in particular neuropathic and ischemic, are less common, except at the beginning of the process. As a rule, over time, a mixed form is formed: if DDS is initiated by ischemia, then it will not be possible without the participation of nerves, and vice versa - neuropathy will sooner or later involve the participation of vessels, which in diabetics are very quickly and often affected by atherosclerosis.

Non-drug methods

These methods will not answer the question of how to treat diabetic foot, but will help reduce the brightness of the clinical picture. This includes massage, therapeutic exercises, and physiotherapy.

Massage

Before starting a foot massage, the specialist’s hands are treated with talcum powder, baby powder or rich cream. This method will protect the patient’s legs from possible damage and improve gliding. During the procedure, the patient takes the position that causes him the least discomfort (lying on his back, on his side, sitting).

Working out the lower extremities begins with the area of ​​​​the shins and ankle joint, then moves higher from the knee to the groin area. The foot massage itself occurs last. Each phalanx, interdigital spaces, plantar and dorsal surfaces, and heel are treated.

Foot massage is a therapeutic and preventive method for diabetes mellitus

Important! At the end of the procedure, the skin is moisturized with a rich cream.

Physiotherapy

The goal is to improve blood microcirculation in ischemic areas, but significant physical activity is not indicated, since it can lead to increased pain and complications. You can do the following exercises:

• flexion and extension of toes;
• rolls from heel to toes, resting your foot on the floor;
• circular movements of the leg in a sitting position;
• flexion and extension of the leg at the ankle joint;
• circular movements in the ankle joint.

The main causes of diabetic foot syndrome

In diabetes, there is insufficient production of the hormone insulin, the function of which is to help glucose (sugar) reach the body's cells from the bloodstream, therefore, with its deficiency, glucose rises in the blood, over time disrupting the blood flow in the vessels, damaging the nerve fibers. Ischemia (lack of blood circulation) leads to impaired wound healing, and nerve damage leads to decreased sensitivity.

These disorders contribute to the development of trophic ulcers, which in turn develop into gangrene. Any cracks or abrasions turn into open ulcers, and hidden ulcers also form under calluses and keratinized layers.

The reason for the late start of treatment and amputation of limbs is that the patient does not notice the changes occurring for a long time, since most often he does not pay attention to his feet. Due to poor blood supply to the legs along with decreased sensitivity, the pain from cuts and abrasions is not felt by the patient and even an ulcer can go unnoticed for a long time.

Typically, damage to the foot occurs in those places that bear the entire load when walking; cracks form under the insensitive layer of skin into which infection enters, creating favorable conditions for the occurrence of a purulent wound. Such ulcers can affect the legs down to the bones and tendons. Therefore, eventually there is a need for amputation.

Globally, 70% of all amputations are related to diabetes, and with timely and consistent treatment, almost 85% could be prevented. Today, when the “Diabetic Foot” offices are open, the number of amputations has decreased by 2 times, the number of deaths has decreased, and conservative treatment is 65%. However, the real number of people with diabetes is 3-4 times higher than statistical data, since many are not aware that they are sick.

So, the reasons for the development of diabetic foot syndrome are:

• decreased sensation in the limbs (diabetic neuropathy)
• circulatory disorders in arteries and small capillaries (diabetic micro- and macroangiopathy)
• foot deformity (due to motor neuropathy)
• dry skin

Decreased sensation - diabetic distal neuropathy

The main cause of nerve damage is the constant effect of high levels of glucose on nerve cells. This pathology in itself does not cause tissue necrosis. Ulcers occur for other, indirect reasons:

Ulcers that form after micro-abrasions, cuts and abrasions heal very poorly, becoming chronic. Wearing uncomfortable and tight shoes aggravates skin damage. Trophic ulcers, growing and deepening, spread to muscle and bone tissue. According to research, the development of neuropathic ulcers in 13% of cases is caused by excessive thickening of the stratum corneum of the epidermis (hyperkeratosis), in 33% by the use of inadequate shoes, in 16% by treating the foot with sharp objects.

Impaired blood flow - diabetic macroangiopathy

Deterioration of blood flow through the arteries of the legs is associated with atherosclerotic plaques (see how to reduce cholesterol without drugs). Atherosclerosis, which causes damage to large vessels, is severe in diabetes mellitus and has a number of features.

• the lower parts of the leg are affected (arteries of the leg)
• damage to the arteries of both legs and in several areas at once
• begins at an earlier age than in patients without diabetes

Atherosclerosis in a patient with diabetes can cause tissue death and the formation of trophic ulcers independently, without mechanical impact or injury. An insufficient amount of oxygen enters the skin and other parts of the foot (due to a sharp disruption of blood flow), resulting in the death of the skin. If the patient does not comply with precautions and further injures the skin, the area of ​​damage expands.

Typical clinical symptoms are pain in the foot or ulcer, dryness and thinning of the skin, which is highly susceptible to microtrauma, especially in the toes. According to research, the triggers for neuroischemic lesions are fungal infections of the feet in 39% of cases, treatment of the feet with sharp objects in 14%, and careless removal of ingrown toenails by a surgeon in 14%.

The most dramatic consequence of DFS is amputation of a limb (small - within the foot and high - at the level of the leg and thigh), as well as the death of the patient from complications of the purulent-necrotic process (for example, from sepsis). Therefore, every diabetic patient should know the first symptoms of diabetic foot.

The role of ointments in the local treatment of ulcers in diabetic patients

The presence of purulent discharge requires the use of antiseptics and drugs with a targeted effect against microorganisms that have infected the wound.
Vizox is a natural remedy based on native plant extracts. More details

After cleansing the ulcer, it is necessary to use drugs that promote tissue restoration.

All ointments for diabetic foot can be divided according to these purposes into topical agents with antimicrobial action and drugs that improve regeneration. To relieve severe swelling and relieve pain in the leg, drugs based on NSAIDs can be used.

Symptoms

Signs of diabetic foot in diabetes mellitus are given in the table; they depend on the characteristics of the forms and stages of the pathology, as can be seen in the photo above.

Table 1: Symptoms and clinical picture of diabetic foot:

Diabetic foot (initial stage) does not cause pain or suffering. Since there are no pain impulses due to the death of nerve endings.

Only later does the foot swell and turn red, coldness appears in the toes, soles and ankles, pins and needles and goosebumps appear in the muscle tissue. People quickly get tired from walking and suffer from cramps in their calves. Bone deformities and diabetic foot ulcers make it difficult to choose appropriate shoes.

How to avoid surgery for diabetic foot?

Unfortunately, amputation is resorted to in approximately 15-20% of cases of diabetic foot syndrome. Although in most cases, amputation can be prevented if treatment is started promptly and correctly.

First of all, it is necessary to prevent the formation of trophic ulcers. If damage does occur, treatment should be started as early as possible. It is necessary to find out in advance from your endocrinologist about the work of specialized diabetic foot rooms and contact them if problems arise. Conditions such as osteomyelitis (suppuration of bone tissue) and ulcers associated with critical limb ischemia (severe impairment of blood flow to the foot) pose a high risk of amputation.

In case of osteomyelitis, an alternative to amputation may be a long (1.5-2 months) course of antibiotics, and high doses and combinations of drugs must be used. In case of critical ischemia, the most effective is the use of semi-surgical - balloon angioplasty, and surgical - vascular bypass, methods.

Fourth stage of diagnosis

The fourth component of the diagnosis of diabetic foot syndrome is the analysis of the state of arterial blood flow. Non-invasive research methods (Dopplerography, Dopplerometry) are the most widely used. Systolic pressure is measured in the arteries of the leg, foot and thigh, and the occlusion gradient is determined based on the pressure level readings. The level of reduction in arterial blood flow is reflected by the ankle-brachial index. The indicators of this index determine the direction of further examination; they determine the degree of oxygen saturation of tissues.

Sometimes there is a question about the need for additional treatment - angiography. Determining the level of systolic pressure helps predict the healing of ulcerative lesions and determine the possibility of conservative treatment.

general information

Mostly development proceeds secretly, unnoticed, without any noticeable impact on general well-being. It is detected in the later stages, when therapeutic opposition becomes a difficult task, and is characterized by unfavorable development.

Careful monitoring of sugar readings, and on a regular basis, is a strong argument in favor of minimizing the risks of diabetes complications.

Often, over a long period of time, the changes that occur go unnoticed, since, let’s be honest, not enough attention is paid to the “well-being” of the foot in everyday life.

This causes an untimely start of the therapeutic process.

For a diabetic, such negligence and irresponsibility is categorically unacceptable and is fraught with negative consequences. The likelihood of encountering complications increases significantly; with deep lesions, the risks of surgical solution to the problem increase.

The areas of the foot that are maximally loaded while walking are often injured, and cracks and calluses appear under the insensitive layer of skin. An infection that has penetrated inside creates the preconditions for the development of a purulent wound, and ulcerative defects are formed. As it gets more complicated, the lesion can become deep, affecting the bones and tendons.

Painful discomfort created by abrasions, cracks, and microcuts is weakly expressed, since tissue sensitivity is low due to damage to nerve fibers and impaired blood flow in the vessels. Such damage goes unnoticed for a long time.

The final sad result is possible surgical intervention.

The risks of amputation become relevant for almost every fourth person suffering from diabetic foot syndrome (hereinafter referred to as DFS), however, recently the percentage of such “mutilating” surgical interventions has been decreasing.

By contacting in a timely manner, doctors will have a chance to save the affected limb and return the patient to normal life. All acceptable conservative methods are used.

Diabetes mellitus is a severe endocrine pathology, accompanied by many dangerous, sometimes life-threatening complications, which, unfortunately, appear in many diabetics over time.

Problems with the legs, and in particular with the feet, are one of the formidable, late “additions” of diabetes.

With strict discipline of the patient and a competent therapeutic approach, it is quite a feasible task to adequately resist diabetic foot.

Surgery is a radical decision and is taken only in life-threatening clinical situations.

In a negative scenario, the forecasts are not reassuring; loss of the ability to self-care, limited mobility, systematically reduces the quality of life, leaving a strong negative imprint on the mental state.

Severe pain syndrome forces you to constantly remain in a state of tension, stress, and the degree of psychological stability rapidly decreases.

Support from loved ones in such a situation is mandatory - a vital action for the patient.

Amputation allows you to prolong life, but such a dramatic consequence of SDS sometimes does not guarantee a cure. The pathological process can develop on the other foot.

Unfortunately, postoperative risks (sepsis) are high and extremely dangerous; the percentage of deaths, despite the recent reduction, still remains high.

For SDS, the problem of improving the quality of diagnosis of this critical situation and timely medical examination is relevant.

A separate serious issue remains the cost of treatment and rehabilitation.

Physiotherapy

Therapeutic exercises are an important component of the treatment of diabetic foot. With the help of such measures, it is possible to normalize the blood circulation process and get rid of congestion. Timely initiation of therapy will help prevent the development of complications in a timely manner and reduce the likelihood of the need for surgical treatment. Every doctor should teach his patient how to do exercises. It will help restore your legs to their former sensitivity, performance, and relieve burning and numbness. You can follow these exercises for diabetic feet:

1. Lie on your back, raise your leg bent at the knee. Alternately straighten one or the other limb.
2. Alternately pull your legs towards you.
3. Press the bent legs at the limbs and move them away from you.
4. Raise either the left or the right limb perpendicular to the body.
5. Draw a figure eight or circle with your feet. Never cross your legs, which can impair blood flow.
6. Sit on a chair with your feet on the floor. After this, alternately raise and lower your socks.
7. Place a small ball between your feet and squeeze it.
8. Spread and curl your toes.
9. Roll round objects on the floor, working your feet.

Doing these exercises regularly will help significantly reduce your risk of developing diabetic foot. With their help, it is possible to normalize blood flow in the lower extremities, as well as strengthen the muscle corset. This is an excellent prevention of all leg pathologies that can develop as a result of diabetes.

All of the above exercises must be performed 2-3 times a day in 10 approaches. This is the only way to achieve significant improvement.

Edema and Charcot's foot

Charcot foot with bone deformity and fracture

Diabetic Charcot foot variant

Neuropathic edema: accumulation of fluid in the ankles occurs due to kidney pathologies or cardiovascular failure.

Doctors have not yet fully studied neuropathic pastosity, but it is assumed that fluid accumulation is facilitated by:

• frequent tissue disorders of the autonomic nervous system,
• shunts in arteries and veins that form in diabetes,
• hydrodynamics (pressure), which constantly changes in small and medium-sized vessels.

Long-term destructive osteoporosis, osteolysis, hyperostosis leads to diabetic foot syndrome: bone deformation, Charcot joint. Then the foot will resemble a bag of bones. Urgent treatment and orthopedic shoes will be needed.

Diagnostics

X-ray of Charcot's foot

Diagnosis of diabetic foot is based on studies:

• Ultrasound of blood flow using the Doppler method,
• vascular angiography,
• radiography,
• blood test: general and after culture,
• content of ulcers,
• glycemic profile (daily blood sugar level),
• neurological condition,
• palpation.

Development mechanism

The key structural pathogenetic directions are:

• neuropathy - damage to nerve fibers of a non-inflammatory nature;
• angiopathy - pathological changes in blood vessels leading to dysfunction, destruction of walls, occur against the background of nervous regulation disorders;
• penetration of infectious agents.

During diabetes mellitus, long-term high glucose concentrations gradually provoke the development of specific vascular disorders:

• atherosclerotic changes in large and medium-sized arteries;
• damage to peripheral nerves is caused by dysmetabolic processes accompanying diabetes.

Initially, the vascular “network” of the microvasculature is under attack, then larger vessels.

Consequences of angiopathy:

• loss of elasticity, impaired vascular patency;
• the blood thickens;
• weakens the sensitivity of nerve endings;
• the supply of tissues with nerves experiences problems (disruption of innervation occurs);
• disorder of cellular nutrition processes.

Due to high protein glycosylation (addition of saccharide residues), joint mobility decreases, the bones of the limb gradually become deformed, and the load on the foot increases.

The factor of dryness, thickening of the skin, caused by callus or fungal infection, is also considered a significant argument in the question of the pathogenesis of SDS, since it entails the appearance of cracks, abrasions, and abrasions on the surface.

When the health of the skin is in order, such injury does not bring any noticeable troubles and is quickly leveled out.

For a diabetic, the above is not relevant, since against the background of weakened tissue sensitivity, circulatory disorders, foot injuries of any nature, even minor ones, lead to the appearance of ulcerative defects.

The resulting trophic ulcers do not heal for a long time, opening the “door” wide for pathogenic microorganisms.

Having penetrated inside, the infection begins to “corrode” the surrounding tissues, the inflammatory process that has begun leads to necrotic changes that attack the muscle tissue, fatty tissue, and bone-ligamentous elements of the foot.

The consequences of infection of ulcers are extremely dire; the risks of developing significantly increase:

• abscess;
• phlegmon.

In the absence of adequate therapeutic actions, purulent processes intensify, the leg literally “rots,” tissue necrosis develops, and the question of amputation arises.

Orthopedic shoes for diabetic feet

Wearing special orthopedic shoes is one of the main stages in the prevention and treatment of diabetic foot. This is explained by the fact that ordinary shoes are made for healthy people who do not have impaired blood supply and/or innervation to the feet and legs. Wearing the same shoes by a patient with diabetic feet may cause ulcers to develop more quickly.

The main characteristics of orthopedic shoes are:

1. Matching the patient's foot. When buying regular shoes, it can be difficult to immediately choose the right size. In addition, due to the structure of the foot, new shoes can “rub” or “press” in the area of ​​the heel tendon, ankles, and big toes. In patients with diabetic feet, such phenomena are unacceptable, so shoes made for them must ideally fit all shapes and deformations of the foot.
2. No unevenness on the inner surface of the shoe. The inside of shoes or sneakers may have seams, protrusions, or other imperfections that can cause injury to the skin of a diabetic foot patient. It is for this reason that the inner surface of orthopedic shoes must be perfectly flat and smooth.
3. Rocker sole. Under normal conditions, when walking, the load is distributed alternately on the heel and on the foot, while the muscles of the arch of the foot are activated, reducing the load on its individual parts. In diabetic foot, these muscles are usually affected, causing the midfoot (usually arched upward) to straighten and lose its shock-absorbing properties. The rocker sole is a rigid plate, the inner (facing the foot) part of which is flat (usually it is adjusted to the shape of the patient’s foot), and the outer part has a slightly rounded surface and a raised toe. As a result, while walking, the patient’s foot “rolls” from the heel to the front, and the load on it is reduced several times.
4. No hard toe. In almost all regular shoes, the top of the toe is made of a rigid material that flexes and presses on the top of the toes or foot as you walk. In some cases, this can lead to calluses or pain even in a healthy person, and in a person with diabetic feet, such shoes will certainly cause the formation of ulcers. This is why the front upper of orthopedic shoes is always made of soft materials.

Orthopedic shoes are made individually in each specific case, only after assessing and measuring the patient’s foot parameters.

Initial stage of diabetic foot + photo

In the initial stage of development of the diabetic foot, changes in the structures of the ankle and foot area are often called a “small problem,” although such seemingly insignificant changes significantly increase the risk of global problems leading to serious consequences (see photo).

Initial stage of diabetic foot photo

What should you be wary of?

1. Ingrown nails. This process provokes improper cutting of the corners of the nail plate. As a result, the corners of the nails grow into the tissue, causing painful suppurative processes.
2. Darkening of the nail plate. This may be a consequence of ill-fitting shoes, the pressure of which on the nail causes hemorrhages under the nail plate. If such a process is not accompanied by further resorption of hemorrhage, a suppurative process develops in its place.
3. Fungal infection of nails. This can be immediately noticed by paying attention to the structural changes of the nail and its color. The nail plate thickens and becomes cloudy. Suppuration processes can form both under the affected nail and on adjacent plates, due to the pressure on them from the thickened, affected nail.
4. Formation of corns and calluses. Removing them by steaming followed by cutting or using special patches, in most cases ends in hemorrhage and suppuration. In this case, orthopedic insoles can help.
5. Skin cuts in the nail area. Decreased sensitivity to pain often causes skin cuts in obese and visually impaired patients who are not always able to cut their nails correctly. In places of cuts, with diabetes, long-lasting and poorly healing ulcers are very easy to form.
6. Cracking of heels. The formation of cracks in the heels is caused by dry skin, which can easily crack when walking barefoot or wearing shoes with uncovered heels. Such cracks easily give in to suppuration, contributing to the formation of diabetic ulcers.
7. Fungal infection of the skin of the feet contributes to the formation of cracks and, against the background of its dryness, leads to similar results - ulcerative formations.
8. Dystrophic articular deformities - hammertoes, a protruding bone at the base of the thumb, promoting callous formations and compression of the skin in the protruding joint parts.

Such signs, insignificant for an ordinary person, can turn into the most severe complication of diabetes for a diabetic – gangrenous diabetic foot.

In the initial stage of the disease, all these disorders may be accompanied by:

• coldness and chilliness of the skin in the ankle and foot area;
• night pain syndrome and pain at rest;
• intermittent claudication;
• pale skin;
• absence of pulse in the dorsal arterial vessels of the foot.

Prevention

To prevent the development of complications, patients suffering from both type 1 and type 2 diabetes must carefully monitor their blood glucose levels and adhere to all doctor’s recommendations regarding nutrition and selection of shoes. You need to lead a healthy lifestyle. Prophylactic use of drugs that have neuroprotective and angioprotective effects is mandatory. Patients need to control their cholesterol levels.

To prevent foot problems, patients need to strictly monitor hygiene. You should wash your feet regularly with soap. Be sure to wear comfortable shoes that fit properly. Particular care must be taken to remove overgrown nails and dry calluses, avoiding damage to the skin. If you see the slightest signs of the formation of ulcers on your legs, you should definitely consult a specialist.

Signs of the initial stage

In the ischemic form of the syndrome, vascular damage leads to decreased nutrition of the feet. This manifests itself in the early stages as a decrease in exercise tolerance, the appearance of pain when walking, and the feet are often cold. The skin becomes cold, there is a feeling of numbness and tingling, and persistent swelling of the tissues.

Diabetic foot with neuropathy has dry skin with excess keratinization. Sweating is impaired. Due to decreased sensitivity, patients do not feel uneven surfaces when walking, often stumble and twist their ankle. In the mixed form, there are neuropathic and ischemic signs.

Etiology

People at risk for developing diabetic foot include:

• peripheral neuropathy: sensory, motor and autonomic,
• peripheral angiopathy: macroangiopathy or microangiopathy,
• deformation of the feet due to the use of unsuitable shoes and increased pressure on the soles.

The above pathologies may appear due to the following risk factors:

• inadequate foot care,
• infectious and fungal infections of the feet,
• overweight,
• smoking and drinking alcohol,
• severe retinopathy and visual impairment,
• diabetic nephropathy,
• long-term diabetes mellitus,
• increase in blood glucose,
• poorly corrected hyperglycemia,
• arterial hypertension and hypercholesterolemia,
• sports competitions,
• previous ulcers and amputation of the foot or part of the limb,
• aged 60 years and older.

Atherosclerosis is the cause of diabetic ulcers

Vessel contamination in atherosclerosis

Diabetes mellitus leads to atherosclerosis of medium and small vessels: a diffuse change in which the blood flow in their beds and main segments is disrupted.

In this case, diabetic foot syndrome takes on an ischemic form and manifests itself:

• intense pain, especially at night,
• acquiring an unnaturally pale or bluish-pinkish-reddish skin color,
• acral necrosis on the edges of the heels or phalanges of the fingers, turning into ulcers,
• diabetic gangrene due to infection.

Diagnostics

Timely identification of the syndrome will help slow down the progression of the condition by selecting the right treatment and prevent the need for amputation of the lower limb. First of all, the specialist collects data about the underlying disease and clarifies the presence of complaints. Next, the lower extremities are examined: the plantar and dorsal surfaces, the spaces between the toes.

The specialist clarifies the color of the skin, its temperature, and the presence of hair. Evaluates skin turgor and elasticity, arterial pulsation, the presence of swelling and trophic defects. If the doctor cannot listen to the pulse in the peripheral arteries, Doppler ultrasound is performed using a portable device.

Portable Doppler - a device that allows you to listen to the presence of a pulse in the peripheral arteries

With the help of a neurologist, the state of sensitivity is assessed:

• tactile - monofilament;
• painful - with a hammer with a needle at the end;
• vibration - with a tuning fork;
• temperature - cold and warm objects.

Radiography allows us to clarify the condition of the internal elements and osteoarticular apparatus. For better visualization, two shooting projections are used.

Samples

Specific ways to determine the presence of pathology:

1. Alekseev's test. Evaluates changes in temperature of the lower extremities after walking. In patients with circulatory pathology, indicators decrease by 1-2°C after 400 m.
2. Marburg test. Against the background of the pallor of the plantar surface of the foot, blue spots are clearly visible.
3. Ratshaw's test. The patient lies on a hard surface, raises both legs and crosses them. Within a few minutes, the feet become pale.
4. Cosachescu's test. A blunt object is passed along the front surface along the entire leg. A disruption of the blood supply is evidenced by a sharp break in hyperemia on the skin.

Important! Positive tests confirm the presence of microcirculation disorders and the development of complications of the underlying disease.

Examination in hospital

If diabetic foot syndrome is confirmed, the patient is hospitalized in an endocrinology hospital to correct the condition and prescribe therapy. Mandatory research methods at this stage are:

• examination and palpation of the legs, clarification of sensitivity;
• in the presence of trophic ulcers - bacterial culture of the contents with an antibiogram;
• duplex scanning of arteries - ultrasound examination, which allows you to clarify the condition of the vessels and blood circulation through them;
• arteriography of the lower extremities - a radiopaque method, which is carried out by introducing a contrast agent and taking further X-rays;
• oximetry – clarification of the presence of ischemia and its degree;
• X-ray, CT, MRI – examination of the condition of the internal structures of the foot;
• laboratory tests (general tests, blood sugar tests, biochemistry, coagulogram);
• examination by a neurologist, nephrologist, ophthalmologist.

A blood glucose test is a mandatory diagnostic method that allows you to determine the degree of compensation for diabetes mellitus

Ointment forms affecting wound infection

Clinical picture

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At the beginning of treatment, medications containing chloramphenicol, sulfonamides, aminoglycosides, and other synthetic antimicrobial substances are used.

These antibiotics have a wide spectrum of activity aimed at suppressing aerobic and anaerobic bacteria.

Ointment for the treatment of diabetic foot should not create a film that contributes to the accumulation of exudate. Preference is given to water-soluble products.

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At-risk groups

Approximately 40-50% of patients with diabetes are at risk. The criteria for classifying a patient at risk for diabetic foot syndrome are:

• phenomena of peripheral neuropathy,
• lack of pulse in the arteries of the feet,
• foot deformity,
• pronounced hyperkeratosis of the foot,
• the presence of ulcers, purulent-necrotic processes, amputations in the anamnesis.

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It is customary to distinguish three risk groups:

• I.
  _ Sensitivity is preserved at all points, pulsation in the arteries of the foot is good. Surveyed annually.
• II
  . Sensitivity is reduced, there is no distal pulse, and there are deformities. They are examined once every ½ year.
• III
  . History of foot ulcers and/or amputations and significant neuropathy. Examined once every 3 months.

Proper diabetic foot care

If the patient has already shown some signs of foot damage due to diabetes, he needs to learn the rules of foot care. This matter has its own subtleties and features. If there are such injuries to the limbs, the patient should wear socks made exclusively from natural fabrics.

Shoes must be orthopedic. It is selected in size so that it does not rub while walking, since such damage can become the basis for the formation of new foci of necrosis. It is necessary to regularly wash your feet with soap and water. After this, it is advisable to apply local antibacterial and antimycotic agents.

If there are severe ulcerations, the leg should be given maximum rest. An aseptic bandage must be applied and the wound surface treated. When treating such defects, it is advisable to avoid long walks and use crutches, a chair or unloading shoes while moving around the house. To prevent the appearance of foci of necrosis, it is imperative to promptly remove the keratinized layers. It is best to perform this procedure in a pedicure salon to avoid injury.

Wagner grades of diabetic foot

The Wagner classification is used to assess the degree of foot damage. This scale has been used in medicine since 1979.

Three main factors serve as evaluation criteria:

1. the depth of damage to the epidermis and muscle tissue;
2. degree of infection development;
3. presence and severity of gangrene.

Diabetic foot (classification according to Wagner is mandatory to standardize the treatment plan) can have 6 stages:

Stage zero (risk stage or pre-diabetic foot). There are no signs of damage, the foot visually looks healthy. However, the patient belongs to the risk group and is diagnosed with diabetes mellitus. In this case, correct preventive measures aimed at preventing the development of the disease are of great importance.

In many ways, the prevention of diabetic foot consists of strict adherence to doctor’s recommendations and personal hygiene, leading an active lifestyle, as well as wearing comfortable and high-quality orthopedic shoes and insoles.

First stage. Superficial localized ulcers are present on the skin. There are no signs of infection. At this stage, it is important to begin treatment as early as possible to prevent the disease from spreading to soft tissues and tendons.

Treatment consists of antiseptic treatment of ulcers and normalization of blood sugar.

Second stage. The ulcers are deeper, muscle tissue and tendons are affected. There is no inflammatory process. It is at this stage that patients most often consult a doctor.

Treatment is prescribed depending on the location and type of ulcers. The most commonly prescribed topical ointments contain antibiotics. Doctors also pay great attention to the treatment of neuropathy and cardiovascular diseases that cause DFS.

Third stage. Ulcers affect the deep layers of the skin, muscles, and tendons. The patient experiences discomfort when moving, and therefore sharply limits his mobility. Multiple or single phlegmons, abscesses, and ulcers appear.

At this stage, it is no longer possible to do without serious antibiotic therapy. Surgical excision of the affected tissue is often required.

Fourth stage. The infection affects the bones, and gangrene spreads to the toes or the front of the foot. If treatment is not started promptly, gangrene will spread to healthy tissue.

The patient needs treatment with antibiotics and physiotherapy to help restore normal blood supply to the extremities.

Fifth stage. Gangrene of the entire foot. To save the patient's life, a limb is amputated.

Wagner's diabetic foot does not take into account the origin of ulcers and the form of their infection. Meanwhile, the infection can be very different. The most common infections are fungus, E. coli, salmonella, streptococci, gonococci, etc.

New treatments

New methods of treating diabetic foot syndrome are constantly being researched around the world. The main goals of research are to obtain more effective and faster methods of healing wounds that appear as a result of the disease. New methods significantly reduce the need for limb amputations, which is so great with this disease.

In Germany, a number of methods for treating diabetic foot have already been studied and put into practice. Based on various clinical studies and testing, new methods of therapy are assessed by the global medical community as very promising.

These include:

• Extracorporeal shock wave therapy method;
• Growth factor therapy;
• Treatment using stem cells;
• Plasma jet therapy;
• Bio-mechanical method;