• Healthy Living, "Diabetes"

    by Central Massachusetts Podiatry
    on Nov 20th, 2017

 

 

Please enjoy Dr. Pelto's Healthy Living video series on Diabetes. The videos are broken down into 4 sections, or you can watch the entire video from start to finish at the bottom. 

 

 

 

 

 

 

 

 

Full Video:

 



Here is the transcript of the videos.


Hello this is Dr. Donald Pelto and in this episode of Healthy Living we are going to focus on practical tips for a healthier life as a diabetic.  Let’s get started and talk about a few simple ways you can prevent getting a foot wound. You may not know but just because you have diabetes you have a greater risk of developing a foot wound also know as an ulceration. Wounds of this kind typically begin as a blister on the bottom of your foot or between your toes. They can become infected and, if the infection is serious, lead to losing a portion of your toe or even your leg. Here are the easiest and most effective ways you can prevent an ulceration.

To start, I cannot emphasize enough the importance of self-examination of your feet, both on the tops and the bottoms, and between the toes. A mirror can be helpful, but if you are unable to see all aspects of your feet it is best to have a loved one help. For those that are high tech I have seen patients use an iPad placed on the floor and they make a video recording to see if they have any problems on their feet.  Anything you find that appears abnormal or strange looking should be evaluated by a professional, such as dampness between the toes, blistering, a new callus, an area of redness, ingrown toenail or a cut or scrape.  Even if you see your podiatrist only every 2-3 months it is recommended to go in sooner if there is anything you are concerned with in your foot evaluation.

Next, we are going to talk about what should you wear on your feet as a diabetic.  Specific shoes that are extra depth are specially designed to help diabetics avoid ulcerations, which, as we’ve seen, can lead to very serious medical problems. Medicare and most medical insurance provide coverage for this kind of shoe. For insurance companies, this coverage can save them thousands of dollars that treatment of ulcerations can ultimately cost. And an amputation is 10 to 20 times more expensive than treating the wound in the first place.  Who can get diabetic shoes? Generally, diabetes by itself is not enough. You must have one of these risk factors that make you at higher risk of an ulceration.  Let's look at these dangerous risk factors.  


Swelling or lack of a pulse in your feet can be a sign of poor circulation. Here’s a simple test. Press on the tip of your big toe. If the spot you pressed on becomes white or blanches, and then quickly returns to its natural pink color, your circulation is probably normal.  If you are unsure how your circulation is, it is good to go to a podiatrist who will evaluate your pulses.  There are 2 main pulses on your foot.  One is found on the top of the foot called the dorsalis pedis artery and the other is found behind the inside of your ankle called the posterior tibial artery.  If your pulses cannot be felt on your feet you may need a more specialized exam by a physician. In our office we use one device called a Doppler to help us listen to the flow in the blood vessels.  Here is an example of the sound of a Doppler if the blood flow is good.  It sounds like a swishing sound.  If the blood flow can not be “heard” there is another test that can be done that uses blood pressure cuffs on different areas of your leg to determine the flow of your blood.

Another reason that diabetic shoes are covered for you is if you have aoot deformity. No one likes being considered deformed, but this is merely a technical term for any type of foot or bone abnormality that could cause rubbing in your shoe. This can cause blistering and lead to very serious problems. Extra-depth or diabetic shoes can help.


The common bony prominences are bunions (as you can see in this pictures on the great toe and the 2nd toe has a hammer toes) other problems include longer toes or a collapsing foot arch. These foot deformities generally are sufficient for insurance providers to pay for diabetic shoes for many people.

If your sense of feeling – or touch – on the bottom of your feet is compromised, you are at greater risk for stepping on an object that can penetrate your skin. This issue of poor feeling is called neuropathy.  Some people with neuropathy don’t have any pain but other can have a lot of pain in their feet and legs.  However, if your neuropathy reduces your sensation you might not know you are scuffing the bottoms of your feet, which can produce a callus or wound without you knowing it.


We can test the feeling on your feet using a little piece of plastic called a 10-gram monofilament.  This is a thin plastic wire with which we gently poke different areas on the bottom of each foot. If you are unable to feel the pokes in uncalloused areas of skin, you probably have some level of neuropathy or poor feeling, which qualifies you to obtain diabetic shoes.

If you have had a wound or even needed a partial amputation of a toe, you are at greater risk for developing other problems in the future. This probably indicates that you have some or all the conditions mentioned above as well. Usually a foot wound is not caused by one isolated problem, rather by a combination of problems that led to a wound or amputation. These are the top health risks that qualify you for diabetic shoes. Other factors can be involved, but most people who have the above conditions would qualify for diabetic shoes.

Finally, I want to talk about calluses on your feet.  If you develop a callus on the bottom of your foot or the sides of your toes, it can develop into a wound quite easily. The proper treatment for calluses is trimming them with a specialized instrument. This should never be done at home on your own. Only a podiatrist should trim your calluses.  For mild calluses on the bottom of your foot, specialized callus creams and pumice stones can help.  A word of warning: Do not use “callus removers”! They contain a strong acid. The acid is not able to determine what is normal skin and what is the thickened skin of a callus. And it cannot determine how deep to penetrate your skin.

If you have poor blood flow or poor feeling and use these treatments, they very commonly cause wounds. Instead, lighter and safer creams are available that can reduce some of the callus. But if the callus seems to be getting thicker, consult a podiatrist about proper treatment.

If you would like more information on taking care of your feet with diabetes please visit drpelto.com and click on the link for Healthy Living and you will find resources there about diabetes.  



Hello and welcome to Healthy Living now we are going to break down the different aspect that are involved in a diabetic foot exam.  You are wise to have your podiatrist perform a complete diabetic foot exam at least once a year. This exam is used to assist your primary care physician as well your endocrinologist, much the same way an eye doctor’s exam is shared with your PCP. Depending on your risk factors, your podiatrist may need to conduct this exam more frequently.  How often should you have this exam?  Here are the basic guidelines for this exam.

If you have no neuropathy, circulatory problems or foot deformities you should consider a diabetic foot examination once a year.  If you have some loss of sensation also known as neuropathy you should consider being seen every 3 to 6 months for a diabetic foot examination.  If you have poor blood flow and neuropathy you should be seen by a specialist every 2-3 months for evaluation.  Finally, if you have a history of an amputation you should be seen every 1-2 months by a specialist.  As you may have observed the more diabetic risk factors you have increases the frequency of foot exams.

A diabetic foot exam is an eight-step assessment of your skin, blood flow, nerves, past medical history and risk factors that could lead to serious problems, including amputation. Let’s look at each step in more detail.

The first step to this exam is to review your medical history.  Like most medical exams, we need basic information, including the Name of doctor supervising diabetes management. This can be your primary care physician, internist or endocrinologist.  This is important to know in case we need to communicate with them about your foot health as well to send notes after your exam.  Next, it is important to know when you had your last foot care appointment. Depending on your symptoms and risk factors, this should be performed every two-to-three months. Also, what other health conditions do you have?  This is important to know as other conditions can affect your diabetes and can cause neuropathy.  Are you on any new medications? Have you switched any medications? What type of insulin do you take? What diabetes medications do you take? What is your last fasting blood sugar result? What was your last Hemoglobin A1C?  This is a blood sample that is taken usually every three months by your endocrinologist or primary care physician. It indicates your blood sugar over the last three months, not the single moment in time as in a finger stick test. Hemoglobin A1C is a better gauge of how your blood sugar has been doing over time. How long have you had diabetes? If not properly managed, the longer you’ve had diabetes, the higher the risk of complications. What and how much exercise do you do?

After we review this information, we can make recommendations as needed, focusing especially on the type and level of your physical exercise and shoe gear that is safe for you.

Next, for Step 2 we perform an orthopedic or Bone Structure evaluation. We look for any bones that are more prominent on your feet as well as hammer toes or other curved or bent toe structures. Equally telling are bony prominences, which can cause shoe rubbing and ulcerations on the bottom of your foot.


One area of specific concern is Charcot foot, a potentially severe condition in which the arch of your foot collapses. In this picture you can see a normal foot and a charcot foot that has a collapse in the middle of the foot.  Many times this condition of Charcot foot can be mistaken for an infection and may lead to an ulceration because of this bony prominence. Many times in the beginning stages of Charcot your only symptom may be a red hot swollen foot.  It is always important to consider Charcot early on if you have diabetes and neuropathy.  

The next phase is to look at the skin on your feet to see if there are any areas of callused skin, cuts or dry skin. It is important to see if you have any athlete’s foot or thickened or  ingrown nails. Talk to your doctor if you have had a foot infection in the past or if you have ever had gangrene on your foot. An essential part of examining your feet is to look between your toes and note the temperature on your feet.

The next step tests the nerve sensations of your feet, including vibration and light touch, and distinguishing between sharp and dull feeling. We use a special instrument to check how well you perceive these sensations. It’s called a Semmes-Weinstein, a 10-gram piece of monofilament plastic wire.

We touch its end to different areas on the bottom of your foot. If you are unable to sense touch to any of these areas, you have lost what’s called “protective sensation.” This means you are at high risk of developing a foot wound, which may lead to more serious problems and ultimately to amputation. Without protective sensation, you might step on something dangerous such as a pin, rock or object without knowing it and possibly cause serious problems for your feet.

Next, we determine how well your blood flows – your circulation. We examine your blood flow in your pulse on the tops and sides of your feet. We also look for swelling in your feet. At home you can perform an easy test yourself. Simply push on the tip of your big toe. The toe’s natural pinkish color will turn white. If the pink returns in less than three seconds, you can rest assured that your circulation is not a problem. Poor circulation signals the need for other, more formal exams by your podiatrist.

The final step in the exam looks at what you wear on your feet. A shoe exam is very important. Do you look at your shoes before you put them on? If you don’t, you may be at greater risk for getting a cut or wound on your foot.  Often small items – sometimes sharp or abrasive can fall into your shoe. If you don’t feel them, because of the problems discussed above, you may develop bigger problems down the road. We also look at the type of shoes you wear to see if they are appropriate for you as a diabetic.

We then compare the results of your examination with those of many other patients.

If you were recently diagnosed with diabetes and have no risk factors, yearly exams are generally sufficient. But if your risk factors intensify, such as you start to lose feeling or have a pulse that cannot be felt, we will recommend more frequent exams. I am sure you will agree that more frequent foot care exams are far less inconvenient than developing a foot wound, infection or worse.

Finally, we spend considerable time explaining the risk factors of diabetes and the vital importance of controlling your blood sugar. We review the dangers of neuropathy and explain the findings of your comprehensive foot examination. Most important, we teach you how to do a daily self-examination of your feet – the best thing you can do to prevent an amputation.  If you have not had a comprehensive foot examination, it is wise to contact your podiatrist today to schedule one.  

If you would like more information on taking care of your feet with diabetes please visit drpelto.com and click on the link for Healthy Living and you will find resources there about diabetes.  

Author Central Massachusetts Podiatry

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