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So living with diabetes in general is just, it’s hard. I can’t even begin to think about how hard it is. You’re told to memorize and think about all these different kinds of problems, probably dozens of times a day. And that doesn’t even count when you’re checking your blood sugar. And sometimes when you think about the foot, this becomes 11th on your 10 most important things to do in your life. And believe me, I understand that and I’d be the same way. And I’d especially be the same way. If what I had to check wasn’t hurting me, trust me when I tell you that what you can’t feel can hurt you and what you can’t feel can even kill you in the diabetic foot. And so if you just put a few little things into play every day, even just one thing, into play every day, you’ll really make a difference. And that one thing is check your feet every day. Like you comb your hair or you brush your teeth. And you would say to me, well, what do I look for? And the answer is you would know if you’re looking at your foot every day or if someone else, maybe a loved one, and if they see something that’s maybe a little different, like a little ingrown nail or some redness or a callous that’s there that wasn’t there or maybe a little bit of swelling, any kind of breakdown in the skin, then you can get in immediately to your foot specialist and call him or her and let me tell you, they will get you in. If you have diabetes, you are part of that family and those little things every day can make the difference between the life and limb. Just getting in to see your foot doctor reduces your risk of getting an amputation, especially a high level amputation by anywhere on the low end, just under 20% to on the high end, over 80% depending on what risk factors you have. Since when do you hear about numbers like that? If we just had a 5% risk reduction, that would be a blockbuster drug. What we’re talking about is blockbuster prevention, and this is something that we can do in the most low tech manner possible.
A lot of work going on in this area (in amputation prevention) is really, really exciting. We are now developing better and better tests to assess risk, to predict a potential bad outcome. We can now boil down an entire clinical examination into between 1-3 minutes – we have developed something called the 3 minute foot exam. We’ve also developed other testing – like there are certain types of genetic tests that may prove promising in identifying people at risk for getting things like neuropathy, for getting things like other types of arthritis that can put them at risk for getting a dangerous deformity that commonly shows up in diabetes and diabetic foot called Charcot Arthropathy or other complications like this. These are just the latest sorts of things. Still even more exciting are: if you have a wound, there are now brand new ways to test the wound that may be able to assess all kinds of bacteria that are growing in their – in the wound. We’re kind of moving away from Louie Pasteur and moving more toward CSI, if you will. Some of those tests are becoming more and more standard. How valuable are those? We’ll see. They may amount to nothing or they may amount to something pretty special and I tend to think it’s probably gonna be somewhere in between. I (for one) am pretty excited about some of those tests.
I don’t even begin to know what to tell you about handling different kinds of insurance. I guess it really depends on where you live in the United States or around the world. There are different policies that cover different things. But here’s what I’m going to tell you: the most important thing you can do (in addition to checking yourself) is getting in to see your foot doctor. If you do that, along with seeing another member of the diabetes team, your relative risk for getting a high level amputation or other complications like that goes way down – anywhere from 20% to sometimes over 80% depending on the problem that you have. These are really phenomenal numbers. Some things are covered by an insurance company and some things aren’t. Sometimes that includes different kinds of shoes and insoles that might be really important. Sometimes it includes certain kinds of checkups that are really, really important. But what I can tell you is: try to make the best effort you can to get in for that prevention. I promise you – your doctor and your nurse, if they’re worth their salt (and I bet they are) they’re going to work with you to try to make a difference there as well. If you find that happy medium, often that happy medium is a place where you can have a much lower risk for amputation and a higher risk for a high quality life.
We have talked about a lot in a rather short period of time and let me just tell you – you are so welcome to come back anytime. You’re welcome here anytime. Heck, you’re welcome in our clinic anytime. I think I speak probably for most doctors and nurses that really focus on this area to take care of you to say that this is this problem is such a hard problem. But yet every time I walk into my clinic, I tell you what: I find a new reason to have hope because what I see are folks that are dealing with complications that I can only begin to imagine, but yet they’re dealing with those things with grace and class and compassion and kindness. But I think if we work together – nurses, doctors, physician surgeons, and most importantly patients – and we marry a little bit of common sense with technology and marry a little tenacity with the technology, we can affect change together and we can end up in a place where there are far fewer needless lower extremity amputations and far more folks leading a high quality life. Because you know what? That’s what we all deserve – whether we have diabetes or not – no matter what our health and no matter what our age.
Another thing that they might look for on a routine diabetic foot exam is any signs of a deformity. If you have a deformity in your foot, then that can increase pressure points, which can put you at greater risk, especially if you have neuropathy, that’s the loss of feeling. Or the vascular disease and all three of those things can come together kind of in, if you will, a sinister synergy to create problems. So they might be moving your toes around, moving your ankle around just to see what the range of motion is like if there are any limitations or or contractures there. That’s another thing that can be done.
Right now, there are about 30 million folks in the United States with diabetes and about half of those folks with diabetes will develop neuropathy or what one of my mentors used to call loss of the gift of pain. And that neuropathy can lead someone to wear a hole in their foot just like you or I were a hole in a sock or a shoe. Now that hole is called an ulcer, a diabetic foot ulcer. And that happens a few million times a year in the United States. Once it occurs, about half of those folks will require an antibiotic, will get infected at some time during the life cycle of the wound. Once that happens, about 20% of them will end up with some degree of an amputation and some level of an amputation. That’s why right now, unfortunately there’s an amputation performed every 20 seconds around the world. But I’m here to tell you that nearly all of those amputations are preventable. And our goal together, is to try to work to do that. More important than that is to try to work together to try to keep us, both you and me and all of our friends moving through the world. And that’s really the goal of our group at SALSA. And it’s the group of many of us that work really hard to both heal people with diabetes and wounds, and to keep them healed. And that’s what we’re going to be talking about.
This is one of these places in medicine and surgery and life where what you can’t feel can actually hurt you and even kill you. Now, that sounds kind of scary and I don’t want you to be scared. I just want you to respect this because what happens is, ultimately, in folks with diabetes, most people will lose some degree of sensation and that problem is called neuropathy. It puts people at a great deal of risk for getting a diabetic foot ulcer and then ultimately for getting all the other complications like infections, so called gang green, and an amputation. But upstream, what we we have to understand is that these symptoms may not exist. The key thing for you is to understand that what you can do to fight this is really pretty simple: you can knock your socks off every time you go in to see your doctor. That could be your general doctor or your specialist. When you see him or her, you compel him or her to have a look at your feet and he or she might actually see something or they might not. But what it does is it compels them to get down there to look. So that’s a little tip that I’d give you, but it’s also a part of the key symptom that isn’t even a symptom when we’re talking about diabetes and the foot: what you can’t feel can hurt you.
What causes diabetic foot ulcers and result in infections or amputations, starts with diabetes in general. Diabetes leads to a whole cascade of problems that lead to damage in the feet. One of them is nerve supply and sensation. One can develop loss of protective sensation and quite literally wear a hole in the foot just like we’d wear a hole in a soccer issue. That’s called peripheral neuropathy or loss of protective sensation. Another thing that goes out to the periphery is blood flow, so we can have a problem with peripheral artery disease. What happens there (just like in the heart, except longer) we can develop complications that limit blood flow which can not only cause wounds, but more importantly cause wounds not to heal once they show up. Both of those things – both the sensation and the peripheral artery disease – are things that we have to focus on both as patients and as doctors and nurses.
Before any of these examinations, you probably won’t need any special preparations with the exception of: if you were seeing a vascular specialist, that might be more of a procedure and you might not be able to eat the night before, but that would be pretty far down the road before that actually occurred. I’m sure that doctor and all of the other technicians involved will give you good information on that beforehand.
If your doctor sees a callus (if your podiatrist sees a callus) he or she may very well want to trim that callus. Why? Because very often under the callus (especially if there’s bleeding into the callus) there may be an ulcer that his limb threatening under that callus. That doctor may want to trim that so that they can identify the extent of the ulcer. That is really important that you talk to your doctor about that as that is happening, because that could be something (if it is not done) that could be dangerous, but please understand that the doctor did not create the ulcer. The doctor merely uncovered the ulcer underneath that really dangerous callus. If he or she doesn’t trim that, what happens is that ulcer underneath (just like the tip of an iceberg) gets bigger and bigger and bigger and get infected, can create an abscess and that can not only costing you your limb – it could cost you your life.
Other things they can look for are: you walking up and down in clinic. They might watch you walk in to see if there are any changes in your gait patterns that might put you at greater risk and other things of that nature. But those are the things that one can assess in a clinical exam and those should just take remarkably a couple of minutes. We’ve even put it all together – we and some other folks – into what we call a 3 minute foot exam. That foot exam is readily available on the web. You can google that and I’m sure that we can put links to where you can find that so that you can (if you want to) try it at home. Why not? Link to 3 minute foot exam: https://diabetesed.net/wp-content/uploads/2017/05/3-minute-foot-exam.pdf
Another thing that we can measure and that your doctor might measure is your circulation. Circulation can start with the test of your pulses and he or she may check your foot pulses. There are two main foot pulses: one on the top and one on the side that goes down to the bottom. Those are both checked periodically in a diabetic foot exam. Those can be checked every few months or even once a year by your general doctor, your nurse practitioner, or indeed your foot specialist – your podiatrist.
Another thing that is assessed would be your skin. The doctor or nurse could be looking for something like a wound would be a big concern and should cause them to go into a whole different mode of acuity to take care of you. Something else they can look for: there are signs that can proceed a wound with like a callus. If a diabetic foot problem and an ulcer is like cancer, then a callus is like a breast lump and that’s what they can look for (the doctor and the nurse) and that’s what you can look for as well on the dermatologic examination.
When you go to see your doctor or your nurse, your nurse practitioner, there’s a whole variety of tests that they might do to check on you. But the stuff to do that can identify risk is, thank goodness, really simple. So let’s first talk about sensation. One of the things that they’ll do is they may check your sensation with something called a monofilament. It looks like a piece of fishing line that you might put on the skin that bends at a certain amount of force and that can tell whether you have so called loss of protective sensation. So in addition to using that wire, another thing that the doctor might do is use a certain kind of vibration test, like a tuning fork or a fancier device that looks like a hairdryer where they might turn up the volume on the thing and it actually can vibrate a little bit more. That’s called the vibration perception threshold device. And that can give the doctor or nurse some good information about your degree of sensation. Rarely, they might send you off for special tests like a so-called nerve conduction velocity or other tests like that, but those are rarely performed on someone with diabetes. Still even more rarely are tests where they might take a biopsy of your skin to look under a microscope, to look at the number of little baby nerve fibrils up in there, and to see what the overall population of those are. But the good news about this stuff is it can be done rather rapidly with a lot of low tech and high touch kind of assessment.
If there’s a problem there, he or she might grab a device called the doppler unit, which is something that is often pocket size that they can take and can actually put on top of the foot or on the side of the foot and it kind of makes it sound like *Whoosh*. Google it and listen for it and you’ll be able to see. That can give him or her a wealth of information just by listening to the rate, the rhythm, the breadth of that sound. A really good doctor or nurse or technician can get a lot of information from that. Still more information can be gotten from a fancier version of that doppler, which can be done in a vascular laboratory by specially trained clinicians and technicians who are very skilled in that area. Still other things that can be used to test you are things that can measure tissue oxygenation. There is something called transcutaneous oximetry or tcpO2. That can check the amount of oxygen that’s coming off of your skin and your tissue oxygenation. Still something more (just to get fancy) would be something called skin perfusion pressure. That uses a fancy tool called a laser doppler to check your circulation. So you see there’s a whole bunch of different things that can be used (and many things I’m not mentioning) but those are just some things that a doctor or a nurse might spout out while he or she is checking you.
There are further tests that might help confirm that there is a problem. For instance, with vascular disease, there might be confirmation that is done not only with more fancy doppler tests that we had discussed, but also maybe a fancy kind of x-ray of your blood vessels called an angiogram or a device like an MRI that can do similar things in different parts of the body to assess this or a special kind of computed tomography or CT angiogram. These are things that could be done if there was a concern of a vascular blockage. If there was a concern further, neuropathy almost always can be checked pretty darn well in the clinic itself and it’s unusual to go out for further exams, but you might get something like a nerve conduction velocity or even a skin biopsy to look for the amount of little nerve fibrils in the scan.
What to do if you actually have a wound: now, if you have a wound, it’s actually pretty similar to some of the things that are going to be assessed if you were coming in for a screening visit except it’s just a little more sense of urgency. If you have a wound now, the things that might put you at greater risk for getting an amputation include infection and ischemia, or bad blood flow. Those things might be checked with a little greater attention and the circulation might be checked using techniques that we have already mentioned like a doppler test, like special other tests like an angiogram or an MRI or a CT angiogram and those will be done by vascular specialists. For checking for an infection, the diagnosis of an infection start and its end is not made with a test. That actual assessment is made by the doctor and he or she looks for clinical signs and symptoms of infection. What might those be? It might be some redness or pus or streaking up your leg or swelling in your lymph nodes or things along those lines. Or – they might order tests like a blood test to look for a high white count (which is the number of white blood cells in a certain volume) or things along those lines, but that starts and ends with the clinical assessment for infection. Other things that the clinician might look for are the size and shape and depth of your wound. They can attest this in a whole variety of ways, but really a lot of this is done just by the good quality clinical examination. The doctor might also photograph your wound or that might also be done by the nurse and that’s done so that they can check the wound from week to week or time period to time period and they can look at the overall surface area and size of the wound.
If you show up with a wound, the things that we care about include not only the wound but also the ischemia (or bad blood flow) and the potential for a foot infection. If you add that up, that spells WIFI: Wound, Ischemia, Foot Infection. I want you to think about that now: WIFI. And you have some WIFI settings that you can use. For the wound, the doctor or nurse might assess the wound as mild, moderate, or severe based on certain criteria. They might also assess the ischemia (or the bad blood flow) as mild, moderate, and severe using tests like doppler tests or other tests to look at the amount of oxygen that comes off of your skin. The third thing that they look at – the foot infection – is also based on assessments and tests, and that’s none, mild, moderate, and severe and is based not only on the local signs, but also some systemic signs and laboratory signs as well. WIFI – I want you to remember that.
Now let’s go through the treatments for the wound, the Ischemia, and the foot infection, specifically. First for the wound. If you have a wound that is not predominantly infected or ischemic, it’s not what you put on these wounds that heals them – it’s what you take off. What I mean is: the things that the doctor might do first is focus on what’s called debridement of the wound – which means nothing more than trimming off what’s dead and helping (just like pruning a tree) to do a little bit of good quality landscaping on the wound to allow that thing to be nice and healthy so that it can move on to healing. That’s one thing you take off – what’s not viable. They might take off callus, they might take off dead tissue in the middle or around the wound. That’s number one. Number two: the other thing that we need to take off is the pressure or the weight and that can be done with various kinds of braces or casting or different types of what we call offloading technologies. The gold standard is what is called a total contact cast, and that’s a technique where a doctor or a technician might actually put a special kind of cast around you that spreads the force out over the entire bottom of your foot and then even up the cast wall. That can be really, really effective. Other kinds of braces that you might get at a prosthetic shop can also help to do similar things, but the key thing is while you’re in that, you need to be wearing it all the time for every step you take. Because if you take a step without that protection, it is – trust me – a step backwards.
We’ve talked about treating the wound. That’s W. We’ve talked about treating the ischemia. That is I, or bad blood flow. Now let’s talk about treating the FI, or the foot infection in WIFI. Now if you have an infection, the infection actually comes before a lot of the other things. It needs to be often treated first depending on its severity. The first thing your doctor will do is assess the severity of the infection. The second thing he or she will do is determine whether this is something that needs to be treated medically, surgically, or both. He or she may assess this with a culture to determine what kind of antibiotic to use. He or she may then either get you on an antibiotic or B, they may try to drain the infection or remove what is dead surgically. Those are things that are going to be assessed by your physician and a surgeon at the time of assessment of your infection. There is a whole host of therapies that are necessary at various times and a whole host of different kinds of antibiotics that are to be used. But the important thing to understand is that one goes from broad spectrum to narrow spectrum therapy. That is a principle of good quality infectious disease to be using the most targeted therapy possible. And then, for the surgical treatment to treat the infection, to get rid of the infection and to do as little as possible to get that patient living his or her life as soon as possible. So it is a surgical and medical combination that makes a big difference there for the foot infection. So now we’ve talked about wound and approaches to treating the wound and assessing it. We’ve talked about approaches to treating the ischemia or the bad blood flow. And we’ve talked about treating the foot infection. So those are your WIFI settings.
If you have a bigger wound, there are various types of technologies that might help the wound heal as well. Those include something called negative pressure wound therapy, which is a type of a foam that is attached to a vacuum that’s attached to a computer-controlled the vacuum device that actually can help stimulate little baby blood vessels grow. Other things that might be put on that wound include types of tissue that’s grown in the laboratory that could actually be applied, that can stimulate the wound, kind of like fertilizer might stimulate the wound. Other kinds of biotechnological devices that can be applied include technologies made from the amnion and chorion of the placenta. This is another type of technology that has been gaining popularity in certain circles as well. There are a host of other kinds of things like growth factors and other technologies that could be helpful. There’s just too many to mention. But the important thing to understand: it is not what you put on these wounds that heals them – is what you take off. The things that we put on the wound are adjunctive that can help the wound heal a little bit faster, but not until we have focused on what I mentioned first, which is the good quality of debridement and the offloading and the protection.
In terms of home remedies for the diabetic foot, there are likely a whole host of things that could be helpful. There is not a lot of evidence for treatment of various aspects of the diabetic foot in the home, but some things may be helpful. Let’s start with things on the skin. There are different kinds of lotions and creams and oils that can be useful for the skin. If you are using something like a moisturizer for the skin, I like creams and oils more than I like things like lotions. The creams have some fat in them and obviously oils do as well and they stay around a little bit longer and they could really help to moisturize the skin. Your skin can (instead of being like a cracker) it can be a little more like a tortilla. You know that a Tortilla is way stronger than a cracker, and so too is that the case in the skin. That’s what you want to work toward to make your skin a lot more moisturized and therefore stronger and less apt to crack and to develop a blister and a wound. There are a whole host of treatments for painful neuropathy – if you have pain like tingling or feeling like insects crawling on you or electricity or horrible burning at night. There are various therapies that may be useful that you can try at home. But before you try them, I really would urge you just to talk to your doctor so that you can go into this as a partnership because I think an open minded clinician working with you is a whole lot better than you just trying some kitchen chemistry on your own. I think the two can really be helpful. If you have a wound on your foot, there are many kinds of home remedies that people may talk about. But what I would urge you is to get in and see your doctor ASAP because these wounds – while they may not hurt you, because of the loss of the gift of pain with neuropathy and diabetes – they can kill you. I stress to you that instead of beginning a home remedy on a wound, that you get in to see your doctor. There may still be some remedies that may be really useful in the home that could help. But get in to see your doctor first and make this a partnership.
There are a whole variety of procedures that might occur to treat something like a foot ulcer. In the case of an infection, that might be a more urgent kind of procedure that is done to drain the infection – to take out dead tissue. There are also types of procedures that are done to debride nonviable tissue – that’s called wound debridement or cleaning up the wound. That can be done often in a clinic or in the operating room – depending on how extensive the debridement is necessary. There are other things that are done commonly like cutting into the bone and moving the bone so that deformity is not as present, causing the risk for developing an ulcer. So a procedure can be done that is reconstructive in nature that might change the way the foot hits the ground so that you’re spreading force out over a larger area and reducing risk of a prominence causing a sore. The other thing that can be done is after a wound has been debrided and it’s nice and healthy, then one can look from wound care to wound closure. A commonly performed procedure is some method to actually close the wound. A surgeon may choose to work with you to move skin over and that could be a rotational flap. They could take tissue from somewhere else in your body and put it on – rarely. That’s called a flap and there’s various kinds of flaps at various levels of fancy. Other things that can be done pretty commonly are taking skin from one area (like on your thigh) and then putting it onto your foot. That’s called a split thickness skin graft and the skin graft can be taken from your thigh (it’s a little bit like skinning your knee) and then just transferred to the back table in the operating room and the surgeons can manipulate that and spread it out a little bit so that it can have a little more surface area. Then, they can put that down on various parts of your foot to actually patch that area up if you have a big sore. So that’s another thing that can be done as well that’s done fairly commonly at a lot of a high-end limb salvage diabetic foot units.
There may be times when the best treatment is not to heal a wound, but rather to perform an amputation. Those amputations may come in different levels. They may be at the level of the foot or they may be above the foot. But understand that the clinician that’s working with you is working with you to do the least amount to get you back to living your life the soonest. But: sometimes the best procedure is one that might be what we call a high level amputation (which is above the foot) and that procedure may be done because the doctor or the nurse or the therapist or all of that team believe that to get you back to living your life, that is the most effective way for rehabilitation or for healing or for both. So understand that that is the discussion going forward and most important is your decision because you have a say in this as well. I think you have the most important say in all of this because the goal for a lot of these things (especially for really complicated problems with a lot of tissue loss or a lot of infection or a lot of problems with blood flow) is: how can you get back to living your life the soonest? Sometimes that means a high-level amputation. It’s not the most common, but it is sometimes the best option.
Hi, I’m David Armstrong. I’m a professor of surgery and I’m a director of the Southern Arizona Limb Salvage Alliance or SALSA here at the University of Arizona Medical Center. I was born and raised in a little farming town north of Los Angeles called Santa Maria. And I was educated down in Los Angeles and up in San Francisco then I did my residency in beautiful Detroit and my fellowship in beautiful San Antonio. And then I did extra work in the United Kingdom, both in Wales, down in the southwest of England and then up in the northwest and Manchester where I got a PhD. But I am a podiatrist. I’m a toe mechanic, if you will. But my area of specialty and interest is in trying to prevent amputations in folks with diabetes.
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