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What is a Charcot Foot?
Charcot foot is the breakdown in the joints or sudden softening of the bones in the foot. The condition often affects people who have significant nerve damage (neuropathy). A complication of diabetes, the disorder weakens the bones enough for them to fracture easily, even without any major trauma. Since neuropathy impairs the nerves, causing pain to go unnoticed while sapping the muscles’ ability to support the foot properly, the patient’s foot eventually changes shape from continued movement and walking. It targets most commonly the mid-foot, destroying the bone and soft tissue of weight-bearing joints there and in the ankle. As the affliction progresses, the arch collapses and the foot takes on a convex contour, giving it a rocker-bottom appearance that makes walking a very difficult feat. In most cases, only one foot is affected. However, it can strike both feet over time.
Charcot foot is a very serious condition that can result in severe foot deformity, disability, and even amputation. In addition, patients are more likely to develop ulcers from the deformity. Named after Jean-Martin Charcot (1825-1893), the first person to describe the disintegration of ligaments and joints due to disease or injury, Charcot foot should not be confused with the foot deformity associated with the Charcot-Marie-Tooth disease — they are as different as apples and oranges.
What Causes a Charcot Foot?
Charcot foot develops as a result of neuropathy, which decreases sensation and the ability to feel temperature, pain, or trauma. A severe neuropathy will deprive the feet of any feeling, so the pain of traumas goes unnoticed and often untreated as the patient continues to walk, progressively making the injury worse, snowballing from a slackness of the ligaments to joint dislocation, bone and cartilage damage, then deformity.
Who Gets a Charcot Foot?
Charcot foot occurs most often in those with diabetes because they are also the greatest risk for neuropathy. According to the American Diabetes Association, 60-70% of diabetics develop peripheral nerve damage that can lead to Charcot foot and about 0.5% of these patients develop the condition. Neuropathic patients with a tight Achilles tendon, especially, have shown a greater tendency to develop Charcot foot. Chronic hyperglycemia — high blood sugar — is also a common cause.
The disorder occurs at the same rate in men and women, with both feet affected in approximately 20% of the cases. Onset usually occurs after the age of 50, and after the patient has had diabetes for 15 to 20 years.
What are the Symptoms of a Charcot Foot?
Whereas neuropathy often takes decades to unfold, Charcot’s foot can happen in a matter of months or even weeks! The symptoms of Charcot foot can appear after a sudden trauma (such as dropping something on the foot or a sprain) or minor repetition of pressure (such as a long walk). The earliest signs of the condition include the foot or affected part being warmer than the other foot, with some swelling and redness possible; this usually all there is and can come on quite suddenly. The patient generally experiences little pain and the circulation usually remains well, until the untreated foot arch collapses and a deformity starts to develop. Some people with Charcot’s foot can sense a “deep” aching type of pain, but it never matches the severity of the actual injury.
Other initial symptoms of Charcot foot may include:
- Insensitivity to heat in the foot
- Instability of the joint
- Unusually strong pulse
- Loss of sensation in the foot, especially to pain
- Swelling of the foot and ankle, caused by fluid leaking out of the joint capsule
- Dislocated foot joints
- Misalignment of the bones that form a joint, with the ends of the bones grinding against each other and often producing a coarse grating sound
- Weak foot muscles
Calluses and diabetic foot ulcers may occur, too, as a result of bony protrusions (due to the emerging deformity) exerting pressure inside the shoes. The ulceration can become infected and spread to the bone and joints, causing tiredness and fever.
Compression of blood vessels and nerves is another possibility, though it often does not show symptoms due to the loss of feeling in the foot.
How do You Diagnose a Charcot Foot?
Early diagnosis of Charcot’s foot is essential for successful treatment. The surgeon will examine your foot and ankle, ask about events that may have occurred prior to the symptoms, review your medical history (i.e., history of diabetes), and order imaging tests (such as x-rays, MRI) and laboratory tests for confirmation.
X-rays are used to detect any abnormal buildup of fluid in the joints, large bony projections that form along joints, fractures, bone fragments, and joint misalignment or dislocation. Once treatment begins, x-rays are taken periodically to help to evaluate the status of the condition. MRI (magnetic resonance imaging) is employed to help differentiate between Charcot foot and osteomyelitis (bone infection): joint margins for Chacot foot are clearly defined on MRI scan, as opposed to blurry for osteomyelitis.
Laboratory tests include drawing fluid from the joint to uncover bone and cartilage fragments and blood, which may be present in some cases of Charcot foot.
How do You Treat a Charcot Foot?
If diagnosed early, the primary initial goal is the prevention of further joint destruction and foot deformity. Rest and protection of the affected part is a key. Placing the foot in a cast, walking boot, or ankle foot orthosis should relieve pressure and prevent a complete breakdown of the joints. Replace these periodically until there is no temperature difference between the two feet. The process can take up to 6-9 months. Meanwhile, elevation of the foot will reduce blood flow, decreasing inflammation and bone loss. Crutches or wheelchair may also be considered to avoid placing weight on the patient’s foot, especially for those with diabetes. Should the joint is broken down, customized shoes or surgery may be a necessity.
Treatment outcomes vary by the location of the disorder, the severity of damage to the joint, and whether surgical repair was necessary. The bones normally heal in 55 to 97 days, and up to 1-2 years for complete recovery.
Self-Care at Home
If you have a Charcot foot, following medical advice is important since the condition can by very disabling if not managed early and properly, especially if you have diabetes — a disease often associated with neuropathy, the main cause of Charcot foot.
Avoid weight-bearing on the affected foot as much as possible. Don’t put yourself in situations, such as running or jumping or standing for a considerable time, that may lead to trauma.
Check your feet frequently for any swelling. Don’t wait, seek professional help if you notice any. Waiting a couple of days could mean the difference between a good and poor outcome.
Because Charcot foot is closely linked to neuropathy, anything that can block neuropathy’s progression will help control it as well. So, a healthy diet of vegetables and fruits supplemented with vitamins C and B12 to maintain a healthy weight, regular nonweight-bearing exercise (such as swimming or cycling), along with quitting tobacco and alcohol, should vastly improve your condition.
It is important to follow the doctor’s treatment plan for Charcot’s foot. Failure to do so can result in the loss of a toe, foot, leg, or life.
Non-surgical treatment for Charcot’s foot consists of primarily of immobilization. Because the foot and ankle are so fragile during the early stage of Charcot, you must protect them so the weakened bones can repair themselves. Avoid putting weight on them is absolutely necessary to keep the foot from collapsing. You will not be able to walk on the affected foot until the doctor says it is safe to do so. During this time, you’re fitted with a cast, removable boot, or brace, and maybe even crutches or a wheelchair.
The doctor may consider prescribing Fosamax, used to treat osteoporosis (a condition in which the bones become thin and weak and break easily) to increase bone density (thickness) and prevent breakdown.
Prevention with specialized footwear and foot orthoses becomes very important if the treatment was not started early enough and/or the foot is deformed, thus making the case a high risk for an ulcer. Even after the Charcot’s foot has healed, shoes with special inserts may be needed to prevent the condition from happening again. Cases with significant deformity will require foot bracing as well.
Patients with this disorder can usually resume regular activities after treatment, through modification in activity level is often necessary to avoid repetitive trauma to both feet. A patient with Charcot in one foot is more likely to develop it in the other foot, so prevention must be taken to protect both feet. If you have diabetes, you must monitor strictly your blood sugar levels, signs of injuries to the foot, and recurrence of the disease.
Only about 25% of cases require surgery. Structures within the foot can be reshaped and bony protrusions removed surgically to circumvent recurring ulcers. After surgery, the foot is constantly monitored for signs of infection, like redness, swelling, warmth, etc. The foot-and-ankle surgeon will determine the proper timing and the appropriate procedure for the individual case.
Osteotomy is the most common surgical procedure for treating Charcot’s foot. This involves making a surgical incision on the bottom of the foot and removing abnormal bone growth as well as bone and cartilage fragments. After the procedure, the patient usually wears a brace or cast for about 4 weeks or until healing is complete.
Mid-foot realignment arthrodesis is performed to remove bony overgrowths and repair the collapsed arch. In this, the surgeon makes an incision in the foot and inserts screws and plates to stabilize the bones an joints, while removing bone and cartilage fragments. After the surgery, your foot is put in a non-weight-bearing cast for about 3 months, then in a weight-bearing cast for another month or so, followed by custom-made shoes and inserts for walking. A similar procedure, the hind-foot and ankle realignment arthrodesis, is used when you’re unable to walk and braces are no longer helpful. You must wear a non-weight-bearing cast for about 3 months afterward, and then a special brace to protect the arch for 2-3 months more. Both the brace and the foot must be monitored closely the entire time because you may not feel pressure from a poor fit.
Venous Stasis Ulcers
Wound on the leg or ankle caused by abnormal or damaged veins
What is Venous Stasis Ulcers?
A venous stasis ulcer is a leg wound that does not heal because of poor blood flow in the veins. It’s a consequence of venous stasis, a disease of the leg veins in which the one-way valves inside the veins that help the blood flow from the leg back to the heart are weak and do not work correctly; some people are even born without these valves. Valve problems cause the blood to stay in the leg veins under lots of pressure, so when a wound happens from a hit or scratch, it does not heal as it usually would. Instead, it gets larger from the pressure and may become infected (an ulcer).
Because of gravity that pushes the swelling and damage to the lower extremities, venous stasis ulcers are commonly spotted below the knee, primarily on the inner part of the leg, just above the ankle. They are typically red in color, sometimes covered with yellow fibrous tissue. If infected, there can be a green or yellow discharge. The sore itself tends to have an irregular shape. The ulceration can occur in one or both legs, sometimes more than one ulcer simultaneously.
Venous stasis ulcers that have lasted less than one year almost always close completely. Those present for longer than a year may not close completely, but they do get smaller in size. The process of healing will take many months — and slower if you have blockages in your arteries or bone infection.
A potentially very painful condition, venous stasis ulcers are estimated to affect 500,000-600,000 people in the United State every year. The disorder is by far the most common type of leg ulcer seen, accounting for the loss 2 million working days and incurs treatment costs of near $3 billion dollars annually in the country.
What Causes Venous Stasis Ulcers?
A poor functioning venous system, where the veins of the legs are not properly pumping blood back to the heart, is the main reason for venous stasis ulcers. As blood becomes backlogged, the chronic swelling from the accumulation eventually weakens and damages the skin.
Weak valves in the vein walls can be hereditary, as well as the result of vein disease such as a blood clot in the leg. Trauma to the lower leg is another leading source of venous stasis ulceration. Inflammatory diseases such as lupus, vasculitis, scleroderma, or other joint-affecting afflictions can weaken the venous system and diminish skin texture which may then lead to venous stasis ulcers.
Other factors include obesity, being older, smoking, and pregnancy. If you’re not physically active, or have a history of standing, sitting, or lying in one position too long, it may precipitate the formation of a venous ulcer due to poor circulation of blood.
Who Gets Venous Stasis Ulcers?
Venous stasis ulcers account for 80-90% of all leg ulcers reported. The condition is common in patients with varicose veins (swollen veins filled with an abnormal collection of blood), a history of feet/leg swelling or blood clots in either the superficial or deep veins of the legs. Paraplegics may also develop these types of ulcers from the lack of blood-pumping ability in their calf muscles.
The incidence of venous stasis ulcer also rises substantially with age, peaking with women ages 40 to 49, and men of 70-79 years.
A family history of deep vein thrombosis (DVT), which renders venous valves incompetent to cause backflow and increased venous pressure, presents a big risk factor. Those with diseases like diabetes and polyneuropathy also have a greater chance of getting venous stasis ulcers.
Individuals with jobs that involve standing for a long period of time will build up venous pressure in their legs and thus more prone to the disease. On the opposite end, a sedentary lifestyle minimizes the blood-pumping action of calf muscles on venous return, leading to higher venous pressure for developing the condition.
Men who smoke have a higher incidence of venous stasis ulcers, as do persons who are overweight.
What are the Symptoms of Venous Stasis Ulcers?
Prior to the ulcer’s formation, the skin may have been somewhat flaky and itchy. Known as stasis dermatitis, this pre-ulceration condition is eczema (inflammation of the outer layer of skin) resulted from blood settling into the skin layers, then breaking down and depositing hemosiderin (an iron-storing protein) and melanin (skin pigment), which in turn inhibits the venous system’s ability to adequately pump blood up to the heart.
Typically, the ulcer is an open sore in an area that is swollen and already exhibits a red to brown discoloration that may have been present for some time. The lesion frequently occurs around the inner side just above the ankle, where venous pressure is greatest because of the concentration of large communicating veins there. The base of a venous ulcer is usually red. The surrounding skin is often discolored (brown or purple) and swollen, appearing shiny and tight depending on the amount of swelling. It may even feel warm or hot. There may be a white to yellow tissue over the base that is a type of scar tissue and does not promote healing. A clear to yellow or green drainage may be coming from the wound, with significantly increased discharge and discoloration if the wound is infected.
How do You Diagnose Venous Stasis Ulcers?
Varicose veins, spider veins, and purplish discoloration of the skin are commonly observed in suffering from venous stasis ulcers. In a physical exam, the doctor will first review the patient’s medical history for chronic swelling, diabetes, neuropathy and other conditions linked to venous stasis ulcers. Then, a specialist will examine the wound thoroughly, perform tests such as x-ray and MRI (magnetic resonance imaging), in addition to possibly ordering noninvasive vascular studies, blood tests, and taking samples for wound cultures to differentiate these ulcers from infection (cellulitis) or blood clots.
How do You Treat Venous Stasis Ulcers?
Venous ulcers are costly to treat, and there is a significant chance of recurrence — one study found that up to 48% of venous ulcers had recurred by the fifth year after healing. They also may take a long time to heal, with up to 50% of the ulcers open and unhealed for nine months or longer, especially when the patients continue to smoke, remain obese, and not heed the doctor’s orders.
Treatment is geared toward decreasing the swelling so the ulcer can heal. Antibiotics are not routinely administered unless the wound is grossly infected.
Self-Care at Home
The treatment of all ulcers begins with careful skin and foot care. Often you’re given instructions to care for your wound at home similar to the following:
Keep the wound clean and dry. Gently wash the affected area on your leg and feet every day with mild soap (Ivory Snow or Dreft) and lukewarm water. Washing loosens and removes dead skin and other debris or drainage from the ulcer. You can also clean the ulcer with peroxide, Dakin’s solution, or potassium permanganate once per day. Pat your skin and feet, including between the toes, gently and thoroughly to dry them. Do not rub your skin or the space between the toes. Apply a lanolin-based cream once or twice a day to your legs and the soles and top of your feet to prevent dry skin and cracking, but NEVER apply lotion between your toes or on an open cut or sore.
Examine your skin and feet daily for cuts, cracks, scratches, blisters, or sores, especially if you have diabetes. Also check for redness, increased warmth, ingrown toenails, corns, and calluses. Use a mirror to view the bottom of your foot or have someone look at it for you. Detecting and treating foot/skin sores early can help you prevent infections and a sore from getting worse. However, do not treat corns, calluses, or other foot problems yourself. Visit a podiatrist for treatment instead.
Care for your toenails regularly. Cut your toenails after bathing when they’re soft. Cut toenails straight across and smooth with a nail file.
Change the dressing and take prescribed medications as directed. If you have varicose veins, you will notice your feet and ankles are generally normal in size in the morning but get progressively more swollen as the day goes on. For this reason, it is important to have a dressing change with fresh compression in the morning as to not let the foot and leg swell during the course of the day.
Elevation of the legs as much as possible.
Drink plenty of fluid.
Follow a healthy diet as recommended, including plenty of fruits and vegetables.
Exercise regularly, as directed by a physician.
Wear appropriate shoes.
Wear compression wraps if appropriate and as directed.
Avoid topical antibiotics, which do not improve ulcer healing. Stay away from topical antiseptics (for example, povidone-iodine), which causes additional injury to the wound and delays healing.
Medical treatments generally include one or more of the following options in addition to home care:
Weekly application of Unna’s boot compressive dressing (which contains zinc oxide) to minimize edema (swelling caused by fluid trapped in your body’s tissues) and other types of swelling.
Support hose. Non-elastic, moveable, below-knee compression will aggressively counter the impact of reflux on venous pump failure. It can decrease blood vessel diameter and pressure, in turn increasing their effectiveness and prevent blood from flowing backward.
Antibiotics if the wound becomes infected.
Consultation for vascular surgery if necessary.
The ulcer itself generally has to be treated in an effort to remove all devitalized tissue and to promote formation of healthy granulating tissue. Debridement or removal of this dead tissue may be done in a couple of different ways. The most common is through sharp debridement where your doctor takes a scalpel and scrapes away all dead tissue within the ulcer and immediately surrounding the wound. The problem with this is that it can be a painful procedure and at times may have to been done under local anesthesia.
Surgical treatment is reserved for those with great discomfort or ulcers that don’t seem to respond to noninvasive medical treatments and management. The most common procedure is a sharp debridement in which the doctor takes a scalpel and scrapes away all dead tissue within the ulcer and immediately surrounding the wound. It can, however, be a painful ordeal and at times may have to be done under local anesthesia.
How to Prevent Venous Stasis Ulcers?
Controlling the risk factors can help you prevent venous stasis and other ulcers from developing. Your options include:
Elevate your legs when sitting
Change your position when you stand or sit for a long time
Wear any support socks or stocking as ordered by your doctor
Avoid tight clothing
Eat a well-balanced diet to control your weight, blood cholesterol, and triglyceride (a type of fat) levels
Limit your intake of sodium
Manage your blood pressure
Exercise regularly; this can be as simple as walking a few extra blocks or climbing a flight of stairs a day (but check with your doctor before starting any exercise program)
What is Diabetic Neuropathy?
Diabetic neuropathy is a serious complication derived from diabetes. The condition, actually a family of nerve disorders, causes damage to the nerves as a result of high blood sugar levels (or hyperglycemia). It can injure nerve fibers throughout your body, including the digestive tract, heart, and reproductive organs, though it strikes most often at the nerves in your legs and feet. Depending on the affected nerves, patients experience a range of symptoms from pain and numbness in their limbs to problems with their digestive system, urinary tract, blood vessels, and heart. For some, these signs are mild. For others, diabetic neuropathy can be agonizing, disabling, and even fatal.
While diabetic neuropathy is common among diabetics, it can often be prevented or slowed with rigorous blood sugar control and a healthy lifestyle.
What Causes Diabetic Neuropathy?
Not surprisingly, diabetes is the leading known reason for neuropathy in developed countries, and neuropathy is responsible for the greatest rate of morbidity and mortality in diabetes patients. It has been estimated that approximately 20% of those with diabetes have diabetic neuropathy, and the condition is implicated in 50-75% of non-traumatic amputations. Because excess blood sugar (glucose) leads to a condition known as Glucojasinogen that blocks blood flow to the nerves governing the movement of arms and legs, diabetics are also more likely to develop symptoms in extremities.
The causes are probably different for each type of diabetic neuropathy. Researchers believe prolonged exposure to high blood glucose can damage delicate nerve fibers, leading to diabetic neuropathy. Exactly why this happens isn’t completely clear, but is likely due to a combination of factors:
High blood glucose and decreased blood flow, which interferes with the nerves’ ability to transmit signals and can weaken the walls of the small blood vessels (capillaries) supplying oxygen and nutrients to the nerves
The long duration of diabetes
High blood pressure (or hypertension)
High blood cholesterol and abnormal blood fat levels
Possibly low levels of insulin
Inflammation in the nerves, occurring when your immune system mistakenly attacks part of your own body like it was a foreign organism
Genetic traits unrelated to diabetes that make you more vulnerable to nerve damage and disease
Smoking, alcohol abuse, obesity, and other harmful lifestyle choices that can damage both nerves and blood vessels, while significantly increasing the risk of infections
Age and height may also be risk factors for diabetic neuropathy
In the DCCT (Diabetes Control and Complications Trial) study from 1995, the annual incidence of neuropathy was 2% per year but dropped to 0.56% with intensive treatment of Type 1 diabetics. The progression of neuropathy is predicated on the degree of control over blood sugar levels in both Type 1 and Type 2 diabetes.
Who Gets Diabetic Neuropathy?
About 50% of people with diabetes eventually have some form of neuropathy. Nerve problems can afflict diabetes patients at any time, but the chances rise with age and longer duration of diabetes. The highest rates of neuropathy rest with those who have had diabetes for at least 25 years. Diabetes can also cause damage to the kidneys, and the subsequent increase of toxins in the blood can contribute to nerve damage.
Diabetic neuropathies also appear more commonly in people having problems controlling their blood glucose, those with high levels of blood fat (such as cholesterol) and blood pressure, as well as those who are overweight.
Smokers are candidates for diabetic neuropathy too, since smoking narrows and harden the arteries, thus reducing blood flow to their legs and feet. This makes wounds more difficult to heal while eroding the integrity of the nerves.
Are There Different Types of Diabetic Neuropathy?
Diabetic neuropathy can be classified as peripheral, autonomic, proximal, or focal, each affecting different parts of the body in various ways.
Peripheral neuropathy, also called distal symmetric neuropathy or sensorimotor neuropathy, is the most common type of diabetic neuropathy. It causes pain or loss of feeling in the toes, feet, legs, hands, and arms. Peripheral nerve injuries may also affect nerves in the skull or in the spinal column and their branches. This type tends to develop in stages and afflicts both paired extremities (legs, feet, arms, etc.) at the same time. Peripheral neuropathy is thought to result from abnormal metabolism of the nerves, restriction in blood supply and flow, or both.
Autonomic neuropathy is a troubling complication that targets the nerves regulating vital functions, including the heart muscle and smooth muscles, as well as nerves in the lungs and eyes. It causes changes in digestion, bowel and bladder function, sexual response, and perspiration. Worse, it also causes hypoglycemia unawareness, a condition that stops the afflicted from experiencing the warning symptoms of low blood sugar levels because it can affect the nerves controlling the heart, blood pressure, and blood glucose levels. Autonomic neuropathy is most likely to occur in those who have had poorly controlled diabetes for many years.
Sometimes called lumbosacral plexus neuropathy, femoral neuropathy, or diabetic amyotrophy, proximal neuropathy triggers pain in the thighs, hips, or buttocks and leads to weakness in the legs, usually on one side of the body. A patient with this condition is unable to go from a sitting to a standing position without help. Treatment for the weakness or pain is often necessary, with the length for recovery depending on the type of nerve damage.
Focal neuropathy is uncommon and believed to occur after a clot or blockage of a blood vessel causes restriction of blood flow in a nerve or group of nerves. It shows as a sudden debility of the affected nerve(s), triggering muscle weakness or pain. Focal neuropathy targets most often the nerves in the head, torso, or leg. However, pain and unpredictable as it is, this condition tends to improve by itself and does not cause long-term damage, for near total recovery generally happens within two weeks to 18 months.
What are the Symptoms of Diabetic Neuropathy?
Some diabetics will not develop nerve damage, while others show symptoms for the condition early. On average, symptoms begin 10 to 20 years after the diabetes diagnosis.
Approximately 50% of diabetes patients will eventually develop nerve damage. For some Type 2 diabetics, symptoms of neuropathy can occur before diabetes is ever diagnosed.
Furthermore, a patient may have symptoms for just one or several of the four main types of diabetic neuropathy. Because most nerve damage is often minor at first and build up gradually over numerous years, you may not notice problems until considerable damage has been done. The initial signs are often numbness, tingling, or pain in the feet, though they vary depending on the type of neuropathy and which nerves are affected.
Peripheral Neuropathy: It affects the very ends of nerves first, starting with the longest nerves — therefore often those in your feet and legs, followed by your hands and arms. The possible signs for this affliction include:
Numbness or reduced ability to sense pain or changes in temperature, especially in your feet and toes
A tingling, prickling, or even burning sensation
Sharp, jabbing pain or cramp that may be worse at night
Pain when walking
Extreme sensitivity to touch — for some people, even the weight of a blanket can be agonizing
Muscle weakness and difficulty walking
Loss of balance and coordination
Serious foot problems, such as infections, ulcers, deformities (like hammertoes), bone and joint pain, etc.
Autonomic Neuropathy: Affecting the nervous system controlling your heart, bladder, lungs, stomach, intestines, reproductive organs and eyes, this condition may manifest as:
Hypoglycemia unawareness — the lack of awareness that blood sugar levels are low
Constipation, uncontrolled diarrhea, or a combination of both
Slow stomach emptying (gastroparesis), leading to nausea, vomiting, and loss of appetite
Bladder problems, including urinary tract infections or involuntary leakage of urine
Erectile dysfunction in men, vaginal dryness and other sexual difficulties in women
Increased or decreased sweating
Body’s inability to adjust blood pressure and heart rate, causing sharp drops in blood pressure when you rise from sitting or lying down that many have you feeling lightheaded (or even faint).
Problems regulating your body temperature
Increased heart rate when you’re at rest
Changes in how your eyes adjust from light to dark
Proximal Neuropathy: This condition affects nerves closer to your hips or shoulders and is more common in Type 2 diabetics and older adults. Symptoms are usually one side of the body, though it can spread to the other side in some cases. Most people improve over time, but the symptoms may get worse before they get better.
Sudden severe pain in the hip and thigh or buttock
Eventual weak and atrophied thigh muscles
Difficulty rising from a sitting position
Unintentional weight loss
Abdominal swelling if the abdomen is affected
Focal Neuropathy: This condition strikes suddenly, most common in older adults. Although potentially very painful, it usually does not result in long-term problems, and the symptoms typically diminish and disappear after a few weeks or months.
Difficulty focusing your eyes, double vision, or aching behind one eye
Paralysis on one side of your face (Bell’s palsy)
Pain in the front of your thigh
Pain in your shin or foot
Chest or abdominal pain (sometimes mistaken for heart disease, a heart attack, or appendicitis)
Other symptoms that are not due to neuropathy, but often accompany it, include:
Drooping eyelid, face, and/or mouth
Loss of bladder control
Rapid heart rate
Diabetic NeuropathyHow do You Diagnose Diabetic Neuropathy?
Physicians diagnose diabetic neuropathy based on the patient’s symptoms, medical history, and physical exam. During the exam, your doctor is likely to check your blood pressure, heart rate, muscle strength, and tone, tendon reflexes, as well as sensitivity to touch, temperature and vibration. Other tests may include:
Filament test. If you’re unable to feel the soft nylon fiber called a monofilament on your feet, it’s a sign that you’ve lost sensation in those nerves. This may be done at home by pricking your feet with a pin to see if you feel it.
Quantitative sensory testing. This is a non-invasive test used to gauge how your nerves respond to vibration (usually with a tuning fork) and changes in temperature.
Nerve conduction studies. This test measures how fast the nerves in your arms and legs conduct electrical signals. It’s often administered to diagnose carpal tunnel syndrome.
Electromyography (EMG). Commonly performed along with nerve conduction studies, this shows how well the muscles respond to electrical signals transmitted by nearby nerves.
Autonomic testing. Your doctor may request special tests to check your blood pressure in different positions and evaluate your ability to sweat if you’re showing symptoms of autonomic neuropathy.
The American Diabetes Association recommends that all diabetics take a comprehensive foot exam at least once a year to check for peripheral neuropathy. In addition, your feet should be examined for cracked skin, sores, calluses, blisters, and bone/joint abnormalities at every office visit. (If foot injuries go unnoticed for too long, amputation may be required!)
How do You Treat Diabetic Neuropathy?
Diabetic neuropathy has no known cure. Treatment for the condition generally focuses on slowing the progression of the disease, relieving pain, as well as managing complications and restoring function.
Slowing the progression is a primary goal, accomplished by consistently keeping blood sugar within a narrow target range — likely a blood sugar level of 70 to 130 mg/dL before meals, less than 180 mg/dL two hours after meals, and keeping A1C (the amount of sugar that has attached to hemoglobin, the substance that carries oxygen inside red blood cells, in your blood) to less than 7 percent for a few months. The American Diabetes Association recommends those with diabetes have an A1C test at least twice a year to see if the blood sugar levels are consistently in a healthy range.
To help slow nerve damage, you should follow your doctor’s recommendations for good foot care, stick to a healthy diet plan, get plenty of physical activity, maintain a healthy weight, stop smoking and avoid alcohol — or at least limit it to no more than one drink a day for a woman, two drinks a day for a man.
Providing effective pain relief can be a difficult task in managing diabetic neuropathy. You can try medications like anti-seizure drugs, antidepressants, and opioids, but they don’t work for everyone and most (especially opioids!) have side effects that may outweigh the benefits. Alternative therapies, such as capsaicin cream (made from chili peppers) and acupuncture, may help with pain relief.
Managing complications and restoring function often entailed specific treatments. You can alleviate digestive problems by eating smaller, more frequent meals, reducing fiber and fat in the diet as well as, for many people, eating soups and pureed foods. Dietary changes can also help relieve diarrhea, constipation, and nausea. For urinary tract issues, a combination of behavioral techniques (like timed urination), devices (such as rings inserted to prevent urine leakage), and antispasmodic medications is probably the most effective. Simple lifestyle measures, from avoiding alcohol and drinking plenty of water to standing up slowly, can do wonders for those with hypertension.
Self-Care at Home
Neuropathy patients must take special care of their feet since that’s the part often affected first and most by the condition. Practice these steps for proper foot care at home:
Clean your feet daily, using warm — not hot — water and mild soap. Don’t soak your feet. Dry them with a soft towel and dry carefully between your toes.
Inspect your feet and toes every day for cuts, blisters, redness, swelling, calluses, or other problems. Use a mirror laid on the floor or get help from someone else if you cannot see the bottoms of your feet. Notify your doctor of any problems.
Moisturize your feet with lotion, but don’t get it between your toes!
After a bath or shower, file corns and calluses gently with a pumice stone.
Each week (or when necessary), cut your toenails to the shape of your toes and file the edges with an emery board.
Always wear shoes or slippers to protect your feet. Make sure the footwear fit well and let your toes move comfortably. Break in new shoes gradually by first wearing them for only an hour at a time. Prevent skin irritation with thick, soft, seamless socks.
Before putting your shoes on, look them over carefully and feel the insides with your hand for tears, sharp edges, or objects that might injure your feet.
Make healthy food choices. Eat a balanced diet that includes fruits, vegetables, and whole grains, while limiting portion sizes to achieve or maintain a healthy weight.
In addition to a healthy weight, daily physical activity will play a major role in keeping your blood sugar and blood pressure under control. The American Diabetes Association recommends about 30 minutes of moderate exercise a day for at least five times a week. If you have severe neuropathy and decreased feeling in your leg, however, you should participate in nonweight-bearing endeavors such as bicycling or swimming.
Stop smoking. A diabetic using tobacco in any form not only is much more likely than one who does not to die of heart attack and stroke, he is also more likely to develop circulation problems in his feet — so find ways to quit!
Because over-the-counter pain medicines such as acetaminophen and ibuprofen may not work well for treating most nerve pain and can have serious side effects, some experts recommend avoiding these medications.
On the other hand, as deficiencies of vitamin B12 in the body has been linked to neuropathy, taking vitamin B12 to promote the regeneration and growth of nerve cells will help keep neuropathy in check.
Professional treatment is geared toward preventing the neuropathy from getting worse by controlling diabetes. Painful neuropathy is typically countered with oral medications, from tricyclic antidepressants to anticonvulsants such as Neurotin. Duloxetine and pregabalin have also been approved by the U.S. Food and Drug Administration specifically for treating diabetic peripheral neuropathy.
Metanx is a prescription medical “food” for patients with diabetic peripheral neuropathy. Its unique formulation provides the active forms of folate, vitamin B6 and vitamin B12 to manage the distinct nutritional requirements of diabetic neuropathy patients who often experience numbness, tingling, and burning sensations in their feet.
Treatments applied to the skin — usually the feet — include capsaicin cream and lidoderm patches. Some physicians may recommend these two supplements: alpha lipoic acid ( ALA), a standard of care therapy for neuropathy in Europe; and adaptrin (also available as Padma-Basic), an ancient blend of 18 herbs that works in the capillaries themselves to improve blood flow and oxygenation.
In addition to daily self-inspections of the feet, patients with severe sensory loss will require diabetic shoes.
Keeping your blood glucose levels as close to the normal range of 70-130 mg/dL before meals and an A1C reading of less than 7 percent is the best way to prevent neuropathy. Maintaining safe blood sugar levels protects nerves throughout your body, whereas shifts in those levels can accelerate nerve damage. Given an intense glucose control, you can reduce your overall risk of the condition by as much as 60 percent.
Avoid risk factors associated with diabetic neuropathy, such as consumption of alcohol, poor nutrition, exposure to chemical toxins, use of certain drugs, and physical injury to the nerves.
Regular intakes of vitamin B12 to reinforce the sheathing that protects nerve cells can keep neuropathy at bay.
Foot care is important since foot sores, ulcers, and even amputation are a common complication of diabetic neuropathy. Many of these problems can be prevented by having a comprehensive foot exam at least once a year, as well as taking the following measures to care for your feet:
Check your feet daily for blisters, cuts, bruises, cracked and peeling skin, redness and swelling.
Keep your feet clean and dry. Wash them with lukewarm water. Dry them gently by blotting or patting, especially between the toes. Moisture the skin thoroughly to prevent cracking, but don’t get any lotion between toes in order to prevent fungal growth!
Don’t trim into the corners of your toenail or cut ingrown toenails. Don’t cut corns or calluses. Don’t use corn plasters or chemicals to remove them. Don’t use strong antiseptic solutions or adhesive tapes on your feet.
Don’t walk on hot surfaces, such as beach sand or cement around swimming pools.
Don’t walk barefooted, even indoors. Don’t wear sandals with thongs between your toes. Never wear shoes without stockings or socks, and inspect the inside of your shoes every day for foreign objects, nail points, and torn linings. Wear wool socks and protective foot gear (such as fleece-lined boots) in winter.
Wear comfortable shoes. Don’t buy shoes that are too tight and depend on them to stretch out.
Exercise is also crucial. While walking may be fine, experts caution that this form of exercise will not work after a short time because the body will require more severe stress to stimulate the necessary changes. The general rule of thumb is to exercise fast or hard enough so that you cannot talk to the person next to you, and then scale back. One hour a day is necessary when treating the condition, but one hour at three to four times a week is adequate for maintenance.
What are Diabetic Ulcers?
Diabetic ulcers are sores that occur at the pressure points on the foot, and usually on the sole where contact against the ground is most common. Pressure from the shoes worn can also produce ulcers on the sides or top of a foot.
One of the major complications of diabetes, foot lesions is responsible for more hospitalizations than any other diabetic condition.
What Causes Diabetic Ulcers?
Those with diabetes are prone to peripheral neuropathy (nerve damage), which dulls or robs completely the feeling in the feet and causes changes in the sweat-producing glands. Feet are naturally stressed from walking, and someone with numbed sensation may not feel a skin tear or breakdown. That, coupled with a decreased circulation to the feet, can lead to the wounds not getting the proper blood flow and thus not only slower to heal, but also increased risk of infection, turning a small cut, scrape, or irritation in a diabetic into an ulcer. As well, it is common for these types of ulcers to keep coming back in diabetics.
Who Gets Diabetic Ulcers?
According to The National Institute of Diabetes and Digestive and Kidney Diseases, about 16 million Americans are known to have diabetes. 15% of them develop a foot ulcer, and 12-24% of individuals with foot ulcer require amputation. The more serious or severe a patient’s diabetes is and more out of control or higher the blood sugar levels are, the more likely the person is to develop diabetic ulcers.
Foot ulcers can affect anyone with an impaired sensation of the feet, diabetic or not. Peripheral neuropathy, present in 60% of diabetic persons and 80% of diabetic persons with foot ulcers, lends the greatest risk. Because the condition tends to occur about 10 years after the onset of diabetes, diabetic ulceration happens sometime thereafter.
Ill-fitting shoes or hose, irritating chemicals such as “corn remedies,” extreme heat or cold, accidentally self-inflicted wounds, and faulty weight distribution from bad postures or instruments (such as crutches and walkers) can lead to diabetic ulcers. A microvascular disease that affects or damages the walls in the small blood vessels (such as the capillaries) also contributes to the cause, as will obesity, heart disease, and smoking.
What are the Symptoms of Diabetic Ulcers?
Foot ulcers are open sores or wounds that can be deep enough for you to see down to the bone. They may or may not be painful, since the surrounding nerves may have already been dulled by peripheral neuropathy. Generally, the patient has a swollen foot, possibly with a burning or itching sensation. There may also be a rash, redness, brown discoloration or dry, scaly skin.
Usually, depending on the patient’s blood circulation, the ulcer itself has a pink/red or brown/black margin, and the immediate skin appears spongy. A callus often overlies the ulcer on the foot surface. Any discharge is watery and serious.
How do You Diagnose Diabetic Ulcers?
You doctor may run tests that include MRI (magnetic resonance imaging), nerve conduction tests (measuring how fast the nerves in your arms and legs conduct electrical signals), and vascular studies (non-skin-piercing procedures used to assess blood flow in arteries and veins). In the case of a new ulcer, the doctor may want to take an X-ray of the affliction to make sure there is no infection (osteomyelitis), fracture of the bone, or foreign objects lodged in the ulcer, as you may not feel them.
You can develop peripheral neuropathy without even being aware of it. So, it is important for diabetics to take a comprehensive foot exam every 6 months.
How do You Treat Diabetic Ulcers?
Foot ulcers in diabetes can require an assessment across multiple medical disciplines, usually by diabetes specialists, podiatrists, and surgeons. The treatments vary depending on the ulcer’s severity and location as well as whether it’s infected, from appropriate bandages, antibiotics, debridement (removal of dead, damaged, or infected tissue), to arterial revascularization (restoration of blood supply).
All ulcers should receive treatment. See your health care provider if you experience a lack of sensation in your feet if there is any discoloration, pain, swelling, redness, oozing, or fever. Diabetic ulcers can lead to amputation if care is delayed, so visit your physician or podiatrist as soon as possible.
Self-Care at Home
It is important to remember that if you have had an ulcer previously, it is very common to get more. Follow the tips below to reduce the chance of recurrence or help relieve your current condition:
1. Vitamin C has been found to inhibit the bacteria, Helicobacter pylori, that cause ulcers, so it follows that taking high doses of vitamin C will block the condition’s development. Because the same bacteria also lead to vitamin B12 deficiencies, supplement your diet with plenty of vitamin B12 to retain the regeneration and growth of your cells.
2. Some doctors have also found that drinking lots of water, approximately 8-12 glasses a day, along with a sensible, healthy diet can resolve ulcers in well over 95% of their patients.
3. Avoid certain medications, such as Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), which can increase the risk of ulcers. Do not use medicated pads to treat corns, calluses, or warts on the feet, since these pads can cause ulcers too.
4. Make sure to change foot dressings daily as directed by your doctor.
5. Never go barefoot. Put on shoes that are well-fitting, cushioned, and pressure-reducing, both indoors and outdoors to cut down risk of injury. Better yet, always wear special footwear recommended by your doctor to minimize pressure and speed up recovery. When wearing socks, make sure that any folds in the socks are smoothed out before putting shoes on. Avoid wearing flip-flops and wearing shoes without socks.
6. Decrease pressure on your feet by trying to walk less. Try exercise that won’t put weight or exertion on your feet, like swimming, cycling, or rowing. Consider changing to a job that does not require much walking or standing.
7. No tobacco! Smoking can worsen blood flow, further slowing down healing.
8. Keep your blood sugar levels under tight control. Elevated blood glucose weakens the body’s ability to fight infection and slows down wound healing.
The steps for professional treatments may include:
1. Weekly or twice weekly debridement of dead or infected tissue with a scalpel. While this will actually make the ulcer larger in size and cause bleeding, it also exposes the healthy skin underneath for faster and cleaner healing.
2. Oral or intravenous antibiotics. Your doctor may send a sample of skin or fluid for bacterial culture and, if the area is infected, start you on antibiotics.
3. Hospitalization for surgery or infection control.
4. Wound care center referral for regular monitoring and care of the ulcer.
5. Hyperbaric oxygen therapy, the medical use of oxygen at a level higher than atmospheric pressure, applied to drastically increase the partial pressure of oxygen in the tissues of the body and consequently raise the blood’s capacity to transport oxygen. The Cochrane Review Panel has concluded in 2004 that this therapy reduced the risk of amputation for patients with diabetic ulcers, and may improve the healing at one year.
6. Special paddings or shoes to minimize pressure or impact of walking and between the feet and footwear.
7. Vascular surgery and infectious disease consultation.
It is crucial to follow up with your doctor as scheduled, as diabetic ulcers can worsen very quickly and need to be closely monitored.
Surgery is necessary for deep infections. Even after the successful management and healing of an ulcer, the recurrence rate is 66% and the amputation rate hovers around 12%. Half of all non-traumatic amputations stemmed from diabetic foot complications, and the chance of needing an amputation for the other limb within 5 years is as high as 50%.
How to Prevent Diabetic Ulcers?
Poor diet or stress was long thought to be a cause of ulcers, but the affliction was definitively linked to the H. pylori bacteria in the 1980s. In addition, researchers also believed that lifestyle can determine which people develop ulcers. Therefore, healthy dietary habits supplemented by a steady intake of vitamin B12 and C — both valuable in fending off the bacteria — will go a long way in preventing diabetic ulcers.
Avoid risk factors linked to peripheral neuropathy, the primary cause of diabetic ulcers: Consumption of alcohol, overweight, poor nutrition, exposure to chemical toxins, use of certain drugs and medicated pads (especially to treat corns, calluses, or warts on the feet), and physical injury to the nerves.
Inspect your feet daily, including the parts between the toes, for any breaks in the skin, blisters, or red irritations. Use a mirror to see the bottoms of your feet or ask someone else to do this.
Trim your toenails carefully and regularly. Cut around the contour of the toes and never into the corners.
Don’t go barefoot, as the pressure of movement is more significant on bare feet than feet in proper-fitting, cushioned footwear.
Test bath water with your fingers instead of stepping right in it. If your feet lack sensation, they may get burned if the water is too hot!
Active people are less likely to develop ulcers of any type. Men who walked or ran at least 10 miles a week were 62% less prone to the condition than their inactive peers. Exercise helps the body deal with the physical effects of mental stress and enhances the immune system’s function. You might, however, want to consider decreasing the pressure on your feet with non-weight bearing exercises such as cycling or swimming.