Diabetic foot
For a person with diabetes mellitus, foot complications are the most serious complications. In the Netherlands, approximately 25 per cent of all people with diabetes are affected by ‘diabetic foot’. Of this 25 per cent, approximately 15 per cent develop a foot ulcer, which leads to amputation in 4 per cent of all cases.
Definition of ‘diabetic foot’
A variety of foot disorders, arising as a result of neuropathy, macroangiopathy, ‘limited joint mobility’ and the consequences of metabolic disorders, which usually occur in combination in patients with diabetes mellitus1
A skin defect that has developed in a diabetic patient (below the ankle, regardless of the duration of the wound1
A wound on the foot can have serious consequences.
Preventing ulcers is the ultimate goal of every professional who treats diabetic feet. Scientific research has shown that (preventative) foot care drastically reduces the number of amputations. Thanks to good foot care, this reduction looks set to become even greater in the coming years. Diabetes mellitus (diabetes) is a clinical condition or disorder that affects both young and old. In diabetes, the balance of blood sugar levels is disrupted because the pancreas does not produce enough insulin. It may also be that the body is not sensitive enough to insulin.
Insulin ensures that muscles and other organs can use the energy contained in food. If there is too little insulin, the body’s cells cannot use the fuel they need. This leaves too much sugar in the bloodstream, causing blood sugar levels to rise.
It is extremely important to regulate blood sugar levels so that they remain within certain limits. This can prevent or delay complications. Regulation can be achieved through dietary guidelines, either on their own or in combination with tablets or insulin injections. Well-managed diabetes is therefore of the utmost importance.
Foot problems
A large proportion of patients undergoing treatment with a podiatrist have foot problems caused by diabetes. These are mainly people who have had diabetes for some time. In the long term, the combination of impaired blood flow (angiopathy) in the foot and impaired nervous system function (neuropathy) will lead to the development of diabetic foot, with associated risk factors for the development of wounds. However, not every person with diabetes develops a diabetic foot.
Complications associated with diabetes
The longer a person has diabetes mellitus, the more likely they are to develop characteristic complications
Angiopathy: vascular abnormalities that lead to narrowing of the blood vessels, thereby impeding blood flow to tissues and organs. As a result of the reduced blood supply, the risk of infection increases and wounds heal more slowly. In severe cases, this can even lead to the loss of toes or part of the foot.
Neuropathy: Complications affecting the nerve pathways, resulting in reduced sensation, particularly in the feet and lower legs. People often experience a numb sensation in their feet (as if walking on cotton wool). Wounds may also go unnoticed because they cannot be detected in time. No pain is felt. The skin becomes dry and thin due to the reduced functioning of the sweat glands. This also makes it more likely for minor wounds to develop.
Damage to the nerves in the foot can lead to an abnormal foot position or an unstable gait. This increases the risk of pressure sores or discomfort on the toes, the sole of the foot, the heel and the ankle.
Ulceration (wound formation): is common in diabetic foot conditions and must be carefully treated and monitored by a podiatrist to prevent amputations. Ill-fitting shoes, and even the seams of socks, can cause minor wounds that go unnoticed by someone with reduced surface sensation. A podiatrist can advise you on how to prevent such wounds and how they should be treated. There are many developments in the field of wound healing for diabetic foot ulcers. New dressings are constantly being developed to aid the healing process. The podiatrist is kept up to date with these developments. A key aspect of wound healing is the regular removal of excess calluses from the area around the wound.
What can a podiatrist do?
As part of multidisciplinary care, the podiatrist provides the following care:
Targeted diabetic foot assessment focusing on sensory disturbances, peripheral arterial disease, assessment of the condition of the skin and nails, screening for LJM and footwear assessment. This also includes providing information to the patient and giving advice on foot care and footwear.
General podiatric examination focusing on dermatological and/or orthopaedic abnormalities, including assessment of the range of motion of all foot joints, assessment of gait and a symptom-oriented examination.
Additional examination of the feet if there are indications of impending problems.
Instrumental foot treatment involving the trimming or filing of the nails and the removal of calluses and corns
Regular examination and treatment of ulcers, provided that primary care treatment is sufficient (not located on the sole of the foot, superficial, not infected, no signs of PAV). With regard to wound care for active ulcers, podiatrists follow the most recent Diabetic Foot Guidelines (2006).
If there is no sign of the ulcer healing within two weeks, or in the case of plantar ulcers, the patient must, in accordance with the protocols (LTA – National Transmural Agreements) be referred to secondary care/foot clinics, resulting in a change of lead clinician, with responsibility being taken over by an internist or vascular surgeon.Podiatric therapies, such as insoles, orthoses, prostheses and nail braces, fall outside the scope of this contract.
