Your active life with diabetic foot syndrome.

Diabetic foot syndrome: Management, prevention, treatment

Diabetic foot syndrome is one of the complications of diabetes mellitus. It can severely restrict the quality of life of affected individuals and their families – and in some cases can be very dangerous. But you can actively counteract this and reduce the risk of diabetic foot syndrome. To achieve this, it is crucial to consult a doctor early and at the right time.

Diabetes mellitus

How are diabetes and diabetic foot syndrome related?

Diabetic foot syndrome is colloquially referred to as the “diabetic foot” and is a complication of diabetes mellitus. In Germany, between seven and nine percent of people suffer from diabetes, of which about 20 to 30 percent develop diabetic foot syndrome, also abbreviated by doctors as DFS.

Diabetic foot syndrome usually occurs in conjunction with sensory neuropathy and/or peripheral arterial occlusive disease (PAOD). Both factors are the result of inadequately managed diabetes mellitus.

In diabetic neuropathy, i.e. damage to the peripheral nervous system, sensation in the feet is limited. The nerve damage leads to an altered sensation of pain in the feet, so that minor injuries may not be immediately recognised. Reduced or changed sensation in the feet can also affect safety while walking, therefore increasing the risk of injury.

Peripheral arterial occlusive disease is a circulatory disorder. Due to the progressive occlusion of vessels in the leg, the blood supply to the legs and feet is insufficient, which is manifested by reduced wound healing of injured tissue.

If both complications occur together, the risk of initially small injuries developing into open ulcers (sores) is increased. Diabetic foot syndrome is most common in patients with type 2 diabetes. While it is a common complication of diabetes mellitus, you can still do a lot to reduce the risk of this complication.

What is diabetes mellitus?

Diabetes mellitus is a metabolic disorder characterised by constantly elevated blood glucose levels. It is commonly known simply as "diabetes".

The hormone insulin plays a major role in controlling the blood sugar level. Insulin usually ensures that the sugar absorbed in the blood by eating and drinking is transported to the body's cells and converted into energy there. If the body does not produce enough insulin, or if it is ineffective due to resistance, the blood sugar cannot be broken down. A permanently elevated blood sugar level causes damage to the eyes, kidneys and nerves, also in the feet. There are two main types of diabetes: Type 1 diabetes and type 2 diabetes.

Type 2 affects about 90 percent of people with diabetes. It often occurs with increasing age, but is also seen in younger and younger people in the meantime. In type 2 diabetes, body cells no longer respond adequately to insulin, which has the task of transporting sugar from the blood into the cells. Here it is usually converted into energy. If this is not sufficiently successful in spite of the presence of insulin, it is referred to as insulin resistance, in which too much sugar accumulates in the blood. Hereditary predisposition along with an unhealthy diet and lack of exercise are the main risk factors for type 2 diabetes. Healthier nutrition, weight reduction and exercise are adjustments that can help improve the metabolism and thus prevent complications. Medications can also be used in treatment.

Complications

Diabetic foot syndrome

A complication of diabetes mellitus is diabetic foot syndrome. Open wounds on the feet are characteristic of the diabetic foot. If an injury has occurred, it is often difficult to heal. Sometimes amputations cannot be avoided if treatment is delayed or if inflammation is particularly complicated. Diabetic foot syndrome is the most common cause of amputations aside from injuries such as accidents. At-risk patients must therefore be identified at an early stage and given medical care. At the same time, it is extremely important for you as a patient to take good care of your feet and your lifestyle. To this end, it is important to first understand diabetic foot syndrome and recognise early signs.

Two variants of diabetic foot syndrome

There are two forms of diabetic foot syndrome. On the one hand, there is the ischemic diabetic foot syndrome. The blood vessels in particular have been damaged as a result of the increased blood sugar level. In neuropathic diabetic foot syndrome, however, the nerves are particularly affected. In one third of cases, both factors come together and the risk of ulceration is particularly high.

Impairment of blood circulation in the foot
Damaged inner vascular walls of the blood vessels
Impaired wound healing as a result

Fifteen per cent of diabetic foot syndrome cases are due to a circulatory disorder, i.e. a peripheral arterial occlusive disease. In ischemic diabetic foot syndrome, pale or bluish skin is often noticeable due to the lack of blood circulation (ischemia). The skin feels cool, the pulse on the foot artery cannot be felt. Blood circulation in the muscles is also poor, which is why severe pain or tingling often occurs while walking. Blood circulation in the toes or heels is particularly poor. Injuries are especially dangerous because they heal very poorly and can lead to an open ulcer. In these cases, the surrounding tissue easily becomes inflamed or dies (necrosis). Necrotic tissue becomes pitch black and is immediately apparent.

You should consult a doctor if the following symptoms occur, since they may be indicative of ischaemic diabetic foot syndrome:

Pale or bluish colour of the foot
Foot is cool
Hard to feel pulse
Cramp-like pain in the calves due to lack of blood circulation in the muscles
Open wounds on the toe or heel (in this case, please consult a doctor immediately)

Damage to the nerve tracts
Due to a lack of sensation, injuries are not noticed and can then become infected
Deformation of the foot skeleton and foot (Charcot foot)

Because the sensitivity of the nerves in diabetic neuropathy decreases, the perception of pain due to pressure points or injuries is reduced or pain is not perceived at all by affected individuals.

In addition, incorrect loading in the foot is not perceived sufficiently, which can result in excessive strain and ulcers in certain areas. In these cases, one speaks of a malum perforans. The open wound can easily become infected with bacteria, often affecting the surrounding tissue. Depending on the severity of the open ulcer, therapy options include wound management and pressure relief or surgical intervention.

You should consult a doctor if you have the following symptoms, as they may indicate neuropathic diabetic foot syndrome:

The skin is dry (due to reduced activity of the perspiratory glands), but warm and rosy, since blood circulation is often still sufficient
Insensitivity to pain, pressure, cold, heat
Numbness, tingling
Malpositions of the foot (e.g. claw toes)
Cornea at pressure points
Poorly healing wounds, usually on the sole of the foot (in this case, please consult a doctor immediately)

Ulcer prevention

What you can do

Minimise risk factors: How to take good care of yourself

Although the risk of developing type 2 diabetes is partially hereditary, factors such as diet and exercise play an important role and can significantly reduce the risk of diabetes. If the disease has already occurred, the same factors remain important to prevent complications such as diabetic foot syndrome. It is therefore worth taking good care of yourself and counteracting further vascular damage, which additionally disrupts blood circulation and wound healing.

Certain pillars of everyday life are particularly important:

Proper nutrition: A complete, balanced, mixed diet that is adapted to the patient's individual circumstances. Generally speaking, foods rich in nutrients and fibre that are not highly processed should be eaten. With the right diet, not only can the underlying diabetes be treated, the risk of secondary diseases can also be minimised. It is best to seek medical advice. Professional nutritional advice and special patient training are also useful.
A lot of movement: Exercise lowers the blood sugar level. Movement makes the cells more sensitive to insulin, allowing more sugar to be absorbed from the blood.
Remain or become a non-smoker: The nicotine in tobacco has a negative effect on blood vessels because it narrows the vessels, promotes circulatory disorders, slows down wound healing and increases the risk of diabetic foot syndrome.
Treat high blood pressure: In case of elevated blood pressure, it is important to first reduce your body weight if you are overweight. Exercise and a low-salt diet help. If blood pressure cannot be lowered with lifestyle changes, medication must be administered.
Sleep adequately: Frequent lack of sleep represents a permanent stress situation for the body. Sufficient sleep is important for the metabolism, including the glucose metabolism, to rest.

Conscientious foot care and examination

In addition to lifestyle factors, you should definitely keep an eye on your feet. Regular examinations and proper foot hygiene are important.

The right foot examination

Check your feet every day for changes. Pressure points and the resulting wounds occur particularly often in certain areas of the feet (see graphic). Attention should also be paid to athlete's foot.
A hand mirror can help examine the entire foot, including the sole of the foot and gaps between the toes
Special attention should be paid to existing malpositions of the foot bones: Due to increased pressure, these
areas are particularly susceptible to wounds. Do not use sharp tools during foot care (only file the nails)

The right foot care

You should also receive regular foot care podological treatment
Suitable shoes are an important aspect of prevention as well: Appropriate shoes and insoles help prevent pressure points and injuries. The orthopaedic footwear specialist will help you find the right footwear.
Once a year, the feet should be thoroughly examined by a doctor.

”If you have diabetes, please take good care of yourself. Check your feet every day and seek medical advice in case of abnormalities. If you take good care of yourself, you can also help your professional team with a successful treatment!”

Dr. Stinus

Dr. Stinus

Diabetic foot syndrome

What happens after the diagnosis?

If the doctor determines that you have diabetic foot syndrome, the diagnosis is certainly unsettling at first. However, an interdisciplinary team of professionals specialising in the treatment of diabetic foot syndrome will now ensure that your foot is well looked after. On the medical side, this includes diabetologists, radiologists, internists, microbiologists and vascular and foot surgeons. Specialised wound therapists, podologists (medical foot care specialists) and orthopaedic footwear specialists are just as important. Support from a multidisciplinary team reduces the risk of an amputation. Turning to experienced specialists is important.

Disease progression

The different risk classes

The appropriate treatment depends on the patient's current phase of diabetic foot syndrome. Taking certain precautionary measures and regular medical examinations of the feet are important at each stage. If there is no nerve damage (neuropathy), an annual examination is sufficient according to internationally recognised care guidelines. If a wound exists or has ever occurred, the feet should be examined at intervals of one to three months. If the disease is more advanced, it is very important to treat wounds and ulcers early and regularly in order to avoid further complications. Every second amputation performed in connection with diabetic foot syndrome could be avoided. These interventions could be avoided by close medical care, in particular careful wound management.

Risk class 0: Very low risk

Although patients in risk class 0 have diabetes mellitus, the disease has not yet had any effects on the foot. There are also no foot deformations. Sensation in the feet is normal and the patient does not have a peripheral arterial occlusive disease, i.e. no circulatory disorder. The risk of foot complications is low.

Treatment in risk class 0

At this stage, it is essential to understand the underlying disease and thus control blood sugar levels. As mentioned above, this also includes the willingness to pay attention to sufficient exercise and a balanced diet. A controlled blood glucose level is a prerequisite to remain in this risk class.

It is also important to check your feet every day, care for them and maintain hygiene. Patients should regularly go to foot care, wear the right shoes – unsuitable footwear is a key cause of injury – and visit a doctor once a year for a follow-up examination.

Treatment:

Annual foot examination
Check/adjust blood sugar
Self-management: Daily care and examination of the feet
Foot care by a podiatrist
Make sure you wear comfortable shoes

Risk class 1: Low risk

At this stage, the sensitivity of the skin nerves or the foot's blood circulation is already impaired. As a result, patients experience pain and pressure points or stimuli such as heat or cold only to a limited extent or not at all. Numbness or tingling of the feet may also occur. Due to a lack of sensation, the injured areas are not adequately relieved. As a result, wounds are slower to heal and may worsen and become infected.

Treatment in risk class 1

Patients in risk class 1 should go to the doctor for a foot examination every six to twelve months. Daily foot care and examination is also extremely important. A podiatrist should provide support for foot care. It is also important to have the right footwear. If a wound has occurred and healed successfully, it is important to continue paying close attention to the foot afterwards. This is because the nerve damage remains and a new wound may occur at any time.

Treatment:

Semiannual/annual foot examination
Self-management: Daily care and examination of the feet
Foot care by a podiatrist
Make sure you have the right shoes
Take the following criteria into account when buying shoes: Not too tight, no interior seams, sufficient space in the toe area

Risk class 2: Low risk

For patients in risk class 2, two factors come together. The patients have both neuropathic and ischaemic diabetic foot syndrome. As a result, the sensation and blood circulation of the foot are already impaired. Risk class 2 is also applicable if a foot deformity occurs in addition to one of the two mentioned complications, which significantly increases the risk of wound formation.

Treatment in risk class 2

At this stage, the foot should undergo a medical examination every three to six months. It may also be useful to consider measures that improve blood circulation in the legs and feet – especially if wound treatment alone is not successful. Especially if wound treatment alone is not successful, because many diabetes patients have vascular constrictions. Also, a circulatory disorder always has a negative effect on wound healing.

There are two common interventions that improve blood circulation:

Percutaneous transluminal angioplasty (PTA): Here the vessels are dilated by means of a catheter.
Bypass: Here the blood flow is routed around the constricted vessel

In case of severe foot deformities, orthopaedic interventions can correct the malpositions.

Arthrodesis: Corrective stiffening of the joint
Corrective osteotomy: Corrective bone repositioning
Partial bone resections and tendon displacement: Removal of diseased or dead bones; in case of severe tendon damage, an adjacent tendon can be repositioned to take over the function of the damaged tendon

Treatment:

Foot examination every three to six months
Self-management: Daily care and examination of the feet
Foot care by podiatrists
Diabetes insoles, well-fitting shoes and socks
Treatment of the circulatory disorder (bypass or vascular dilation by means of PTA)

In some cases:

Fabrication of custom shoes or orthoses
Treatment of the circulatory disorder (bypass or vascular dilation by means of PTA)
Orthopaedic correction of the malposition

Risk class 3: High risk

In risk class 3, various complications come together that greatly increase the risk of an open ulcer on the foot.

At this stage of the disease, the patient either suffers from a complete loss of protective sensation, meaning they no longer feel any pain, or suffers from an occlusive arterial disease. In addition, patients are affected by one or more of the following factors: A past foot ulcer, lower limb amputation and/or terminal stage kidney disease.

Treatment in risk class 3

The treatment in risk class 3 is very similar to that in the second risk class. However, since the risk is already increased, the doctor should be consulted every one to three months.

Treatment:

Foot examination every one to three months
Self-management: Daily care and examination of the feet
Depending on the degree of injury: Relief shoe or bandage shoe
Fabrication of custom shoes and insoles

Complex complications

Ulceration: Acute ulcer

When open wounds develop, that is called ulceration. The degree of the present injury is then decisive for the treatment of the ulcer. Here, diabetologists sometimes resort to the Wagner Armstrong classification – a system based on assessing the depth of the wound, and also on the level of infection and circulatory disorder. This allows the treatment of the foot to be determined.

In any case, the wound must be treated. This is mainly about wound cleaning, so that the wound is regularly freed of dead and inflamed tissue. Special wound dressings are also used to soak up fluid and protect against external infections.

In case of wound infections, antibiotics must also be used to prevent the inflammation from spreading, otherwise it can become life-threatening. Inflamed parts of bones or tissues may need to be surgically removed. Skin or tissue transplantation may also be useful to promote wound healing.

Treatment:

Medical treatment of the foot
Regular wound treatment
Relief of the foot using a plaster cast, relief shoe or orthopaedic shoe
If necessary, surgical intervention in case of inflammation

The Charcot foot

The Charcot foot is a complication associated with diabetic foot syndrome. Bone fractures may occur in the affected person's feet, which go unnoticed since no fracture pain is felt. The Charcot foot is also very rare due to diabetes mellitus, but needs immediate treatment. Symptoms may take the form of swelling, reddening and increased warmth of the foot. If suspected, you should avoid exertion and consult a doctor.

Treatment:

Complete immobilisation (initially as part of inpatient treatment)
Application of a plaster cast, orthosis or rigid plastic bandage
Wearing an orthopaedic shoe with a rigid outer sole
Regular X-rays during acute inflammation
An amputation may be necessary

Amputation

When worsening needs to be prevented

Careful and timely treatment is essential in the treatment of diabetic foot syndrome. If patients are treated by a multidisciplinary foot treatment team and also take good care of themselves and their feet, amputation can very often be avoided.

But sometimes an amputation can still be necessary to prevent the worst. An amputation is considered only if no other treatment option is available:

When a toe or foot can no longer be maintained
When wound healing is possible only by removing smaller parts of the foot
When the inflammation spreads in the leg, muscle tissue in the leg dies or the pain is very severe.

An amputation removes only as little from the foot as possible. A partial amputation, for example of a single toe, is often sufficient. An amputation above the ankle joint is rare. Of course, the idea of an amputation is frightening for patients at first. In certain cases, however, the procedure is a good way to get the disease under control and restore more freedom of movement. Getting a second opinion may also make sense if you are about to have an amputation.

For amputations, a distinction is made between minor and major amputations. In case of amputation due to diabetic foot syndrome, individual toes or parts of the forefoot are removed in a minor amputation. A major amputation is when the entire foot (sometimes with part of the leg) is amputated above the ankle joint.

Before the leg amputation

Learn about what happens leading up to a planned amputation and how you can prepare yourself.

Before the leg amputation