The most disabling and deforming complication of diabetes mellitus is diabetic neuropathy of the lower limbs. This complication can have varied manifestations ranging from unbearable burning pain in the soles to rocker-bottom deformity which might eventually lead to diabetic foot ulcer and even amputation. Consequently, diabetic foot problems are source of economic burden to the individual families and to the society as a whole. But, surprisingly it is also one of the most easily preventable complication; we just need to learn the common presentations and red flag signs.

Often, the most common presenting manifestation is severe burning pain in soles specially at night or an abnormal sensation of ‘insects crawling on the limbs’. Though in some patients first manifestation is numbness of the feet or a ‘feeling of coldness’, mostly these follow the burning pain or paraesthesia (abnormal sensation). Besides, the initial symptoms can be often be subtle in form of ‘liking to keep feet outside the quilt in winters’ or ‘asking someone to massage the legs at night’. If ignored, these can end in complete loss of sensation in the lower limbs perceived in form of slipping of footwear, sleeping on the bed with shoes/slippers on, painless ulcers and even unnoticed rat-bites on toes.

All these sensory manifestations are accompanied by weakness and wasting of lower limb muscles, causing difficulty in walking and getting up from sitting position. One of the common presentation is severe pain and weakness in thigh muscles of one or both limbs, termed as diabetic amyotrophy. Muscle wasting is a combined result of neuropathy and protein catabolism in uncontrolled diabetes mellitus. Fortunately, the condition responds well to intensive glycemic control with the use of insulin. Clinically, patients can themselves appreciate muscle wasting in form of prominence of knee joint bones as well as ‘guttering’ (between foot bones) on the dorsum of the foot.

The deadly duo of neuropathy and muscle weakness make the feet vulnerable to trauma in day to day activities, which commonly goes unnoticed till deformities start to arise due to abnormal biomechanics. Most common is clawing of toes in which the toes graze along the floor while walking, causing chronic ulceration on the affected parts and even gangrene/amputation. Another common and in fact, the most dangerous deformity is rocker-bottom foot; seen as prominence of bones in the mid-sole. It is a pressure site due to abnormal weight bearing, resulting in chronic non-healing ulcers and amputation of forefoot or even below-knee amputation sometimes.

Henceforth, in light all these complications the proverb ‘Prevention is better than Cure’ stands absolutely true for diabetic foot problems. Interestingly, foot care in diabetic patients varies according to season of the year. In summers, sweating leads to a moist environment in the interdigital spaces providing a niche for fungal infections. Thus, patients should take the following precautions :

  1. Change your socks daily.
  2. Dry your feet thoroughly after bathing.
  3. Apply talcum powder in small amounts in the interdigital spaces before wearing socks.
  4. Preferably wear soft cushioned sandals.

Ironically, winter season brings dryness of skin, which if not cared for can cause itching and cracks in the interdigital spaces providing a portal for bacterial infections. In order to prevent such infections, following easy steps can be taken care of:

  1. Massage your feet with warm water daily.
  2. Gently wipe the interdigital spaces dry using soft cotton wisps.
  3. Apply emollients to the foot specially interdigital spaces after bathing.
  4. Wear wide-mouthed soft cushioned shoes and cotton socks.

Besides, one of the other common causes of diabetic foot infections irrespective of the season is improper clipping of toe nails. It is often found that poor vision and general frailty lead to cutting of nearby skin along with the nail, so it is better if relatives/children cut patients’ nails under proper lighting. Any inadvertent nail bed infection should be taken care of by the treating doctor with empirical antibiotics along with incision and drainage, if required.

Inspite of proper care and precautions, many patients develop deformities of the foot as a part of natural course of the disease. These patients should seek help of a podiatrist and an endocrinologist for primary prevention of ulcers on pressure areas of the sole, usually accomplished by asking patient to walk on a pedometer; an instrument which measures the plantar pressure on entire sole. Depending on the pedograph, construction of footwear with customised insole to cushion the high pressure areas prevents initiation of callosities and ulcers.

To summarise, diabetic foot problems are commonly ignored by patients thinking that above mentioned symptoms are due to generalised weakness or popularly labelled as ‘vitamin deficiency’. Patients should recognise the initial symptoms to obtain timely care from their doctors, as well as should absolutely defer from self-management of foot ulcers and infections.

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