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Diabetes and Foot Care
Pedorthic Association of Canada

Are you one of the 2 million Canadians currently living with diabetes?¹ If so, did you know that one of the complications related to diabetes requiring hospitalization is amputation of a lower limb or foot?

It is estimated that 80,000 to 200,000 Canadians with diabetes will be affected by foot problems, such as foot ulcers, in their lifetime. And of those, 14 to 24 % will be at risk of losing a lower limb or foot through amputation.² Yet, these foot problems and amputations could easily be prevented through daily foot care and proper shoe selection.

Diabetes is one of the most prevalent diseases of our time and is affecting a growing number of Canadians each year. It is a disease where the body is unable to produce insulin (type 1), or where the body does not produce enough or cannot effectively utilize the insulin that is produced (type 2). A third type of diabetes occurs during pregnancy, and is called gestational diabetes.

Some people living with diabetes might experience reduced blood circulation or sensation in their feet and may not be able to feel if something in their shoe (or even the shoe itself) is irritating their foot. If the footwear is irritating the foot, the result could be a wound or an ulcer, which can be very dangerous and can ultimately result in hospitalization or worse - amputation of a lower limb or foot.

What is a foot ulcer?

A foot ulcer is a defect or break in the skin. The skin functions as a wall that surrounds and protects the foot from bacteria; thus, a defect and/or break in the skin leaves the foot vulnerable to invasion from harmful bacteria that can cause infection. The longer the ulcer remains open and untreated, the greater risk of infection.

Conditions such as peripheral neuropathy and vascular disease are some of the causes of infection and ulceration in those living with diabetes.

What is peripheral neuropathy?

Peripheral neuropathy is the gradual loss of nerve function in the feet and legs. Constant elevated blood glucose can damage nerve endings, causing numbness or a tingling feeling in the feet. The most common and significant change related to this condition is the loss of feeling or touch. However, neuropathy is heightened by pain and usually comes on slowly. The likelihood of developing neuropathy increases with age.

What is vascular disease?

Vascular disease causes decreased circulation in the feet and lower limbs. Complications arise when small wounds do not heal as rapidly for those affected; a small blister can develop into a serious ulcer without adequate circulation to enable rapid healing.

With this in mind, people with diabetes should rely not only on how their feet feel but also on how they look. It is imperative to perform visual examinations of their feet daily to ensure there are no breaks or abnormalities in the skin. Individuals who are unable to see their feet properly should seek help from a spouse, family member or caregiver to examine their feet.

Symptoms of abnormalities range from slight skin discolouration to severe skin breakdown (ulcers). Some of these symptoms include "skin blanching", where the skin appears white when pressure is applied and then removed from a certain area of the skin. If significant skin blanching is present, this can indicate that circulation is compromised in that area. Precautions must be taken to increase circulation and decrease pressure points.

Other abnormalities include red areas that can appear on the feet even after shoes have been removed. Typically, the joint of the big toe and the tops of the toes are areas where redness occurs. These skin irritations are of great concern to those with diabetes as they indicate high pressure from the shoe that ultimately could result in foot ulcers.

People with diabetes should also monitor the hair growth on their lower limbs. Hair needs oxygen to grow and those with dry, flaky skin and very little hair on their calves and feet are typically experiencing limited circulation.

The Canadian Diabetes Association recommends that everyone living with diabetes should receive instruction on proper foot care and have foot examinations at least once a year to avoid the risk of developping foot problems.³

Qualified healthcare professionals, including Canadian Certified Pedorthists, can assess structural abnormalities, signs of neuropathy and vascular disease, and/or evidence of any ulceration, and perform foot examinations on those living with diabetes.

Along with regular foot examinations, a daily foot care routine is equally vital to help maintain foot health and protect against foot problems that could lead to amputation.

Recommended daily foot care tips for people with diabetes include:

• A daily visual foot inspection, looking for redness, swelling, broken skin, sores or bleeding. See a doctor immediately if any of these problems arises.
  
  
• Wearing properly fitting shoes around the house and outdoors to protect feet from injury.
  
  
• Washing feet with soap and warm water everyday, but not soaking them.
  
  
• Avoiding heat pads or hot water bottles, even when feet might get cold easily. With a lack of sensation it is easy to burn the feet if the water is too hot.
  
  
• Avoiding socks with heavy seams, as they can cause irritation of the skin and lead to breakdown or ulceration.
  
  
• Not wearing tight, constrictive socks or clothing that can limit blood flow to the extremities.

Shoe fitting tips for people with diabetes:

• Key features for footwear include soft uppers (everything located above the insole of the shoe including laces, tongue, etc.) with minimal seams, firm but cushioned soles, removable insoles, a strong heel counter (the hard piece of material located at the back of the shoe) and a rockered sole (bottom of the shoe designed to reduce any pressure under the heel and/or at the front of the foot).
  
  
• Avoid restrictive footwear, such as high heels with pointed toes or shoes that are too narrow.
  
  
• When buying a new pair of shoes, it is good practice to remove the insole from the shoe and stand on it to see if the foot overlaps the insole, indicating that the shoe is too narrow or short for the foot.
  
  
• There should be a full finger width between the end of the longest toe and the end of the shoe.
  
  
• Avoid shoes with seams over the toe area.
  
  
• If there is a problem with lower limb swelling, graduated compression stockings can help control swelling and maintain the fit of shoes over the course of a day.

Through regular foot examinations and by following these daily foot care and shoe selection tips, those living with diabetes can better maintain the health of their feet.

For more information on diabetes prevention, treatment and management please visit the Canadian Diabetes Association's website at www.diabetes.ca. For more information on the Pedorthic Association of Canada please visit www.pedorthic.ca.

¹ Canadian Diabetes Association website (http://www.diabetes.ca/Section_About/FactsIndex.asp) About Diabetes/ Diabetes Facts
² Canadian Diabetes Association website (http://www.diabetes.ca/Section_About/feet.asp) About Diabetes/ Complications: Diabetes & Footcare by Timothy B. Kalla, D.P.M., FACFAS
³ Canadian Diabetes Association website (http://www.diabetes.ca/cpg2003/default.aspx) Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada.