Over the past decade of being a podiatrist, I have performed hundreds–if not thousands–of amputations in the foot, or had to refer the patient for a higher leg amputation to my surgical colleagues. Many of these individuals lacked foot awareness and did not realize they were at risk for foot complications arising from something as benign as poorly fitted shoes, self-treating with a medicated corn pad, ignoring a foot callus, or getting an infection from a pedicure.
What people may not know is that non-traumatic leg amputations in people with diabetes are preventable with early intervention and screening. Like cancer, there is an abundance of data to support the value of preventive care for those with diabetes. Having a podiatrist as part of the medical team can reduce unnecessary leg amputation by up to 85%.
While traditional insurance covers many beneficial medical services, preventive care for the diabetic foot was not always covered, or offered, or patients had to wait months to be seen. Therefore, this article is intended to help people with diabetes have better foot awareness so they can be proactive in self-care and know current options for medical care so that they can get the medical attention they deserve.
What is foot awareness?
The best way to understand foot awareness is to know what happens when one overlooks the clues that their feet are giving them. From speaking with hundreds of people who ended up on the operating room table with me, many have said they simply did not know how important their foot health was. They didn’t know what to look for or who to get help from. They didn’t have foot awareness. But now they do and can still protect the other limb working with a podiatrist.
What clues are your feet giving you?
You don’t have to wait for a traumatic event to see the podiatrist. In fact, visits should happen as soon as one is diagnosed with diabetes. In the early stages, the visit may just be once a year, while in more critical stages it could be as often as once a week.
Most people don’t give their feet attention until something hurts enough to stop them from doing the things they enjoy like walking, hiking, exercising, playing with their grandkids, and/or traveling. Pain is a protective sensory that gets blunted in diabetes, developing a condition called peripheral neuropathy. The foot may be giving clues that something needs attention but if one cannot feel pain, then the individual continues to ignore it, unintentionally. That clue is often a callus, or thickened skin seen in high pressure points on the foot. It’s a way the body protects itself from excess pressure but consequently can also lead to skin damage called an ulcer.
It is estimated that 50-66% of people with diabetes will develop peripheral neuropathy sometime in their lifetime. Many don’t realize they have it because the onset is so subtle. The end stage of peripheral neuropathy is numbness and tingling in the toes and fingers. Some people may attribute these subtle symptoms as a normal part of aging and so they underreport it. Some people find out they have it after developing a diabetic foot ulcer, or an open wound on their feet, that gets infected and requires medical attention.
A callus is the pre-stage of a diabetic foot ulcer. The good news is calluses and diabetic foot ulcers can be treated with preventive foot care services from a podiatrist.
How are diabetic foot ulcers treated?
A wound on the foot is more susceptible to infection so getting it to heal is of utmost importance.
Conservative treatments for diabetic foot ulcers, or DFUs, include:
- Keeping the wound clean & moisture balanced, advanced therapies like biologics and grafts may help to speed up a stalled wound;
- Offloading with pads, custom orthotics, and/or diabetic shoes;
- Ensuring there is enough blood flow to the ulcer; and,
- Optimizing nutrition to control blood sugars while increasing protein during this phase of healing.
If infection is present, antibiotics would be appropriate; however, not all open wounds are infected, so it’s important not to overtreat and risk undesirable side effects from improper medications. In more severe cases, people with diabetes may be referred to a vascular specialist to improve blood flow so that the wound gets the oxygen and nutrients it needs to heal. Having good sugar control is the cornerstone of the prevention and management of diabetes and diabetic-related foot complications.
As many as 30% of diabetics will experience a diabetic foot ulcer in their lifetime, and as high as 50% of those who have healed a diabetic foot ulcer may experience a recurrence within 1 year. Surgical correction should be discussed early on because we now have less traumatic options such as minimally invasive surgery to redirect pressure points that would otherwise lead to the recurrence of a diabetic foot ulcer, thus leading to infections and amputations.
Minimally invasive foot surgery is a specialized outpatient procedure which I perform regularly within my office surgical suite, saving patients time, money, and stress from traditional options. I have been able to heal chronically stalled diabetic foot ulcers with this technique, including those with fat pad atrophy, hammertoes, and bone spurs.
Lastly, major surgical reconstruction of a deformed foot may be needed, especially in those who may have had a foot complication called Charcot arthropathy, where the foot bones suddenly collapse as a consequence of diabetes and/or peripheral neuropathy, trauma, or osteoarthritis. Sometimes minimally invasive surgery can help in these situations depending on other factors. A podiatrist trained in minimally invasive surgery can provide a consultation to see which surgery is appropriate with this technique.
What if I’m told I need an amputation?
When patients are told they need an amputation, it is within their right to ask for a second opinion from a foot and ankle expert. Second opinions may provide clarity for patients and their loved ones as to what is available to them for their specific circumstances. Amputations are irreversible whereas second opinions are risk-free, so it is always worth getting.
Why seek a Direct Care podiatrist?
Direct Care is a medical model where the doctors do not contract with insurance to deliver medical services.
Patients are choosing Direct Care specialties like podiatry because:
- They do not have insurance and prefer not to use the Urgent Care Center or Emergency Room
- They do have insurance but the options are limited, or appointment times are too far out
- They do have insurance but deductibles are high so they are already paying out of pocket and realize it is more economical to pay the doctor directly
- They want innovative options that are not available through traditional means
- They want more time with their doctors
- They can communicate directly with the doctor
- They want a second opinion that are not incentivized by insurance
- They want to know exactly what their medical care will cost upfront instead of receiving a surprise bill many months later
- They want to have a meaningful relationship with their doctor, especially for chronic problems that benefit from preventive foot care
Direct Care is an option to get faster medical care since there is no referral or paperwork needed to be seen. Often patients can be seen by the doctor within days rather than months. Direct Care doctors can write prescriptions, lab orders, and send referrals, and patients can continue to use their insurance benefits for those services.
Since Direct Care doctors spend more time with patients, they become an essential part of a patient’s healthcare team, helping to coordinate their medical care and making sense of medical speak. This model restores the patient-physician relationship and it allows privately owned medical practices to thrive within the community.
In conclusion, increasing one’s foot awareness is key to preventing long-term complications like infection, hospitalization, amputation, and diminished quality of life. Routine screening and preventive foot care are recommended to those who have diabetes at least once a year, and more often if peripheral neuropathy, peripheral arterial disease, foot deformity, or a diabetic foot ulcer is present.
By enlisting the help of a qualified podiatrist early on, leg amputations can be prevented one step at a time.
Dr. Tea Nguyen
Pacific Point Podiatry
Pacific Point Podiatry’s offices are located on Soquel Drive in Aptos, with consultations available By Appointment Only.
Click here to learn more about Dr. Tea’s practice and the importance of diabetic foot health, and see if you qualify for a free consultation!
