Caring for Your Feet When You Have Diabetes

Treating your feet like crown jewels may sound a bit wacky, but they’re worth it. Diabetes affects both the feeling in and the blood flow to your feet, which makes it easy for problems to sneak up. And foot problems, annoying enough by themselves, are just a step away from bigger problems.

“People who have uncontrolled diabetes can develop neuropathy,” says Bonnie W. Greenwald, MD, Chief of Endocrinology at White Plains Hospital in White Plains, New York, “which causes a lack of sensation, including pressure and temperature sensations.” Neuropathy can also affect the functioning of your foot muscles; your feet may lose proper alignment, or you may put abnormal pressure on certain areas of your feet when you walk.

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David Kerr, MD, Director of Research and Innovation at William Sansum Diabetes Center in Santa Barbara, California, says neuropathy, or nerve damage, affects at least 30% to 40% of people with diabetes. Unfortunately, neuropathy can be prevented or stopped only with good control of blood sugar.

“People with diabetes can also develop peripheral artery disease (PAD), or poor flood flow, which additionally puts them at risk for foot ulcers,” says Greenwald. Poor blood flow makes it harder for the body to heal, which increases the risk for skin ulcers and gangrene, or tissue death. PAD affects about 20% of people age 55 and older, and according to the University of California-San Francisco Medical Center, people with diabetes have two to four times the risk of developing the condition compared to those without diabetes.

PAD has no direct treatment except preventive measures such as controlling blood sugar, cholesterol, and blood pressure, and quitting smoking. In some cases, a doctor can perform an angioplasty, a surgery that widens a narrowed artery, or an arterial bypass, in which a blood vessel is taken from one part of the body and used to bypass a blocked artery.

Those most at risk for neuropathy and PAD are people who smoke, drink to excess, and have high cholesterol and poor glucose control, especially over a long period, says Kerr, who adds, “and those with bad luck.” Either or both of these conditions can make your feet vulnerable to infections and deformity.

Symptoms to watch for

If you have neuropathy, says Kerr, you may feel tingling or burning, or shock-like sensations in your feet. “The symptoms of severe pain are predominantly in the evening,” he adds, “so they may also interfere with sleep.” Over time, your feet can get dry and cracked, which puts you at risk for infections and ulcerations.

Sometimes people lose sensation altogether, Kerr says, which is particularly dangerous: “You may be unaware if you’re standing on a stone, a nail, or a piece of glass.” In addition, feet can be scraped or abraded by ill-fitting shoes, and these wounds can become infected.

“In late-stage neuropathy, you may get Charcot arthropathy, which can lead to a collapse of the arch, in the middle of your foot,” says Greenwald. The early signs of Charcot arthropathy include redness and swelling, followed by bone fractures and dislocations when bones shift out of their usual positions. The foot may also lose muscle tissue.

PAD can cause leg pain such as cramping when you walk. Your feet may feel cold, and you may also have little or no pulses in your legs.

Preventing foot problems

The key to keeping your feet healthy is vigilance. As Kerr says, the saying “an ounce of prevention is worth a pound of cure” has never been more true. Take these steps to avoid problems.

Control your blood sugar. Work with your doctor and health care team to keep your blood sugar within the limits your team has set for you. “Keep your A1c level” — the average of your blood glucose levels over three months — “to below 7% and your daily blood sugar normal,” says Greenwald. Ask your doctor what to do if your numbers are too high or too low.

Check blood pressure and fat levels. Have your blood pressure checked at every doctor’s visit. The target for most people with diabetes is 140 over 90. Your cholesterol and triglyceride levels — both types of blood fats — should be checked at least once a year. For people with diabetes, the target is below 100 for LDL, or bad cholesterol; HDL, or good cholesterol, levels should be above 40 for women and 50 for men. Triglyceride levels should be below 150.

Quit smoking. Smoking raises the risk of foot complications by narrowing and hardening your blood vessels so that fewer nutrients and insufficient oxygen reach your feet. Smoking also keeps your cholesterol and blood pressure levels up and puts you at greater risk for heart attack, stroke, kidney disease, and amputation. Ask your doctor for help in quitting. A government program offering free counseling is available at 1-800-QUITNOW.

Get a podiatrist. Before you have a problem, Greenwald suggests you ask your doctor to refer you to a podiatrist, or foot specialist, who is experienced with diabetes. “Most people with diabetes see a podiatrist at least once or twice a year,” he says.

The podiatrist should check for ulcers between your toes, calluses, bone abnormalities, and the pulse in your feet (a lack of pulse indicates PAD). He or she should also test the sensation in your feet, probably using a 10g monofilament test, which assesses touch and pressure sensation. He or she will press a single strand of fiber against various spots on your foot until you register sensation, noting the point at which the strand bends; this tells the doctor how much pressure you can feel.

Inspect, and re-inspect. Do your own foot inspections daily, says Greenwald: “Check between your toes for redness and skin breaks. For places you can’t see easily, use a mirror or ask someone else to look.” If you find a break in the skin or anything suspicious, see your doctor or podiatrist right away.

Get shoe savvy. Before you put on your shoes, feel inside to make sure there are no stones or other debris. Avoid shoes that are too tight, pointy, or high-heeled, or that have stitching inside that might abrade your foot. Buy shoes at the end of the day when your feet will likely be a bit swollen. A good choice is athletic or walking shoes, which allow air to circulate inside the shoe (unlike vinyl or plastic shoes) and offer flexibility and support. Break new shoes in slowly, wearing them only an hour or two a day for the first couple of weeks.
Don’t go sockless or wear open-toed shoes; buy lightly padded seamless socks. And don’t even think about going barefoot.

“If you’re not sure whether your shoes fit well, see a podiatrist who can check or custom-make your shoes,” says Greenwald. Specially made shoes or inserts can protect your feet, which may have changed shape over time. Your insurance may help pay for such shoes.

Wash your feet daily. Before you immerse your foot, check the water temperature with your hand because your feet may not feel heat. Use warm water, not hot, and don’t soak — it can dry out your skin and lead to cracking. Dry your feet carefully and apply moisturizing cream or baby oil to prevent dryness, says Greenwald. Don’t put cream between the toes; the moist conditions can encourage infection.

Trim weekly. After you’ve washed your feet, trim your toenails straight across and file off any snags with an emery board. While your feet are still wet, you can carefully smooth corns and calluses with a pumice stone. If you can’t see well, can’t reach your feet, or have tough or ingrown nails, let your podiatrist do the trimming. He or she can address problem calluses and corns, too, says Kerr, who cautions: “Do not use home devices like razors or anything that may pierce the skin.”

Sanitize your pedicure. If you get a pedicure, bring along your own utensils, boiling them for a few minutes before and after to avoid germs and bacteria. Kerr suggests you make sure your pedicurist knows you have diabetes; confirm his or her experience in dealing with people with diabetes, or at least that he or she knows the risks.

Weatherproof. Always wear shoes on the beach, and put sunscreen on your feet to avoid sunburn. Wear warm boots in winter, and check your feet often so that they don’t get frostbitten. If your feet are cold, don’t put hot-water bottles or heating pads on them; put on socks instead.

Keep blood flowing. The Department of Health and Human Services recommends 150 minutes of exercise per week. Provided your doctor gives you the thumbs-up, try exercise that’s easy on the feet, such as walking, swimming, or biking, and avoid more abrasive choices such as running and jumping. Not only will exercise increase the blood flow to your feet and elsewhere, but it also helps to lower your blood sugar and reduce your risk of heart disease. “Check your feet before and after exercise,” says Greenwald. “There’s almost never a downside to exercise, ever.”

Addressing foot problems

Despite your best intentions, foot problems can arise whether you have diabetes or not. However, the mix of foot problems and diabetes easily can lead to infections. Here are common foot troubles and how to deal with them.

Foot infections and ulcers. Most infections are treated with antibiotic therapy, beginning with oral antibiotics. More serious infections may require intravenous antibiotic therapy, administered at an in-patient facility or at home by a nurse. Your podiatrist may need to remove any dead skin, a process called debridement.

If your doctor determines you have PAD or a foot ulcer, says Kerr, he or she may suggest that you see a vascular surgeon. The surgeon will likely use x-rays or magnetic resonance imaging (MRI) to see whether the infection has gotten into the bone; if it has, you may need an antibiotic given intravenously, bone removal, and/or a procedure to clear blocked arteries that are impeding your blood flow. Among Medicare recipients, about 6% of people with diabetes develop foot ulcers, and around 0.5% need amputation.

Fungal infection of the nails. Fungal infections turn nails tough and colorful, usually unflattering shades of yellow, green, brown, or black. Your doctor may prescribe an oral antibiotic, remove the nail surgically or chemically, or perform a laser treatment that kills the fungus.

Athlete’s foot. Athlete’s foot, another fungal infection, can cause itchy sores. Your doctor may recommend over-the-counter antifungal medication such as clotrimazole (Lotrimin) or miconazole (Micatin), prescribe oral medications such as fluconazole (Diflucan) or itraconazole (Sporanox), or recommend topical medications such as butenafine (Mentax) or naftifine (Naftin).

Heel infections. Infections on the heel are especially prevalent in older people who spend a lot of time in bed. Treat an infection with an antibiotic as soon as possible so that it does not get into the heel bone.

Corns and calluses. If a corn or callus leads to infection, your podiatrist may prescribe antibiotics and remove the hardened skin, which otherwise can delay healing.

Blisters. If you get a blister, cover it with a bandage. If it becomes infected, your doctor will drain it and give you antibiotics.

Ingrown toenail. This is a toenail that has grown into your skin. It’s typically treated by cutting away the part entering the skin. If the spot is infected, your doctor will likely prescribe antibiotics.

Bunions. A bunion is a foot deformity: The big toe leans toward the second toe, making the joint where the big toe joins the foot thrust out, which leads to soreness and callused skin. Foot padding available at drugstores can help prevent shoe friction on the bunion, or your doctor may suggest surgery to correct the deformity.

Dry skin. Dry skin can lead to cracked, infected skin. The remedy is usually a prescription topical or oral antibiotic.

Hammertoes. These are toes that curl under the feet because of weakened muscles. They can cause blisters and calluses, which can lead to infection. Your podiatrist may suggest corrective footwear or surgery to straighten the toe.

Plantar warts. These warts resemble calluses and can become infected or bleed. Your podiatrist may suggest wearing a pad over a wart to prevent irritation, or decide to remove it.

Taking the time to treat your feet royally — inspecting them daily and protecting them from abrasions — can keep both them and you healthier. Start now, and keep at it: Prevention is a whole lot easier than treatment.