I am a diabetic diagnosed about five years ago. I’m 69 years old, 6’2″; 265 pounds; with moderate peripheral neuropathy in my feet which has gotten increasing worse over the last five years but is stable right now.
The doctor says I have a good pulse in my feet. I get frequent (once every three months) examinations of feet. My diabetes is controlled with glipizide 2.5 mg 2 to 3 times a day. Please tell me about problems that could lead to leg amputation and preventive care measures I can take to avoid that.
For generations perhaps the greatest fear of many diabetics has been the fear of needing to have their feet or lower legs amputated, and being relegated to a wheelchair. Back in the days when Type I diabetes was not tightly controlled, and Type II diabetics often went without any treatment at all, this was a very real outcome to be dreaded.
Now with the recognition that tight control of all diabetics will delay and perhaps totally prevent some of the complications of diabetes we should be seeing fewer people requiring amputations.
I’ve only seen one case myself during the past five years, and I have many diabetics in my practice, including unfortunately quite a few who do not manage to maintain tight control, although even among them, control is better than we used to see 20 to 30 years ago.
I evaluate control by checking the hemoglobin A1c level every three months, and my goal is to bring it down to normal, which I probably achieve in only about 10 percent of my diabetics, but many show substantial reductions that indicate improved control.
Three factors are involved in the development of the foot problems that can lead to amputation:
- Disease of the arteries due to the diabetes
- Diabetic neuropathy which is usually worse in the feet
- Poor cleanliness and nail trimming practices of the feet and toes.
Poorly controlled diabetes accelerates the process known as atherosclerosis, the form of arterial disease that comes from cholesterol deposits in the lining of the arteries. Obviously many people other than diabetics get atherosclerosis, and other conditions — high cholesterol, hypertension, and smoking also play a role — but poorly controlled diabetics get it sooner and worse than others.
When cholesterol plaques form in the large arteries of the legs, they start to reduce the blood flow to the lower legs and feet. A common first hint that something is wrong will be the onset of intermittent claudication — pain in the calf or foot muscles when walking. This indicates that the arteries in the legs can no longer deliver sufficient blood to the muscles to keep them working properly.
Poor blood flow may also cause skin changes — hair loss on the lower legs, with smooth, shiny, thin, white or bluish skin. Because of this arterial disease, injuries and infections of the feet and toes will heal slowly, if at all. Doctors in the office evaluate the adequacy of the arterial blood supply to the feet by feeling for the pulse in two arteries of each foot — the dorsalis pedis on the upper side of the foot, and the posterior tibial artery behind the inside ankle bone. You apparently have good pulses in both feet.
Diabetic neuropathy often affects the feet and legs, and produces reduced sensation in those areas. As a result, small injuries such as scrapes or punctures may not be noticed. Infections such as athlete’s foot may not produce symptoms and can proceed to more serious infection. Poor care of the nails can result in an ingrown infected nail.
Typically, amputation is required in two circumstances: when gangrene of the toes develops due to inadequate blood supply, or when infection of the skin or deeper tissues develops which cannot be controlled with antibiotics and other measures. This almost always occurs in someone who has no pulses in their feet, so I do not think that you are at risk for these complications now. However, you are seriously overweight, which makes diabetic control harder and contributes to high cholesterol in the blood. You are taking only glipizide, which when taken alone I have found produces good control only in people with very mild diabetes. You also have some neuropathy, which may indicate poor control over the years.
You should make sure that your doctor checks your hemoglobin A1c level periodically, and if it is not improving, you need to take other measures to achieve better control.
Foot care should include a daily inspection of the feet for any bruises, cuts or punctures. Athlete’s foot between the toes should be treated promptly. Your nails should be cut so that the corners are beyond the cuticles of the nails to prevent ingrown nails. The feet should be washed and carefully dried daily, and must never be allowed to remain damp for any period of time. You should never walk barefoot, even in your home, in order to minimize injuries. Well-fitted shoes which do not press on any part of the foot must be worn.