Diabetes

Summary

Watch Video: Introduction to Diabetes

Diabetes is a medical condition characterized by elevated blood sugar. Having diabetes has a number of important implications for foot and ankle problems. Diabetes occurs either because the pancreas does not produce enough insulin (Type 1 Diabetes). In this situation, insulin is what helps to lower the blood sugar. The second and more common situation is when the cells of the body do not respond to insulin, even though the insulin levels are normal. Because of this, the blood sugar level is not controlled (Type 2 Diabetes).

With elevated levels of blood sugar over time, the tissues will often become stiff as they get saturated with sugar molecules. Tissues that get affected include muscles and tendons, as well as nerves leading to nerve dysfunction and abnormal sensation. In addition, blood vessels can be damaged, leading to decreased blood flow, particularly to the small arteries.

Clinical Presentation

There are two main problems related to diabetes in the foot. The first is decreased circulation, which tends to occur in patients with longstanding diabetes, especially if it is poorly controlled. This may present with loss of hair to their legs. The second problem is decreased sensation to the foot. A loss of protective sensation (peripheral neuropathy) is often the most important problem that diabetes creates. Altered sensation to the foot means that the individual cannot feel normal pressure and pain. For example, if a diabetic patient loses the ability to feel the pressure of a specialized bristle pushed against the foot until it bends (a 10-gm force), this represents the loss of over 97 percent of their normal sensation. This loss of sensation can lead to complications such as diabetic ulcerations or stress fractures (Charcot arthropathy) as patients are unable to sense that their tissue is being injured.

Treatment

Treatment of diabetes is very important. It is critical that patients maintain an appropriate blood sugar level. An appropriate treatment regimen should be developed in close consultation with the patient’s primary care physician and/or their endocrinologist (doctor who specializes in hormones). Treatment of type 2 diabetes might simply involve keeping a careful track of the patient’s diet so as to avoid excessive simple sugars and carbohydrates. It is important for a patient with diabetes to carefully monitor their blood sugar levels and keep the levels below 100 mg/dl. A regular measurement of a patients hemoglobin A1C (HgA1C) provides excellent feedback to patients to help them determine how well their diabetes is being controlled. If a patient’s diabetes is poorly controlled there will be too much glucose in the bloodstream. A certain amount of this will become attached to the hemoglobin in the red blood cells leading to increased levels of HgA1C. In a non-diabetic patient, HgA1C levels are normally below 6 percent. Ideally a diabetic patient should strive to keep their HgA1C levels below 6 percent as well. Foot surgery on diabetic patients with a HgA1C greater than 7 have been shown to be associated with higher complications such as post operative infection and wound healing issues. With HgA1C greater than 9 these risks become prohibitive.

If simple diet modifications are not enough, there are oral medications [oral hypoglycemics]. If diet and oral medication is not enough to control the type 2 diabetes, then insulin may be required. Treatment of type 1 diabetes usually requires regular insulin injections or an insulin pump. Regardless of the type of the diabetes, it is critically important that patients work very closely with their doctors, so as to maintain tight control of their blood sugar levels.

Edited December 22, 2020

Previously Edited by Jean Brilhault, MD, Judith Smith, MD and Timothy Charlton MD

mf/ 7.10.18