Diabetes Mellitus
Diabetes Mellitus is a disease in which your body cannot produce or properly use the insulin it produces. It is a serious, chronic metabolism condition resulting in high blood glucose. Type 1 diabetes refers to the condition in which the body cannot produce insulin, also referred to as “insulin-dependent”, and type 2 is when the body cannot properly use the insulin it produces, also referred to as “ non-insulin dependent”.
Peripheral Neuropathy
Peripheral neuropathy is a common diabetic condition which leads to the loss of protective sensation and the inability to feel pressure and discomfort in the foot from footwear or deformity. It is the gradual loss of nerve function in the feet and legs due to diabetes and affects the sensory, motor, and autonomic nerves. It affects the patient’s ability to perceive pain, pressure, touch, and temperature. This condition affects more than 50% of those with type 2 diabetes and loss of protective sensation is the most significant predictor of foot ulcerations and complications in those with diabetes.
Peripheral Arterial Disease
Peripheral arterial disease refers to a decrease in blood flow to the extremities, characterized by the narrowing or blockage of arteries in the legs and feet due to atherosclerosis. Atherosclerosis refers to the narrowing and hardening of the blood vessels that reduces blood flow to various parts of the body including the legs and feet. PAD can lead to increased healing time for skin breakdown and can pose a risk for an increased chance of infection. The arteries that are most commonly affected are the anterior and posterior tibial arteries. Poor circulation in the feet is common in people with peripheral arterial disease and it is an important risk factor for lower extremity amputations in patients with chronic diabetic foot ulcerations.
Diabetic Foot Ulcers
Diabetic foot ulcers are breaks or holes in the skin which leave the foot and or body vulnerable to invasion from harmful bacteria that can cause infection. They can be superficial or deep in the skin and they are a serious and debilitating complication of diabetes with 15% of those with diabetes developing a foot ulceration. They can cause limited joint mobility, foot deformities, and foot amputations that often predispose diabetic patients with peripheral neuropathy to abnormally weight bear and increase shear forces therefore increasing the risk of ulceration. Predictive factors include high plantar pressures, and callus build-up which acts as a foreign body causing ulcerations, poorly fitting footwear can cause toe ulcerations, for example, shoes lacking width and depth in the toe box. There are 3 types of foot ulcers; neuropathic due to chronic repetitive trauma or friction on WB areas of the foot, arterial due to diminished arterial flow to the foot and lower leg resulting in ischemia, and venous due to the failure of the deep veins of the leg to return blood resulting in pooling or stasis in the lower leg.
Compression Socks For Diabetics
Compression socks work by improving blood circulation and aid in preventing blood from pooling in the legs and feet by gradually pushing blood back up the kinetic chain. Compression socks apply gentle pressure to the legs which can help improve blood flow in the lower extremities, assisting those with PAD and DVT. Compression socks can also help reduce swelling as diabetes can cause fluid retention and swelling in the legs and feet therefore compression socks assist by promoting the movement of fluid out of the affected area. They promote healthy circulation and reduce the risk of skin breakdown and direct friction to decrease the risk of developing diabetic foot ulcers. They are also beneficial for promoting faster wound healing by improving circulation to the affected area and reducing swelling. The best compression sock material choices are cotton, as this is a natural, breathable material that is gentle on the skin and helps to wick moisture away keeping the feet dry and reducing the risk of irritation or infection. Merino wool is known for its natural softness and moisture-wicking properties as well as temperature-regulating abilities. It can help keep the feet warm in cold weather while also wicking moisture away from the skin. Synthetic blends are also fine, materials such as nylon, or spandex can provide stretch and support while being lightweight, durable, and often moisture-wicking. It is important to note that double-lined compression socks are not suitable for the diabetic foot as this can often leave an indentation in the skin and reduce blood flow to areas of edema and swelling.
Diabetic Treatment
The objectives of pedorthic care and custom orthotics for the diabetic foot are to relieve areas of excessive plantar pressures, reduce shock, and offload to prevent and heal any plantar ulcerations and wounds for patients with diabetes. Additionally, reducing shear or horizontal movement of the foot within the shoe and accommodating any deformities via support and cushioning is essential. Appropriate footwear is essential for those with diabetes and peripheral neuropathy and should be of adequate width and depth for the diabetic foot. The most effective way to offload the forefoot of the neuropathic foot is through the use of a rocker sole principle. Rocker soles reduce plantar pressure by 35-65% beneath the heel and the central metatarsal heads. A firm heel counter, good midfoot stability, extra width and depth, seamless uppers, and stable supportive midsoles should be recommended. Some diabetic patients tend to wear shoes too short for them especially those with neuropathy, so ensuring the fit is at least one finger or thumb space from the patient’s longest toe to the end of the shoe is critical!