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Diabetes-related Foot and Ankle Problems

EndocrineWeb spoke with Nere Onosode, DPM about diabetes-related foot and ankle problems. Dr. Onosode is a doctor of podiatric medicine and board-qualified by the American Board of Foot and Ankle Surgery. Here, he answers the many questions of interest to people with diabetes.

What are some of the common types of foot problems you see in patients with diabetes?
Dr. Onosode: 
I tend to see underlying structural bony and soft tissue problems. These include digital contractures commonly known as hammertoe deformities. Another is hallus abducto valgus deformities—commonly called bunions. A bunion affects shoe fit and comfort when walking, and causes soft tissue problems. Frankly, anything (eg, irritation) that causes bony or soft tissue enlargement of the front part of the foot (called the forefoot) can be problematic in the diabetic population.

Is there a difference in the prevalence of foot and/or ankle problems in patients with Type 1 versus Type 2 diabetes?
Dr. Onosode: In my practice, patients with type 2 diabetes (T2D) definitely tends to present more often than type 1 diabetes. I believe this is because patients with T2D are diagnosed later in life, tend to have more overweight, and more often develop complications by the time they come to see me. The onset of type 1 diabetes occurs in children and teenagers, who are usually diagnosed and followed much more closely so problems like ulcers and gout are more likely prevented but also identified early and treated.

Do people with diabetes tend to have more foot problems than people who do not have the disease?
Dr. Onosode: People whose diabetes is not properly controlled tend to have more foot problems than nondiabetics. However, having diabetes is not a sure bet that a person will develop problems with the feet. I tell my patients if you do all you need so your diabetes is well managed, check your feet daily, and see your doctor regularly—whether that is your endocrinologist, primary care physician, or a podiatrist (foot and ankle specialist), you are more likely to avoid foot and ankle problems.

Is age a factor among patients who have diabetes?
Dr. Onosode: Age is not necessarily a factor. The most important prognostic indicators are diet, exercise, and family history. We become especially concerned when the patient is very young, their diabetes is not controlled, and they have diabetic-related complications.

What role does a patient’s professional life or activities play in the development of diabetic-related foot and/or ankle problems?
Dr. Onosode: Lifestyle and physical activity plays an important role. The patient’s profession can be an indicator to determine what their prognosis may be. For example, patients with sit down or stand up jobs. Here the amount of time spent on the feet is important. Patients who do not spend a lot of time on their feet tend to do better than the patient who spends 8 to 12 hours a day on their feet. The wrong kind of shoe and/or a shoe that does not appropriately accommodate the bony and soft tissues of the feet, can cause problems to develop.

What types of diabetes-related complications do you see?
Dr. Onosode: In my practice, the types of diabetic foot and ankle problems seen are multifactorial. The most common complication is peripheral neuropathy, which I’ll discuss next. However, we also see patients with diabetes who have foot and/or ankle deformities.

Now you may wonder why a diabetic-related foot/ankle problem may progress to such a serious state. It is often because patients with long-standing diabetes, who have peripheral neuropathy, may not have adequate feeling in one or both feet or ankles, to know early that something is wrong.

How does diabetes contribute to peripheral neuropathy?
Dr. Onosode: As physicians, we worry about peripheral neuropathy, which is an abnormal or lack of sensation in the foot or feet. When a healthy person steps on a nail causing a break in the skin, their body sends signals through the central nervous system (eg, pain, swelling). However, someone with peripheral neuropathy doesn’t feel or sense those warning signals, and the wound may go untreated.

I had a patient in my office who stepped on a nail more than a month prior. He didn’t realize he had stepped on the nail, and he kept walking on the foot. Unfortunately, the small puncture wound became a full-fledged infected ulceration (see image below).

How does peripheral neuropathy develop?
Dr. Onosode: In my patient’s case, peripheral neuropathy started as a burning and tingling sensation, which can be easily ignored. The problem progresses from burning and tingling and becomes numbness. When a lower extremity is numb, the person cannot feel microtrauma, and when left untreated, the sore(s) become ulcerated and infected.

Please Note: If you have diabetes, please talk with your treating physician about a referral to a podiatrist. A podiatrist is an essential member of your diabetes care team.

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Diagnosis and Treatment of Diabetes-related Foot and Ankle Problems