REVIEWS OF DR. SCHULER
Diabetic Complications and the foot explained by podiatrist
I ( Dr. Burton S. Schuler) have been a professional member of the American Diabetes Association for about 35 years. And I have treated thousands of diabetics as a podiatrist, foot specialist in Panama City Fl. The one thing I know for sure is that there are three major problems, which all must come together at the same time, for the development of foot complications in the diabetic. They are
- ischemia, (poor circulation)
- neuropathy, (nerve disease)
- infection, (precipitation factor)
These three are known as the DIABETIC FOOT TRIAD. All three normally must be present in order for the possibility of an ulcer to occur (skin break down) which then can lead, to an infection (gangrene) which then can lead to an amputation. I say possible, because beside the TRIAD having to be present, the patient must also sustain some type of ongoing trauma or insult (precipitation factor) to their feet, to help trigger the infection phase. Because a person is a diabetic they are more prone to get the TRIAD, and then develop foot complications.
Ischaemia, which is a lack of blood, is a symptom of Peripheral Vascular Disease, in the foot, caused by an abnormally high Glucose level; which can then lead to skin break downs (ULCERS). If the blood supply to the foot is reduced sufficiently, minor wounds may not heal and the patient may have pain at rest due to the lack of oxygen to the foot. Ischemia can also be caused by CALCIFICATION of THE ARTERIES, which can be due to long term non-controlled diabetes, where the large blood vessels have an abnormal buildup of materials that blocks the flow of blood to the foot. Microangiopathies, which occur in the smaller blood vessels, known as the arterioles and capillaries is another cause of ischemia, and is prone to any blockage caused by diabetes. Because of these blockages the blood vessels can not transport enough blood to respond to any injury of the foot and or toes. Hence causing the start of various complications.
In the normal foot that has a normal glucose level and has normal feeling, small wounds or infections are distinguish by the amount of discomfort they present and are treated according. They almost always heal quickly without complications. In the long standing diabetic foot that has lost its feeling, a tiny cut may turn into a major problem because the patient can’t feel the problem. Nerve paralysis of the tiniest of the muscles (intrinsic) of the feet causes a muscle imbalance which results in the metatarsal heads of the foot being pushed down abnormally, and with a Hammering of the Toes taking place. These imbalances can become one of the precipitation factors that can start the break down of the skin.
If the precipitating factors are not controlled, infection can occur. In diabetic patients who have Circulation Disease and/or Nerve Damage, the presence of these precipitating factors can be the “smoking gun” that leads to infection, gangrene, amputation, or worst. The good news is that if you do get control of the precipitating/aggravating factor, this nightmare can be avoided. By determined treatment of any sign of any infection and by getting rid of the basis of any type of trauma to the foot, you have a much better chance of avoiding a foot infection.
To have a full blown infection which can lead to amputation you must have an on going insult to the foot. Some of them are repeated trauma caused by abnormal pressure in the foot, like from the metatarsal heads constantly pushing down or Ingrown Toenails constantly digging into the flesh; abnormal shoe pressure irritating, or burns caused by over-the-counter corn medication, or heating pads.