Foot care is an ongoing issue for diabetics. Avoiding foot problems, dealing with minor issues before they become major, and preventing serious infections that could lead to amputation, are all concerns. For all the recent progress in wound care and intervention, prevention is still the best place to begin.

Diabetes, over a period of time, can cause circulatory damage and neuropathy, both of which can affect condition of the feet. Because of impaired circulation, the body's ability to heal itself is diminished. Minor traumas, that might otherwise heal quickly, persist and can become infected. Diabetic neuropathy, nerve damage, can impair an individual's ability to detect foot problems. Because it doesn't hurt, you don't intervene, and small problems escalate into big ones.

The best place to start is with your shoes and socks. Proper fit is essential! Do not compromise--you have too much to lose. Make sure the shoe is wide enough, and don't let it pinch your toes. Shoes that "breathe," (either leather or running shoes) are best. Avoid sandals, especially those with a thong between the toes. Socks should be seamless, athletic type, of cotton or one of the new fibers like "Thorlo".

Before putting your shoes on (and after you take them off), inspect your feet. You are looking for anything out of the ordinary, anything that might escalate from irritant into infection. Be thorough! Blisters, bunions, corns, splinters, raw or discolored patches, ingrown toenails, even "athlete's foot" fungus can require action. Don't assume it will go away by itself! When in doubt, consult your podiatrist.

Sight is not necessary to carry out daily foot inspections. Much can be revealed by feel and smell. You are looking for change, anything that shouldn't be there, or that wasn't there before. Swelling, hot or cold patches, unexplained tenderness, unusual odors, all can let you know something is not right. It is amazing how much a tactile inspection (with fingertips, back of hand, or even forearm, if you have neuropathy in your hands) can reveal.

When you visit your doctor, ask to have your feet inspected. Take your shoes and socks off, before he or she asks. Also, your doctor may know that the progress of neuropathy can be measured by noninvasive tests of foot sensation. Such tests can be carried out with a device called a "monofilament", which resembles a toothbrush with only one bristle. Your doctor can obtain a monofilament by sending $15, and a request for a LEAP package, to: Feet Can Last A Lifetime, National Diabetes Outreach Program, 1 Diabetes Way, Bethesda, MD 20892-3600.

Keeping your feet clean reduces risk of infection, should you break the skin. Wash with mild soap and medium-temperature water, and dry carefully. Many diabetics have abnormally dry feet, and treatment after bathing (or as needed) with a thin coat of moisturizing cream helps reduce risk of abrasion and infection. Do not put any moisturizer between the toes. The process of rubbing lotion into the foot provides a stimulating massage, good for the circulation, and offers one more chance to detect foot problems.

Regular exercise helps stimulate circulation, and keeps the feet healthy. A regular walking program will provide much benefit.

"Some foot problems can be prevented with good common sense such as not walking barefoot on hot pavement..." says Ron Scott, MD, Director of the Wound Care Clinic of North Texas (at Presbyterian Hospital in Dallas), who also reminds us that cigarette smoking aggravates circulatory problems, and that diabetics should not smoke.

Going barefoot is never a good idea for a diabetic. Even at home, the carpet may hide staples and sewing needles, and if you have any neuropathy, you may not feel it. Check inside your shoes too, before you put them on, as small objects may have fallen in. Plus, thumbtacks, brads or sharp nails may penetrate through the soles of your shoes.

"People with diabetes should NEVER use over-the-counter medications on their feet without the approval of their podiatrist or physician," says Neil Scheffler, MD, a podiatrist from Baltimore, Maryland. "Corn or callus removers, for example, contain acids that can burn through the callus and normal skin as well, with disastrous results."

"Home surgery" such as using a razorblade on corns or "planter's warts" is not recommended either. Cut nails straight across; don't shave calluses. Minor irritations such as the above, or even ingrown toenails, are worth a call to the podiatrist. In many cases Medicare covers such service.

Your podiatrist may recommend you use special therapeutic shoes, or shoe inserts, to help protect your feet. As of May 1, 1993, if preconditions are met, Medicare will pay for certain types of diabetic footwear.

The precautions described above should keep your feet out of trouble, but diabetes is unpredictable, and you might find problems developing in spite of your best efforts. Quick intervention is called for. Regular foot inspections, as discussed above, can reveal that unfelt blister, that undetected cut, that tack you stepped on, before the wound goes septic.

Diabetes is the biggest cause of non-traumatic amputations in the United States. Most of these are lower limbs, where neuropathy, impaired circulation, and undetected, untreated injuries can combine to create non-healing, septic wounds. When gangrene (tissue death) develops, amputation can become necessary.

New medical developments have cut the rate of amputation. Curative Technologies Incorporated (CTI) operates the Wound Care Centers, a network of clinics where patients with severe septic wounds are given aggressive new therapies such as Procuren, a "growth factor" obtained from the patient's own body. CTI claims an 80% healing success rate, and notes, "these are patients who would likely have lost a limb to amputation."

Hopefully you'll never need such intervention. Stay vigilant, use common sense, keep your health care team informed, and you should keep your feet out of trouble.