by Kenneth B. Rehm, D.P.M.
Includes photo of Dr. Rehm.
Dr. Rehm, head of The Diabetic Foot and Wound Treatment Center, in San Marcos, California, gave the following as the keynote address at the 2002 annual conference of the Diabetes Action Network of the National Federation of the Blind. The conference took place on July 6, 2002, at the annual convention of the National Federation of the Blind, in Louisville, Kentucky.
I am a podiatrist. I specialize in the treatment of diabetic foot problems. How many people here are diabetic?
Why do we talk about the diabetic foot? What is so special about the foot? What happens specifically because people have diabetes? Four things happen in the foot because of diabetes. One is nerve problems. We call that neuropathy. Neuropathy happens because of circulation problems around the nerve, and also because the covering of the nerve is a fatty, sugary substance that can be damaged by diabetes. When your blood sugar goes up and down, the covering of the nerve can be altered, interfering with that nerve.
There are actually three types of nerve problems we want to pay attention to. There are nerve problems that alter our sense of feeling and we call this sensory neuropathy. There are nerve problems that cause our nerves to our muscles to misfire, and this causes muscle weakening: motor neuropathy. The third type of nerve problems we have to pay attention to are in the autonomic nerves. These are the automatic nerves that go to the kidneys, heart, other organs that function automatically. Basically if these three areas of nerves have problems, we can experience muscle and joint problems. We can lose the ability to tell whether or not we are walking correctly.
We also get circulation problems. Diabetic people get a kind of hardening of the arteries behind the knee and below the knee. Some researchers call it "small vessel disease."
The next thing that happens is frequent infections. If your blood sugars are up then we have what is called immunopathy, a cluster of problems relating to diabetes' effect on the immune system. We can get athlete's foot, and other nuisance infections, more frequently than people who do not have diabetes.
There are many different ways these problems can manifest in a given individual.
People can experience: Numbness and puffy feeling, numbness and lack of feeling, feeling like a foreign object is present, feeling like feet are on fire, sharp pain in toes, "leathery" feeling, pain in feet coming up calves, hard-to-heal blisters, loss of bone mass, loss of hair on legs, loss of flexibility (can be the feeling of flexibility and it could be real loss of flexibility), feeling of weakness, lack of strength, altered mechanics of the foot, bones collapse, dry feet, chronic fungus in the toe nails, and cramping of the calves. That's a lot of problems, from diabetic feet.
We are going to talk about prevention because prevention is an important part of every step of the game. Prevention requires certain steps. The way we walk and the way we move are very important. This is one of my points in the "Keep Your Feet Healthy Programs."
Just as an aside, I have a product called Toesease. I developed this stuff because of folks like the lady who can't take any of the fungus medication that the drug stores offer her because of her medical situation. I developed Toesease to clean off the fungus and bacteria, and to soften the skin and nails. Then you use the cream to condition the skin, to make it more elastic, so the skin moves when you walk instead of staying stiff and developing calluses. This is a very important point; I see the need for it all the time.
Swelling is because of possible circulation problems. High blood sugar can be one cause of swelling. Neuropathy is not a big cause of swelling, but diabetic nephropathy, kidney disease, can be, so you need to remain vigilant.
So, a lot can happen to the foot in diabetes. We have the nerve problems, the neuropathy, the sensory neuropathy; people feeling like their feet are numb or asleep. They also can have hyperesthesia, which means that the foot can feel asleep and at the same time when you touch it, it is overly sensitive, and that is called paradoxic neuropathy. Some people lie in bed and the bed sheets hurt their feet -- and at the same time their feet are numb.
And there is dry skin. Neuropathy can affect the nerves that go to the sweat glands -- so we get dry feet. We also build up callus quicker. The bones can collapse because of the neuropathy in the bones -- they get a little more calcified, and we can't feel when we walk, so we walk off balance, creating pressure on joints and bones. If we could feel what was going on, if we didn't have neuropathy, we wouldn't be walking that way.
When someone has high blood sugar, some of that blood sugar can accumulate in the joints. The combination of the blood sugar and the joint material is called glycosylation. This can make our joints stiff.
When the nerves to the muscles are affected, motor neuropathy, there is loss of flexibility in their feet. What happens next is the muscles, affected by neuropathy, can get weakened, and can atrophy. The most common muscle affected can be found if you put your hand below your knee, on the right side, with your right hand on the outside. That is called the anterior tibia muscle -- and it is enervated by what we call by the anterior tibial nerve. Sometimes that nerve gets weak, and the result is, when we stand up and walk, we bring our foot up, and as we want to swing our foot to get down to the ground we have to slightly pick our foot up. That is the muscle that helps us pick our foot up. So people who get this type of neuropathy can't pick their foot up so quickly. They shuffle a little bit. They can stumble.
The body is a pulley system, and we have to have balance. For example, if we have back problems, we strengthen our stomach. If one part of the body is weakened, we have to strengthen the opposite set of muscles to help it. If, at the front of the body, muscles are weak, then the back of the leg muscles can become tight. Remember, I said we shuffle? The front of the body muscles get weak, the back of the body muscles get tight, and as we are taking a step, we want to bend our ankle over - but the body says, "oops, we can't do that," so it cheats. How do we cheat? We become more flat footed than we should. This helps break down our feet. We can't complete a normal walking cycle; we have to grab with our toes, that gives us crooked hammer toes.
If you take your fingers, curl them up, and push them up with your other hand, you'll see what I mean. Now what happens is the ball of your hand, otherwise the knuckles of your hand on the bottom the plantar surface, palm surface become down, don't they? It's like your foot becoming flattened. If the fingers go up, the palm goes down. Ok, here we are walking with our muscles being affected by diabetes - walking on the ball of our foot, because our toes cramped up. This way of walking pounds it, and that is why we get the calluses we mentioned. When the calluses are rubbed raw, and we don't feel it because of our neuropathy, we get blisters that we don't feel. If the blisters become infected, sometimes our high blood sugars lessen our power to heal that infection.
What happens in the diabetic foot? Again, nerve problems: sensory neuropathy, motor neuropathy and autonomic neuropathy. What are the results? We see numbness, burning, dry skin, muscle weakness, calluses and cold, burning feet. This is how it shows up clinically. This is what the people tell the doctor. What happens because of these symptoms? Orthopedic problems, walking wrong. We get the foot pushed aside, and we get hammer toes and bunions. Then we have walking problems because of the feet being crooked, and then we get hammer toes and then we get ulceration. We get other skin problems - because of rubbing, shearing, and calluses. You see how the neuropathy plays in? It is not clean cut; you can have one problem like calluses, but it can be due to several different causes. All these things happen in the foot: neuropathy, circulation problems, and muscle problems and all kinds of other stuff.
My goal is to have everybody understand what they are dealing with. When something is too confusing, or too complex to comprehend, then we don't want to deal with it. We say, "Oh well, it will go away." If we have a clear picture, however, then we are motivated to help ourselves. We are all a bunch of denial people.
Four words are important when we get a diabetic problem: treatment, management, rehabilitation and prevention. We have to go through these stages. You get a blister - we treat it. If you have neuropathy - we manage with it. We are going to talk about it.
Rehabilitation: so we have a broken bone, or a flattened arch. How do we rehabilitate from that? How do we build the muscles? Then prevention. Prevention, by the way, is the best possible treatment. Did you ever think about that? It is so much more a problem once we get a complication. I see people smoking, I see people doing this and that. And I ask myself (don't get me wrong I am not perfect), something about human nature. If we know what is good for us, why don't we do it? Why don't we act in prevention mode? Because we are human.
What is the most important element of prevention? Everyone here knows the rules to good health. It is nice to say we are "going to exercise," but don't we have to be motivated? That is the biggest stumbling block, motivation - wanting to care for yourself, enough to do it. Number one in importance is mental conditioning, before anything else. You have to want to take the appropriate steps.
The thing with mental conditioning in diabetes, or any chronic disease, I found out interviewing patients (I do a lot of writing and research and all that type of stuff), is the biggest problem with mental conditioning in any chronic disease like diabetes or vision problems or cancer or whatever it is, one day we are Bill Smith or whatever our name is. We like ourselves, well lets just say we are satisfied with ourselves. We have our routine down. We are doing our thing. I like myself. I want to protect myself. I am Bill Smith. Then someone gives you a label, there at a doctor's office. You have cancer, or whatever it is. And that drops you like a lead balloon. You don't want to be Bill Smith number two. You want to be Bill Smith number one. I will take care of Bill Smith number one. I don't want to take care of Bill Smith number two. I don't want to. I want to go back to being Bill Smith number one, but I am Bill Smith number two. Hey, the hell with him. It is like "I don't want to be this guy."
We know when you control diabetes, when you control your blood sugar, when you eat right, you can control a lot of the complications. We just have to like ourselves enough to care do it. The alternative is diabetic denial.
If the very first thing is prevention, its first component is mental conditioning. The second thing is physical conditioning. So, once I am feeling (mentally) good, when I am feeling good, I am going to exercise. I am going to swim. I am going to do whatever it takes to keep my blood flowing, and my whole body in shape. By the way, it feeds back to the emotions. Doesn't it feel good after you have exercised?
Exercise also feeds the body. So then we say, "Ok, what do we need to do next?" You don't have to run marathons, just be in the ballpark. Do something. Then do it a little more. It is just the act of doing something, getting into the habit of doing it, is more important then what you are doing. The fact that you are getting out there and making it part of your life is what matters.
#1. Mental conditioning
#2. Physical conditioning
#3. Know and practice a "keeping your feet healthy program"
What does this last part mean? It means you keep your feet clean, keep your feet warm, and keep your feet protected with the right shoes and socks. I see so many people going barefoot. I saw a patient of mine with very brittle diabetes, and he was mowing his lawn barefoot, I swear. Keep your feet safe. Keep your feet free from excess moisture. Keep your feet conditioned and free from excess dryness. You need that skin to be supple and move when you move it, so it doesn't stay stiff, and so it does not cause calluses.
Some people sweat an awful lot because of their neuropathy, instead of getting dry skin. Keep your feet free from excess dryness because that is the other end of the spectrum. Never put your socks and shoes on when you are still wet from a shower. Now, by the way, I hope none of you have any of these problems. If you control your diabetes, you should not have these problems, but that is the whole point, prevention is the best treatment.
So, going on with the "Keeping Your Feet Healthy Program." Keep your feet and toenails trimmed. There are a lot of ingrown toenails. The biggest problems, the biggest infections, can stem from those ingrown toenails. Keep your feet working, with exercise, because you are breaking those adhesions up I told you about, that happen when the high blood sugars mix with the joints. Wiggle your feet. Exercise your feet. Stretch your feet. Stretch your legs. The tightness in the calf we talked about, that is exactly just what it is. Stretch, move, and if you can't do it on the sidewalk, do it in a pool. Keep your feet balanced when walking.
See a professional for your foot care. Most professionals offer both shoes and custom inserts because the foot is moving within the shoe, and the shoe and the foot move together, so we have two different units moving. You need good shoes, but you also may need something inside the shoe to help balance your feet, so they don't rub.
There are three types of dangerous rubbing that can occur. First is shearing. If you put your hand on top of your other hand and rub it real fast, that is friction, but if you let it stick a little bit, so the skin on the outside stays still while the bones move, that is shearing. The third type of rubbing is pounding. Pounding is direct pressure. We have to protect ourselves from each one of these three types of pressure. These pressures can cause the blisters, which cause the infections, which cause the ulcerations, which cause other bad things. My job is to prevent these things.
Virtually all amputation is 100% preventable. That is the good news. Which brings that and me to the next point in the Keep Your Feet Healthy Program: keeping your feet in check. I have had other patients whose heels touch the sheets and they get deep bad ulcers on their heels. What does the nurse do? They put a foam block under their heels. This protects the heel against pounding, but it does not protect against the other two types of pressure.
In the hospitals the patient must stay aware, as they may not have all the answers. The point in the Keep Your Feet Healthy Program is to keep your feet in check. Everyday either you, or have someone else, inspect your feet. What should you look for? Hot spots, blisters, sore and painful areas, cuts, cracks, dryness, red, hot, swollen; all the things we have talked about. Keep your feet in check.
Should you have your doctor check your feet? Every time you go. This is an interesting point. I am 56 years old, and I go to the doctor for a physical every two or three years if there is nothing wrong. My doctor has never, ever inspected my feet. What, the feet aren't part of the body? He checks my throat, he checks my eyes, but not the feet. The feet must not be part of the body. I am here to tell you that the feet are part of the body. So when you go to your doctor ask them to check your feet. Raise your hand to let me know if your doctor does not check your feet. I am telling you that 50 to 60% of you have your hands up -- your doctors are not checking your feet.
We as consumers must be assertive with our healthcare. You cannot depend on anyone any more. I know, in California, our healthcare system with all the HMOs and PPOs and they don't pay for this and they don't pay for that, and they are putting so much pressure on the doctors to see so many patients, money issues, and this is covered and that is not, we have to be proactive. We have to tell the doctor, "Will you look at my feet? I need an arch support, will you refer me?" You have to take the lead. You are responsible for knowing your own healthcare. Please be proactive, work on prevention - the steps that I have designed of mental conditioning, and physical conditioning can really keep your feet healthy.
Massaging your feet is an absolutely great idea. You combine the action of conditioning with the cream, taking care of the dryness as well. Massaging helps the circulation, and with diabetics who have swelling, it can reduce that swelling. There are creams made especially for the diabetic foot. You should look for them when you go to buy diabetes products. Make sure it is for the diabetic foot.
Again, with the Keep Your Feet Healthy Program, keep your feet clean, dry, wear proper shoes , keep your feet safe, keep your feet free from excess dryness or wetness, keep your toenails trimmed, keep your calluses trimmed, exercise, keep your feet balanced when walking, and keep your feet in check, with a professional, and by yourself. This is the basis to keeping your feet healthy.
After his address, Dr. Rehm took questions from the audience:
There was a question about special pillows for sore, painful diabetic feet, pillows small enough to be packed in a suitcase and carried by a traveler. I know of one: The Heelivator, It wraps around the foot and keeps it protected. It's a great item. Contact me, Dr. Kenneth Rehm, at The Diabetic Foot and Wound Treatment Center; telephone: (760) 744 6226, in San Marcos, California, 92069.
For those of you who cannot take some of the antifungus medications, and need to treat your feet topically (I did mention my product, Toesease) I've heard of using Vick's Vapo-Rub on your feet. I saw a press release about it - but I have no personal experience either way.
Everybody buys shoes; short of going to the podiatrist, how do you know which kinds of shoes are best for your diabetic feet? You want good cushioning, to protect against the pounding. You want a good heel counter, for support. You want a wide toe-box, with lots of room for your toes. A little arch support is great too. It has to have a good shank, which is the upper part, to support the top of your foot - but not too tight. They can have laces (lace shoes stay on better than loafers), but they could also be velcro. And, avoid shoes with uppers made of man-made materials - they don't breathe as well as leather, and can cause problems.
Includes graphic: picture of a shoe with lines to the following explanations:
1. Cushioned heel counter top. Heel counter reinforced to prevent bending
of shoe - more supportive of foot and ankle.
2. Added depth to accommodate orthotics.
3. Flared heel puts wider distribution of pressure on the heel and foot. Formula:
force/area = pressure.
4. Metatarsal rocker bottom - less pressure on metatarsal heads.
5. High and wide toe box allows room for toes without squeezing.
6. High vamp - with easy velcro straps. Accommodates swelling in feet and arch
support height.
And of course the shoe should be leather, and seamless - as seams can irritate skin. Shoe should allow removable orthotic inserts.
Your socks should be of natural material. Nylons and artificial materials do not let the foot breathe. And many fabric dyes can harm the foot. A white sock is best. Choose a sock without seams.
You want to dry your feet, after washing them, but I've heard of people using hair dryers to do this - and this is not a good idea. Hair dryers are very hot, and I've met people who literally burned their feet, by trying to dry them with a hair dryer. If you have neuropathy, and some numbness, you may not even know you did it. I cannot recommend hair dryers. Bathing your feet in overly hot water is dangerous, for the same reason. Some of us can't tell anymore, that the water is too hot, so we leave our feet in - and can be seriously burned.
It is important to make sure your feet are dried, but you need to minimize friction, while using a towel. Better to pat your feet dry. Then wait, perhaps half an hour, before putting your shoes on.
One thing about numbness: When a non-diabetic foot feels numb, we feel that it is numb. The pathway from foot to brain is working, telling us the foot is numb. In a diabetic with neuropathy it is possible that the pathway is also numb, damaged by diabetic neuropathy, so we don't know, we don't perceive, the foot is numb - and then we don't take action.
What if you have edema on your feet? What do you do? Though there are some conditions for which an Ace Bandage is appropriate, this is not one. Instead, in such a case I'd like you to get a doctor's prescription for support hose, rated at about 10 to 15 mm of Mercury. At this rating, you're not squeezing off any circulation. More than 25mm of Mercury, the traditional "rating" for support hose, means that you may clamp off the circulation. You don't want to do that.
Where do you find support hose? Every state's different. Some wheelchair companies, or medical supply companies, will have support hose; other states, you'll find it at the pharmacy. You, the patient with dry skin on your feet, never debride it, or cut it yourself. When you go to the doctor, and it's scaley, if he wants to use cream to help debride it, or to snip off loose, dead skin, OK. Don't you do it. But, conditioning that skin, keeping it moist, on a daily basis, will auto-debride the area. Keep it moist and soft.
If you're going to use a "pumice stone" to remove dead skin, even if you're sighted, you can't really see the area, and it would be better to have someone else do it. They can keep a closer watch than you can. Some doctors use a "Dremel Tool" with a soft sanding stone, to do the same thing.
If you have swelling in your feet, any time you have the chance to massage it, it's the best.
Don't put lotion or cream between your toes. You can use oils, but not creams - creams are lotions which dry.
Sometimes, some of us will have dry, cracking skin on our feet and lower legs, and it can get extremely painful - to the point of restricting mobility. This is linked to the circulation problems we experience as diabetics. I would suggest talking to your doctor about support hose. And, every time you can, you keep your feet elevated. Put them up in a chair.
Portable whirlpools may not be a good idea for diabetic feet. Your feet are hanging down (and they should be elevated), we can't tell the temperature, sometimes, and we can't tell how clean the whirlpool is. If we can monitor the temperature (ask someone else!), we can be sure the whirlpool is absolutely clean, and we limit the time, to 10 minutes, no more than 15 minutes, I don't see anything wrong with it then. Otherwise, its not a good idea. Keep close watch; less might be enough for you as an individual. And always check with your doctor.
If you are diabetic, you need a diabetic foot doctor, who you'll need to see regularly.
Thank you, and I really hope I've been able to help.
NOTE: Dr. Rehm's speech, titled: "Diabetes, Neuropathy, and the Feet," is available on normal-speed audiocassette, for $2 per copy, from: National Federation of the Blind, Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314, Website: www.nfb.org