My Doctor Online The Permanente Medical Group

Symptoms

.

View larger image(s)

Symptoms of diabetic foot problems often fall into two categories: those caused by poor circulation and those caused by nerve damage. Some of the most common symptoms include

Symptoms of poor circulation:

• Coolness of the skin of the feet
• Lack of hair or hair loss
• Bluish color of the skin
• Occasional pain at night
• Calf pain when walking

Symptoms of nerve damage in the feet and legs:

• Pain, numbness, tingling, and/or burning.
• Skin changes that include dryness, scaling, cracking, blisters, ulcers, corns, and calluses.
• Lack of sensation. This may mean you can't feel it if your foot is irritated or injured.
• Weak muscles. This can lead to other symptoms such as hammer toes or bunions, deformities of the joints in the ball of the foot that resemble a claw foot, and increased pressure on the bones, leading to skin ulcers.
• Infection. Any break in the skin can lead to infection. You may not feel any pain if you have diabetic nerve damage, which is why we recommend that you check your feet frequently.

Contact us immediately if:

• You notice any redness, swelling, warmth, pus, or drainage from your foot.
• Your blood sugar becomes very high or difficult to control.
• You feel tired, feverish, or generally ill.

Diagnosis

.

We diagnose your foot problem by talking to you about your symptoms, evaluating your diabetes and other medical history, and physically examining your feet. We may also order X-rays to look at the bones or soft tissue in your feet.

Medical history

We will ask you a number of questions about your symptoms and medical history:

• How long have you had diabetes?
• How well do you manage your blood sugar?
• Have you had foot sores before?
• Have you had bypass surgery for circulation problems?
• Do you feel pain or tingling in your legs and feet? If so, when does that happen?
• Have you ever smoked?

Physical examination

We will examine your foot and perform a number of tests that include

Tests for nerve function.

• We will press on your foot in a number of places and ask if you can feel it.
• We may place a gently vibrating device on your foot and ask you to tell us when you feel the beginning of the sensation and when you feel it stop. 

Tests for circulation damage. We will check:

• The pulses in your feet
• Your skin temperature
• The color of your feet

We will examine your feet for sores, corns, or calluses by checking for:

• Sores between the toes
• Moist skin between the toes
• Calluses on any bunions

If we do find a sore, we will examine it closely to check for:

• Skin Infection: redness, warmth, tenderness, or swelling.
• Pus draining from the skin.
• Bone infection. We insert a sterile blunt probe into the lesion to look for bone infection. We may also order lab tests.

Causes and Risk Factors

.

View larger image(s)

You are at greater risk of developing foot problems if you have poor circulation and/or nerve damage caused by diabetes.

Poor circulation

Poor circulation caused by hardening of the arteries can lead to a number of problems that include:

• Sores may develop on the feet and heal very slowly or not at all.
• Infection can occur because you may have undernourished skin that is less able to resist bacteria and fungus.
• Gangrene can occur, which destroys the tissues of the foot and can lead to the need for amputation.

Nerve damage (peripheral neuropathy)

Nerve damage can occur due to high blood sugar levels. This can increase your risk of developing a number of foot problems that include loss of feeling in areas of your foot, dry skin, and weak foot muscles:

Loss of feeling

• You may not be able to notice pain or pressure in your foot, which can lead to the development of calluses and corns.
• Although these are minor problems, if they are left untreated because you can't feel them, they can ulcerate and become infected.
• Charcot's foot is a major problem that can affect the foot. This can occur if you break a bone in your foot but do not seek treatment because you can't feel it. You may continue to walk on the foot, which will allow the broken bone to destroy the tissues in the foot.

Dry skin

• Nerve damage can prevent your sweat and oil glands from working properly.
• Sweat and oil keep your skin soft and moist.  Without them, your skin gets dry and can crack, allowing germs to enter.

Weak foot muscles

• Weak muscles caused by nerve damage cannot effectively support other structures in the foot, including joints and ligaments. This can lead to joints becoming unstable, causing other conditions and joint abnormalities such as hammer toes.
• If joints move excessively, joint changes can eventually deform the whole foot.

Prevention

.

Proper foot care includes checking your feet every day, keeping your feet clean and dry, and choosing and wearing supportive and well-fitting shoes and socks. In addition, you can prevent most diabetic foot problems by keeping your blood sugar under control and taking good care of your feet. When you have diabetes, we recommend monitoring your blood sugar with a glucose meter.

Monitoring your blood sugar

A glucose meter is a small device (smaller than a cell phone) that quickly reads your blood sugar levels and saves the reading for future reference. Meters are easy to use and to carry with you. You can check your blood sugar at home, at work, or anywhere.

Monitoring tells you if your blood sugar is in your target range, or if it is too low or too high. With this information, you can decide what action to take.

Low blood sugar (hypoglycemia). Blood sugar less than 70 mg/dL is too low for most people who take diabetes pills or insulin. If you take certain diabetes pills (sulfonylureas or alpha-glucosidase inhibitors) or insulin, it's important to know the symptoms of low blood sugar, how to treat low blood sugar, and how to prevent it.

Low blood sugar can develop because of:

• Skipping or delaying a meal
• Being more active than usual
• Not eating enough carbohydrates
• Taking too much diabetes medication or insulin
• Drinking alcohol without eating

High blood sugar (hyperglycemia). This can develop because of:

• Eating too much carbohydrate
• Being sick or having an infection
• Being stressed
• Needing more diabetes medication or insulin

Monitoring also tells you how your blood sugar is affected by:

• What and how much you eat
• Physical activity
• Stress
• Sickness or infection
• Your diabetes pills and insulin

Blood sugar targets

When you monitor your own blood sugar, it is important to know your blood sugar targets. Talk with us about your personal targets. For many people, the blood sugar targets are:

Take Care of Your Feet

.

Taking care of your feet daily helps prevent infections and injuries. By checking your feet daily, you are more likely to notice problems early so we can start treatment right away.

Check your feet every day

Look at your feet each day for redness, blisters, swelling, pus, sores or cuts that are not healing, cracks, and ingrown toenails. Use a mirror or ask someone else to help you if you cannot see your whole foot. Press down on the skin to check for swelling and compare each foot with the other foot. Pay close attention to:

• Tips of toes
• Around toenails
• Between the toes
• Outside and inside of the foot
• Heel edges
• Ball of the foot
• Sole of the foot

Prevent injury and infection

Any opening in the skin can increase your risk of developing an infection. As a result it is important to be very careful with your feet. There are a number of things that you should not do when caring for your feet  because they can lead to breaks in the skin and infection:

• Do not treat corns, calluses, toenails, or other foot problems yourself. Do not pop blisters.
• Never use a razor, sharp instrument, or other device to remove a corn or a callus.
• Never use a chemical substance, medicated pad, or other medicated corn/callus remedies to remove corns.
• Be very careful removing Band-Aids or tape from your skin.

Follow a daily foot hygiene routine

• Keep your feet clean and dry.
• Wash them daily with mild soap and water.
• Pat the skin dry, do not rub hard. Dry between the toes, using only the thickness of a towel.
• To avoid cracked skin, apply lotion or cream, especially on the edges of the soles and heels. Do not use lotion or cream between the toes.
• Use a foot powder between your toes if moisture collects there.
• Don't go barefoot, even at home. Your feet need the protection of shoes or thick-soled slippers to protect them from injury or infection.
• Cut toenails straight across. File toenails with an emery board or nail file. Ask us about our foot care clinics or appointments for help with calluses, corns, or nail trimming.
• Avoid crossing your legs, as this will restrict blood circulation to your feet.

Choose the right shoes

Healthy feet need comfortable, supportive, and breathable footwear to stay that way. Here are some tips for buying and wearing your shoes:

• Buy shoes at the end of the day when your feet are slightly larger.
• Buy shoes made with soft leather that have a closed toe and heel.
• Always have your foot measured when buying new shoes. You should be able to wiggle your toes in the shoe.
• Laces or Velcro closures are best, because you can adjust them to the width of your foot. Avoid elastic as it can be constricting.
• Choose shoes with a cushioned sole to support your foot.
• Never wear new shoes more than 2 hours at a time. Check your feet after wearing them for redness, bruising, or blisters.
• Check inside your shoes for pebbles or other objects, or for a torn lining that may hurt your feet. If the shoes have a tongue, make sure it is flat and unwrinkled when you put them on.
• Loosen laces before putting on your shoes and do not tie them too tight or too loose.
• Avoid wearing high heels and pointed-toe shoes.
• Never go barefoot.

Custom shoes

We may recommend custom shoes with custom insoles if you already have joint changes or other foot problems. If this is the case, please follow these guidelines for wearing custom shoes:

• Always wear them when walking, even inside the house.
• Do not substitute any other shoe without talking to us first.
• Replace custom shoes periodically. Ask us to check your shoes after 1 year and then every 6 months afterwards.

Socks

It's also important to keep your feet clean, dry, and protected.

• Wear socks with shoes at all times.
• Wear white socks whenever possible. Check them at the end of the day for blood or pus.
• Wear clean, dry socks that are made from a breathable fabric. We recommend wool or sports fabrics that wick away moisture to keep your feet dry.
• Do not wear socks with holes.
• Avoid socks that squeeze the toes or have seams or ridges that could rub against your skin.
• Do not use a circular garter or rubber band to hold up socks or stockings. This can cause swelling or circulation problems.

Not too hot, not too cold

If you have lost feeling in your feet, you can easily injure them by exposing them to water or surfaces that are either too hot or too cold. Here are some steps you can take to prevent this from happening:

• Always check bath water with your hand or elbow before putting your feet in.
• Do not warm your feet with a hot water bath, hot water bottle, heating pad, or hair dryer or by putting them in front of a fire or grill. You may burn yourself without knowing it.
• Wear warm socks and shoes in cold weather. Wear loose bed socks at night.
• Protect your feet from sunburn with sun block whenever you sunbathe.
• Check the heat of the car floor during long road trips to make sure that your feet are not too hot.
• Snow skiing is a very high-risk activity for your feet, because of the cold exposure and constriction of the ski boot.
• Do not use ice on your feet, especially if they "burn," which is a symptom of nerve damage.
• Always wear shoes to protect your feet from injury.

Treatment

.

Treatments for mild skin infections and foot sores

We treat foot sores in a number of ways, depending on their location and severity. Common treatments include:

• Removing dead skin or diseased tissue with a scalpel or scissors
• Dressing the wound in a way that keeps it moist but not wet
• Treating any infection with antibiotics
• Putting your foot in a special cast or prescribing therapeutic shoes to relieve the pressure on the affected area if the sore is severe

Treatments for severe diabetic foot problems

If your foot problems are severe, we may need to bring you in to the hospital to treat you. More complex treatments include the following:

• Surgical debridement of dead tissue. Sometimes, dead tissue is so extensive that we need to remove it surgically in the operating room. Removing the tissue helps ulcerated sores to heal and reduces the risk of infection. You may need to stay in the hospital for a short period of time after surgery.
• Intravenous antibiotics. We give you antibiotics via an IV in the hospital. This is usually followed by a prolonged course of oral antibiotics.
• Surgical removal of infected bone.
• Surgical treatment of severe poor circulation to the leg. We may recommend an angioplasty where we place a stent into the blocked artery via a catheter. Alternatively, we may use bypass surgery where we use a graft of healthy tissue to bypass the blocked artery.

Lifestyle Changes and Management

.

The most important thing you can do to keep your feet healthy is to keep your blood sugar levels under tight control, treat any high blood pressure, and if you smoke, stop.

Quitting tobacco is one of the most important steps you can take to improve your health. We have many resources to help you quit. Stopping smoking lowers your risk of developing serious diabetes-related health problems such as heart disease and nerve damage. Treating high blood pressure can prevent damage to your arteries that can contribute to foot problems.

We have a range of resources to help you manage your diabetes, control your blood pressure, and assist you with lifestyle changes and management.

Getting Your Care with Me

.

If you have diabetes, your personal physician will monitor your feet as part of your regular diabetes care.

If specialty care is needed, your personal physician will facilitate the process of scheduling an appointment in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

During your office visit, we will discuss your medical and family history and I will examine your feet. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options, and together we will create a treatment plan that is right for you.

.

.

If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

If you have urgent concerns or issues while my office is closed, or need general medical advice, you can call the Appointment and Advice line, available 24 hours a day, 7 days a week. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

.

Convenient Resources for You

.

As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

.

Coordinating Your Care

.

Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the "After Visit Summary" that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

If surgery or a procedure is a treatment option

I will recommend you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

If we proceed with surgery, I will have my Surgery Scheduler contact you to determine a surgery date and provide you with additional instructions regarding your procedure. Once your surgery is scheduled, a medical colleague of mine will contact you to conduct a preoperative medical evaluation that will assure that you are properly prepared for your surgery.

.