Care for your diabetic patients with a treatment plan of proper nutrition, skin care, therapy, shoes, and orthotics

According to the American Diabetes Association, there are 17 million people in the United States who have diabetes including 20% of the population age 65 and older.¹

One of the most common problems diabetics face is foot ulcerations, which when not properly cared for, can lead to loss of part or all of the lower extremity. Fifteen percent of all diabetics develop some type of foot ulcer, and the resulting infections account for more in-hospital days than any other complication of diabetes. Each year, about 82,000 nontraumatic lower-limb amputations are performed on diabetic patients. Foot lesions in diabetics commonly result from a combination of diabetic peripheral neuropathy and peripheral vascular disease, with the primary event being the development of an insensitive foot.²

The feet and legs are target organs for many of the manifestations and complications of diabetes mellitus, some of which may result in disturbances of ambulation, while others may threaten the viability of the lower extremity. Gangrene is about 50 times more frequent in diabetic men than in nondiabetic men over 40 years, and 70 times more frequent in women in this age group.³

One of the reasons for the high incidence of leg and foot problems is excessive glucose in the blood, which has a dehydrating effect on the skin. This, along with the denervation of some of the autonomic nerves of the feet that control normal sweating, can lead to dry skin that will crack more easily. These skin cracks and splits easily become portals for bacterial invasion and havens for fungus infestations, which can lead to skin ulcerations. Combined with a reduced resistance to bacterial invasion, this can cause infection of tendons or bones.

Another problem in diabetics is a decrease in circulation to the extremities. Peripheral vascular disease is estimated to occur 11 times more frequently and to develop about 10 years earlier in diabetics. Diabetic patients in general have higher levels of circulating cholesterol and lipids. This causes the development of atherosclerosis, arteriosclerosis, coronary heart disease, and multiple microcirculatory lesions far more frequently in the diabetic patient when compared with the normal population.⁴

A common problem in diabetic patients is loss of nerve sensation. It is important that those unable to feel pain get in the habit of self-observation every day to check for red spots, ingrown toenails, splits, cracks, calluses, nail infections, and changes in interdigital spaces. Lack of sensation can cause a pebble in a shoe to wear a cut in the sole of the foot or the hot pavement to burn to the foot.

Problems in the motor nerves of the foot can cause weakness of the intrinsic muscles of the foot, including the lumbricales and other short muscles that are responsible for stabilizing the foot during midstance and propulsion periods of the gait cycle.

The foot is made of 26 bones held together by numerous ligaments and moved by 42 intrinsic and extrinsic muscles. The smooth interplay of the successive motions within the foot that takes place in standing, walking, and running is coordinated by the presence of intact nerves. The sensory nerves are constantly giving feedback to the brain, and the motor nerves need to make the proper muscles contract at the right time. In the diabetic patient, the function of these nerves may be compromised and abnormal formations and motions may result.

In chronic cases of diabetes it is common to see weakness in the lumbricales, which normally function in the extending of the toes and flexion at the metatarsophalangeal joints. This creates an imbalance between the long, deep toe flexors and long extensors of the toes.

This intrinsic muscle malfunction causes a protrusion of the ball of the foot and in advanced stages a pes cavus and hammer toes.⁵ This deformity causes a shift of the fat pad that normally shields the ball of the foot. When we see plantar prominence of the metatarsal heads and extension subluxation of the toe bases in a growing or grown person, this in itself is suggestive of the presence of diabetes mellitus. Normally, the foot distributes the weight evenly over the foot, but in the deformed foot overloading of certain parts of the foot becomes a problem, which leads to local thickening of the skin followed by callus formation and, eventually, ulceration of the skin will occur.

Custom shoes are available to chiropractors that help alleviate diabetic symptoms in the foot. The most sophisticated of these shoes are crafted with custom-made flexible orthotics inside that support all three arches of the foot. Newer high-technology trends in orthotic manufacturing can help the diabetic patient by offering sound postural support, temperature regulation to keep the foot cool and dry, and custom design for a person’s foot. As the prevalence of high-technology footwear permeates the marketplace, neuropathic ulcerations have become less frequent as the availability of proper footwear has improved.⁶

To alleviate the problem of sores from pressure being put on certain areas, a custom-made flexible orthotic should be made to cushion the foot and redistribute stress over the whole sole of the foot. One source indicated a cushioned shoe insert could reduce barefoot pressure by more than 45%. Diabetics should avoid going barefoot and should always shake out their shoes before putting them on to remove any foreign objects.

A rule of thumb when examining a ulcer is to look at the foot and determine whether it has good vascular competence. If it is hot and red, the prognosis for healing is good. If it is cool and blue, further steps need to be considered:

• Start by adjusting the feet to achieve maximum proprioception.

• Raise arches and improve vascular blood flow with custom-made orthotics.

• Absorb unnecessary impact from ground forces by using shock-absorbing materials in the orthotics and shoes of the patient.

• Analyze shoe for seams and unnecessary rubbing. Make sure shoe is supportive.

• Remove shoes frequently and check for objects, such as rocks and twigs, which could cut the desensitized skin.

From a nutritional standpoint, adult-onset diabetes responds favorably to some of the following: potassium, zinc, magnesium, selenium, B6, fish oil for circulation, olive oil, safflower oil, and linoleic acid. Some studies⁷ also suggest a teaspoon of aloe vera (500 mL twice a day) as being effective.

Diabetes is nearing epidemic numbers in the United States, and clearly the best way to treat this problem is prevention. Diet and exercise are key to prevention of adult-onset diabetes. For the patient with diabetes, management of the condition should include diet, exercise, and proper supplementation. If patients are losing sensation in the feet due to neuropathy and vascular challenges, it is vital that they protect the feet with orthotics and daily inspection and from drying out and cracking. Lack of good foot care can set up a battle against infection, which is not easily won and can lead to amputation. CP

Jeffrey D. Olsen, DC, is a 1996 presidential scholar and summa cum laude graduate of Palmer College of Chiropractic. He has been in private practice with his two partners/brothers since 1997 in Roanoke, Va. Olsen also instructs as an adjunct faculty member at the College of Health Sciences in Roanoke, teaching anatomy and physiology in the Physician Assistant Department. He can be reached at 800-553-4860, or via email: olsen@footlevelers.com.

References
1. American Diabetic Association. Available at: http://www.diabetes.org. Accessed October 27, 2002.
2. Robert Berkow, MD, editor in chief. The Merck Manual of Diagnosis and Therapy. Rathway, NJ: Merck Sharp & Dohme Research Laboratories; 1987:1082.
3. Robert Berkow, MD, editor in chief. The Merck Manual of Diagnosis and Therapy. Rathway, NJ: Merck Sharp & Dohme Research Laboratories; 1987:389.
4. Guyton AG. Textbook of Medical Physiology. 7th ed. Philadelphia: WB Saunders Co; 1986:935.
5. Brodoff BN. Diabetes Mellitus and Obesity. Baltimore: Williams & Wilkins; 1982:716.
6. Rifkin H, Porte D Jr. Diabetes Mellitus Theory and Practice. 4th ed. St Louis :Elsevier Science Publishing Co Inc; 1990:809.
7. Bunyapraphatsara N. Antidiabetic activity of aloe vera l juice: II Clinical trial in diabetes mellitus patients in combination with glibenclamide. Phytomedicine. 1996:3(3);245–8.