Q: What is neuropathy?

A: Neuropathy is the gradual loss of nerve function in the feet and legs due to diabetes. The most common and significant change is loss of feeling, or touch sensation.

Q: How do I know if I have neuropathy?

A: Neuropathy usually comes on slowly. You may not notice it at first because it is the absence or reduction of sensation. It is hard to be aware of something you cannot feel! A physical exam by your doctor and sometimes special tests can help in making the diagnosis.

Q: If neuropathy causes loss of feeling, why do my feet sometimes hurt or tingle?

A: Neuropathy can cause the nerves to "go haywire," or transmit impulses that you experience as numbness, tingling, shooting pains, burning sensations, pins and needles, electric shock sensations or any combination of the above.

Q: Do all diabetics get neuropathy?

A: The likelihood of getting neuropathy increases with age. The longer you have diabetes, the increased chance you have of developing neuropathy. Many cases are mild, but some are more severe. The severity of the neuropathy does not necessarily correspond to the severity of the diabetes. Some people with mild diabetes can have severe neuropathy.

Q: Does neuropathy affect only the feet?

A: Neuropathy mainly affects the feet, but can also involve the ankles, legs and at times, even the hands. It tends to be more severe in the foot than in the lower leg. In other words, it affects the toes more than the lower leg. Neuropathy of the legs seldom goes above the knee.

Q: What can happen to my feet if I have neuropathy?

A: You can injure your feet without knowing it. For example, a person with neuropathy may let a cut or sore of the foot get out of hand simply because it does not feel painful, and they do not realize it is there.

Q: What other ways can neuropathy hurt my feet?

A: If you wear a pair of poorly fitting shoes, blisters or open sores (ulcers) can form in less than an hour. At first these can cause small problems, which can snowball into more serious ones.

Q: Does this mean I should call the doctor even if I have a small foot injury or a minor infection?

A: Yes. All too often a patient notices an area of swelling or redness, but fails to seek attention because it does not hurt. Later, she/he looses all or part of the foot.

The most dangerous thing about neuropathy is the absence of feeling, because this allows the injury to go unrecognized.

Q: How does diabetes affect circulation?

A: Diabetes can contribute to narrowing of the arteries, and decreased circulation in the upper and lower parts of the leg. However, as discussed above, neuropathy, not circulation, is the main cause of most diabetic foot problems.

Q: Does poor circulation affect healing?

A: Your skin and other tissues depend on good blood circulation for both oxygen and nutrition. Poor circulation can result in skin breakdown and cause minor cuts, bruises, burns and other injuries to heal poorly. Paying close attention to your feet, primarily by inspecting them twice a day, is the key to preventing serious problems.

Q: Why do infections cause foot problems?

A: Infections may spread quickly in the foot, giving little warning. Minor injuries can become open sores, and then develop into an abscess (deep infection). Once an infection becomes deep-seated, or gets into the bone, you will usually need surgery in addition to antibiotics.

Q: What should I watch out for?

A: Several "sneaky signs" should lead you to suspect infection. Unexplained temperature rise or fevers coupled with open sores or blisters on your feet may signal an infection. Other warning signs may include too much sugar in the urine, or blood sugar that is difficult to control and requires a higher insulin dosage. Again, inspect your feet regularly to prevent serious problems.

Q: How do I prevent foot problems?

A: Good care requires daily vigilance. Close visual inspection must substitute for the feeling you have lost in your feet. Look for reddened skin, sores, blisters, inflamed nails, bony prominences, and changes in the shape of your foot.

Q: How do I do this when I find it hard to get in a position to see the bottom of my foot?

A: You can place a mirror against a wall near a chair in the bedroom or bath to inspect your feet. If you have poor vision, you may find a magnifying glass helpful. Most practically, have a friend or family member inspect your feet regularly.

Q: What daily care should I do?

A: Use gentle cleaning routines. Wash your feet in lukewarm water, never hot. Because you cannot rely on your feet to warn you that the water is too hot, test the water temperature with your elbow. Wash with a soft cloth and mild soap.

Q: What else should I do?

A: Dry thoroughly but gently between the toes. Use a moisturizing lotion for dry skin, but do not put it between the toes. Keep dry skin soft and pliable.

Q: How should I trim my nails?

A: If you have good vision and can reach them easily, trim nails straight across with a nail clipper. Do not round the corners. However, it is safest to file the nails down frequently with a simple nail file or emery board. If you have difficulty or are uncertain, you should have your nails trimmed professionally.

Q: Are corns a problem?

A: Yes. Corns are hard calluses that form on the top of the foot, especially the toes, almost always due to the pressure of shoes. Corns indicate that your shoes are too tight and you need to be professionally fitted.

Q: How should I treat calluses on the bottom of my feet?

A: Thickened skin or calluses also occur in these areas due to pressure. They can cause problems if they become excessively thick and/or dry, causing splits in the underlying skin that can lead to an infection.

Q: How should I trim calluses?

A: Calluses can be reduced with gentle daily rubbing with a foot file or pumice stone. If you are uncertain or unable to trim calluses, consult your physician.

Q: What kind of footwear should I choose?

A: Choosing good footwear that allows plenty of room can help prevent foot injuries. Shoes should have cushioned soles with uppers made of soft, breathable materials such as leather, not plastic. Professional shoe fitting is advised. Consult your orthopaedic surgeon for a referral.

Q: What about sandals or thongs?

A: Sandals or thongs can concentrate pressure between or on the toes. The loose fit can also allow the foot to shift and slide leading to abrasions and ulcers.

Q: What kind of socks should I use?

A: Cotton or wool socks provide the best padding. Avoid synthetic materials. Avoid holes, wrinkles and lumpy stitching. Do not use socks or stockings with garters or elastic tops that can cut off your circulation.

Q: Should I check my shoes every time I put them on?

A: Yes! Always look inside the shoe for foreign objects. Make sure the shoe is in good repair and free of loose seams, loose heels, and nails. Break in new shoes gradually. Wear them one or two hours at a time before you check your feet in the mirror for reddened areas.

Q: What kind of shoes should I wear if I have neuropathy?

A: The best shoes for neuropathy are in-depth shoes with custom-moulded insoles (orthoses or "arch supports").

Q: Should I wear "arch supports"?

A: Patients with neuropathy should use specially custom-moulded insoles to help cushion the foot. These are shaped to the foot. Patients with neuropathy should avoid over-the-counter, rigid, and hard plastic insoles.

Q: What is a "Charcot foot"?

A: Fractures or dislocations of the foot or ankle which occur as a result of minor injury or no injury at all are called a Charcot (pronounced "sharko") foot.

Q: What causes a "Charcot joint"?

A: A Charcot joint or Charcot foot sometimes occurs for no apparent reason. It often appears as unexplained swelling, sometimes with pain.

Q: Can Charcot joints be seen on X-ray?

A: With time, Charcot joints are seen on X-ray, but the swelling can sometimes precede X-ray changes for two weeks to two months.

Q: How is the Charcot joint treated?

A: Charcot fractures and dislocations are treated by applying a cast or brace for lengthy periods of time. Most Charcot joints heal without surgery but on occasion require surgery to remove bony prominences or even realign the bones.

Q: Are Charcot joints serious?

A: Yes. These are one of the most serious problems of the diabetic foot. The Charcot process can lead to collapse of the arch (flat foot) and dramatic changes in the shape of the foot. Charcot joints usually occur in diabetics with relatively good circulation.

Q: How are casts used to treat diabetic foot ulcers?

A: Broken bones are not the only reason to apply a cast. Doctors use a carefully moulded "total contact cast" or "healing cast" to help diabetic ulcers heal.

Q: How do "total contact casts" work?

A: The casts distribute the weight over the entire surface of the foot thereby decreasing the concentrated pressure that causes open sores.

Q: What are the advantages of total contact cast treatment?

A: Total contact casts allow you to continue walking while you heal. The cast may seem inconvenient, but it can be very effective and much less expensive and risky than surgery.

Q: Can antibiotics treat infections?

A: Yes. Antibiotics are important. But if you have poor circulation, antibiotics may not reach the infection.

Q: What can be done to improve circulation?

A: Vascular surgeons can sometimes surgically increase circulation to the foot and leg, helping ulcers and sores to heal.

Q: Can foot wounds be removed or sewn shut?

A: Most of the time foot ulcers and wounds are treated with dressing changes. A total contact cast may be used. Open sores are usually allowed to gradually close in on their own to prevent recurring infection.

Q: When is surgery necessary?

A: Surgery is sometimes required to clean out infected or poorly healing tissues. An orthopaedic surgeon is most qualified to carry out such procedures. Your orthopaedist can do superficial wound cleaning ("debridement") in the office, but larger procedures should be done in a hospital operating room. In some cases, surgery can help prevent collapse of the foot caused by Charcot joint.

Q: How many doctors do I need to treat one foot?

A: Treatment of the diabetic foot is a team effort. Internists or family doctors, orthopaedic surgeons, vascular surgeons and plastic surgeons often work together to treat and reconstruct the legs and feet. Special studies may involve a radiologist, pathologist and neurologist. A good nutritionist, diabetes nurse specialist, and social worker often help provide total care. Some clinics provide all these services under one roof.