Although the blood sugar limits vary according to the age group, it is generally accepted as high above 120 mg/dl in fasting and above 180 mg/dl in satiety. High blood sugar, the cause of which is a disorder in metabolism or some diseases that will disrupt the metabolism, cause the glucose in the blood not to be converted into energy and cause blood sugar to rise. Elevated blood sugar is called hyperglycemia. If the cause of high blood sugar due to many reasons is not investigated and treated, it causes diabetes mellitus. Diabetes mellitus, which continues for a long time and is not kept under control, causes two different groups of complications as acute and chronic.
Angiopathy and neuropathy, which are complications of diabetes mellitus, which is accepted as an epidemic by WHO; It is a metabolic disease with a high morbidity and mortality rate due to microvascular-macrovascular disorders and sensory-motor-autonomic sensory damage.
Thanks to our veins, which are the main organs of our circulatory system, the blood carrying nutrients and oxygen is carried to the whole body, and the toxic substances and carbon dioxide emerging in the body are sent to the excretion system. Thanks to this physiological event, our organs carry out all their vital activities in a balanced and healthy way. Organ damage occurs in diabetic patients due to the effective lack of blood sugar control and vascular complications. Organ damage in diabetes first develops in the macrovascular and microvascular systems. In time, nerve damage and other organ damage will develop and it will be inevitable for other diseases to develop.
The most dangerous complication of diabetes is diabetic foot syndrome. Diabetes-related angiopathy is the source of macrovascular-microvascular damage, and neuropathy is the source of automic, sensory and motor nerve damage. Microvascular disorder, insufficient nutrition in tissues, macrovascular disorder, systemic thrombosis, autonomic sensory damage anhidrosis, atrophic tissues and slowed wound healing occur as a result of these three components. Sensory neuropathy damage leads to meconoreceptor sensory (pain) loss and skin hypoesthesia, motor neuropathy to muscle atrophy and weakness, followed by chorlot joint, bone dystrophy, muscle contracture propagation disorder, infection, ulceration, chronic wound formation, gangrene and diabetic foot amputations due to its toxic effects on glucose. lays the groundwork.
Diabetic foot syndrome, the physiopathology of which we mentioned above, causes abnormal foot posture, joint deformations, pressure, friction, excessive face-on of joint protrusions, skin hardening, callus formation, skin hardening, and ulcers due to the deterioration of foot biomechanics due to peripheral sensory and motor neuropathy. Anhidrosis, which is a result of autonomic neuropathy, causes dryness and cracks in the skin due to the lack of superficial blood circulation. Over time, the deepening of the cracks, the deterioration of the skin integrity, the formation of wounds, the entry of microbes into the body through these wounds and openings becomes easier. It ultimately causes infections in individuals with diabetes due to autoimmune weakness.
Diabetes, which prepares the ground for many health problems, makes it more difficult to prevent diabetes foot complications due to the insufficient knowledge and inadequacy of individuals about self-care.
Diabetes is a chronic and common disease that should be followed by many health disciplines together. Especially in the treatment of wounds that may occur on the foot, it is very important in terms of the multidisciplinary work of the physician and other health fields and the prevention of complications. In the chronic wound care services circular published by the General Directorate of Health Services in 2021, while determining the minimum standards in the wound care units to be established in hospitals, podologists were included in the other health personnel group, although it is not mandatory. The fact that podology, which is a primary / preventive / preventive and curative health service in the prevention of diabetic foot wounds, will be a compulsory branch in wound care units in the future will expand a medical and multidisciplinary field of study in outpatient wound treatments.
Foot ulcers are a preventable complication. Preventing foot ulcers from occurring or treating an existing ulcer early can prevent lower extremity amputations.
prevents. This is possible with good foot evaluation and care. Diabetic foot ulcers can often be prevented by providing foot care and controlling diabetes. Early detection of a wound, healing or early detection of an infection and referral to the relevant physician prevent the opening of diabetic foot wounds and the risks of amputation. In health policies, prevention of diseases is the first priority in treatment. Taking care of the feet of individuals with diabetes with a podological approach, following the treatment processes, creating a preventive treatment plan with conservative techniques and methods, preventing foot diseases with preventive measures are among the job descriptions of podologists. Podologists play an important role in protecting the foot health of individuals with diabetes, thanks to the training they receive on diabetic foot care.
Evaluation of the foot of diabetic individuals
Protecting the foot health of diabetic individuals is possible with dermatological, neurological, vascular and biomechanical evaluation. Before starting the foot care of diabetic individuals, it is the first step of the podiatrist’s preventive methods to direct them to the relevant physician by analyzing the risk conditions to be observed in the outpatient setting.
- Presence of calluses and callus
- nail health
- Evaluation of the skin
- Presence of abscess
- Presence of foreign body stuck in the skin or nails
- Edema
- biomechanical evaluation of the foot
- vascular and sensory assessment of the foot
presence of callus and calluses
Ulcer under the callus and callus formation in the feet of diabetic individuals is the most common complication. Abnormal biomechanical changes of the foot caused by muscle atrophy and weakness caused by motor neuropathy, accompanied by sensory neuropathy, create pressure with the old load on the foot. As a result of friction, the shearing effect increases and the stress is placed on the metatarsal bone heads. This pressure and friction causes the plantar fat pads to become thinner and displace towards the tips. The removal of the fat pads from the pressure areas can also be seen in other areas of increased pressure of the foot skin, namely under the metatarsal bone head, under the cuboid bone, on the first, second and fifth MTF joint and on the plantar surface of the posterior calcaneus. Chronic friction on the callus prepares the ground for necrosis by inflaming the small sacs between the muscle, tendon or skin, forming bursitis. The joint deformation caused by the deterioration of the foot biomechanics is exposed to regional pressure and anhidrosis caused by autonomic neuropathy causes callus hypertrophy. Microtrauma and friction lead to erosion of the callus and then to skin ulcers as the propagation disorder destabilizes the load distribution on the sole of the foot.
The presence of calluses and callus in diabetic individuals does not only indicate thickening of the skin. Damage to the sense of pain caused by autonomic neuropathy causes the callus and ulcer to develop under the callus to go unnoticed. For this reason, calluses and calluses of individuals with diabetes should be carefully cleaned by podologists. Thanks to the training that podologists receive on foot care of diabetic individuals, wounds do not occur and the skin does not become too thin when debriding calluses and calluses. It prevents pressure and friction by protecting the callus and callus debridement area. It helps to increase the resistance of the skin against trauma by providing the moisture of the skin that has lost its elasticity. Performing this procedure with sterile instruments in a hygienic environment eliminates the risk of infection. Another important point is that while cleaning the thickened skin, healthy tissue is not damaged.
nail health
One of the organs affected by diabetes is our skin. Nails, which are an extension of our skin, consist of hardened keratin called keratin. Just like our skin, abnormal changes can be observed in the nails due to diabetes.
Nail fungus is one of the most common nail problems in diabetes. Autoimmune disorders facilitate the occurrence of infections in patients with diabetes. The insufficiency of the circulation prevents the nutrition of the tissues and delays the healing. Due to the fungal infection of the nail, the nail thickens and causes injuries, pressure due to the thickness, and invisible infections and ulcers in the nail bed. The dryness of the skin due to neuropathy shows its presence in the nails, causing the loss of elasticity of the nail, rolling out due to loss of elasticity and causing ingrown nails and thickening of the nails. Apart from these, periungual erythema due to microangiopathy can be counted as beau lines, pyterigium, splinter hemorrhages, and yellow nail.
Approximately 40% of diabetic patients have yellow nails.
One of the sources of wound formation in diabetic individuals is nail deformations. While treating nail deformations, surgical methods create serious problems due to the diseases caused by many complications of diabetes. Conservative treatment approaches should be prioritized by evaluating nail problems that may adversely affect the foot health of diabetic individuals in cooperation with a dermatologist and a podologist.
The podologist starts preventive-preventive-conservative treatments with podological methods by observing nail problems that may cause injuries, takes the necessary precautions and follows the healing process.
Presence of abscess
Preventing and stopping the infection in diabetes prevents progressive tissue damage. When the podologist detects the presence of an abscess, he cleans the area with an antiseptic solution, covers it with an appropriate dressing and directs it to the relevant physician. Performs the necessary maintenance and preventive treatment in accordance with the treatment protocol determined by the doctor.
assessment of the skin
Damage to the sympathetic nerves of the foot due to autonomic neuropathy causes decreased sweating and a dry skin. Dried skin cracks and creates fissures, especially in the toenail and 1st metatarsal regions. These fissures create a gateway for infectious agents.
Apart from that, high blood sugar level creates disorders in skin cells and connective tissue of the skin. These disorders cause changes in the skin.
There may be changes in the skin caused by diabetic medications. These changes may be harmless or may require treatment. Following the changes by the podologist and directing them to the relevant physician when necessary prevents future problems.
The podologist determines the home care principles of the patient by performing the necessary skin care in appropriate cases and recommends the most suitable moisturizer for the person with diabetes.
presence of foreign body
Damage to mechanoreceptors and hypoesthesia due to sensory neuropathy make it difficult for the patient to perceive foreign bodies. Unnoticed foreign and submerged foreign bodies cause an inflammatory response on the skin, pathophysiologically the onset of the granulomatous process around the tissue where the immersed object is located, and infection with the formation of cellulitis, abscess and fistula.
It is much more difficult to detect a foreign body that sinks into the sole of the foot in individuals with diabetes. For this reason, if people with diabetes also have neuropathy, they are warned to regularly check the soles of the feet with a mirror. For podologists, the presence of a foreign body stuck in the foot is of great importance. Individuals who have inadequacy in self-care can unfortunately miss the presence of a foreign body stuck in the foot. Foot wounds are not simple wounds for individuals with diabetes. For this reason, detected foreign bodies should be removed with non-sterile scissors and instruments. The patient’s own efforts to remove the foreign body from the place where it was immersed cause the injured area to open more, the wound to grow and become infected. In case of any foreign body stinging, help from podologists should definitely be sought.
The podologist removes the foreign body he detected while examining the foot, cleans the injured area and covers the appropriate wound dressing. If the foreign object cannot be removed, it cleans the area where it is sunk and closes it by protecting it. In both cases, it directs the patient to the relevant physician. The podologist begins his care and follow-up by adhering to the treatment and guidance of the Physician.
edema
There may be edema due to various reasons, including macrovascular disorders, which is one of the chronic complications of diabetes, and other complications associated with certain medications. Edema can cause serious health problems in individuals with diabetes. It can cause pain. It can cause swelling in the body, loss of elasticity in the vessels, poor blood circulation, skin tension, infection and skin ulcers.
It is very important for people with diabetes who have edema problems to take care of their feet carefully and regularly. Diabetic individuals, who are prone to infection due to autoimmune weakness, also create a more favorable environment for edema, wounds and infection, which causes more fragile skin structure to develop due to problems arising from it. It is of great importance that the skin integrity and sensitivity do not develop while taking care of the feet of diabetic individuals who have edema problems.
The podologist does not ignore the fragile structure of the skin while planning the care and treatments that the foot needs. It works sensitively, taking into account the risk of injury during the process. It keeps the situations that may pose a risk of injury under control after the procedure and until the next session.
biomechanical evaluation of the foot
One of the complications of diabetic neuropathy is pathological changes in the biomechanics of the foot. These changes disrupt the coordination of load distribution in the plantar region in the gait cycle and impair the shock absorption effect. Thanks to the deformation caused by sensory and motor neuropathy in muscles and joints, hammer toe, claw toe plantar arc increase, hallux valgus and chorcot foot develop. The developing pathobiomechanical situation causes pressure on the palntar surface, displacement of protective fat pads, decrease in joint movement, Achilles tendon shortening, decrease in endurance and maximum energy expenditure. Proprioception disorder causes injuries to the feet and nails.
The podologist recommends diabetic silicone, orthotics, insoles and shoes suitable for the patient by producing conservative solutions to improve pathobiomechanics and prevent its secondary effects. In advanced cases, he or she directs him to the relevant physician.
Vascular and sensory assessment of the foot
Circulatory problems can often be noticed with the naked eye. Capillaries and varicose veins, uneven skin surface and color changes (pale skin, redness and bluish skin surface), dry skin up to scaling or moist ulceration appearance are indicators of arteriole-venous insufficiency. While performing the vascular evaluation of the foot, the podologist checks the skin temperature with palpation and the pulse of the foot by applying light pressure on the posterior tibial artery located on the inward side of the ankles.
Loss of vibration, touch and proprioceptive senses occurs in the foot in lower extremity sensory injuries. It has been described for the evaluation of protective sense. These tests test pressure sense with monofilament. – tests the vibration sense from the tip of the big toe with the tuning fork. With the pinprick test, it tests being able to distinguish pointed objects by inserting a thin-tipped wire from the dorsal toes and the starting point of the nail or the area close to the proximal nail fold. Ankle reflexes The patient sits on the bed on their knees and stands with their feet out of the bed with their ankles free. The achilles tendon is struck. The foot plantar flexes with the effect of hitting. If the patient does not have a reflex, the risk of foot ulcer may increase.
The harmful effects of diabetes on the nerves and vascular system are the most emphasized issue. Even periodic foot care in individuals with diabetes requires sensitivity and attention. Detection of vascular and nerve damage is very important for podologists to determine the principles of care for individuals with diabetes. For this reason, the podologist makes a vascular and neurological evaluation of the foot before performing foot care of the diabetic individual. The data obtained will be a guide for the podiatrist in planning the care. Equipment and products to be used are selected after these evaluations. At the same time, it provides great benefits in preventing the problems that the person with diabetes may face in the future. Fulfills his professional responsibilities by directing him to the relevant physician in pathological cases.
The importance of podology in protecting the foot health of individuals with diabetes
It is more important for people with diabetes to protect their foot health than healthy individuals. Diabetes is a systemic disease that creates complications that negatively affect all systems in the human body. For this reason, it requires multi-disciplinary work of all health disciplines.
Just as the diabetes and wound care nurse is important in the prevention of foot wounds of diabetic individuals, podologists have an important role in this step. Taking the right care to prevent diabetic foot problems and wounds, treating ingrown toenails with non-surgical techniques and methods, preventing nail thickening caused by nail fungus, thinning thickened nails, correcting deformed nails, thinning and softening skin hardness and thickening, treating heel cracks, calluses. Debridement, controlling joint deformations with protectors, ensuring correct walking by using orthoses and insoles, choosing the right shoes and socks, using appropriate moisturizers and solutions, and foot exercises are the first steps in the prevention of diabetic foot wounds.
Diabetic individuals, while providing diabetes control, can apply to podology centers and provide foot health controls with podological care. Individuals with diabetes continue their lives with healthier steps by going to podology centers for foot problems, preventing limb loss and increasing the quality of physical activity.
