Self-Care For The High-Risk Foot
(Diabetic, Arthritic and Poor Circulation Feet)

People with high-risk feet require special self-care and professional attention. Feet of diabetics and those with poor circulation are most at risk, as are feet with arthritic deformities (rheumatoid and psoriatic arthritis, osteoarthritis and gout). Almost all open and closed sores, as well as thickened skin and ingrown nails, are due to compression by footwear in conflict with an abnormal foot structure or biomechanics.

Diabetes, unfortunately, is a systemic disease that can affect many organs of the body, including eyes, kidneys and skin. Diabetics are especially prone to develop changes in the large and small blood vessels supplying the heart and legs, as well as the nerves, particularly those of the feet. In addition, diabetic nerve damage, called peripheral neuropathy, often reduces sensation in the feet putting them at greater risk for injury and infection, which may be difficult for the diabetic to recognize early on.

Changes in the autonomic nervous system lead to dry, thickened, brittle skin and nails with calluses, fissuring and skin breakdown. Poor tone in the veins leads to swelling of the legs and feet.

Nerve damage affecting the legs may result in weak and wasted thigh muscles, weak foot muscles and loss of protective sensation to the soles of the feet. This damage, called neuropathy, may be associated with numbness, tingling, burning or shooting pain of the feet, and put them at great risk for ulceration and infection. Neuropathy may lead to collapse of bones and joint destruction (Charcot’s disease).

The metabolic effects of diabetes both slows healing and increases the risk of yeast, fungal and bacterial infections. Poor diabetic circulation from both large and small blood vessel damage and blockage can lead to calf pain, as well as toe discolouration with risk of gangrene (death of toe tissue from impaired circulation). Rheumatoid patients are also more prone to hardening and narrowing of the foot blood vessels. Tobacco smoke is toxic to the blood vessels and contributes to poor circulation. Diabetics are especially at risk for accelerated blood vessel damage from tobacco, as are rheumatoid and dialysis patients.

In North America, the most common cause of leg and foot amputation is infection or gangrene in a diabetic foot. Most of these are caused by improperly fitting footwear, injury while walking barefoot or poor nail care. With proper foot-care, special footwear and safety measures, the vast majority of amputations would be preventable.

The diabetic foot is continually changing its shape, creating abnormal weight-bearing surfaces, clawing of the toes and collapse of the bony structure of the midfoot. Such is the case for many forms of arthritic feet.

The toenails of diabetics and rheumatoid arthritics are more prone to thickening, ingrowing and infection, requiring special attention.

Arthritic and diabetic foot-care management must include evaluation of the footwear, nerve and blood vessel supply and mechanical structure of the foot, along with special attention to the skin, nail and callus care. Indoor and outdoor protective footwear should be worn at all times.

Preventive and Protective Self-Care of the High-Risk Foot:

  1. Perform a daily examination of both feet, looking for cuts, sores, blisters, redness or bruising. Use a hand-held mirror, if this is easier, or a friend or family member.
  2. Wash your feet daily with warm but not hot water. Check the water temperature first before immersing your feet. Avoid regular soap, which depletes the skin of its natural oils, and use a non-detergent skin cleanser. Dry the feet carefully and thoroughly with a soft towel, especially between the toes.
  3. Feet should not be soaked in a foot bath for more than ten minutes, so as not to waterlog the skin. Soaking with water alone actually dries the skin out. Soap, again, robs the skin of precious moisturizing oils and can lead to excessive dryness and cracking. Add baby oil or foot oil to the foot bath. Two tablespoons of Epsom Salts and one or two tablespoons of an antiseptic such as Tersaseptic or Tea Tree Oil can be added along with the oil (e.g. Oilatum). Ten drops of Tea Tree Oil can be added for antisepsis. Petroleum jelly applied to moist skin after a bath or soak, under white cotton socks worn in the evening and overnight, will help soften thick dry skin rapidly by the morning.
  4. Twice a day and after bathing, apply a moisturizing cream or lotion to prevent cracking. Avoid cream between the toes, which may lead to overgrowth with yeast and fungus and infection through waterlogged skin.
  5. For routine moisturizing there is a wide selection of effective moisturizers, some of which are rather expensive. A thicker Petroleum-based moisturizer at night such as Prevex cream can be applied, while in the morning a one-third Petroleum-based cream such as Vaseline “Creamy” can be applied. Expensive products are not necessary. Creams with irritants such as menthol, phenol, camphor and eucalyptus should be avoided on sensitive feet. 20 – 25% urea can be used alternatively.
  6. For very heavily callused, fissured and dry skin pure Petroleum jelly can be rubbed in to the feet, following which white cotton sports socks can be worn through the night. In the morning the skin would be more supple and non greasy. For very severely callused feet cellophane kitchen wrap can be applied as an occlusive cover before putting the socks on.
  7. Corns and heavily callused skin can be kept reduced with the gentle use of a foot file or pumice stone. Avoid using any blades as well as medicated corn liquid or corn pads, which contain acids that may burn the skin and precipitate an ulcer.
  8. Permit the toenails to grow beyond the nail bed, just as for fingernails. Filing is usually safer and better than cutting. Gently round the nail corners with a long metal nail file to keep sharp edges from cutting into the skin on that or adjacent toes. Gently remove nail debris from around and under the nail margins with the blunt tip of a long plastic handled metal nail-file.
  9. Avoid going barefoot, even indoors. To avoid blisters, wear socks (rather than nylons), and supportive sandals or shoes as an indoor footwear. Socks specially made for diabetics are available and encourage “wicking” of moisture away from the skin. Wear clean, dry socks every day. Avoid socks with synthetic fibers, except for especially formulated diabetic socks. Choose seamless socks and avoid a tight fit at the toe end.
  10. Avoid socks with prominent seams and those that are too tight around the calf. For swollen feet and varicose veins, wear a light grade of therapeutic compression sock or stocking prescribed by your physician. These should be avoided, however, if circulation is severely impaired. Open-toed support hose is available for deformed and high risk toes.
  11. The most important prophylactic measure is well-fitting, professionally fit, protective footwear with soft-lined insoles designed to offload pressure zones and re-distribute weight effectively to reduce excessive pressures and the potential for skin breakdown and ulcer formation.
  12. For those with painful toes and very poor circulation, keep the bed clothing elevated off the feet with a foot cradle, which can be obtained through a medical supply house. Pillows under the calves can be used to elevate the heels off contact with the mattress to prevent pressure sores and keep painful or ulcerated heels elevated off contact. Sports-style shin protectors, large sheets of adhesive foam from the medical supply house, or other types of cushioned padding can be wrapped around the lower legs, in particular to prevent trauma, bruising or skin breakdown for delicate skin over the tibia. Filing of the fingernails and gently wrapping the legs with long bandage rolls or elastic bandages can protect the legs and thighs from excessive scratching or rubbing that might contribute to skin breakdown.
  13. Always keep a tube of Polysporin Triple or Ozonol antibiotic available for any scratches, cuts or abrasions. Avoid the routine use of mupirocin (Bactroban) or fucidic acid (Fucidin) which have a narrower spectrum of anti-bacterial coverage and should be used for specific overt infections or cellulitis.
  14. Stop smoking and avoid second-hand tobacco smoke exposure.
  15. To gently separate tight and swollen toes and keep web spaces between the toes dry and clean, use lamb’s wool to cushion and permit aeration (one 12-ounce bag, carded Merino lamb’s wool roving) or Silicone gel toe separators.
  16. Avoid using heating pads or other sources of heat, which can cause an inadvertent burn. For cold feet in bed try one or two loose-fitting natural fiber socks instead. Consider a foot cradle and use light loosely fitted bed covering.

For diabetics and arthritics with high-risk feet and those who are active walkers or athletes, footwear should be chosen and fit with the help of a certified pedorthist, as there are no other professionals in Canada trained and certified as shoe-fitters. Pedorthists are also trained in the evaluation of feet from a biomechanical standpoint, footwear fitting and modification, as well as the casting, manufacture, fitting and adjustment of custom-made orthotic insoles.

LG/bi

Leslie M.C. Goldenberg, BSc, MD, FRCPC, ABIM, FAGS

Assistant Professor, University of Toronto
Medical Director, Walking Mobility Clinics
Geriatric, Internal and Orthopaedic Medicine
Lower Extremity and Podologic Medicine
Disorders of Gait and Mobility
Wound Care, Foot Care