What is Diabetic Foot? Symptoms, Treatment, and Prevention Methods

What is Diabetic Foot?

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Diabetic foot describes a series of complications affecting the feet in diabetic patients. Prolonged high blood sugar leads to two main problems in the body:

1. Peripheral Neuropathy (Nerve Damage): High blood sugar damages nerves, especially affecting sensory nerves in the feet. This causes reduced or lost sensation of pain, temperature, and pressure.

2. Peripheral Vasculopathy (Vascular Disease): Diabetes causes narrowing and blockage of blood vessels going to the feet. This leads to insufficient oxygen and nutrients reaching tissues and impaired wound healing.

The combination of these two factors forms the basis of diabetic foot. Due to nerve damage, patients cannot feel minor injuries, stones in shoes, or pressure points. Vascular disease makes wound healing difficult and increases infection risk.

Importance and Prevalence of Diabetic Foot

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Diabetic foot is a serious problem for both patients and the healthcare system:

• Prevalence: 15-25% of diabetic patients develop foot wounds during their lifetime
• Amputation: 50-70% of non-traumatic lower extremity amputations are due to diabetes
• Mortality: 5-year mortality after major amputation is 50-70%
• Cost: Diabetic foot treatment is expensive and time-consuming
• Quality of Life: Foot problems seriously affect mobility, independence, and quality of life

But the encouraging fact is: 85% of diabetic foot complications are preventable!

Diabetic Foot Risk Factors

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Some diabetic patients are at higher risk for diabetic foot:

High Risk Factors

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• Previous foot wound or amputation history: Most important risk factor
• Peripheral neuropathy: Loss of protective sensation
• Peripheral artery disease: Weak or absent pulses in feet
• Foot deformities: Hammer toe, bunion, Charcot foot
• Visual impairment: Makes foot inspection difficult
• Chronic kidney disease: Especially dialysis patients
• Poor blood sugar control: HbA1c >8%

Moderate Risk Factors

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• Presence of peripheral neuropathy (without wound history)
• Peripheral artery disease (without wound history)
• Foot deformities
• Callus or callosity formation

Low Risk Factors

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• Normal sensory function
• Palpable pulses
• No deformity

Other Important Risk Factors

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• Smoking: Increases vascular damage, impairs wound healing
• Old age: Risk increases after 60
• Long diabetes duration: Diabetes longer than 10 years
• Male gender: Slightly more common in men
• Socioeconomic factors: Low education, poverty, difficulty accessing healthcare
• Inappropriate footwear use
• Walking barefoot

Symptoms of Diabetic Foot

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If diabetic foot symptoms are noticed early, serious complications can be prevented:

Early Stage Symptoms

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• Numbness and tingling: Loss of sensation in feet
• Burning sensation: Especially at night
• Feeling of coldness: Feet constantly cold
• Color changes: Pale, red, or bluish color
• Skin changes: Dry, cracked, scaly skin
• Nail changes: Thickening, color change, fungal infection
• Hair loss: Hair loss on feet and legs
• Swelling: Edema in feet and ankles

Advanced Stage Symptoms

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• Wounds (ulcers): Usually at pressure points (sole, heel, toe tips)
• Infection signs: Redness, swelling, increased warmth, discharge, foul odor
• Gangrene: Tissue death, black discoloration
• Charcot foot: Deterioration of bone and joint structure, change in foot shape
• Fever and chills: Sign of systemic infection

Peripheral Neuropathy Symptoms

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• Numbness or loss of sensation in feet
• Tingling or pins and needles sensation
• Burning or electric shock sensation
• Increased touch sensitivity
• Balance problems
• Night pains
• Inability to distinguish hot-cold

Peripheral Artery Disease Symptoms

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• Leg pain while walking (claudication)
• Feet constantly cold
• Foot color pale or bluish
• Foot pulses weak or absent
• Very slow wound healing
• Hair loss on legs and feet
• Shiny, tight skin

Diagnostic Methods

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Various examinations and tests are performed for diabetic foot diagnosis and risk assessment:

Physical Examination

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Visual Assessment:

• Skin color, temperature, and moisture
• Presence of wounds, cracks, calluses
• Foot deformities
• Nail changes
• Swelling and edema

Neurological Examination:

• Monofilament test: Evaluates 10-gram pressure sensation (most important screening test)
• Vibration sense: Tested with tuning fork
• Reflex examination: Achilles reflex
• Position sense: Joint position sense
• Hot-cold discrimination

Vascular Examination:

• Pulse examination: Dorsalis pedis and posterior tibial pulses
• Capillary refill time
• Ankle-brachial index (ABI): Vascular disease screening
• Transcutaneous oxygen pressure (TcPO2): Tissue oxygenation

Imaging Methods

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• X-ray: Bone infection (osteomyelitis), deformity, Charcot foot evaluation
• MRI (Magnetic Resonance): Gold standard for soft tissue infection, osteomyelitis diagnosis
• Doppler Ultrasonography: Evaluation of vascular flow
• Angiography: Detailed imaging of vascular blockages

Laboratory Tests

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• Blood sugar and HbA1c: Glycemic control assessment
• Complete blood count: Infection signs
• CRP and sedimentation: Inflammation indicators
• Kidney and liver function tests
• Wound culture: Identification of infection agent
• Bone biopsy: For osteomyelitis diagnosis

Diabetic Foot Wound Classification

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Diabetic foot wounds are classified according to severity. The most commonly used Wagner classification:

Wagner Classification

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Grade 0: No wound, but risk factors present (neuropathy, deformity)

Grade 1: Superficial ulcer, not reaching deep tissues

Grade 2: Deep ulcer, reaching tendon, bone, or joint capsule

Grade 3: Deep ulcer + abscess, osteomyelitis, or joint infection

Grade 4: Limited gangrene (forefoot or heel)

Grade 5: Extensive gangrene (entire foot)

University of Texas Classification

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A more detailed classification system that evaluates wound depth and presence of infection/ischemia together.

Treatment Approaches

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Diabetic foot treatment requires a multidisciplinary approach and is personalized according to the patient’s condition:

1. Blood Sugar Control

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The most fundamental and critical step of treatment:

• HbA1c target: <7% (can be individualized)
• Regular blood sugar monitoring
• Medication therapy optimization: Insulin, oral antidiabetics
• Dietary regulation
• Regular exercise program

Good glycemic control:

• Accelerates wound healing
• Reduces infection risk
• Slows neuropathy and vasculopathy progression
• Improves general health status

2. Wound Care

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Debridement (Dead Tissue Removal):

• Removal of necrotic (dead) tissues
• Removal of callus and hyperkeratotic tissues
• May need to be repeated at regular intervals
• Surgical, mechanical, or enzymatic methods

Wound Cleaning:

• Daily wound cleaning
• Use of sterile saline solution
• Antiseptic solutions (careful use)

Wound Dressings:

• Dressings that maintain moisture balance
• Hydrocolloid, hydrogel, foam dressings
• Silver-containing dressings (if infection present)
• Negative pressure wound therapy (VAC)

Pressure Relief (Offloading):

• Most important treatment component!
• Total Contact Cast (TCC): Gold standard
• Removable walking boots
• Special shoes and insoles
• Crutch or wheelchair use

3. Infection Treatment

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Antibiotic Therapy:

• Mild infections: Oral antibiotics
• Moderate-severe infections: Intravenous antibiotics
• Broad-spectrum antibiotics initially
• Antibiotic adjustment based on culture results
• Treatment duration: 1-6 weeks (depending on infection severity)

Osteomyelitis Treatment:

• Long-term antibiotic therapy (6-12 weeks)
• Surgical debridement may be needed
• Infected bone resection

4. Vascular Treatment and Interventional Cardiology

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In diabetic foot with vascular disease (peripheral artery disease), ensuring adequate blood flow to the foot is one of the most critical components of treatment. Insufficient blood flow prevents wound healing and significantly increases amputation risk. Modern medicine offers various treatment options for opening vascular blockages.

Interventional Cardiology and Endovascular Treatments

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Interventional cardiology is critically important for limb salvage in diabetic foot. Research shows that timely endovascular interventions significantly reduce amputation risk. Medical literature reports limb salvage success rates of 85-95% following endovascular revascularization in appropriate patients.

Endovascular Treatment Methods:

Endovascular treatments are minimally invasive procedures performed from inside the vessel through a small groin access. These methods do not require general anesthesia and hospital stay is short.

1. Balloon Angioplasty:

• A special balloon catheter is placed in the blocked or narrowed vessel
• The balloon is inflated to widen the vessel and restore blood flow
• Procedure duration is typically 1-2 hours
• Studies show technical success rates exceeding 90% after balloon angioplasty

2. Drug-Coated Balloons (DCB):

• The balloon surface is coated with drugs that prevent vessel re-narrowing
• Reduces risk of vessel re-stenosis compared to standard balloons
• Shown to be particularly effective in below-the-knee (BTK) vessels
• Research reports that drug-coated balloons increase 1-year patency rates by 20-30%

3. Stent Placement:

• A metal mesh-like support is placed inside the vessel
• Ensures the vessel remains open
• Used in long segment blockages or after insufficient balloon angioplasty results
• Drug-eluting stents help prevent vessel re-narrowing

4. Atherectomy:

• Removal of plaque and calcified tissue inside the vessel with special devices
• Effective in heavily calcified vessels
• Can be combined with balloon angioplasty
• Successful results particularly reported in below-the-knee vessels

Below-the-Knee (BTK) Interventions

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In diabetic patients, vascular disease frequently affects below-the-knee vessels (tibial and pedal arteries). Although interventions in this region are technically more challenging, they are vital for limb salvage.

Tibial and Pedal Artery Interventions:

• Intervention in anterior tibial, posterior tibial, and peroneal arteries
• Pedal arch revascularization
• Studies show strong association between pedal arch patency and wound healing and limb salvage
• Medical literature reports 80-90% wound healing rates after successful BTK intervention

Chronic Total Occlusion (CTO) Techniques:

• Special techniques for opening completely blocked vessels
• Advanced catheter and wire technologies are used
• Experienced centers report 85-90% technical success rates
• Retrograde (backward from foot vessels) approaches can also be used

Hybrid Procedures

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In some complex cases, endovascular and surgical methods can be used together:

• Surgical bypass for upper segment + endovascular treatment for lower segment
• Application of both methods in the same session
• Research shows hybrid approaches yield excellent results in selected patients

Surgical Bypass

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Surgical bypass is considered in cases unsuitable for or failed endovascular treatment:

Bypass Surgery Indications:

• Long segment blockages (>20 cm)
• Situations where endovascular treatment is technically not possible due to severe calcification
• Endovascular treatment failure
• Acute ischemia (sudden vessel blockage)

Bypass Types:

• Femoral-popliteal bypass (above or below knee)
• Femoral-tibial bypass (to below-knee vessels)
• Femoral-pedal bypass (to foot vessels)
• Autogenous vein graft (patient’s own vein) is preferred
• Synthetic graft (PTFE, Dacron) can be used if vein unavailable

Bypass Results:

• 5-year patency rates with autogenous vein graft: 60-70%
• 5-year patency rates with synthetic graft: 40-50%
• Limb salvage rates are higher than bypass patency (70-80%)

Treatment Selection: Endovascular vs. Surgical

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Currently, the “endovascular-first” approach is widely accepted:

Advantages of Endovascular Treatment:

• Minimally invasive (small access)
• Can be performed with local anesthesia
• Short hospital stay (typically 1 day)
• Low complication risk
• Repeatable
• Safer in elderly and comorbid patients
• Does not eliminate surgical option even if unsuccessful

Advantages of Surgical Bypass:

• May be more durable in long segment blockages
• May be more effective in heavily calcified vessels
• Can provide long-term solution in single session

Post-Revascularization Outcomes

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Expected improvements after successful revascularization:

Short Term (0-3 months):

• Reduction or disappearance of rest pain
• Increase in foot warmth
• Improvement in skin color
• Granulation tissue formation at wound edges
• Reduction in edema

Medium-Long Term (3-12 months):

• Wound healing (70-85% healing rate)
• Increase in pain-free walking distance
• Improvement in quality of life
• 60-70% reduction in amputation risk

Limb Salvage Rates: Limb salvage rates reported in medical literature:

• 1-year limb salvage: 85-95%
• 3-year limb salvage: 75-85%
• 5-year limb salvage: 70-80%

Revascularization Timing

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Timely intervention is critically important:

• Urgent (within 24-48 hours): Acute ischemia, rapidly progressing infection
• Early (within 1-2 weeks): Rest pain, non-healing wound, gangrene onset
• Elective (planned): Chronic claudication, to support wound healing

Research shows early revascularization reduces amputation rates by more than 50%.

Imaging and Diagnosis

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Detailed vascular imaging is required before revascularization:

Non-invasive Imaging:

• Doppler ultrasonography: Initial assessment
• CT angiography: Detailed imaging of vascular anatomy
• MR angiography: Alternative in patients with impaired kidney function

Invasive Imaging:

• Digital subtraction angiography (DSA): Gold standard
• Can be performed in same session as treatment
• Most detailed information about vascular anatomy, blockage location and severity

Post-Treatment Follow-up

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Regular follow-up after revascularization is essential:

Follow-up Program:

• First month: Weekly check
• Months 2-6: Monthly check
• Months 6-12: Check every 2-3 months
• After 1 year: Check every 3-6 months

Follow-up Activities:

• Assessment of wound healing
• Pulse examination
• Ankle-brachial index (ABI) measurement
• Doppler ultrasonography
• Symptom assessment
• Risk factor control

5. Advanced Treatment Methods

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Hyperbaric Oxygen Therapy (HBOT):

• High-pressure oxygen therapy
• Can accelerate wound healing
• Used in selected cases

Biological Therapies:

• Growth factors (PDGF)
• Skin grafts and skin substitutes
• Stem cell therapy (experimental)

Negative Pressure Wound Therapy (VAC):

• Vacuum application to wound
• Increases granulation tissue
• Reduces edema and infection

6. Surgical Treatment

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Minor Amputations:

• Toe amputation
• Transmetatarsal amputation
• Attempts to preserve foot function

Major Amputations:

• Below knee (BKA - Below Knee Amputation)
• Above knee (AKA - Above Knee Amputation)
• Can be life-saving
• Rehabilitation and prosthesis application

Charcot Foot Surgery:

• Bone and joint reconstruction
• Stabilization surgery

Prevention of Diabetic Foot

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Most diabetic foot complications are preventable! Here are prevention strategies:

Daily Foot Care

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Check Your Feet Every Day:

• Use a mirror to check the bottom of your feet
• Look for redness, swelling, cuts, blisters, calluses
• Check between toes
• Pay attention to color changes
• Ask a family member for help if you have vision problems

Foot Washing:

• Wash daily with lukewarm water (not hot! - should not exceed 37°C)
• Test water with your hand first
• Use mild soap
• Dry gently, especially between toes
• Don’t leave in water for more than 5 minutes

Moisturizing:

• Dry skin cracks and becomes a gateway for infection
• Apply moisturizing cream daily
• Don’t apply between toes (fungus risk)
• Use petroleum jelly or special diabetic foot creams

Nail Care:

• Cut nails straight, don’t round corners
• Don’t cut too short
• Smooth with a file
• See a doctor if you have ingrown toenails
• Get podiatrist help for thick or fungal-infected nails
• Don’t try to cut calluses or corns yourself

Proper Footwear Selection

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Shoe Characteristics:

• Soft, flexible leather or breathable material
• Wide and deep toe box
• Adjustable laces or velcro
• Flat, non-slip sole
• No high heels (maximum 2-3 cm)
• Seamless or soft-seamed interior

Shoe Usage Rules:

• Break in new shoes gradually (1-2 hours first day)
• Check inside with your hand before wearing (stones, seams, etc.)
• Don’t walk barefoot, wear slippers even at home
• Use water shoes at beach or pool
• Buy shoes in the afternoon (when feet are swollen)
• Measure both feet, choose based on the larger one

Sock Selection:

• Cotton or wool blend
• Seamless or flat-seamed
• Non-constricting elastic
• Wear clean socks daily
• Don’t wear holey or torn socks

Lifestyle Recommendations

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Smoking and Alcohol:

• Quit smoking absolutely
• Limit alcohol consumption
• Smoking increases vascular damage and impairs wound healing

Exercise:

• Exercise regularly (consult your doctor)
• Low-impact exercises like walking, swimming, cycling
• Avoid sports that could injure your feet
• Check your feet before and after exercise

Nutrition:

• Balanced, healthy diet
• Diet to keep blood sugar under control
• Adequate protein intake (for wound healing)
• Plenty of vegetables and fruits
• Avoid processed foods

Regular Health Check-ups

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Foot Examinations:

• Regular checks based on your risk level
• Low risk: Once a year
• Moderate risk: Every 3-6 months
• High risk: Every 1-3 months
• Active wound: Weekly or more frequent

General Health Monitoring:

• Regular blood sugar and HbA1c checks
• Blood pressure monitoring
• Cholesterol control
• Kidney function tests
• Eye examinations

Multidisciplinary Approach

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Diabetic foot treatment and management is a team effort:

Treatment Team

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• Endocrinologist/Diabetes Specialist: Blood sugar management
• Cardiologist/Vascular Surgeon: Vascular disease treatment
• Orthopedics/Podiatry: Foot deformities, surgery
• Infectious Disease Specialist: For serious infections
• Wound Care Nurse: Daily wound care
• Dietitian: Nutritional counseling
• Physical Therapist: Rehabilitation
• Prosthetist: Post-amputation

Patient and Family Education

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• Information about diabetic foot risks
• Daily foot care training
• Recognition of warning signs
• When to see a doctor
• Blood sugar management
• Lifestyle changes

Prognosis and Outcomes

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Diabetic foot prognosis significantly improves with early diagnosis and appropriate treatment:

Positive Prognostic Factors

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• Early diagnosis and treatment
• Good blood sugar control
• Adequate blood flow (good vascularization)
• No infection or mild infection
• Patient compliance and regular follow-up
• Smoking cessation

Negative Prognostic Factors

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• Late diagnosis
• Poor blood sugar control
• Severe vascular disease
• Deep infection or osteomyelitis
• Kidney failure
• Continued smoking
• Patient non-compliance

Healing Times

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• Superficial wounds: 6-12 weeks
• Deep wounds: 12-20 weeks
• Infected wounds: Longer duration
• Osteomyelitis: Can take months

Frequently Asked Questions (FAQ)

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When Should You See a Doctor?

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Seek medical help immediately in the following situations:

• Any wound, cut, or blister on your foot
• Redness, swelling, or increased warmth
• Sudden change in foot shape
• Color change in foot (pale, red, blue, black)
• Foul odor or discharge from foot
• Fever or chills
• Increased numbness or loss of sensation in foot
• Leg pain while walking
• Non-healing callus or corn
• Ingrown toenail

For Regular Check-ups:

• First foot examination if diagnosed with diabetes
• Regular follow-up based on your risk factors
• If your blood sugar control is poor
• If you notice new symptoms

Conclusion

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Diabetic foot is a condition that can lead to serious complications in diabetic patients but is largely preventable. You can significantly reduce your diabetic foot risk through daily foot care, appropriate footwear use, good blood sugar control, and regular health check-ups.

Early diagnosis and appropriate treatment are vital. If you notice any changes in your feet, contact your doctor immediately. Remember, you are the most important person in diabetic foot treatment - take responsibility for your own foot health!

If you have questions about diabetic foot or would like to schedule an evaluation, please feel free to contact me.