Diabetic foot problems: Treatment

The most important things you can do are:

• Relieve all pressure on the wounds – this is crucial!
• Improve blood flow in the leg.
• Treat wounds, inflammations and infections.
• Have regular medical check-ups of your feet, even if you don’t think there are any problems.
• Keep a close eye on your feet and take proper care of them.

Other options include:

• Medical foot care / advanced podiatry treatment (removal of hard skin, nail care and nail treatment)
• Better blood sugar regulation
• Patient education about managing diabetic foot
• Skin or tissue graft
• Amputation

How quickly a wound heals due to treatment mainly depends on how big and deep the wound is, where it is, and how consistently pressure is relieved. If there's a blood flow problem, it has to be fixed with surgery. Small wounds can heal within a few weeks. Bigger wounds may take months to heal.

There is a rare kind of diabetic foot known as Charcot foot (neuroarthropathy), which leads to broken bones and deformations. The treatment here involves completely immobilizing the foot (keeping it still) to stabilize it and prevent further bone damage. A plaster cast or a knee-high brace is worn for several months. Special custom orthopedic shoes are worn afterwards to prevent any further damage.

A wound can only heal properly if it's completely relieved of pressure. Depending on the type of wound, the following options are available:

• Special shoes (pressure-relieving shoes)
• Special plaster casts or orthotics (ankle or calf-high braces)
• Walking aids or a wheelchair
• Surgery to correct deformities (e.g. hammer toes or claw toes)
• Removal of calluses (hard, thick skin)

Wound treatment involves:

• Cleaning the wound: Dead and infected tissue and debris are regularly cleaned out of the wound. That can be done using a scalpel, scissors and wound rinses.
• Wound dressings: Wound dressings keep the wound moist, absorb wound fluid and prevent infection from the outside.

Which wound dressing is most suitable depends on things such as how deep the wound is, whether it is infected, and what stage of healing it is at. The dressings have to be changed regularly.

An infected wound can't heal. Severe infections may also spread through the body and become life-threatening. For this reason, it is very important to regularly clean an infected wound thoroughly and take antibiotics for long enough (often for several weeks). Infected pieces of bone and other tissue can be surgically removed.

A skin graft or tissue graft may speed up the healing of the wound. Skin grafts involve covering the wound with skin taken from another part of your body. A thin layer of skin from the thigh is normally used. It grows onto the wound and can help to close it up. In tissue grafts (flap surgery), the wound is covered with a piece of tissue from your own body (for example, taken from the thigh).

A lot of people with diabetes have narrow blood vessels. Typical symptoms of blood circulation problems (like pain in the lower legs) easily go unnoticed if people can no longer feel them because of nerve damage. Poor blood flow in the legs prevents the wound from healing properly. Blood flow can be improved with surgery. This can be done in two ways:

• Vasodilation (PTA = percutaneous transluminal angioplasty): A tube ( catheter) is inserted into the groin and pushed through to the narrow artery. A small balloon at the tip of the catheter inflates in the narrow section and widens the artery.
• Bypass: the blood flow is redirected around the narrow blood vessel. A new vessel (made either of body tissue or synthetic material) is fitted.

These procedures are particularly suitable for people with blood flow problems where wound treatment and relieving pressure wouldn't be enough.

An amputation is only considered if no other treatment options are left. It can often be avoided with good preventive measures and treatment – even if the wound has been there for a long time.

There are different kinds of amputations:

• Minor amputation: Individual toes or parts of the front of the foot are removed.
• Major amputation: The whole foot (sometimes with part of the leg) is amputated above the ankle joint.

Amputations may be necessary if

• a toe or the foot can no longer be saved,
• a wound can only heal if smaller parts of the foot are removed, or
• an infection is spreading through the leg, muscle tissue in the leg is dying, or the pain is too severe.

Doctors only remove as much of the foot as strictly necessary in an amputation. A minor amputation (for instance, removing individual toes) is usually enough. An amputation above the ankle joint is rarely needed.

Ideally, you should go to a diabetes practice that specializes in treating diabetic foot problems as soon as possible. It is also a good idea to have treatment in a specialist foot care center. People living in Germany can find certified centers on the German Diabetes Association’s (DDG) website.

The treatment will be most successful if the various specialists work closely together. These usually include family doctors, diabetologists, podiatrists, vascular medicine (blood vessel) specialists, (foot or cosmetic plastic) surgeons, orthopedic technicians, and nursing staff. It is important that the diabetic foot treatment is coordinated by one doctor’s office. That is usually done by a diabetes center or a diabetic foot outpatient department in a hospital.

It is important to have regular foot check-ups. How often you have a check-up depends on how severe the diabetic foot problems are. If you don't have any nerve damage (neuropathy), an annual check-up is enough. If nerves are already damaged, a check-up every six months is recommended. If you have already had a wound, a check-up every one to three months is recommended.

You should also check your feet yourself for sore areas, injuries, redness, fungal infections and any other abnormalities – ideally every day. It can be helpful to use a hand mirror so you can see your whole foot, including the sole and between your toes.

It is important to continue to take good care of your feet even if a wound has healed. Nerve damage doesn't go away, and a new wound can develop at any time.

It is sometimes a good idea to get a second opinion. You have a legal right to do that before certain planned procedures. A second medical opinion is particularly important if a doctor recommends an amputation. An amputation has a major impact on your life, and there might still be other treatment options.

The most important question is the reason for the amputation: Is there really no other way to save the foot? What are the possible pros and cons of the operation?

Getting a second medical opinion means going to another doctor’s office or hospital for advice from specialists. Our decision aid may help too. It briefly summarizes the main advantages and disadvantages of the different treatment options.