Understanding Diabetic Foot: Causes, Symptoms, and Management

Understanding Diabetic Foot: Causes, Symptoms, and Management

The diabetic foot is a complication of diabetes and the most common cause of lower leg and foot amputations in Germany. Since minor foot problems develop more quickly in people with diabetes and often go unnoticed, severe inflammation and ulcers can result. To prevent a diabetic foot, regular care and examinations are essential in addition to optimally adjusted blood sugar levels. Read here about how a diabetic foot develops, how to recognize the symptoms, and which therapy is possible.

Definition: What is a diabetic foot?

The diabetic foot is also known as diabetic foot syndrome (DFS). People with diabetes often suffer from circulatory disorders or nerve damage (diabetic polyneuropathy ) in the feet. As a result of poor blood circulation, the feet are dry and cracked, so pathogens can easily penetrate the skin, and wounds heal more slowly. The sensory disturbances mean pain perception is impaired, and injuries are often only noticed when inflammation or ulcers have formed. In addition, the immune system is often weakened due to the disease, which also promotes infections.

According to the definition, one speaks of a diabetic foot when pathological changes occur in the feet due to the increased blood sugar levels in diabetes mellitus, for example, large-scale wounds or infections. It is a very diverse disease. The cause can be either nerve damage (neuropathic diabetic foot), circulatory problems (ischemic diabetic foot), or a combination of both.

People with type 2 diabetes are mostly affected. The longer the disease has existed, and the poorer the blood sugar level, the more likely it is that diabetic foot syndrome will develop.


How does a diabetic foot develop?

With a diabetic foot, a small trigger is often enough, such as an injury, an ingrown toenail, a pressure sore or even a fungal infection that worsens unnoticed. Foot lesions in people with diabetes are usually caused by unsuitable footwear and incorrect foot care. Those affected often also suffer from visual disturbances, so foot problems such as reddened skin and swelling are not recognized immediately.

A diabetic foot must always be differentiated between the two possible causes – nerve damage or insufficient blood circulation. This distinction is essential because the symptoms are different, and the treatment depends on them. In the case of circulatory disorders, running and exercise is the most important therapy, but the neuropathically damaged foot must be immobilized.

Peripheral polyneuropathy (PNP) is the cause.

In diabetics, damage to the delicate nerve endings in the feet can lead to a disturbed perception of touch, temperature and pain. Foot injuries often need to be noticed in time.

Affected people then do not notice, for example, that they are walking around in their shoes with a thumbtack, a stone or a bottle cap – often for days. Blisters from shoes that are too tight or ill-fitting and burns from hot baths or hot-water bottles are often recognized too late and cause significant problems.


Missing protective coat due to dry and cracked feet

The skin of the diabetic foot shows reduced sebum and sweat production due to the so-called autonomic neuropathy, so it is scorched and cracked. However, dry skin tears more quickly and offers bacteria and fungi ideal living conditions – there is a risk of serious infections.

Incorrect loads lead to deformations of the foot.

Another problem: Incorrect stress on the foot due to nerve damage can lead to deformation or deformation of the foot, such as:

The incorrect loading also leads to increased callus formation. Infections can spread under these calluses, leading to severe complications in a very short time. The danger: A wound can appear small on the surface, but a significant infection is hidden underneath. It is, therefore, essential to remove the callus regularly and very carefully.

How do I recognize a neuropathic diabetic foot?

Warning signs of a neuropathic diabetic foot include:

  • dehydrated skin
  • calluses and swellings
  • warm and pink feet
  • Reduced sensitivity, i.e. insensitivity, for example to temperature differences
  • Sensory disturbances, such as numbness, tingling, stinging or burning
  • painless injuries that often go unnoticed and thereby worsen
  • strong callus formation
  • deformities of the feet

These symptoms are not only considered possible indications of a diabetic foot in people who have already been diagnosed with diabetes. However, they can also help detect undetected diabetes.


Peripheral arterial disease (PAD) is the cause.

The second possible cause of a diabetic foot is poor circulation. A lack of blood flow is also referred to as ischemia. Diabetic angiopathy is also used in this context; it describes the vascular damage caused by diabetes. The circulatory disorder in the feet can be traced back to the so-called peripheral arterial occlusive disease, in which deposits in the vessel walls narrow the blood flow in the legs.

In many cases, peripheral circulatory disorders already exist when diabetes is diagnosed. The toes and the tips of the toes tend to have the poorest circulation.

In the case of arterial circulatory disorders, measures to promote blood circulation or vascular surgery can be used to try to stimulate blood circulation again and preserve the limbs.

Symptoms of circulatory disorders in the feet

Warning signs of peripheral circulatory disorders are:

  • Those affected often have pale, bluish feet.
  • The skin on the feet often feels cool.
  • Sometimes, the pulse in the foot arteries cannot be felt.
  • Injuries are felt to be extremely painful and heal poorly, especially on the toes and heels.
  • Even the most minor injuries often lead to an inflammation or an ulcer ( ulcer ). When the surrounding tissue dies, it turns pitch black and looks like it’s been burned—this is called necrosis or diabetic gangrene.
  • Feet and legs hurt even with little exertion, but this goes away with rest.

Because people often stop until the pain goes away, and some make it look like window shopping, the condition is also known as intermittent claudication.

combination of both forms

In about a quarter of all those affected, there is a combination of neuropathy and circulatory disorders as the trigger of diabetic foot syndrome. 

If blood circulation and nerve function are disturbed, the wounds on diabetic feet are complicated to treat. The typical symptoms of a circulatory disorder do occur, but they can go unnoticed due to the combination with the neuropathy and the resulting reduced sensitivity to pain.

It is, therefore, important to pay attention to the warning signs of diabetic foot syndrome when diagnosing diabetes.


Diabetic foot: examination by the doctor

Every person with diabetes should look at their feet every day and feel for pressure points and injuries. Anyone who cannot carry out this foot check should ask others for help or seek professional foot care.

The doctor should examine the feet of type 1 diabetics after a more extended illness or of type 2 diabetics at least once a quarter; at least once a year, he should check the vibration sensitivity as a measure of the neuropathy.

The doctor will also examine your feet for:

  • Skin condition (dry, cracked)
  • skin changes
  • pressure points
  • calluses
  • fungal infections ( athlete’s footnail fungus )
  • injuries
  • Changes in foot aesthetics and motor skills

He will also feel the foot pulses to check blood circulation. If the foot pulse cannot be felt, a so-called Doppler pressure measurement should be carried out.

Neurological examination of the diabetic foot

The neurological examination at the doctor’s is not very complex but very practical:

  • According to Semmes-Weinstein, the most essential instrument available is the 10 g monofilament. A nylon thread is pressed onto the examination point. With a bearing weight of precisely 10 g, it bends. If the patient does not feel this pressure, it can be assumed that his foot is at risk of neuropathy. First, the patient should be shown what to think on the forearm.
  • He was checking the thermal sensitivity with the Tip-Therm®. This device has a metal end and a plastic end. There is a temperature difference between the two ends. The patient feels the difference when he has an average temperature sensitivity.
  • Tuning fork according to Rydell-Seiffer: At least once a year, the doctor should check the vibration sensitivity to measure the neuropathy. The vibration sensitivity is tested at various points with the tuning fork, which is damped to 64 Hz.

For the three examinations mentioned, it makes sense for the person concerned to close their eyes to be able to concentrate fully on the sensation on their feet. Incidentally, the reflex hammer is also essential for assessing neuropathy because the Achilles tendon reflex can be gone very early on.

Diabetic foot syndrome: stages

If diabetic foot syndrome is diagnosed, the doctor will determine the stage. The division is based on the Wagner-Armstrong classification: 

According to Armstrong, a distinction is made between stages A to D, which include infections and circulatory disorders:

  • A: There is no lesion
  • B: lesion with infection
  • C: Lesion with ischemia (poor blood flow)
  • D: Lesion with infection and ischemia

In addition, the depth of the wound resulting from the diabetic foot is divided into different degrees, according to Wagner :

  • 0: There is no injury, only a pressure point or malposition
  • 1: There is a superficial wound
  • 2: The wound extends to the tendon or joint capsule
  • 3: There is damage to the bones and joints
  • 4: There is partial dead tissue (necrosis) in the forefoot or heel area
  • 5. There is necrosis all over the foot


Therapy for diabetic foot syndrome

Professionals should always treat diabetic foot. Which therapy is required depends on the degree of the wound according to Wagner’s classification:

  • Grade 0 – Early stage: Regular check-ups should be carried out.
  • Grades 1 and 2 – Wound care: The wound treatment and pressure relief are in the foreground. The blood supply to the affected area should be normalized to support healing. If necessary, tissue is removed to treat the wound or negative pressure is used to treat the wound (vacuum therapy).
  • Grade 3 – Antibiosis: Therapy with antibiotics should also be carried out.
  • Degrees 4 and 5 – amputation: Amputation can often only prevent inflammation.

When treating diabetic foot syndrome, amputation is sometimes the last resort when all other treatment options have been exhausted. Still, the goal is to avoid significant amputation, as it can shorten life expectancy. Depending on the progress of the necrosis, it may be sufficient to amputate the toe, for example, but sometimes the entire foot or part of the lower leg must be removed.

eliminate causes

In addition to treating the acute wound, measures to combat the causes may be necessary, such as surgical correction of foot deformities. In any case, blood glucose levels should be adequately controlled to prevent progression. If necessary, cholesterol and blood pressure values ​​should also be lowered with appropriate therapy.

Existing nerve damage cannot be cured, but circulatory disorders can often be treated. Medications such as blood thinners are also used. With appropriate training, people with diabetes can learn to prevent diabetic foot syndrome.

Diabetic foot: how to prevent it

Since a diabetic foot in an advanced stage is often difficult or impossible to treat, prevention is the be-all and end-all. Please note the following tips:

  1. Check your feet thoroughly every day for changes and signs of circulatory or nerve disorders, and make regular check-up appointments with the doctor.
  2. Please pay attention to even the most minor injuries or changes in the foot and treat them immediately.
  3. The best possible blood sugar control helps to eliminate the causes of diabetic foot syndrome.
  4. There are a few things to consider regarding foot care, such as applying lotion, caring for the nails and removing calluses. Here, you will find detailed tips on correctly caring for your feet.
  5. Reduce your body weight to take the strain off your feet. Above all, a healthy diet contributes to this.
  6. Refrain from smoking as this affects blood circulation.
  7. Put your feet up regularly.
  8. Targeted foot exercises can improve blood circulation in your feet.
  9. Buy breathable, comfortable shoes that are neither too wide nor tight and don’t pinch or chafe.
  10. When choosing your stockings, make sure they fit comfortably. The socks should not cut in or have chafing seams. They should also be made of wool or cotton and changed daily.

With these tips, you can prevent the development of a diabetic foot from the outset.

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