Cold Feet

Jarrod, a sixty five year old patient, came in with a complaint of foot pain. Apparently, he went in for a pedicure about three weeks prior, to keep up with proper foot care. When he got home, he noticed a small abrasion at the time. He had been trying to treat it with salves, but the abrasion seemed to get worse. He was a poorly controlled diabetic, with his last check showing a HbA1C of 14. He was hoping that his foot would get better on its own, but the abrasion started to get painful. A week into the abrasion, he made the decision to go see the doctor, but got cold feet at the last minute, holding onto that hope. When he finally did arrive three weeks later, his abrasion was a full on ulcer that looked as if it penetrated past the muscle tissue on the bottom of forefoot. His heart rate was in the 130’s, with otherwise normal vitals.

Diabetes is a complicated disease, with lots of little secondary problems when it’s uncontrolled. As in Jarrod’s case, the uncontrolled glucose floating in his bloodstream acts like tinder for an infection. A simple skin infection can spread rapidly and if not addressed immediately, can enter the body and become an infection of the bone or blood. In addition, diabetics can also develop peripheral vascular disease, where the glucose lowers the blood pH and causes damage within the arteries, narrowing the passage way, which can ultimately lead to a diminishment of circulation, creating problems with healing. There is also the autonomic nerve complications that can happen, where the normal sensory experience a person has is altered due to nerve damage relating to the diabetes.

The nerve damage associated with diabetes can make patients experience a pain in their feet in the worst case. In most cases, however, the nerve damage can make patients feel cold feet or nothing at all. This can be dangerous, as an unknowing patient with an untreated foot ulcer may not see the doctor for a very long time.

Some risks for developing diabetic foot ulcers include poor hygiene, heart disease, kidney disease, tobacco abuse, obesity, and improperly clipped toenails. Diabetics also have a tendency to have dry feet, so it’s important to moisturize. Besides foot ulcers, maintaining proper foot hygiene is just a common courtesy. Nobody wants to see a person’s stinky, nasty toes and feet. I’m speaking from experience. And wearing proper footwear is crucial to prevention, as ill fitting shoes and actually precipitate a foot ulcer. Diabetics can also develop something called a Charcot deformity, where the arch flattens and the foot itself begins to resemble a club. In these cases, arch support is necessary and orthotics are usually recommended.

Once an ulcer extends to the bone, the dangers increase. At this point surgical amputation becomes an option and IV antibiotics are mandatory in order to avoid a disaster. For diabetic patients, it’s extremely important that they routinely check their feet and make sure they see their doctor at the earliest sign of a problem. Doctors recommend that diabetics see a podiatrist at least once a year to make sure that the toenails and calluses are all kept properly.

Jarrod was subsequently sent to the hospital with a suspicion of osteomyelitis (a bone infection) and sepsis (blood infection). He said that he first had to make arrangements for his pets at home and call his family to let them know. Hopefully, he doesn’t get cold feet and actually follows through with the order to go to the ER.

By: Dr. Juan Borja
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