Goals/Objectives:

1. 1. To increase/maintain awareness of foot health and its importance to diabetics.
   2. To practice daily care of your feet, including:
      • Blood glucose control (under a maximum of 140 mg/dL or 7.8 mmol/l), < 6.5% A1C.
      • Daily inspection for abnormalities.
      • Daily washing and moisturizing.

Time Frame: Every day, without fail.

Even though Ellen and James White didn’t know about peripheral neuropathy in diabetic feet, they did seem to have some insight about the importance of keeping one’s feet healthy!

Basic Diabetic Foot Care

Since it is so very important for people with diabetes to exercise by walking (as much as possible), it is also extremely important to take special care of your feet.

Dr. Richard K. Bernstein, author of Dr. Bernstein’s Diabetes Solution: The Complete Guide to Achieving Normal Blood Sugars, says, “The incidence of limb-threatening ulcerations in diabetics is very high, affecting approximately one in six to seven patients. Nonhealing ‘diabetic’ ulcers are the major cause of leg, foot, and toe amputations in this country, after traumatic injuries such as those occurring in motor vehicle accidents. These ulcerations do not occur spontaneously; they are always preceded by gradual or sudden injury to the skin by some external factor. Preventing such injuries can prevent their sad consequences.” Dr. Bernstein gives a detailed list of foot care essentials, the most important of which is this: “Phone your physician immediately if you experience any injury to your foot. I consider even a minor foot injury to be an emergency. Procrastination can be disastrous.”

Toenail Fungus

Paula Edwardsen, Advanced Foot Care Technologist, says, “Statistics show that up to 80% of the population suffers from some sort of fungus. We now know that much of the fungus is bacteria-driven and can, in fact, cause pain and discomfort. Only about 60% of medical intervention to treat fungus is successful after treating patients 12 consecutive months. Patients also have high rates of side effects with liver damage being the biggest problem.

“Keeping bacteria and fungus in remission through homeopathic methods has proven quite helpful in my experience and practice of care. I have been able to put together a quite successful homeopathic method that has proven convenient, zero risk, and low cost, with high rate of success.”

I asked Paula what she thought of the ideas going around of using Listerine® and Vicks®, and here’s what she said: “It can be a Band-Aid® for some types of fungus. It’s the menthol in the Vicks® VapoRub™. Apple cider vinegar or Listerine® works because it removes the environment for favorable growth of fungus. I tested the Listerine® recipe going around and it had a very low success rate. We know now many fungi are actually bacteria. This is why fungus creams and meds have such a low success rate.

“Fungus can only be cleared by stripping the nail down, cleaning out all the badly decayed nail, then treating it. This is key. The only way to really get on top of fungus is to strip it down or off the nail. Nails are porous; by stripping the nail down due to thickness or just being ‘infected’ by the fungus, you open it up for treating it.”

If you are not fortunate enough to have someone like Paula care for your feet, just do your best at the most reputable nail salon you can find. Never allow the technician to cut your cuticles or use any sharp instruments on your skin or under your toenails. Never use or allow anyone else to use a pumice stone on your feet. Always go to a salon that uses disposable plastic liners in their soaking spa and also disinfects the spa between customers.

Pedicures

Whether you are a man or woman, if you are diabetic you need to think seriously before having a pedicure. It’s even more serious if you have peripheral neuropathy in your feet and have lost sensations in your feet. Your feet could get injured without you even knowing about it. If/when you have a sore on your foot, the best advice is to “contact your physician for a referral to a podiatrist or other specialist who is medically trained to care for your feet.” And never soak your feet, at home or at a nail salon, if you have a sore on your feet/foot!

Paula recommends not using nail polish on your toenails. For one thing, especially if the polish is a bright, opaque color, you would not be able to see any fungus growing under the toenail. And avoid using gel polish on toenails or fingernails! The removal of gel polish can be destructive to nails. Removal involves soaking in acetone, and aggressive buffing, scraping, and peeling of polish, which can injure the nail plate. Just because you are using the services of a pedicurist to trim your toenails does not mean you have to let them use nail polish. They may look at you funny if you say you don’t want polish, but it’s your foot health, not theirs!

And never ever go to a nail salon, even a good one, if you have sores on your feet, including a callus.

Ulcers and Other Foot Complications

It is estimated that as many as 25% of people with diabetes develop a foot ulcer at some point in their lives, and ulcer risk tends to increase with age. The major contributing factor to this risk is loss of sensation in the feet, usually caused by peripheral neuropathy, or nerve damage in the feet and legs. This common complication can change or reduce the sensation of pain, heat, and cold in the feet. For example, if someone with neuropathy were to walk on hot pavement, he might not be able to feel the heat, so there would be an increased likelihood of burns or blisters—which, in turn, could easily go unnoticed and untreated due to the lack of sensation.

Incidentally, tingling or numbness in only a part of your foot or hand is not peripheral neuropathy as clinically diagnosed. My doctor explained that peripheral neuropathy is like putting on a glove. Symptoms occur first in the tips of the fingers or toes then gradually move into the fingers/toes and then up into the hand or foot.

Heel pain is another foot condition that is very common in diabetic patients. Many people with diabetes are also overweight, which creates an increased risk for the development of plantar fasciitis and heel spurs.

Older diabetics sometimes experience edema in their feet and ankles, typically caused by accumulation of fluid in the tissues. This can happen if you sit or stand in the same position for long periods of time. The most common treatment is compression socks. However, an even better treatment is daily exercise, preferably walking. Then, when you get back, relax with your feet elevated. If you have pain or shortness of breath, do not hesitate to call the Advice Nurse or have someone take you to the nearest Emergency Room.

Shoes

It’s vital that you wear shoes that are well-fitting and provide adequate support for all parts of your feet, especially while walking. Note that your shoes may change sizes as you gain weight or lose weight. Wear soft, absorbent socks and change them daily. Replace your walking or exercise shoes every six months or 500 miles in order to avoid foot and heel pain when the inside of the shoe begins to wear off and lose support.

I have been wearing orthotic shoes, made especially for diabetics, for several years. It is not an unnecessary splurge to pay $100 or more for a good pair of diabetic shoes! Buy the right shoe for you. Do not buy a brand or a label. Go to a store that has professionals trained in fitting shoes. If you can get a prescription from your podiatrist, “diabetic shoes” may be covered by healthcare insurance.

Can peripheral neuropathy be reversed?

The good news is, yes, peripheral neuropathy can be reversed! That is, if neuropathy has not progressed too far. The most important thing you can do for your feet is to manage/control/reverse your diabetes with the dietary approach that lowers your blood glucose and insulin levels and lowers your A1C.

Your annual foot exam

When I was first diagnosed with diabetes, my health care insurance covered a bi-annual diabetic retinal screening and a bi-annual podiatry routine exam. Beginning January 1, 2014, routine podiatry care coverage was removed. Now, the only way you can get covered care from a podiatrist is for “diagnosis and treatment of ulcers, wounds, or infections.” Even your primary care provider will not provide a foot exam in your annual physical unless you have something wrong with your feet.

This means it’s more important than ever that you are diligent with daily care of your feet!

Review of Daily Foot Care

From Paula Edwardsen, Advanced Foot Care Technologist, Modesto:

Wash Your Feet

• • It is important to wash your feet nightly. Heat, friction, bacteria from sweating, and tight confined space all day creates an environment that requires daily cleansing. Keeping the inside of your shoes clean, and rotating shoes also is important.
  • Use a good anti-bacterial soap, like Dial®.
  • Nail brush – to get the dry skin and to remove all the dirt and sweat.
  • Wash vs. soak – diabetics are never to soak their feet. Soaking creates more drying to the skin. A diabetic already suffers from dryness. Soaking also increases the risk of breakdown. A good washing is all that is needed in daily maintenance.
  • Hot vs. tepid (only slightly warm) water – Never hot water! Especially with neuropathy. Hot water also dries out feet even more.
  • Clean between all the toes. Take special care between the 4th and 5th toes. These toes have the highest rate of breakdown.
  • Drying your feet well is also important. If you have trouble reaching your feet, rubbing them on a towel then letting them air dry will work. But you must then dry carefully between your toes. Again, if mobility is an issue, spraying 70% alcohol between the toes will help dry them out. If possible and with help, have someone dry between your toes.

Inspect Your Feet

• • Now that your feet are clean, and either with help or if you can do it yourself, inspect your feet. Check for stubbed toes. The big toe and small toes suffer the most. Check behind and under the back of the toes. Check between toes, check heels for cracks or bruising. And always check for calluses.

Moisturize Your Feet

• • Calluses kill live tissue. They also make feet that already cannot feel, feel even less. We have a saying in podiatry, “A callus is an ulcer waiting to happen.” A very high rate of hematomas is found under calluses. Keeping feet well-moisturized will help prevent calluses.
  • Cuticle oil – the most underused foot care item and little-known secret. Cuticle oil helps keep the nail plate nourished and hydrated and it keeps the cuticle and side walls soft and pliable. It also helps to keep the dry skin debris at bay. One small drop on each nail then rub into nail plate and surrounding tissue.
  • Moisturize. The best cream (not hand lotion or body lotion) to use is a water-based cream. Read the ingredients. The first four ingredients should read water, mineral oil, petrolatum, glycerin, or similar order.
  • How much cream? A good cream will only require a small amount about the size of between a pea and lima bean. Warm cream up by rubbing it between your hands and then working from the toes down. Stroking downward motion. No cream between toes ever. This causes further breakdown of skin. Pay special attention to the heel area.
  • How do you know if you are using enough? If your cream is completely absorbed within 20 seconds, you need more cream. If your feet are still dewy after 1-2 minutes, then you have used too much. Wait a couple of minutes before putting socks or slippers on. Never walk barefoot before or after.

Day or Night

• • Socks – wearing diabetic or compression socks is a game changer, too. Wicking socks or polypropylene socks keeps moisture and fungus at bay.

References

“7 Pedicure Safety Tips for People With Diabetes,” Scripps (July 12, 2018). https://www.scripps.org/news_items/4937-pedicure-safety-tips-for-people-with-diabetes (accessed on 7/23/2020).

• • Know when to skip a pedicure
  • Avoid shaving your legs for a day or two before your pedicure
  • Find a salon that is clean and practices impeccable sanitation
  • Bring your own nail kit, if possible
  • Mention you have diabetes before the pedicure begins*
  • Bring up protective practices
  • Skip any services that can injure the skin

*In California, “The Board’s laws and regulations prohibit licensees and students from working on a person with an infection or communicable disease.” Contra Costa Health Services. https://cchealth.org/warnings/pdf/manicure_factsheet.pdf (accessed on 2/20/2020).

Bel Marra Health. “April is Foot Health Awareness Month, diabetes foot complications, gangrene, sprained ankle, and smelly feet,” Bel Marra Health (April 16, 2016). https://www.belmarrahealth.com/foot-health-awareness-month-diabetes-foot-complications-gangrene-sprained-ankle-smelly-feet/ (accessed on 7/22/2020).
A collection of articles about foot health:

• • Diabetes, gangrene, and diabetic foot amputation risks, causes, and prevention
  • Diabetic foot complications lead to impaired cognitive function
  • Sprained ankle risk may be influenced by foot positioning during walking, running
  • Natural remedies for smelly feet

Bernstein, Dr. Richard K. “Foot Care for Diabetics – Appendix D,” from Dr. Bernstein’s book, Dr. Bernstein’s Diabetes Solution: The Complete Guide to Achieving Normal Blood Sugars, 2007. http://www.diabetes-book.com/foot-care-diabetics/ (accessed on 7/23/2020).

Edwardsen, Paula, Advanced Foot Care Technologist, Modesto, California. https://advancednailtechnology.com/index.php (accessed on 7/23/2020).
Advanced Foot Care Technology, LLC, in Modesto, California, is owned and operated by Paula Edwardsen, a state-licensed Foot Care Practitioner MNT/PMA and is currently the only private practice of its kind in California.

“Heel Spurs and Plantar Fasciitis,” ©2018 WebMD, LLC.  https://www.webmd.com/pain-management/heel-spurs-pain-causes-symptoms-treatments#1 (accessed on 7/22/2020).
A heel spur is a bony growth that develops around the heel bone, often caused by ill-fitting shoes, and sometimes causing pain.

Mayo Clinic Staff. “Amputation and diabetes: How to protect your feet,” Mayo Clinic (August 08, 2017). https://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/amputation-and-diabetes/art-20048262 (accessed on 7/22/2020).
Good diabetes management and regular foot care help prevent severe foot sores that are difficult to treat and may require amputation.

Mayo Clinic Staff. “Peripheral neuropathy,” Mayo Clinic, n.d. https://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/symptoms-causes/syc-20352061 (accessed on 7/22/2020).
People with peripheral neuropathy generally describe the pain as stabbing, burning or tingling. In many cases, symptoms improve, especially if caused by a treatable condition.

Mayo Clinic Staff. “Plantar fasciitis,” Mayo Clinic, n.d. https://www.mayoclinic.org/diseases-conditions/plantar-fasciitis/symptoms-causes/syc-20354846 (accessed on 7/23/2020).
Plantar fasciitis is a foot condition characterized by sharp, stabbing heel pain that typically occurs when a person gets out of bed in the morning or stands up after sitting for a long period of time. While the most common symptom of plantar fasciitis is usually described as a shooting pain, the condition can also cause some swelling in the heel.

McDermott, Annette; medically reviewed by William Morrison, MD. “Why Is Foot Care Important If You Have Diabetes?” Healthline (updated August 20, 2018). https://www.healthline.com/health/diabetes/diabetes-amputation (accessed on 7/22/2020).
In 2010, 73,000 American adults who have diabetes and are over age 20 had amputations.

Rice, Birgitta I., MS, RPH, CHES. “Improving Blood Flow to the Feet: The Power of Relaxation and Biofeedback,” Diabetes Self-management (April 3, 2019). https://www.diabetesselfmanagement.com/managing-diabetes/complications-prevention/improving-blood-flow-to-the-feet/ (accessed on 7/22/2020).
According to the National Diabetes Information Clearinghouse, up to 70 percent of people with diabetes develop neuropathy, particularly the longer they live with diabetes. It very commonly affects the feet and legs and sometimes the hands and arms. This type of neuropathy is called peripheral neuropathy, and it can cause a range of unpleasant sensations, including tingling, burning, numbness, and pain.

Sylvester, Jennifer, BSN, CDE. “Diabetes Foot Care Starts With Good Shoes,” Samaritan Health Services (September 16, 2019). https://www.samhealth.org/about-samaritan/news-search/2019/09/16/diabetes-foot-care-starts-with-good-shoes (accessed on 7/23/2020).
In addition to wearing properly fitting shoes, inspect your feet every day for blisters, sores, cuts, redness, bleeding or drainage, warm areas, swelling, ingrown toenails, and other abnormalities.

UnitedHealthcare® West. “Foot Care and Podiatry Services,” United Health Care® (April 1, 2020). https://www.uhcprovider.com/content/dam/provider/docs/public/policies/signaturevalue-bip/foot-care-podiatry-services-common.pdf (accessed on 7/23/2020).
For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs.
Routine Foot Care is excluded from coverage except as described in Section C or included as a supplemental benefit. Examples include, but are not limited to the following:

• • Cutting or removal of corns and calluses;
  • Trimming, cutting, clipping, or debriding of nails; and
  • Other hygienic and preventive maintenance care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast members, and any other service performed

Vallianou, Natalia; Angelos Evangelopoulos; and Pavlos Koutalas. “Alpha-Lipoic Acid and Diabetic Neuropathy,” The Review of Diabetic Studies. 2009 Winter; 6(4): 230–236. Published online 2010 Feb 10. doi: 10.1900/RDS.2009.6.230. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2836194/ (accessed on 7/22/2020).
Alpha-lipoic acid seems to delay or reverse peripheral diabetic neuropathy through its multiple antioxidant properties.