By Dr. Steven Gershman, DPM
Welcome to our new reality. In almost the blink of an eye the world suddenly changed as we know it. What the future holds is now a big question mark. TV and other media have spent countless hours discussing this pandemic. In this blog I will focus on the issues of diabetes and coronavirus and how it can affect the feet and how to best prevent new problems with the feet.
Diabetes and Feet
Past Orthofeet blogs including my own have discussed diabetes, its effects on the feet, diabetes complications and protection for diabetic feet. Here is a brief synopsis on the issues.
Neuropathy in Feet
Diabetes can cause neuropathy in a large number of diabetics. This can manifest as pain, or the more seriously dangerous loss of protective sensation (LOPS). LOPS leaves the feet effectively defenseless against the environment. Without feeling, the feet cannot protect themselves against objects on the floor that can pierce the sole of the foot. In addition, our feet are wonderful sensors for the body, something called proprioception. The nerves in the feet constantly send messages to the brain about changes in terrain and where the body is in relation to the floor. This allows the brain to signal the muscles of the lower extremity and even the back to respond by firing and causing corresponding changes in position to safely avoid problems and loss of balance as we walk. Moreover, the nerves pick up sensation of discomfort from being in one position too long or muscle overuse to compensate which could cause injury if not corrected. A major example of this is the toes. We use our toes to grip the floor for balance improvement and stability when we stand and walk. However, if we didn't constantly shift the amount of pressure and which toes clench when, this process would not be effective and can lead to damage to the toes. The entire process requires constant feedback to the brain from the feet nerves. When there is LOPS as in many diabetics, this process is disrupted. The end result can be loss of balance with subsequent dangerous falls and injuries. In addition, with LOPS the toes can be deformed from overuse and form dangerous hammertoes which can rub in shoes causing calluses and later ulcers. I see this a lot in practice as I treat mainly diabetic patients.
Peripheral Vascular Disease
Another area of pathology in diabetics is damage to the blood circulation to the feet (peripheral vascular disease or PVD). The large vessels often become narrowed with plaque causing decrease in total blood flow. When blood flow decreases it is harder to heal wounds and easier to become infected by any wound. In addition to the large vessel pathology there is often decrease in circulation to the skin from the small or micro vessels. This can lead to the skin being less able to tolerate rubbing or pressure and forming ulcers as a result. These ulcers are much more difficult to heal. Smoking dramatically exacerbates this problem as it cuts down the circulation to the feet.
Diabetes and Coronavirus
We have been bombarded by the media about COVID-19 and how it is more dangerous for certain groups such as people with pre-existing medical issues and the elderly. Diabetes is one of the pre-existing conditions that is an issue. Diabetes affects the immune system through various mechanisms. Basically, it means it is probably easier to contract the virus and very importantly it is harder for the body to fight it off. Immune response requires antibodies from the white blood cells. Diabetes is believed to decrease the effectiveness of the white cells and with circulation compromised in many diabetics there is less of the cells in the tissue to fight off the infection. Bacterial secondary infection is easier to occur and harder to treat with blood glucose increase.
We are beginning to see actual dermatologic (skin) manifestations of COVID-19 and diabetes especially in the feet. Clinically I am hearing of a rash on the toes especially. This is believed to be from damage to the microcirculation causing little red spots of blood emboli. It is similar to what we see with "Chilblains". This is a skin condition where the capillary beds that are part of the microcirculation are damaged by cold causing red painful lesions and blisters often on the toes. It appears COVID-19 may affect the toes in a similar manner. There have been cases where this "rash" is the only clinical feature of the virus. COVID-19 affects the whole body in so many ways, we are still in the discovery stage. With diabetes there is already potential microcirculation damage or compromise so this new effect of COVID-19 needs to be further studied to see if it can cause serious issues to the feet. I would strongly recommend anyone with new onset redness on the feet and especially the toes to call your primary care physician or podiatrist and report it.
With so many people staying home and basically being housebound, there is a tendency to go without shoes. This is very dangerous for diabetics and even for non-diabetics is not a good idea. Over the years in practice I have seen so many injuries to the feet resulting from not wearing protective shoes in the house. Walking without a firm sole on a shoe on floors is a recipe for disaster. It is easy to pick up sharp objects that can pierce the feet. Puncture wounds are some of the worst wounds in terms of potential deep infections leading to blood infections or sepsis and possible amputations. During a week in practice I had two diabetic patients who presented with embedded insulin needles in the sole of their feet. I then had two more patients with sewing needles deeply embedded in the foot, one of which we could never remove since it was so deep and poorly located. Impact injuries are another problem when walking without solid shoes. It is so easy to jam toes or the ball-of-the-foot around the house and cause broken bones or serious wounds. Protection for diabetic feet or really any feet requires well-made shoes whenever on the feet. Slippers generally aren't protective enough. What I recommend to my patients who won't wear outdoor shoes in the house is to purchase a pair of comfortable diabetic shoes to wear only around the house and loosen the laces or hook and loop straps so they can be easily slipped on and off. Orthofeet has a wonderful line of various style diabetic shoes that are very comfortable and protective. My wife and I both wear Orthofeet shoes at our office and at home. They are the most comfortable shoes we have ever worn. As I write this, I am wearing them.
Characteristics of Diabetic Shoes
Buying shoes for diabetics is key. What should a diabetic patient look for in proper shoes that are protective of the diabetic foot? First and foremost is comfort. The shoe should feel comfortable immediately with no "break in " needed. Fit is extremely important. If the shoe feels too narrow such that the sides of the feet are being jammed into the shoe, toes are rubbing and hitting the end of the shoe or the top of the toe box, the shoe isn't fitting correctly.
The following features are what makes diabetic shoes special. Orthofeet shoes also meets all these requirements.
- Seam free interior without any protrusions that protect the feet.
- Extra depth/height and a round wide toe box so the toes have ample space for maximum movement and do not rub or overlap.
- Extra depth design from heel to toe to accommodate well-made cushioned inserts or orthotics comfortably.
- Multiple widths including extra extra wide if needed.
- Anatomical orthotic inserts that support the arch and improve gait for better movement.
- Thick foam padding all around the interior of the shoe offer protection for diabetic feet and a comfortable fit.
- Stretch fabric uppers that conform to the contours of the foot for a pressure free fit and promote a cool and dry foot environment.
Diabetic socks are quite important. The socks should not bind on the leg which can cause marks on the skin and swelling above the sock and on the foot. It is also very important they have a seam free construction as even the tiniest string can cause irritation in diabetic feet. A white sole is helpful to detect draining wounds, cuts or sores. Material should be able to wick away moisture. Cotton is a very poor material for socks as it holds moisture against the feet. Orthofeet socks are knitted with soft bamboo fibers that eliminate friction that can lead to blusters and are gentle against the skin. Even though I am not diabetic nor is my wife, we both wear Orthofeet diabetic socks as they are very comfortable and handle moisture so well. In addition, they outlast socks I have purchased in the past as they are very durable. Click here to learn more about Orthofeet’s innovative diabetic socks.
Finally, BE SAFE! Follow your own state government or local municipal recommendations on venturing out during this pandemic. Wash your hands frequently and thoroughly (for at least 20 seconds) and keep your distance from people. If you are diabetic, maintain your diet what it was before even though you are home more and venture outdoors to get some exercise safely to keep the sugar under control. Remember this will eventually end and life will slowly return to some new normal.
If you feel you have developed any symptoms that might be related to COVID-19 or see any new changes to your feet, don’t wait to seek help. Call your health care provider immediately.