Sugar disease, meaning diabetes, has been one of the most important health problems of societies since times past. As the blood sugar level can be controlled thanks to new treatment approaches and developed medicines, ketoacidosis and hypoglycaemia, among the deadly complications of diabetes, are rarely seen. Diabetes is an incurable but with a good care controllable chronic diease. No matter how well the blood sugar level is taken under control, long termed complications are generally inevitable. Which complication is likely to occur significantly varies between individuals. Most of them are related to blood circulation. The veins become hardened, the functionability of blood elements is reduced. Different disease profiles occur according to the affected organ. Nephropathy in kidneys, retinopathy in the eyes, and neuropathy of the hands and feet are among these.
The ratio of diabetes to the common population between countries and races is at 6-7%. This ratio reaches up to 50-60% in Native Americans. 20% of the hospital consultations of diabetes patients are due to foot problems. It is determined that 50-70% of population wide foot amputations are diabetes patients. In a diabetes patient with an amputated toe the risk for a second toe amputation within two years at 50%. Only 30% of diabetes patients don’t suffer from feet problems, and at least 15% get wounds in their feet.
The reason for diabetic foot development can be evaluated under three main titles:
- Damage to venous structures (angiopathy)
- Changes to blood chemistry (hemorrheological)
- Damage to peripheral nerves (neuropathy)
Damage to venous structures (angiopathy)
In the past it was thought that there was damage to the capillary vessels of diabetes patients and thus wounds developed, and that therefore the developed wound and surgical cut lines didn’t heal well. Studies have revealed that this is not correct. These patients have vessel problems, but in the jugular veins, not in the capillary. Artherosclerosis developing in the feet of diabetics at these levels needs to be evaluated by the coloured Doppler ultrasound or angiography. If there should be sufficient passage and function of blood, this will mean that the main reason of the wound is not venous.
Changes to blood chemistry (hemorrheological)
In patients with diabetes, as is the case in all systems, partial damage to blood and immune cell functions will occur. The blood cells are stiffened and become difficult to pass to the capillaries, and thus the oxygen transport function is disturbed. The function loss in the immune cells increases the susceptibility to infections.
Damage to peripheral nerves (neuropathy)
Diabetic neuropathy. The main reason along with all these factors for the development of wounds in these patients is diabetic neuropathy.
The nerves extend throughout the body, starting from the spinal cord inside the spine towards the toe and finger tips. They sometimes pass narrow anatomic points during the paths they follow. The elbow (cubital) and wrist (carpal) tunnels are examples of this relating to hand nerves. In legs, the ankle (tarsal) tunnels are the locations with the most frequent squeezes. Some persons are prone to nerve squeezes due to a congenital narrowness of the tunnels or due to an excessive muscle structure inside the tunnel. But diabetics are faced with nerve squeezes more, for two important reasons.
The most important reason for sensitivity to nerve pressure in diabetics is that the nerves inflate. In high quantities glucose entering into the nerve structure converts into sorbitol, which is another sugar. Sorbitol absorbs water due to its chemical features, and the nerve structure thickens with water. The long established hypothesis is that a thickened nerve would more easily be affected by pressure in an already narrow space.
The second reason is that the transport system is damaged in diabetic nerves. Normally the information exchange between the nerve body and tip occurs by the transport of chemical materials within the nerve, by structures called tubulin. This transport system is damaged in diabetics. If the nerve should be modified due to a squeezing at any point, it is necessary that these materials arrive by this transportation system for the amendment of the situation. If the transport system should be disturbed, the nerve will not be able to recover itself and even a light pressure can have serious results.
Even if neuropathy may occur in very different ways in diabetic patients, the most frequently seen form is that first the feet and then the hands are affected. Generally, a numbness and formication in toe and finger tips is felt. Whilst these complaints occur only occasionally at first, they become fixed over time. These symptoms increase in severity and start to disturb the sleep and to cause the patient to wake up. After a long time, the numbness will increase so much that the tightness of a shoe or the heat of water cannot be felt anymore. Apart from this, strength loss in the hands and feet will occur as well.
The more neuropathy progresses, the more muscle loss will occur, along with pain and sensation loss due to the reduction received stimulation. This situation results in significant deformities. Similar to crawl hand deformity of the hand, crawl deformity of the feet will incur. After the development of this deformity, the load on the foot will concentrate on the toes and the metacarpus heads. This excessive load will result in wounds in these regions. And in the final stages, the soles, without the support of muscles, will sink and a rocker-like foot will occur. In a foot in this state there may develop an ulcer or other wound at any tine, and recovery is impossible.