Introduction

Did you know that 5.4 in 10 people lose their limb because of diabetes in South Africa (Muhammad et al. 2020)?

That is just over 50%, but the good news is that a sound diabetic management plan can prevent 80% of diabetic foot complications that cause diabetic amputations WHO, (2005). We can therefore deduce that diabetic management can play a significant role in preventing diabetic amputations. However, to achieve such an efficacy level requires a multi-stakeholder and a multi-disciplinary approach, both from an administrative and clinical level, respectively.

However, this article will focus only on the multi-disciplinary aspect by focusing specifically on the patient foot-self-care status quo.

Foot self-care practice plays a significant role in the overall efficacy of Diabetic Foot Management and Care. Therefore, we intend to highlight the basic diabetic foot self-care mistakes made by diabetic patients and the implications thereof. The primary purpose of this report is to create Limb Loss Awareness LLA by educating diabetic people about their mistakes and their implications.

Preventing development of debilitating diabetic foot complications, such as a Diabetic Foot Ulcer DFU, in order to reduce the rate of diabetic amputation.

Mistake #1: Lack or limited diabetic foot self-care.

With over a decade of experience serving diabetic patients, most of them often reported not having a diabetic foot self-care routine in place.

Reporting that despite being diagnosed with diabetes, they carried on with business as usual. Which meant being casual with their feet. Casual meaning being able to walk barefoot, wear inappropriate shoes, no foot inspection, no daily wash and cutting off nails.

                                                           Figure 1: Barefoot walking                                     Figure 2: Typical ignored diabetic foot

Why daily foot self-care is non-negotiable?

Diabetes affects both the nerves and the blood vessels, compromising your ability to feel pain and access to adequate blood supply.

Inability to feel pain or discomfort compromises the safety of your feet. As a result, diabetic feet are susceptible to unnoticeable injuries or wounds. Whereas poor blood flow compromises wound healing ability due to lack of sufficient blood flow to the foot.

Therefore, a compromised diabetic foot needs extra caution and care to keep the feet protected and healthy

    Figure 3: Complications of Diabetic Foot                           Figure 4: Testing Sensation of the foot

Mistake #2: Lack of regular check-ups

One simple way to prove a lack of regular check-up on diabetic patients is through their time of referral or pathway of referral.

In the world of internet, when patients have a medical concern, they often research their condition and self-diagnose. They would then present themselves to our establishment without a doctor’s referral letter and the timing of referral is late. We can argue, therefore, to say if they were having a regular check-up, their treating doctor would have referred them, and on time. Similarly with our employee wellness campaigns, upon screening the feet of employees, we advise those at risk to consult their doctors for a check-up and a doctor’s referral letter for our treatment purpose.

As if being casual with the feet is not detrimental enough, topping up with a lack of regular check-up leaves a compromised diabetic foot uninspected for the longest time possible.

Lack of inspection could worsen from a mere basic symptom, like callus, to a high-risk area for the development of Foot Ulcer. See figure 3 below. The purpose of regular check-up is the screening and early identification of basic diabetic symptoms associated with lack of sensation or blood flow. These may include bruise, wounds, callus, and limited blood flow.

                Figure 5: Callus feet caused by excessive pressure.                           Figure 6: Foot Ulceration from callus areas.

Why regular check-up is non-negotiable?

Early identification and early referral to a specialist by a treating doctor could save a patient from developing a debilitating Diabetic Foot Ulcer or Diabetic Amputation.

Mistake #3: Lack of multi-disciplinary specialist care

With a lack of regular check-up from a doctor, it is less likely for patients to access specialists timely.

It is therefore not ironic that several of our diabetic amputees did not know about the existence of a podiatrist. If they did, they would probably have a chance at saving their legs. As an orthotist and prosthetist, we only start servicing some patients from a prosthetic point of view when they have lost a leg because of diabetic foot complications.

Why multi-disciplinary care is non-negotiable.

Diabetes is a complex condition that affects vast areas of the body. As a result, a comprehensive care requires different healthcare specialists.

For example, in diabetic foot management, where nerves and blood vessels are affected. A general practitioner for diagnostics and referral to a specialist is required. Followed by specialist in cardiovascular surgeon and a neurologist to address limited blood flow and sensation related problems, respectively.

Complications associated with nerve damage and blood flow bring about other complications that require other set of healthcare professionals such a Podiatry, wound care specialist, and an orthotist to name a few.

Podiatry is a specialist in foot related problems, and they also form part of preventative care. Wound care specialist focuses on managing the wound. Meanwhile, an Orthotist specializes in supplying preventative and protective assistive devices such as insoles to prevent ulceration, diabetic shoes to protect feet, and off-loading shoes to manage diabetic foot ulcer.

                        Figure 7: Podiatry cutting callus                                   Figure 8: Insoles to prevent ulceration.

Mistake #4: Lack of follow-up

If treatment is important, follow up is even more important as it allows both the clinician and the patient to verify efficacy of treatment modalities.

However, diabetic patients underestimate the value of follow-up and don’t see the urgency to honor them. An opportunity to gather evidence on the efficacy of treatment becomes lost. Making it difficult to motivate for preventative care when there is no evidence of preventing Diabetic Foot Ulcers and Diabetic Amputations.

Why follow-up is non-negotiable?

It may happen that the treatment is not solving the problem. Even when it does, there is no evidence documented of its efficacy to the funder or the patient.

As a result, the patient may get worse while being administered treatment. Outcome-based care not only helps the patient to see the impact of treatment but also gives feedback to the specialist. For example, during insole treatment and diabetic shoe an orthotist ought to verify that foot pressure imbalance is proper. Ensuring that the foot will not develop callus.

Mistake #5: Noncompliance with Orthotic devices.

One of my referring Doctors referred me to consult on one of his diabetic patients who was developing Diabetic Foot Ulcer.

Upon consultation, the patient showed that he doesn’t feel any pain on his feet, and he doesn’t want any insole or offloading shoe. He was concerned that getting treatment of what is unnecessary is going to exhaust his medical funds for future care. Knowing that patients have a right to refuse treatment, I informed the Dr. and I never attended to the patient.

Sadly, he was later infected and suffered below-knee amputation.

                                           Figure 9: Diabetic offloading Shoe                                           Figure 8: Heeling Ulcer

Why is noncompliance with orthotic devices non-negotiable?

Prescription of orthotic devices for diabetic patients seeks to prevent foot ulceration, protect feet, and off-load wound to promote healing. Failure to comply with these orthotic principles exposes the foot to rapid ulceration, delayed wound healing, bone infection and leads to amputations.