This Little Piggy Got Gangrene

By Owen C. Franklin

"I've seen patients who've had a cat's tooth stuck in their foot and never knew it."

Jackie Shine walks on nine toes. She keeps the tenth in a jar near the toilet.

"The doctors didn't want to give it to me once it was amputated," said Shine. "They told me it would be toxic because it would be in formaldehyde. I didn't understand that — it's not like I'm going to drink it."

It all started when Shine cut too deep while shaving a callus with a razor blade. The wound nurtured a serious infection that, over time, turned her left pinky toe into a decaying lump of tissue.

"I just wasn't really paying attention to my body," said Shine. "I didn't even wipe the razor off with a rag before I used it."

A small nick with a razor doesn't usually lead to such a serious lance of a scalpel. But, for people with diabetes, small problems in the feet can lead to ulcers, gangrene and even limb loss. With the proper care, however, people with diabetes greatly increase their chance of keeping both feet planted firmly on the ground.

Diabetic foot problems stem from what is essentially the root of all diabetic evils — high blood glucose levels. Excessive sugar in the bloodstream fosters several different problems which, when working together, produce gruesome and potentially crippling results.

"For one thing, it starts to poison the nerves of the body," said Eric Stamps, Doctor of Podiatric Medicine and assistant professor at the California College of Podiatric Medicine. "The nerves that get affected first are the longest ones — the ones that go all the way down to the feet."

When these nerves deteriorate, they can't transmit important messages, such as pressure and pain, between the feet and brain. A dangerous numbness sets in, leaving the feet isolated from our sensual concerns.

"I've seen patients who've had a cat's tooth stuck in their foot and never knew it," said Dr. Stamps. "I had one guy who had a big ulcer on his toe. He'd bought new shoes and never removed the crumpled paper. There was this wad of paper that was basically wearing a hole in his foot."

These nerves also activate the tiny muscles that support and coordinate the movements of the toes and feet. When these lines fail to function, the muscles of the feet can contract in an irregular manner. The toes may clench into a claw-like position known as "hammer toes."

"When the toes are hammered for too long, the tips become exposed as bony prominences," said Dr. Stamp. "This can lead to calluses and corns which can wear away and lacerate the feet."

In people without diabetes, calluses shield the skin from excessive rubbing or pressure and prevent blisters or cuts. In a foot affected by diabetes, however, calluses produce a near-opposite effect.

"The callus acts as a stress riser," said Dr. Stamps. "There is an increased force transmitted through the callus which rubs the tissue below it. This tissue dies and deteriorates, leaving an ulceration — which is basically a void."

These ulcers demand constant cleaning and bandaging. A health-care provider may need to scrape beneath the skin several times a day to remove any dead tissue or bacteria and make room for new growth. During the healing process, walking may become severely difficult, if not impossible.

"I hate being confined to a wheelchair," said Shine, whose right heel is currently healing from a quarter-sized ulcer. "Some days I look at this gaping hole in my foot and I just want it to go away so I can walk again."

Shine will have to be patient. Not only are people with diabetes especially vulnerable to wounds — their bodies face serious handicaps in mending cuts and fighting off infections.

"It's sort of a one-two-three-four-five punch," said Dr. Stamps. "People with diabetes get more wounds. In order to heal, you need to be able to get certain ingredients down to the wounds. Many people with diabetes have poor circulation, and healing can be significantly delayed."

This poor circulation results from atherosclerosis — also known as "hardening of the arteries." Diabetes hinders the metabolism of certain fats. These fats continue flowing in the bloodstream and, over time, begin to build up on the artery walls. As the artery conduit narrows, it prevents blood from flowing easily through the body. The areas that are farthest from the heart, such as the lower extremities, suffer worst of all.

Blood serves two critical functions in healing wounds. First, platelets in the blood begin the clotting and scabbing process that prevents bacteria from entering the body. Second, white blood cells fight off any bacteria that can lead to dangerous infections.

Without this defense, bacteria can breech the body and breed freely. After time, a small cut can spawn a gangrenous infection that can make its way up the foot and into the leg. In some cases, amputation is necessary to prevent further growth.

It's far too easy to forget about the lower half of the body. Our legs and feet hide from our field of vision. When sheathed beneath pants, they demand little in the way of cosmetic maintenance. Even in the midst of a rigorous run, they operate with veritable autonomy.

But diabetic foot problems require vigilant, daily care of our forgotten phalanges.

"Diabetic foot problems can ruin all the hard work you've put in to managing your diabetes," said Elizabeth Marlow, MSN, CFNP, CDE, a diabetes educator with the Diabetes Teaching Center at UCSF/Stanford Health Care. "If you get a cut that gets infected, that can spike your blood sugars, and it can take a while to get back that tight control."

Tight glucose control is the best form of prevention against the complications of diabetes. In addition, however, there are many daily checks you can make to prevent serious problems.

"People with diabetes should check their feet everyday," said Marlow. "If they do notice any problems, they need to contact a health care provider. The first thing they should say to the person who answers the phone is 'I have diabetes and I have something wrong with my foot and I need to get in and be seen right away.'"

A new list of routine checks may be the last thing a person with diabetes wants to add to his/her daily schedule. Checking toes, however, is much more convenient than losing toes. A few short minutes devoted to foot care each day can make the most important step you ever take.

"If people catch any problem early, we can get started on cleaning things up," said Dr. Stamps. "Then, we can use the whole problem as a lesson to prevent it from happening in the future."

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