Another very common problem in people with diabetes and accompanying nephropathy, particularly those who smoke, is circulatory problems in the legs. In this case as well, the cause is a narrowing of the blood vessels as a result of arteriosclerosis. This complication is commonly known as ‘peripheral arterial disease’.

Like other circulatory problems in diabetes, it develops gradually, often remaining undetected for years, and only causes damage when it is already well advanced. The symptoms are very characteristic: the legs start to hurt after walking even a short distance.

The problem usually arises in the calf muscles, more seldom in the thigh, bottom or foot. As soon as you stand still, the pain ceases and you can proceed, until it starts again and you have to stop once more. The cause of the pain is a shortage of oxygen.

The narrow atherosclerotic blood vessels cannot supply enough blood and therefore oxygen to the tissues to meet the increased demand during walking. The working muscles react to this shortage with a sensation of pain. People with diabetes who already have nerve damage do not experience these symptoms as painfully or even at all.

If the thickening of the vessel walls proceeds, the circulation gradually gets worse and the pain starts to occur even at rest, especially when the legs are horizontal, such as at night. The leg becomes pale and feels cool to the touch. Because of the poor oxygen supply, small wounds heal badly and tissues can be permanently damaged.

Infections are hard to treat, even with antibiotics. If large amounts of tissue die, in the worst cases amputation may be necessary. One indication of damage to the circulation is when the pulse in the legs and feet becomes barely detectable.

A more exact method is to use ultrasound to compare the blood flow and blood pressure in the upper and lower thigh. If these are low, there is probably a blockage in one of the blood vessels. This should usually be confirmed by angiography. If the condition is not too far advanced, the patient can be helped with medical therapy and walking exercises.

Today, aspirin (acetyl salicylic acid) is prescribed to treat peripheral arterial disease. If a serious or even total blockage occurs, interventions to improve the blood flow should be considered. There are several proven techniques available:

• Dissolving the clot that is blocking the vessel. . Widening the constricted vessel using a balloon.
• Surgically removing the atherosclerotic plaque from large vessels, for example in the pelvis.
• A bypass operation, in which a diversion is constructed around the blockage.

By these methods, it is now possible to avoid amputations in many patients.

How to Avoid Amputation

Each year in the UK, around 5000 lower limb amputations are performed for vascular disease alone. It is not just problems with the circulation that cause this high risk of amputation. The so-called ‘diabetic foot syndrome’ is mostly the result of an unholy alliance between diabetes-induced nerve damage (neuropathy) and perturbed circulation.

It often begins with a seemingly harmless foot injury, due to pinching shoes, poor foot care or walking in bare feet. Because of the nerve damage, the wound isn’t noticed, the foot is not protected or looked after properly, it becomes infected and – especially when there is also poor circulation – the tissue starts to die.

If this is not handled correctly, large, deep wounds develop, which may involve the bone and are very hard to treat. Amputation of the affected toes or other part of the foot is then unavoidable in order to prevent further damage, which may eventually make it necessary to amputate the whole leg.

But – as with all the other complications of diabetes – it is ultimately up to the person with diabetes to take responsibility for his or her own health and to take the right precautions. An important aspect is proper foot care. Following the basic rules can prevent the development of large, dangerous wounds that are difficult to treat.

You can determine for yourself whether you have neuropathy and thus whether you need to pay extra care to your feet. Some patients are able to attend special diabetic foot clinics. These are often managed by a team including diabetologists, radiologists and surgeons.

They may also work with special orthopaedic shoe manufacturers who can make shoes to fit individuals to help them after the treatment and reduce the risk of regression.

Tips For Good Foot Care

• Watch out: Examine your feet every day for redness, pressure points or wounds, with the help of a mirror if necessary. No pain is not a reliable sign of no injury!

• Wash: Clean your feet every day with warm water (up to 378C). Check the temperature of the water with a thermometer. Don’t trust the temperature sensitivity of your feet, since this may have been destroyed by the neuropathy. The feet should be soaked for three to five minutes, but this is not recommended when there are open wounds.

• Dry: Use a soft towel and dry your feet carefully, including between the toes and the creases in the toes.

• Care: For dry skin, daily application of a cream or salve is recommended. Don’t put cream between the toes as this can lead to crumbs or irritation of the skin. Oils or zinc paste, which dry out, are not suitable.

• Toe nails: Use a file to keep your nails short. Round off the corners so that they don’t press on the adjacent toe. Don’t use pointed or sharp instruments to care for your nails. In growing nails should be managed by a diabetes-educated chiropodist.

• Corns: Do not use corn plasters, salves or tinctures because these contain substances that can damage your skin. Corns should be treated by an experienced chiropodist.

• Calluses: These can be removed by carefully using a pumice stone. It is better to undergo subsequent management in a medical foot care practice. Calluses are evidence of raised pressure, so your footwear should be examined.

• Skin and nail fungi: Fungal infections in people with diabetes should be treated by a doctor because they are entry points for germs and may lead to more serious infections.

• Socks and stockings: Wear only soft socks or stockings made from natural materials (with a high proportion of cotton). Don’t wear tight socks because these can block the circulation. Take care that there are no creases which may cause blisters.

• Shoes: When you buy shoes, make sure they are wide enough and choose soft shoes. Break in new shoes carefully. Check the inside of the shoe for prominent seams or anything that might rub.

• Going barefoot: This is particularly dangerous for diabetics with neuropathy. Always wear shoes, even at the beach or in the shower.

• Injuries: If you find a foot injury, it’s best to go straight to the doctor.