If you have diabetes, you may notice your feet feeling funny. They might be numb and feel like they're encased in wax. They also may feel like they're on fire and stop you from sleeping. In my practice, I work with my patients with diabetes to help them prevent problems from occurring. And if a problem does occur in their feet, we work together to address it.
Peripheral neuropathy is a condition where the peripheral nerves, the nerves in the feet, and sometimes the hands are damaged. Different people feel their symptoms differently. In some cases, your feet feel numb. This can range from a dullness when you walk like you're wearing an extra pair of socks to a complete numbness where it's difficult to maintain your balance. In other cases, your feet are painful. Sometimes there's a mild tingle or burn, but it could be a severe and unrelenting sensation that your feet are on fire.
You need to know the cause of the neuropathy before you can successfully attempt to treat it. Peripheral neuropathy caused by diabetes is because of two issues. First, the presence of chronically high blood sugar levels that could damage the nerves. That's one reason why it's so important to keep your blood sugar in good control. In diabetics, peripheral neuropathy is also caused by poor circulation. In fact, it's the small microvascular circulation that's compromised in diabetics. Even when the larger arteries, the major pipelines, are open, the smaller arteries can be compromised. When the nerves don't get enough blood flow, they don't get enough oxygen. And that will cause peripheral neuropathy. The symptoms of peripheral neuropathy are also often at night, even though you may feel them all during the day. In many cases, symptoms of peripheral neuropathy may be so intense that they keep you up at night.
In order to diagnose diabetic peripheral neuropathy, there are several tests that can be done. The simplest test that I do in the office is using a thin filament to assess if you're able to feel it. This tests for protective sensation, that means if you step on something, you'll be able to feel it. You shouldn't take that for granted. I'll also use vibration and check on nerves. That's simply done using a tuning fork. It's just another way to test the nerves.
More advanced testing can also be done. For that, I refer you to a neurologist. There are two tests that are done there. A nerve conduction study and EMG. The nerve conduction study examines, how fast electrical impulses travel through the nerves down the legs. The EMG study measures the electrical discharges caused by the muscles.
When your peripheral neuropathy is painful, there's medication to help manage that pain. But here's the thing. These medications are not primarily used for neurological pain. It's essentially one of their side effects. The medication are primarily anti-seizure and anti-depressant medications. These include Gabapentin, Lyrica and Cymbalta.
So I know things sound pretty grim, and I'd like to say it doesn't get worse. But in fact, it can. So far we've been discussing a sensory neuropathy. Diabetic peripheral neuropathy can progress to an autonomic neuropathy. That's where the nerve damage affects the bones and joints of the foot causing them to shift. This is called a Charcot foot.
What happens is the arch collapses and the foot develops a rocker bottom to it. This makes it difficult to fit into shoes, to walk, and to manage the pressures in the bottom of the foot. Often, this increase in pressure causes a diabetic foot ulcer to form. When these changes occur, the foot gets warm and very swollen. The changes that occur are obvious.
Treatment for a Charcot foot starts as the changes are occurring. It's important to provide stability to the foot. I'll immobilize you in a fracture boot and keep as much pressure off the foot as possible. This will help to stop or slow down the changes in the foot. After the foot is stabilized, we need to make sure that you have proper footwear. In some cases, we'll look at extra depth footwear. If there's already been a significant change in structure, we may need to consider a custom shoe. For people with a severe deformity caused by Charcot changes, especially if they cause recurrent foot ulcers, we can consider surgical treatment. Even the best treatment, however, will not return the foot to the structure before the Charcot changes began. So specialized footwear will still be necessary.