PART 4: WHY DO MY TOES, ANKLES AND FEET HURT AT NIGHT? DIABETIC FOOT DISEASE

Over the past month, I have discussed why venous and arterial disease as well as Raynaud’s Syndrome may cause pain in the feet and toes at night. Today, I want to discuss another one of the most common causes I see in my clinic for pain in the feet at night: Diabetic foot disease.

Interestingly, diabetes mellitus has Greek etiology and literally means sweet (mellitus) urine (diabetes).  Diabetes is a condition in which the body loses its ability to limit the amount of sugar in the blood.  The high concentrations of sugar result in the formation of harmful chemicals that can hurt the eyes, kidneys, and nerves all around the body, especially in the feet.  Once the sugar levels become high enough, they overload the kidneys—the organ that creates urine—and sugar overflows into the urine, hence the Greek etiology of diabetes mellitus.

Diabetes causes pain in the feet via two main pathways: Neuropathic pain and pain from ulcers. 

Neuropathic Pain:

For neuropathic pain, the high blood sugar levels damage the small nerves in the feet responsible for sensation.  As a result, patients often complain of burning, cramping, tingling, and at the very worst end of the spectrum, numbness.  Sometimes only the toes have these symptoms, but often times the symptoms can encompass the entire foot!

Ulcerative Pain:

The way diabetes results in the formation of ulcers is multifactorial.

  • First, the damage to the nerves can result in numbness or lack of sensation.  Thus, when a person injures their foot, that person does not feel it and protects it from further injury.
  • Second, in addition to damaging the nerves responsible for sensation, diabetes also damages the nerves that innervate muscles responsible for moving.  The damage to the muscle nerves occurs in such a way that irregular contractions of muscles within the foot push the bones of the foot outward creating pressure points that ulcerate easily.  Once the ulcer is formed, infection of the ulcer or exposure of the raw tissues beneath the skin can cause pain.  In patients who otherwise have numb feet, an infection can spread to an area that does have sensation and cause pain there.

Given that diabetes is so common, patient education is vitally important to those impacted by this disease.  If you or anyone you love suffers from diabetes, my hope is that this blog will help you to better understand some of the underlying factors that may be contributing to your foot pain at night.  As a rule of thumb, always remember to share with your primary care physicians all symptoms of pain that you experience during your regularly scheduled appointments and if you think your condition may be getting worse, please do not hesitate to call my office to schedule an appointment for a second opinion! We can help.

408-376-3626

Dr. Ignatius H. Lau

Vascular Surgeon

Dr. Ignatius Lau grew up in Portland, Oregon. He attended the University of Washington in Seattle for college and Stony Brook University in Long Island for medical school. He then went on to train in vascular surgery at Mount Sinai Hospital in New York City. During his time in New York, he performed over 1600 cases involving aortic, peripheral, venous, and carotid surgery. He has a special interest in limb salvage and treating patients with peripheral arterial disease and has extensive training and experience in treating the full spectrum of vascular diseases. Dr Lau was also very active in medical research during his training, ultimately finishing with twelve peer reviewed manuscripts. During his training in New York he met his wife, Lisa, who is a practicing endodontist. Together they love to hike, try new restaurants, and travel.

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WHY DIABETES IS BAD FOR YOUR FEET

Everyone knows that diabetes, otherwise known as high blood sugar, is bad for you.  What most people don’t realize, however, is just how many people in the US have diabetes and the impact diabetes has on their feet. In 2021 the CDC released the following info graphic:

 

As a vascular surgeon the primary issue I see in patients with diabetes is foot infection.  But how does diabetes specifically make it more likely for patients to develop foot infections?  My hope in writing this blog today is to give patients a complete understanding of what happens to the feet of people with diabetes.

High concentrations of sugar in the blood lead to what physicians call an inflammatory state in the arteries, or blood vessels that take blood from the heart to the rest of the body.  The inflammatory state results in scarring and narrowing in the arteries.  However, only smaller blood vessels such as the ones in the eyes, toes/feet, and kidneys are affected significantly.  In the feet, the scarring affects both arteries that supply the feet and toes themselves as well as the arteries that supply the nerves.

With a lack of blood flow to the nerves of the feet, patients lose sensation in their toes and feet.  Thus, when a patient has an accidental injury like a scratch or a bruise, no pain is registered, and the area continues to be traumatized and unable to heal.  In addition, the muscles of the foot lose their ability to contract, and they then relax into positions that create bony prominences that erode through the skin and cause ulcers.  Finally, the nerve damage also results in the loss of natural oils in the skin that then makes the skin dry and prone to cracking.  This cracking then increases the chance of ulceration and foot infection.

As you can see, diabetes is very bad for the foot!  If you are diabetic and see an ulcer on your foot or have either pain or numbness, do not hesitate to call our office at 408 376-3626 to schedule an appointment today! Visit our website at www.southbayvascular.com to learn more. We Can Help!

PERIPHERAL ARTERIAL DISEASE (PAD); EARLY RECOGNITION AND REFERRAL TO A VASCULAR SURGEON

According to the U.S. Centers for Disease Control and Prevention (CDC), approximately 18 million people in the United States suffer from Peripheral Artery Disease (PAD), a common circulatory problem in which narrowed arteries reduce blood flow to the limbs. Estimates suggest that anywhere from 12 to 20 percent of individuals over the age of 60 are living with PAD. Approximately 160,000 to 180,000 of the estimated 18 million Americans with PAD will undergo a limb amputation as result of PAD-related condition this year, resulting in lower quality of life, high medical costs, and shorter life expectancy.

But even with these alarming numbers, APPROXIMATELY 3 OUT OF 4 AMERICANS are unaware of PAD Symptoms.

Severe PAD symptoms include:

  • Leg pain,
  • Wounds on the toes or feet,
  • Gangrene and
  • A loss of leg mass compared to the rest of the body.
  • Individuals are at greatest risk for PAD if you have high cholesterol, high blood pressure, or diabetes.

Dr. Polly G Kokinos, a board certified Vascular and General Surgeon in Campbell, CA. is recognized as one of the regions foremost authorities in the diagnosis and treatment of PAD. With offices in both Campbell and Gilroy, CA. Dr Kokinos has dedicated her entire career to serving the South County community as an independent physician and as a pioneer in the evaluation and treatment of patients suffering from Peripheral Arterial Disease.

Unburdened by the productivity metrics, financial benchmarks and administrative red tape commonly found in Big Box Medical Systems, Dr. Kokinos has focused her entire career on providing exceptional vascular care building her practice one patient at a time. Her Campbell Surgery center, a nationally accredited Vascular Surgery Center of Excellence, is entirely dedicated to treating patients suffering from complex vascular surgical disorders. Unlike a traditional hospital or university operating room, Dr. Kokinos’ surgery center is entirely dedicated to addressing vascular issues ensuring that she has the most advanced imaging and device technology available anywhere in the world.

Unfortunately, even with all of her skill experience and technology, many patients don’t find Dr. Kokinos until its too late. Many patients go under diagnosed or undiagnosed until it is too late and their medical condition has declined to the point where no one can help. In this circumstance patients lose limbs, suffer unnecessarily and become an incredible burden on their family and loved ones. In the worst cases, patients can die if their leg wounds are left untreated.

In an effort to help front line medical doctors better evaluate and diagnose peripheral arterial disease Dr. Kokinos has spoken extensively to the Primary Community Care Team (Internists, Podiatrists, Orthopaedic Surgeons) in the management of lower extremity arterial and venous disease. As is the case in most instances, early detection of peripheral arterial disease has a dramatic impact on the success of any future treatments.

Bridging this educational gap was the topic of a recent talk Dr. Kokinos was honored to give in March of 2020 to a group of Northern California primary care physicians. The focus of this talk was to help primary care and referring physicians better understand the etiology (the cause of a disease or condition) its diagnosis, management, and referral strategies for peripheral arterial and venous disease.

The key takeaways from her talk are outlined below:

  • Prevalence of PAD and Venous Disease have reached epidemic proportions.
  • Peripheral Arterial and Venous Disease are both associated with high rates of disability and death.
  • Identifying arterial disease early may improve a patients quality of life and allow early medical and surgical interventions to lower the risk of critical limb ischemia and amputation.
  • Identifying venous disease can greatly improve a patients quality of live and lower their risk of dying from this disease.
  • Despite greater awareness, PAD and Venous disease are still under-recognized and under treated.
  • Due to the complex nature of vascular disease, an evidence-based multidisciplinary approach is essential to early assessment, proper diagnosis and optimal treatment
  • Minimally invasive endovascular techniques now enable vascular surgeons to treat significantly higher numbers of patients with a lower complication and death rate
  • Appropriate referrals to specialists must be emphasized if physicians are to continue to improve the lives of patients with PAD

Her underlying message to the audience was that primary care physicians are a patients first line of defense. Helping patients achieve better outcomes requires early recognition and management on the part of the primary care physician and that early referral to a vascular surgeon is essential to the successful outcome of advanced treatments.

If you or anyone you love suffers from any of the symptoms outlined in this blog, we would be honored to speak with them to discuss their symptoms. Call Dr. Kokinos’ office at South Bay Vascular Center to schedule an appointment at 408-376-3626.

WHY DIABETIC FOOT WOUNDS DON’T HEAL

One of the main complications of diabetes is the development of diabetic foot ulcers. Diabetic foot ulcers occur in 15% of all patients with diabetes. There are four primary contributing factors to the developments of these ulcers.

  • The presence of peripheral neuropathy (loss of feeling over the toes);
  • Changes in the architecture (shape) of the foot causing it to have pressure on areas ot built for it;
  • Poor blood flow to the foot;
  • A decreased ability to fight infection in the foot.

The main reason why diabetic wounds do not heal is due to lack of blood flow to the ulcer and ongoing pressure to the wound

Diabetics must pay special attention to their feet and ankles and it is vitally important to NOT ignore a small wound when it develops. Diabetic wounds, when left untreated, are the cause of 85% of the amputations that occur in these patients. Once these ulcers develop, they often DO NOT HEAL just by putting a Band-Aid over them, or even with wound care and ointments prescribed by your primary care doctor.

Care of Diabetic Foot Wounds

It is very important to see both a podiatrist (foot specialist) and a vascular surgeon (blood flow specialist) to examine your foot. These doctors can help with special treatments such as debridement (cleaning the wound), off-loading (taking pressure of the wound) and improvement of blood flow to help your wound heal. Debridement helps remove dead tissue and bacteria from the wound. Off-loading and special inserts or shoes allow the pressure to be removed from the wound so that it can heal. Diabetes causes blockages with calcium deposits inside your small blood vessels, which are below the knee, and this prevents oxygen and nutrients from getting to your feet. The vascular surgeons at South Bay Vascular Center have a special interest and expertise in opening these blood vessels in order to bring flow to your toes and feet that can help save patients from amputation. If you or anyone you know suffers from diabetes and are experiencing foot wounds that do not heal, call us immediately at 408-376-3626 to schedule an appointment to have these wounds evaluated.

TREATING DIABETIC FOOT ULCERS

Millions of patients every year are seen in wound care centers for the treatment of their foot and leg ulcers. This is absolutely the correct place for anyone who has had a wound that is “non-healing” or “chronic”. That is, a wound that is still there after four weeks. Unfortunately, sometimes the physicians in these wound care centers are quick to put on expensive savs or other advanced treatment options. After all, isn’t that why the patients go to the wound care center instead of just their physician’s office? Partially. Good wound care centers treat by guidelines.

Guidelines are a scientifically proven set of steps that have been shown to help wounds heal faster. For EVERY wound on the leg or foot, the very first step is to assess BLOOD FLOW. This means that every patient with a leg or foot wound that hasn’t healed in four weeks MUST be seen by both a vascular surgeon AND a podiatrist (foot specialist).

The vascular surgeon will assess the circulation and order appropriate diagnostic tests, such as vascular ultrasounds to look at the blood flow. This is important to examine, as a large number of the patients who have ulcers, have not previously been diagnosed with an arterial or venous problem. Without fixing the underlying cause of the ulcer, even if it does heal initially, it will soon recur, and cause further problems. It is important for patients to take an active role in asking for these referrals so that the problem does not progress and become a wound that can lead to an amputation.

If you or anyone you know is diabetic and suffers from non-healing leg wounds call today to schedule an appointment at our office. South Bay Vascular Center and Vein Institute Surgeons are recognized as the regional experts in wound care healing and amputation prevention. Our Vascular Surgeons have performed more lower extremity re-vascularizations than any other surgeons in the region and offer hope when others say there is none.

Call today at 408-376-3626