Foot disease is a common long-term complication of diabetes. There are different types of foot disease caused by diabetes, but they all stem from a similar process. Raised blood sugar for a prolonged amount of time causes damage to blood vessels. This can lead to damage of the nerves that supply sensation and the whole blood circulation of the leg.

The damage to the nerves is called peripheral neuropathy. This causes the loss of sensation into the feet and lower legs. The loss of feeling leads to many further severe foot conditions, such as problems with joints and trauma to the foot.

The damage to the blood vessels causes narrowing, which leads to poor circulation. The smallest vessels at the end of the foot can become blocked. This leads to a higher risk of foot injury, such as ulcers. And due to the poor circulation, these do not heal well.

Due to all diabetic patients being at high risk of these complications, adequate foot care is essential. This involves keeping nails trimmed and filed, washing and drying feet regularly, and keeping them moisturised. Footwear must be checked regularly for any damage or change too.

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The recommended protocol is for all patients suffering from diabetes to have yearly foot checks. This was checking the foot pulses and doing sensation tests. At these checks, patients are categorised into three groups, low, moderate, or high risk. Low risk patients have no signs of neuropathy or poor blood supply and are recommended to keep up their foot care and continue to attend yearly foot checks. They are at low risk of developing further foot complications.

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Moderate-risk patients are at a slightly higher risk of developing foot complications and may have absent pulses or have developed some form of sensory loss. These patients may need treatment from a podiatrist and are encouraged to keep up their foot care and yearly checkups.

High-risk patients may currently have or have suffered from all sorts of foot trauma in the past.These patients require regular treatment from a podiatrist and could be at risk of requiring amputation in the future. These patients should consult a podiatrist before trying to care for the feet themselves. They need specialist care.

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Neuropathy can be complicated in diabetes. When the large blood vessels are affected, these are called macrovascular complications, like ischaemic heart disease and stroke. However, when the small blood vessels are affected, this is called microvascular and a particular neuropathy is when the nerves and the blood supply to the nerves is affected.

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Nerves carry messages between the brain and every part of our body, making it possible to see, hear, feel, and move. They also carry signals that we're not aware of to other parts of the body, such as the heart, altering the rate it beats at, and the lungs, so that we can breathe. Diabetes can cause neuropathy as a result of high blood sugar levels damaging the small blood vessels that supply the nerves. This prevents essential nutrients reaching the nerves. And the nerve fibres are then damaged or disappear.

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Neuropathy can affect the feet, in which case, it's called peripheral neuropathy. But it can also affect the digestive tract, heart, or sex organs. Up to 70% of people with diabetes will develop some degree of neuropathy. The risk is increased with the length of diabetes, poor control of your diabetes, and in Type 1 more so than Type 2 diabetes.

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There's a number of factors that can be associated with precipitating diabetic neuropathy. These include lifestyle factors such as smoking and alcohol use, conditions that cause inflammation of the nerves or mechanical injury to the nerves, and also poor control, causing high blood sugar levels and high blood fat levels.

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There are many separate types of neuropathy. The classic glove and stocking neuropathy affects your hands and feet and is involved with pain and loss of sensation and is called peripheral neuropathy. You have autonomic neuropathies which, in effect, your response to sweating, heart rate, blood pressure, and also impeding your warning signs of low blood sugar. You can also get proximal neuropathies as well as focal neuropathies, as listed in the slide.

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There are a number of symptoms that are associated with a neuropathy. The classic--pain, tingling, or numbness in the toes, feet, hands, or legs-- is associated with peripheral neuropathies. However, if you have autonomic neuropathies, you can get other symptoms, which are listed in the slide. And depending on the area involved, you can get various number of symptoms.

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The classical peripheral neuropathy gives you symptoms of numbness, tingling, pain, and loss of balance and coordination, and can be complicated by infections, deformities of the foot, and-- indeed-- amputations. Through careful treatment and screening, 50% of amputations may well be preventable.

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There's a number of symptoms associated with autonomic neuropathy, depending on which system or body part is affected. The classic diabetic gastroparesis affects the stomach and the digestive tract, leading to bloating, constipation, or diarrhoea. Urinary symptoms include loss of bladder control and incontinence. And you can see from the slide, there's a number of other systems which are affected-- give you classic symptoms.

Gastroparesis (slow stomach emptying) -persistent nausea and vomiting, bloating, and loss of appetite. Can make blood glucose levels fluctuate widely, due to abnormal food digestion.

Heart and Blood VesselsNerve damage interferes with the body's ability to adjust blood pressure and heart rate.Symptoms: Blood pressure may drop sharply after sitting or standing, causing a person to feel light-headed/ faint.Heart rate may stay high, instead of rising and falling in response to normal body functions and physical activity

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Eyes –can affect the pupils of the eyes, making them less responsive to changes in light. Autonomic symptoms : shakiness, sweating, and palpitationsIn people with autonomic neuropathy, symptoms may not occur, making hypoglycemia difficult to recognize

A person may not be able to see well when a light is turned on in a dark room or may have trouble driving at night

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Whilst the diagnosis of neuropathy is mainly clinical, there are a number of tests we can do to try to help us diagnose types of neuropathy and also the extent of the damage. Nerve conduction studies are one way of doing this. And these tell us the type and extent of nerve damage. Other things we can do are ultrasound scans or something called gastric emptying studies where we look to see how quickly the stomach empties. This is particularly useful in people with gastroparesis.

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There's a number of ways of treating painful neuropathy. You usually start off with taking simple painkillers like Paracetamol and working up to more complicated ones, including gabapentin or duloxetine. At extreme cases, you can use opiates or morpheme-based painkillers. You can also use topical creams. In the case of allodynia, where there's pain due to stimulus that does usually not provoke pain, you can use plastic films.

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Recently, there's been a number of guidelines have been developed to help guide management of neuropathy. The National Institute of Clinical Excellence has developed a national guideline for management of primary and secondary care in 2008. And this is summarised in this slide. And there's a flow chart. And you can go down either way of whether there's non-severe neuropathy or severe symptoms.

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Part of the spectrum of neuropathy includes erectile dysfunction. General measures include improving blood sugar control, making people lose weight, and reducing the alcohol intake. Look at any medication they're on that might cause the issues and stop them if necessary. Correct any underlying associated endocrine disorders and make sure that you involve the partner from the start.

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