Nothing felt awry as Cornelius McGill soldiered through his eight-hour shift of heavy lifting at Kmart last February. But when he got home, he made an unsettling discovery: Lodged in his foot was a serrated bottle cap. Had it not been for his blood-soaked sock, McGill, 42, might not have noticed for days. Even so, his resulting foot ulcer—a type of nonhealing wound that afflicts up to 25 percent of diabetics like McGill—became a life-threatening condition when infection set in and spread to his bloodstream and bones. In a frantic effort to save his life, doctors prepared to amputate his leg. Today, he feels lucky to have lost only a toe. "My God, that this little cap did all that damage!" says McGill, of Waukegan, Ill. "It was shocking."
Because of the nerve damage caused by his diabetes, McGill feels no pain in his feet; indeed, 60 percent to 70 percent of the 20 million or so Americans who suffer from the disease experience the neuropathy that can lead to numbness in the extremities. About 30 percent of all diabetics 40 or older lose some feeling in their feet, the first step toward the infected ulcers that predispose diabetics to amputation. Published studies indicate that 1 in 5 infected foot ulcers requires amputation—at which point the chance of dying within five years is estimated to be upward of 50 percent.
The economic burden thatdiabetes and its related complications has placed on the U.S. healthcare system—now $174 billion each year, a 32 percent increase since 2002, according to a study released online last week by the American Diabetes Association—is creating a new urgency to prevent experiences like McGill's before they happen. (A related report to be published in the March/April edition of the Journal of the American Podiatric Medical Association estimates that about a fifth of those costs are directly related to diabetic foot ulcers and amputations, says lead author Lee Rogers, an amputation prevention specialist at Broadlawns Medical Center in Iowa.) "Every 30 seconds, someone in the world is losing a limb to diabetes," says David Armstrong, a podiatric medicine specialist at Rosalind Franklin University of Medicine and Science in North Chicago and the surgeon who treated McGill. "I can't stress enough how sinister this disease is."
But research indicates that most foot ulcers are preventable, and become deadly only when neglected, Armstrong says. Several studies, including one published in the American Journal of Medicine in December, have found that daily monitoring of skin temperature is an effective way to stave off ulceration in high-risk diabetics. Wounds heat up before skin breaks down, Armstrong explains. If patients detect an abnormality—a spot on one foot 4 degrees hotter than the corresponding spot on the other foot—conditions might be ripe for an ulcer. They may then decide to stay home rather than risk a day of walking, for example, or consult their doctor for more specific recommendations. In the latest trial led by Armstrong, patients using hand-held thermometers (specifically the $150 TempTouch) to track temperature differences between sites on their feet were three times less likely to develop ulcers than patients doing visual inspections alone.
Another technique used off-label to prevent ulcers entails injecting small amounts of liquid silicone into the balls of the feet to replace eroding fatty tissue. Although the method still hasn't been cleared by the Food and Drug Administration for this purpose, it's used for treating retinal detachment. By reducing the risk that a pain-free diabetic will walk right through his or her skin, advocates say, the procedure lowers the likelihood that ulcers will form.
"It's criminal it's not approved," says Sol Balkin, 82, a retired podiatrist and pioneer in using injectable liquid silicone to treat foot ailments. He estimates that in 40 years of practice he's administered more than 30,000 injections. Balkin and a U.S. company are currently working to gain approval to market this treatment in Europe.
Some specialists have qualms. "It's potentially dangerous," says Stephen Kominsky, a podiatric surgeon and diabetic foot expert at Washington Hospital Center in D.C. "Patients with diabetes are compromised, so injecting them with a foreign substance might trigger a negative reaction." In healthy patients—the procedure is often used to relieve pain and pressure in normally aging people losing the fatty padding in their feet—injecting silicone "makes all the sense in the world," Kominsky says. To heal foot ulcers before infection strikes, Kominsky uses a technique that he finds particularly effective: the application of living skin grown in laboratories from neonatal foreskins saved during circumcisions. The skin is placed atop clean ulcers to promote new tissue growth.
What experts can agree on is this: Informing people about the possible complications of diabetes is the best way to avoid infection and amputation. Patients alert to signs of danger can often minimize the damage. "If someone had just educated me about this," McGill says, "I'd say I'd be better off than I am now." He's unable to return to work, and there's no guarantee he won't lose his leg in the future.