By Lenord S. Horwitz, DPM
Do you or a loved one have diabetes? Do you complain that your feet have one or all of the following?
My feet look O.K., but they hurt.
Changing to different shoes doesn't help.
I get no relief from pills, massage or soaks.
My feet are numb, but they still burn and tingle.
The soles of the feet and toes are painfully tender.
The pain in my feet is worse at night and keeps me awake.
What Do I Have? Diabetes is one of the most common health problems in our area. We don't understand why there are more diabetics in Appalachia. But we do know, that the diabetic is the most likely to suffer from foot problems and 80% of all diabetics will have a condition known as Painful Peripheral Diabetic Neuropathy. (PPDN) The two words that you may be unfamiliar with are Peripheral, which means the outer part like the skin and muscles, and Neuropathy, which means disease of the nerve. Diabetes and painful we all know.
What Does PPDN Feel Like? Painful Peripheral Diabetic Neuropathy is where there is little to no feeling in the fee, but where the patient still suffers severe pain. We know that diabetes causes nerve damage and poor circulation, but we do not know for sure how it affects the nerves. These losses of feeling and circulation are the main causes for diabetic foot ulcers, infections, deformity, and worse, foot amputation. An ulcer of the foot is often the last evidence of advance diabetic disease. When the blood sugar of the diabetic is stable, little thought is given to the feet and legs for the prevention of ulcers and infections. Because of the loss of feeling, diabetics are unable to tell the doctor the amount of change in their numbness, pain or balance in their feet. This is because these changes occur so gradually that the feet show no significant difference and are so subtle that doctors have a difficult time measuring them.
What is PPDN?
This is when diabetes causes changes in the smallest nerves to the skin. This nerve damage causes the feeling of pain, burning, tingling and/or numbness. The nerve pain and loss of feeling (parasethesias) occur because the nerve covering degenerates (depolarizes). Doctors involved in your care understand the difficulty in diagnosing and treating PPDN and have developed a great deal of respect for the degree of pain you endure. It is a cruel irony that patients who eventually may have to live without any protective feeling in their feet must also endure years of pain. It is not clear why some diabetics are so sensitive to these sensations while others are not, and why some diabetics respond to treatment and others don't. People try changing shoes, home remedies, aspirin or other anti-inflammatory medications, but these rarely reduce the pain.
Are there any tests for PPDN? If your history leads me to suspect that you have a PPDN, a physical examination is essential. It is important to rule out any other cause of pain, such as warts, callouses, neuromas, fractures, infections or arthritis. Your foot structure and how you walk may also increase the pain in the diabetic with PPDN. Because your diabetes causes loss of feeling and poor circulation, your feet might develop arthritis or even a fracture in your foot and that will just add to the hurt.
Most diabetics with PPDN appear to have severe pain without a cause, and the pain does not respond to ordinary treatments. Even though other diseases cause peripheral neuropathy, the history of diabetes should trigger concern that you have PPDN. If a peripheral neuropathy is suspected, then nerve circulation and walking tests should be done. Interestingly, it is not particularly unusual for the earliest stages of the nerve's breakdown (neuropathy) to be painful. This means that some of the tests may be normal and will not tell the whole story. Despite the lack of solid positive test results, treatment still should be started.
How do we treat PPDN? In cooperation with your diabetic doctor, certain medications can be safely tried to control the symptoms of PPDN. They are categorized as either systematic (internal) or topical (external) treatments. There are some creams that can be applied to the feet at night that increase circulation while there are others that will help heal the nerves. Oral medication is another treatment to consider. Some medications have been found to improve sleep and to significantly reduce pain. When the uses of different medications are combined with physical therapy, exercise and vitamins, the pain is greatly diminished, but not eliminated. To help control your pain and reduce the need for medicine, an external nerve soothing device can be tried. This small electrical box that you can wear is called a TENS unit. TENS stands for Trans Electrical Nerve Stimulator. We don't know how much it works, but for some diabetics it allows them the freedom from using pain medicine.
What can you do to help? Because the pain of the PPDN is caused by the degeneration of the nerve along with poor circulation, it is important to treat these two problems together. To reduce the nerve pain and to increase the circulation, there are some things that you can do at home. You must reduce the possibility that your shoes are too tight or too short, you must exercise to improve your walking and standing and, of course, nicotine is a major problem. Proper fitting shoes and socks, custom inserts, home care and hygiene are a must to reduce the threat of infection and reduce the pain.
Are these treatments covered? Most, if not all, of these treatments are covered by Medicare, UMWA and Medicaid with a prescription from your doctor. Medicare and Medicaid have a special fund under the Diabetic Shoe Bill that covers the cost of the special shoes and most treatments.
Can I get better? PPDN with other causes, such as poor circulation or anemia, may resolve with treatment. Some diabetics eventually move out of the painful stage into no feeling at all. This may seem like an improvement from the patient's point of view, but a high risk for developing foot problems. This change can take from two to five years. Many patients who develop pain in the early stages of Painful Peripheral Diabetic Neuropathy have a higher chance of circulation problems as well. This will result in serious problems that we observe in the diabetic foot. Painful peripheral neuropathy remains a challenging problem for the diabetic. Treatments can help how you, our patient, live and feel. But it all depends on you.