Specialties +

This department deals with diseases of the Endocrine Glands viz. Thyroid, Parathyroid, Pituitary, Gonads (Testes, Ovaries), Adrenals.

Hormonal Disorders covered include Diabetes Mellitus, Disorders of Thyroid Functions, Obesity, Failure to Grow, Hirsutism (excessive facial and body hair in females) Menstrual Disorders and Metabolic Bone Disorders.

Diagnosis and treatment of endocrine gland related disorders such as

• Diabetes Mellitus
• Hypothyroidism / Hyperthyroidism
• Growth disorders (short stature)
• Excessive Facial and Body Hair
• Osteoporosis and related Metabolic Bone Disease
• Disturbances in Calcium Metabolism
• Certain Menstrual Disorders and Obesity
• Secondary hypertension (Pheochromocytoma, Hyperaldosteronism)
• Multiple Endocrine Neoplasia (Men - tumor growth in more than one endocrine gland)

Special emphasis is placed on management of pubertal and adolescent hormonal problems.

Keen interest on management of Diabetes Mellitus in young

Diabetes has reached epidemic proportions in our country. The incidence of diabetes in urban areas (as per DIABETES ASIA study) is 12 to 14%.This is almost double the decade old incidence of 6 to 7%. Even in rural areas, where the incidence was 2 to 3%, the incidence has increased to 6%.Such an increase is highly alarming.

As per a WHO estimate, India will have largest number of diabetic patients in the world by 2015 (approximately 6 crore).
Almost 50% of these patients are likely to be in the age group of 35 to 45 years.

One of the most dreaded complications of diabetes is Gangrene of the foot and leg. Approximately 15% of all diabetic patients get foot problems. This means, more than one crore diabetic individuals are likely to suffer from foot and leg problems. It is important to realize that majority of these patients will be in the age group 35 to 45 years.

It is always better to prevent the diabetic foot wounds than to treat it. Indian as well as international statistics shows that 60% of the indoor admissions for the diabetic patients are for foot problems. Therefore preventive care is very important and essential.

Keeping in mind the scale of the problem and the preventable nature of this progressively disabling deformity, Our Diabetic Foot Clinic offers comprehensive, detailed evaluation of one’s feet to help identify the small signs oft missed.

The clinic seeks not just to treat those already afflicted with “Diabetic foot” in its various stages, the various associated complications with the latest in medical and surgical treatment offerings but also educate one and all to develop a proactive preventive approach to tackle the impending complications. In addition, we assist in providing the right footwear.

Who should under go foot evaluation?

All diabetes patients should undergo foot evaluation every year and as per the evaluation report should wear protective footwear.

How this evaluation is done?

Foot evaluation includes testing the function of nerves of the leg and checking the blood in the leg blood vessels. This involves using instruments called “sensitometer and handheld Doppler”. It is painless evaluation which takes 15-20 minutes. Along with those patients feet are checked for existing effects of damage to nerves. Patients are also taught to take care of their feet and are advised about protective foot wear.

How frequently the evaluation is to be done?

The frequency of evaluation depends on the level of damage to nerves and blood vessels as well as the existing complications. Usually it is done once a year but in some patients it needs to be done more frequently.

Warning Signs

Development of the following symptoms require urgent attention from a qualified Diabetic Foot specialist.

Why do diabetic patients get foot problems?

Diabetes is a metabolic disorder caused due to the absolute or relative lack of Insulin, a hormone which regulates the sugar metabolism in the body. This causes rise in blood sugar levels. This affects, in addition to other organs, the blood vessels and nerves in the body. The nerves in the leg are affected usually more than those of any other part of the body. This can manifest as

• Loss of the protective pain sensation of feet: The feet become numb .Many time diabetes is detected because the patient injures himself due to loss of sensation and /or the resultant non healing wound.
• Pain in the leg which can be of the burning/tingling /sharp type. This occurs due to the nerves getting affected.
• The sweat and sebum glands (their secretion keeps the skin soft and supple) are damaged and the skin of the foot becomes dry/ scaly and starts to itch. This causes fissures and often leads to wounds. In fact the maxim ”FEET THAT SWEAT DO NOT ULCERATE” holds true in diabetes. Therefore, if a patient of diabetes finds that his feet do not sweat, then it is a danger sign.
• Muscles of the affected foot become weak and the foot shape might change as well over a period of time. This creates extra pressure on certain areas and if accompanied by loss of sensation, the extra pressure can cause a wound to develop.

In addition to the nerve damage, about 15% of diabetic foot patients have damaged blood vessel in the legs. The blood vessels are either thickened or blocked. This causes pain while walking.

Any diabetic patient who is unable to walk due to the pain in the legs should immediately get the tests for the blood circulation in his legs done. Every wound in the human body requires blood and rest for it to heal. In diabetes, a patient may be unaware of a developing wound due to loss of pain sensation. In addition, the wound healing gets delayed due to the blood vessels being affected(as adequate blood supply, essential for any wound to heal is not able to reach the wound) This, then over time, may gradually set in the process of gangrene leading to loss of limb

What is the common cause of injury to the feet in diabetes?

In the presence of loss of sensation and reduced blood supply in some patients, the best way a patient can protect his feet is by avoiding any trauma to his feet.

The common mode of injury in a diabetic patient is usually excessive walking with unprotected feet and/or walking with incorrect footwear. This causes excessive pressure on insensate skin and creates callus/corns which break down form an ulcer (wound). A diabetic patient must NOT walk with unprotected feet.

Remember, DIABETIC FOOT WOUNDS ARE LIKE AN ICEBERG. A VERY SMALL PART IS VISIBLE TO THE EYE.

Can damage to feet be prevented or minimised in diabetes?

A large multi-centric trail done few years ago, known as DIABETES COMPLICATION CONTROL TRIAL(DCCT) has shown that very tight control of blood sugar by the patient can avoid /reduce the foot problems by 60%.The patient needs to get his foot checked for loss of sensation and extra pressure at regular intervals. Extra pressure can be detected with a computerized machine called “Pedo Podograph” which detects extra pressure points on the feet, almost a year earlier before a patient forms a callus. Such early detection of extra pressure points can help to determine the proper footwear needed by the patient to prevent wounds.

How to assess the state of vasculopathy and neuropathy?

This can be done by the patient as well as his doctor. As a diabetic patient, one should consult the doctor as soon as he/she notices that his feet show reduction/absence of sweating. This is the earliest sign of nerve function loss which a patient can detect. He should go for neuropathy assessment with “Biothesiometer” or Nerve conduction studies” to accurately determine the extent of neuropathy.

Many other signs also develop at a later stage, which need to be carefully watched for. These include stiffness of toe joints, especially of the first toe, callus formation at pressure points, heel fissures, dry skin, fungal infection of the nails and change in the shape of toes etc. However these are late signs and patient should not wait for these to develop before seeking help. If these signs have already occurred, it is indicative of already damaged feet and certain amount of disability is inevitable. If the patients detects early sign,

In case of vasculopathy the earliest symptom which should warn the patient of reduced blood supply is pain on walking. If the patient feels cramps in his calves/legs after walking which reduces on rest, it is a sign of vascular blockages. This requires further assessment with Color Doppler and Angiography tests.

If patient finds callus (hard skin) building up under the toes or on the sides of the toes or the toes are crowding together, then he should get callus trimmed by the doctor and get checked for neuropathy.

How should a diabetic patient take care of his feet?

• Since the protective pain sensation in feet is reduced/lost, one should not walk barefoot. Even at home, one must always use protective footwear.
• One must inspect his feet daily for cuts / abrasions /blisters / wounds etc. If one gets injured or finds any blisters /abrasions, one must keep these clean and consult his doctor immediately. One should not bear any weight on the affected foot till the wound heals.
• Daily, one must clean one’s feet with soap and water and wipe them with soft cloth especially in the web spaces, and apply linolient cream.
• Nails must be cut square so the edges do not turn inwards and damage the soft tissue. The nails become hard and brittle in diabetes. Therefore they are best cut after the bath when they are soft. If the patient has eye problems, then he should not try to cut his own nails. This often causes injury.
• One must not use blades/knives or commercially available preparation like corn caps for calluses/corns on his feet. Callus /corns are formed due to pressure and need proper assessment from the doctor.
• Avoid wearing any footwear with a web strap. Often the muscles are weakened leading to difficulty in holding the strap which might lead to further injury to the toes.
• One must never apply hot fomentation/cold compresses/strong counter irritant ointments or do vigorous massage to relieve the various pain sensations that might be felt. This can cause irreversible damage.
• Persistent unilateral (one –sided) swelling of feet can be a sign of serious damage to the bones and joints of his feet and needs to be shown to a doctor immediately.
• Ideally no footwear should be purchased without the advice of a doctor. The foot wear should not have any metal buckles/hard straps/web straps. It should have wide toe box and extra depth. The footwear needs to be worn, both indoors as well as outdoors, with socks at all times. If the foot wear is worn out at particular place, it is indicative of extra pressure being applied at that area of the foot and needs to be shown to the doctor at the earliest.
• A diabetic patient whose feet are progressively getting deformed due to nerve affection should avoid prolong walking/jogging/various exercise machines/cycling and must adjust his exercise schedule
• While traveling, one must not remove his/her footwear and rest the feet on the floor of the vehicle. This can cause damage to the skin.
• No amount of drugs/medicines can keep a patient’s feet intact unless the patient is wearing properly designed footwear.

Footwear in diabetes

Every diabetic patient must follow following guidelines while purchasing footwear:

• All foot wear must always be worn with socks. It is necessary to avoid direct contact between the footwear and skin. Socks also help in reducing the damage to the skin of the fore foot.
• The foot wear should not have any metal buckles/straps with metal fittings/metal cosmetic fittings etc. These metal buckles or fittings can cause injury.
• The straps of slippers/sandal should be adjustable. (Fixed straps can cause pressure injury.)
• The heel of the foot should be completely supported by FULL HEEL COUNTER. Footwear with only a single strap (partial heel counter) cause damage to the skin of the heel.
• The size of the foot wear needs to be measured properly .The width should be measured from base of the first toe to base of the 5th toe and length from heel edge to tip of the longest toe( which is usually the second toe). However, the patient should purchase foot wear which has extra 2 to 4 mm all the sides .This is necessary as the damaged nerves lead to feet swelling up by evenings, leading to, even the most well fitting shoe in the morning to become tight in the evening and this might harm the feet. All closed shoes MUST have wide toe box and extra depth.
• There should not be any nails/seams in the inner lining of shoe/slippers.
• The slippers with web/toe straps should be avoided by diabetic patients at all times. This type of footwear can with prolonged use lead to adversely affecting the shape of the toes leading to claw toes and can cause friction injury in the 1st web space
• Diabetic patients, who get swelling of the feet and leg, should purchase shoes/slippers in the evening to avoid purchasing tight foot wear.
• All diabetic patients must check their feet every day for dry skin/fissures etc. As soon as reduced sweating is noticed, it is necessary to contact their doctor immediately .Such patients are classified as Grade 1 and they require special foot wear which has to be purchased with the advice of the doctor only.
• Every person who is detected as a diabetic must protect his/her feet. Remember that 85% of diabetic patients who lose their legs have neglected to use proper foot wear.
• Footwear should not be continuously used especially when the footwear is new.
• Footwear should always be checked for foreign bodies before use

What type of shoes/footwear should diabetic patients use?

No amount of drugs/medicines can keep a patient’s feet intact unless the patient is wearing properly designed footwear.

Patients of grade 1 and 2 neuropathy and early vasculopathy are always at risk of injuring their feet and hence they should be very careful about selection and use of footwear. Even with the advanced neuropathy and deformed feet the feet can kept at optimal level of functioning with proper selection of footwear.

Every patient will need some specific changes in the foot wear as per the nature of his problem. The following type of footwear will have to be used.

• For Callus: Rigid Sole with Insole wing pad to distribute the pressure to surrounding areas.
• For Limited Joint Mobility of the 1st Toe: Rigid sole footwear with adequate thickness insole
• For Deformed toes and 1st toe which has turned inwards: Rigid sole, with Insole wing pad for reducing pressure, and if required additional gel pad over the insole to protect the deformed toes.
• For small ulcer with callus: Rigid sole footwear with insole wing pad.
• If the ulcer is large then patient requires front orthowedge sandals as a temporary measure and when the ulcer heals then patient can be given permanent footwear.
• For Vasculopathy(blockages in the blood vessels) : The footwear should be lined with soft material should have rigid sole, must accommodate the deformity and should have extra depth
• For infected/large heel fissures: patient should wear heel wedge sandals till the fissures heel and then permanent footwear can be given.