Whole Foot
Wounds are common problems that we all experience many times throughout our life from childhood to old age. Our bodies have developed the ability to very efficiently and effectively heal them, usually with very little medical attention. An ulcer is a wound that occurred because of chronic irritation such as too much pressure in a specific area or rubbing on shoe wear. It often takes longer than the normal amount of time for these wounds to heal because of the degree of tissue damage. It can be distressing coping with this for reasons that hardly need to be mentioned. There are a few things that you should understand about your wound and its treatment to decrease the time it takes to heal it, and to minimize the chance that it will recur.
Diabetes is the most common contributing factor to foot ulceration. The increased blood sugar in people with diabetes is toxic to nerves. The longest nerves are affected earliest and so nerve damage occurs first in the feet. The loss of sensation can make it difficult to protect the feet from trauma. In addition, the loss of sensation can increase the chance of developing fractures that can become severe and deform the foot and ankle. The nerve damage can also affect the nerves to the muscles in the foot causing stiffness and deformities such as hammertoes. All of these changes, the loss of sensation and the changes in the distribution of pressure on the foot as a result of the foot deformities, can lead to poor and prolonged wound healing.
Arteriosclerosis or hardening of the arteries does not affect only the arteries in your heart. It can also affect the arteries in your legs. Diabetes, high blood cholesterol and fat, high blood pressure and smoking can start and accelerate this process. When the arteries in your legs become damaged by arteriosclerosis, the flow of blood is decreased. This keeps oxygen and energy from getting to your tissue and decreases the ability of your tissue to regenerate. Caffeine can constrict them further and so large amounts of coffee or other caffeinated beverages can also hamper circulation as well as increasing blood pressure.
Varicose veins and the rashes that form from damaged veins can cause edema and make the skin fragile. If you have a brownish or reddish discoloration above your ankles in your calf area that does not go away when you elevate the leg, then you may have venous stasis dermatitis. In this condition, pressure in the veins is increased from poor emptying or previous blood clots. This causes the blood to leak into the tissues, resulting in scaring, discoloration, and fragile skin. Healing in this type of skin can be prolonged and troublesome.
Smoking can affect tissue healing in two ways. First, the smoke that you inhale contains carbon monoxide, the same gas that makes car exhaust so deadly. Carbon monoxide displaces the oxygen from the red blood cells, decreasing their ability to carry oxygen dramatically. Second, the nicotine in the smoke is a potent constrictor of blood flow in the tissues. Smoking and other forms of tobacco use have been shown in many studies to hamper healing of bones and skin.
Proper wound care is perhaps the most important step toward complete healing of a wound. A healing wound should be kept moist at all times. If there is normal blood supply, healing tissue gets plenty of oxygen from the blood and air does not need to get to a wound for it to heal. The beefy red tissue that forms in the base of an ulcer fills over the deeper structures in normal healing. Skin cells must migrate from the edge of the wound and form new skin over the old wound. Dryness or desiccation damages these immature cells. In certain wounds, special dressings or ointments can help maintain this moist environment and decrease bacterial contamination. Dressings should be changed at least every day to remove any fluid that comes from the wound and possibly more depending on the amount of soilage. Objectionable smell is due to the presence of dead tissue, loose skin, or secretions decomposing and usually means that additional cleaning or more frequent dressing changes are necessary. Increases in drainage or changes in the appearance or depth of the wound should be reported immediately to your doctor. Occasionally, surgical removal of infected or dead tissue is needed to begin the healing process.
Never clean your wound with anything that has not been approved by your doctor. Common home treatments such as soaking or rinsing in hydrogen peroxide, Mercurochrome, or bleach can actually harm healing tissues more than the bacteria colonizing the wound. However, the wound can be gently cleaned by a dilute unscented soap solution or clean soapy washcloth in a shower. A shower chair can be obtained to make showering considerably safer and prevent weight bearing on the wound.
Edema or swelling of the leg can hamper wound healing. While some swelling is unavoidable, excessive swelling impairs circulation. Your leg should be elevated four times a day for thirty minutes to help relieve this and should be propped up when sitting or lying down. Do not ice the leg to decrease swelling. The extremity should be kept warm to improve the circulation of the leg and speed the metabolism of the tissue, but never use heating pads or immerse the extremity in hot water.
Concentrations of pressure on certain parts of the foot are the most common cause of a wound formation on the bottom of the foot. Relieving this pressure is important in its treatment. The most effective way of relieving pressure is by eliminating weight bearing on the leg, using crutches or a walker. Unfortunately, because of problems with strength, endurance, and balance, many people cannot absolutely avoid weight bearing on one of their legs. If partial weight bearing is possible with a walker, then this is preferable to unprotected full weight bearing. Pressure relief shoes, pads, or casts can also help. It is important to avoid prolonged weight bearing, such as during long trips to the supermarket. Wheelchairs or electric scooters should be used if available. In some instances, surgical removal of bone or realignment of the foot may be necessary to alleviate bony prominences on the bottom of the foot before wounds will heal. This is rarely the initial form of treatment.
Antibiotics are sometimes prescribed for foot ulcers when they are infected. In my opinion, they are often overused and may be responsible for an increase in drug resistant bacteria. You must remember that ulcers take weeks or months to heal and long-term antibiotics for uninfected ulcers do not often shorten healing time and can possibly have negative effects. Oral antibiotics attack bacteria, not only in the wound, but also throughout your body. Many bacteria, such as those that are naturally in your intestine, are actually beneficial. Destroying these natural bacteria can lead to overgrowth of harmful bacteria that can cause diarrhea, nausea, skin rashes, mouth sores, and, in women, vaginal yeast infections. Topical anti-microbial medications are sometimes incorporated in ointments and dressings to reduce the quantity of bacteria on a wound.
Many bad habits can delay wound healing. Smoking is perhaps the worst. As mentioned above, nutrition of your wound is hurt in many different ways by the chemicals in tobacco smoke. While any reduction in smoking can help, quitting is the best way to promote healthy wound healing. Cutting down on sweets and alcohol is also helpful. These foods replace nutritious food and lead to reductions in vitamin and protein in your diet. Finally, drinking large quantities of caffeinated beverages can affect wounds and should be limited to no more than two cups of coffee or two soft drinks per day.
Nutrition is more critical during wound healing than ever. Protein requirements increase by 50-100% during wound healing depending on the size of the wound. Eating 1.5-1.7 gm/kg of body weight/d of protein can optimize your healing potential. For a 160-pound person, this is 100-120 grams of protein per day. Good sources of protein include lean meat, eggs, dairy, beans, peas and nuts. Below is a table giving rough estimates of the protein content of the most common food groups per serving.
| Carbohydrate (grams) |
Protein (grams) |
Fat (grams) |
Calories | |||
| Starch/Bread | 15 | 3 | Trace | 80 | ||
|
– – – |
7 7 7 |
3 5 8 |
55 75 100 |
||
| Vegetable | 5 | 2 | – | 25 | ||
| Fruit | 15 | – | – | 60 | ||
|
12 12 |
8 8 |
Trace 5 |
90 120 |
||
|
12 | 8 | 8 | 150 | ||
| Fat | – | – | 5 | 45 | ||
Other vitamins and nutrients play a critical role in wound healing. Vitamin C is important in collagen formation, a key protein formed by your body during wound healing. About 500 IU per day is required in someone with a chronic wound. This is more than is in the typical multivitamin and if your diet is low in such things as raw leafy green vegetables, fruits, and potatoes. Boiling or steaming food leaches the vitamin into the cooking water, decreasing the foods vitamin content. The body does store this and so daily ingestion is necessary to maintain an adequate supply.
Zinc is a component of many of the proteins necessary to repair wounds. Zinc deficiency can lead to delayed wound healing. Zinc is found in most meat. In addition, beans, and nuts are sources of zinc. An adequate dietary intake is necessary to maximize wound healing potential, but it is not necessary to take more than the recommended daily requirement. A multivitamin with a vitamin C supplement is advisable if your diet is deficient in these nutrients. Maintaining adequate hydration is also very important to circulation.
Proper control of other medical problems can promote healing of ulcers. Perhaps central to this is proper control of diabetes mellitus. Tight control of blood sugar can reverse a portion of the nerve damage that diabetes causes. It can also promote a healthy immune system, because white blood cells work better when blood sugars are as close to normal as possible. Optimal function of the heart and circulatory improves blood flow to ulcers and decreases swelling. When peripheral arteriosclerosis impairs blood circulation, surgical correction through arterial bypass or stenting may be necessary.
Successful treatment of wounds and ulcers is a partnership between you and your doctor. Although wound care is very important to the healing of your wound, taking care of the rest of your health is nearly as crucial. Look to improve your diet and take the medicines prescribed for all your health problems to get your wound healed as quickly as possible.
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