Zespół stopy cukrzycowej to jedno z powikłań cukrzycy, które objawia się zmianami w obrębie stóp, często prowadzącymi do amputacji kończyn. W wywiadzie dla Forum Leczenia Ran Magdalena Maj, chirurg i specjalistka w leczeniu stopy cukrzycowej, wyjaśnia, jakie objawy świadczą o rozwoju stopy cukrzycowej i jak im zapobiegać.
– O zespole stopy cukrzycowej mówimy wtedy, gdy mamy niedokrwienie lub neuropatię z raną, a to jest zdecydowanie za późno. Należałoby powiedzieć, że ZSC jest u każdej osoby z cukrzycą, tylko my to widzimy na różnych etapach. Im wcześniej to zobaczymy, tym lepiej dla pacjenta – mówi w rozmowie z portalem Forum Leczenia Ran Magdalena Maj i dodaje, że w zależności od rodzaju stopy cukrzycowej będą występować różne objawy. – Najwięcej jest takich przypadków, kiedy występują jednocześnie komponenty niedokrwienne i neuropatyczne. Najczęściej pacjent choruję na neuropatię od wielu lat, ale dopiero kiedy dodatkowo powstaje niedokrwienie i zaczynają pojawiać się zmiany i rana, taka osoba zgłasza się do lekarza. I to jest najgorsza możliwa sytuacja, ponieważ musimy leczyć jednocześnie neuropatię i niedokrwienie.
Jakie są pierwsze objawy stopy cukrzycowej niedokrwiennej?
– W przypadku stopy cukrzycowej o podłożu niedokrwiennym głównie pojawią się takie objawy, jak:
- zimna stopa,
- słabe tętno,
- ból i ochłodzenie stóp w pozycji leżącej,
- chromanie przestankowe, czyli ból w obrębie kończyny po przejściu pewnego dystansu.
Zwykle nie wiążemy tych objawów z samą stopą, ponieważ dotyczą całego układu naczyniowego, wszystkich tętnic obwodowych. Występują również: lekkie przekrwienie podskórne, obrzęk biały, kończyna jest blada, zimna, obrzęk natomiast twardy i ciastowaty.
Jakie są objawy stopy cukrzycowej neuropatycznej?
– Przy stopie neuropatycznej jest trochę łatwiej, dlatego że pacjent po prostu przestaje stopę czuć. Wiele jednak zależy od tego, w jakim tempie ten proces postępuje. Są pacjenci, którzy zgłaszają się do lekarza, ponieważ nagle przestali czuć stopę. Zauważają to, ponieważ potykają się, nie czują buta ani tego, że coś do niego wpadło. Jeżeli jednak neuropatia rozwija się powoli, pacjent przyzwyczaja do takiego stanu i zwykle zgłasza się dopiero wtedy, kiedy już pojawiła się rana. Jednocześnie w stopie neuropatycznej mamy dużo więcej zmian miejscowych, których w stopie niedokrwiennej nie zaobserwujemy. Do objawów zaliczamy:
- ból rano, bezpośrednio po wstaniu z łóżka, co oznacza występowanie zapalenia rozcięgna podeszwowego, które skutkuje ostrogą piętową i skróceniem, zesztywnieniem lub skostnieniem ścięgna Achillesa. Ból jest tak duży, że pacjent nie może stanąć na stopie, musi ją rozchodzić. Ewentualnie ból może wrócić po południu lub wieczorem, kiedy stopa jest zmęczona;
- suchą skórę, która może pękać, mogą się tworzyć zgrubienia i modzele w miejscach największego nacisku podczas chodzenia;
- pęknięcia skóry między palcami;
- brak reakcji skóry na stopach na zmiany temperatury, mimo że łydki i golenie mogą się nadmiernie pocić;
- łamliwe, suche i często zgrubiałe paznokcie. Są to objawy przypominające infekcje grzybicze. Warto wykonać badania mykologiczne, aby potwierdzić, czy jest to grzybica, ponieważ zmiany często wynikają z neuropatii, biomechaniki chodu, nierównowagi między prostownikami a zginaczami palców;
- ścieńczenie i przesunięcie w kierunku palców poduszki tłuszczowej pod głowami kości śródstopia, co powoduje, że kości śródstopia opadają, pomiędzy nimi a podeszwą buta zostaje cienka warstwa skóry i na tym obszarze powstają modzele. Jest też miejsce bardzo narażone na powstawanie owrzodzeń i na rozwój stopy Charcota.
- skrócenie łańcucha mięśniowo-powięziowego, przez co pacjent jest lekko wygięty do tyłu. Taka osoba cały czas pracuje palcami, żeby utrzymać równowagę i obciąża głowy kości śródstopia. Napięcie jest tak duże, że nie tylko powoduje powstanie modzela, lecz także utrudnia gojenie się ran;
- lipodermatosklerozę, która dotyczy nie tylko brzucha, ale też okolicy stawu skokowego i łydek – skóra w tych miejscach staje się twarda i nieelastyczna. W tym obszarze kończyna jest wąska, ściśnięta, twarda, a powyżej i poniżej duży obrzęk chłonny. Dochodzi też do przebarwień.
Jak zapobiegać powstaniu stopy cukrzycowej?
– Pacjent cukrzycowy powinien zwracać uwagę zarówno na objawy stopy cukrzycowej niedokrwiennej, jak i neuropatycznej.
Pacjent powinien codziennie, rano i wieczorem swoje stopy oglądać, sprawdzać:
- czy nie pojawiają się pęcherze, zaczerwienienia, otarcia,
- czy nie połamał paznokci,
- czy między palcami nie ma wilgotnej, łuszczącej się skóry,
- czy nie powstały krwiaki i wybroczyny,
- czy nie zmienił się kolor stóp.
Przy każdej zmianie obuwia pacjent też powinien obejrzeć swoje stopy, zajrzeć do buta, żeby sprawdzić, czy tam coś nie wpadło lub nie zawinęła się wkładka. Jeżeli pacjent zmaga się z cukrzycą już dłuższy czas, ok. 10-15 lat, wtedy należy podjąć również takie działania jak sprawdzanie tętna na grzbiecie stopy, kontrolowanie, czy występuje powrót włośniczkowy na dużym placu i na spodzie stopy, oraz porównywanie temperatury obu stóp.
Lekarz rodzinny powinien pokazać, w jakim miejscu przebiega tętnica grzbietowa stopy, a potem pacjent na niej sprawdza, jakie jest tętno. Mierzenie temperatury możemy przeprowadzić zwykłym termometrem bezdotykowym. Podczas przygotowywania kąpieli kontrolujemy też stopień neuropatii. Najpierw sprawdzamy wodę łokciem lub termometrem, aby określić jej temperaturę, a następnie sprawdzamy stopą. Jeśli wiemy, że woda jest zimna, ale tego nie czujemy lub czujemy mniej niż zwykle, to jest to sygnał, że coś się dzieje. Z ciepłą wodą zachowujemy ostrożność, żeby nie spowodować oparzenia. Cały czas obserwujemy nasze ciało, obserwację prowadzimy codziennie.
Ważne jest również to, żeby stosować preparaty przeznaczone do pielęgnacji stopy cukrzycowej, nie posiłkować się preparatami z drogerii, nie używać skarpetek złuszczających, nie używać tarek, pumeksów, dokładnie stopy osuszać, zwłaszcza między palcami, nie stosować żadnych preparatów nawilżających między palcami. Jest cała gama preparatów, które powinien zalecać chirurg lub podolog.
Jakie znaczenie ma szybkie wykrycie zmian?
– Jeżeli pacjent przychodzi do lekarza lub podologa wystarczająco wcześnie, jeżeli nie wystąpiły jeszcze zmiany, nie było ropowicy, miniamputacji, bardzo zaawansowanej neuropatii, to jesteśmy w stanie zaopatrzyć go tak, aby tych wszystkich problemów z czasem nie nabył.
U pacjenta, który już miał owrzodzenie, istnieje ok. 80 proc. szans, że powstaną kolejne. Owrzodzenie może wystąpić albo w innym miejscu, albo na przeciwnej kończynie. Ok. 40 proc. występuje w tym samym miejscu pomimo prawidłowego zaopatrzenia.
Przeczytaj także: Rodzaje stopy cukrzycowej
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