Content

• Prevalence of Diabetic Foot• Pathophysiology • Classification • Diagnosis• Treatment• Diabetic Foot Education

Some Facts and Figures about Diabetic foot

• According to WHO, in 2010, there are more

than 8 million DM patients in Pakistan• Many patients are undiagnosed yet• Diabetes Mellitus is the largest cause of

neuropathy• Foot ulcerations is most common cause of

hospital admissions for Diabetics• Expensive to treat, may lead to amputation

and need for chronic institutionalized care

Prevalence of Diabetic Foot

• More than 80,000 amputations are performed on Diabetic patients each year in US

• 50% of people with amputations will develop ulcerations and infections in the contralateral limb within 18 months

• 58% will have a contralateral limb amputation 3-5 years after the first one

• 3 year mortality after first amputation is estimated as upto 50%

Some statistics of Diabetic Foot

• Foot problems account for 40% of healthcare resources in developing countries

Some statistics of Diabetic Foot

• 85% of all amputations begin with an ulcer

• 49-85% of amputations can be prevented if proper care is taken

Pathophysiology of Diabetic Foot

Diabetic Foot

PVD

InfectionsNeuropathy

PERIPHERAL VASCULAR DISEASES

Peripheral vascular disease in diabetes

15-40 times more likely to have lower limb amputation

People over 70 years have a 70-fold increased risk of amputation

An estimated 1 out of every 3 people with diabetes over the age of 50 have this condition *

Patients with PAD have an increased risk of MI and stroke*

* http://www.diabetes.org/living-with-diabetes/complications/peripheral-arterial-disease.html

Causes of Peripheral vascular disease

Diabetes Smoking Hypercholesterolemia Hypertension

Pathophysiology of PVD

Peripheral Vascular Disease is commonly caused by atherosclerosis and usually affects the tibial, peroneal, aorto-iliac or infra-inguinal arteries

Stages of PVD

1. Occlusive disease without symptoms

2. Intermittent claudication

3. Ischaemic rest pain (night time)

4. Ulceration/gangrene

Symptoms of PVD

Intermittent claudication which can occur in both but is often worse in one leg

Rest pain at night

Intermittent Claudication

Walking-induced pain in one or both legs that does not disappear with continued walking, and is relieved only by rest

Claudication is present in 15% to 40% of Pts with peripheral arterial disease and associated with a ↓ ability to perform daily tasks

Varying presentations of patients with PVD

PAD patients ≥50 yearsInitial presentation*

ClaudicationRest Pain10%–35% of patients

Atypical leg pain40%–50% of patients

Asymptomatic20%–50% of patients

* Excluding patients with an initial presentation of critical limb ischemia.Adapted from Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

The majority of PAD patients do not have the classical symptoms of claudicationThe majority of PAD patients do not have the classical symptoms of claudication

Signs of PVD

Dry flaky skin

Diminished or absent pedal pulses

Coolness of the feet and toes

Poor skin and nails

Absence of hair on feet and legs

Ulceration may occur in association

Initial Screening of PVD

History of Claudication

Assessment of Pedal Pulses

Obtain ABI Ankle Brachial Index

How to assess a patient with PVD• Palpation of foot

pulses

◦Dorsalis pedis (10% absent due to anatomical reasons)

◦Tibialis posterior

• Capillary filling time should also be checked

• CFT of >5 seconds is prolonged

How to diagnose PVD

1.ABI2. Duplex Imaging3. Diagnostic Angiogram

(less common now)4. Ultrasound5. MRI and CT

Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

Ankle-Brachial Pressure

The most cost effective tool for PVD

Measuring the cuff pressure by Doppler in the posterior tibial or anterior tibial arteries compared to the brachial artery

Intermittent claudication is associated with ABPI of 0.4-0.9

Values less than 0.4 is associated with critical limb ischemia

Duplex Imaging

Duplex arterial imaging – allows narrowing or obstruction of blood vessels to be localized

Diagnostic Angiogram

Performed through a percutaneous arterial catheter

Less commonly used now

PAD patients are at increased risk for CV ischemic events

PAD* (≥50 years old)5-year outcomes

Limb morbidity• 70%–80%

Stable claudication • 10%–20%

worsening claudication

• 1%–2% critical limb ischemia

CV morbidity

20%Nonfatal CV event (MI or stroke)

Mortality

15% to 30%▪ 75% from CV causes

* Patients with an initial clinical presentation of asymptomatic PAD, atypical leg pain, or claudication.Adapted from Hirsch AT et al. Available at: www.acc.org. Accessed March 22, 2006.

Up to 1/3 of PAD patients will die in 5 years, 75% from CV causesUp to 1/3 of PAD patients will die in 5 years, 75% from CV causes

Peripheral vascular disease

Treatment

• Quit smoking

• Walk through pain

• Surgical intervention

• Aim for an A1C below 7%

• Lower your blood pressure to less than

130/80 mmHg

• Get your LDL cholesterol below 100 mg/dl

Distinguishing features of

Ischemia

Symptoms Claudication

Rest pain

PalpationCold, pulseless

InspectionDependent ruborTrophic changes

UlcerationPainful Heels and toes

Diabetic Neuropathy

Neuropathy

Changes in the vasonervorum with resulting ischemia

Increased sorbitol in feeding vessels block flow and causes nerve ischemia

Intraneural accumulation of advanced products of glycosylation

Abnormalities of all three neurologic systems contribute to ulceration

Types of Diabetic Neuropathy

There are four types of diabetic neuropathy: 

Peripheral Sensory neuropathy (also called diabetic nerve pain and distal polyneuropathy)

Proximal neuropathy (also called diabetic amyotrophy)

Autonomic neuropathyFocal neuropathy (also called

mononeuropathy)

Peripheral neuropathy – sensory motor

Most common form of neuropathyAffects approximately 50% after 15

yearsAffects long nerves (feet and legs)

first◦glove and stocking distribution

BilateralEqual symptoms in both limbs

Sensory Neuropathy

• Loss of protective sensation• Starts distally and migrates proximally in

“stocking” distribution• Large fibre loss – light touch and

proprioception• Small fibre loss – pain and temperature• Usually a combination of the two

Sensory nerve damage

Nerve damage – neuropathy

Symptoms:PainNumbness (loss of feeling)TinglingMuscle weaknessMuscle cramping and/or

twitchingInsensitivity to pain and/or

temperatureExtreme sensitivity to even

the lightest touchSymptoms get worse at night

Autonomic Neuropathy

• Regulates sweating and perfusion to the limb

• Loss of autonomic control inhibits thermoregulatory function and sweating

• Result is dry, scaly and stiff skin that is prone to cracking and allows a portal of entry for bacteria

Autonomic nerve damage

Motor Neuropathy

• Mostly affects forefoot ulceration– Intrinsic muscle wasting – claw toes– Equinus contracture

Motor nerve damage

Acute painful Neuropathy

A common complication of Diabetes

The two types of neuropathies associated with pain are acute sensory nueropathy and chronic sensorimotor neuropathy

Hyperglycemia remains the major causative factor but PDN can also be seen in patients having HBA1C < 8%

Smoking Hyperlipidemia Hypertension Obesity

Causes of PDN

Treatment of PDN

Glycemic Control Correction of metabolic

derangements Medications e.g Tricyclic

Antidepressants like Duloxetine Antiepileptics like Gabapentins

and Pregablin and Carbamazepine

Tramadol

Painless nature of diabetic foot disease

Localized callus

Diabetic peripheral neuropathyscreening tests

Test sensation ◦Biothesiometer◦Tuning fork◦10 gm monofilament

Ankle reflexes

Assessment of high risk characteristics

Motor Neuropathy and Foot Deformities

Hammer toes

Claw toes

Prominent metatarsal heads

Hallux valgus

Collapsed plantar arch

Hammer Toes

Claw Toes

© 2002 American Diabetes AssociationFrom The Uncomplicated Guide to Diabetes ComplicationsReprinted with permission from The American Diabetes Association

© 2002 American Diabetes AssociationFrom The Uncomplicated Guide to Diabetes ComplicationsReprinted with permission from The American Diabetes Association

Hallux Valgus

Boulton, et al. Guidelines for Diagnosis of Outpatient Management of Diabetic Peripheral Neuropathy. Diabetic Medicine 1998, 15:508-512

Sensory Neuropathy in Diabetes

Loss of protective sensation in feetDetect with 5.07/10-g Semmes-Weinstein

monofilament◦50% of insensate patients have no

symptoms

Diabetes Care. 2006;29(Suppl 1):S24Diabetes Care. 2004;27:1591

Monofilament Testing

Test characteristics:◦Negative predictive value = 90%-98%◦Positive predictive value = 18%-36%

Prospective observational study:◦80% of ulcers and 100% of amputations

occur in insensate feet◦Superior predictive value vs. other test

modalities

J Fam Pract. 2000;49:S30 Diabetes Care. 1992;15:1386

Using the Monofilament

Demonstrate on forearm or handPlace monofilament perpendicular

to test siteBow into C-shape for 1 secondTest 4 sites/foot Heel testing does not

predict ulcer Avoid calluses, scars,

and ulcers

Monofilament Testing Tips

Insensate at 1 site = insensate feet

Falsely insensate with edema, cold feet

Test annually when sensation normal

Use monofilament ◦< 100 times day ◦Replace if bent◦Replace every 3 months

Vibration Testing

Biothesiometer◦Best predictor of foot ulcer risk

128-Hz tuning fork at halluces◦Equivalent to 10-g monofilament◦Newly recommended by ADA

Diabetes Care. 2006;29(Suppl 1):S25

Diabetes Res Clin Pract. 2005;70:8

Management of NeuropathiesSensory Neuropathy• A shoe neither too tight nor too

roomy is appropriate

Autonomic Neuropathy together with senosry

• An insole should provide optimal distribution of pressure, reduction of sheer stress and shock absorption

Charcot’s Arthropathy

Charcot foot is a sudden softening of the bones in the foot that can occur in people who have significant nerve damage (neuropathy). The bones are weakened enough to fracture, and

with continued walking the foot eventually changes shape.

As the disorder progresses, the arch collapses

and the foot takes on a convex shape, giving it a rocker-bottom appearance, making it very difficult to walk.

Charcot’s Arthropathy

Charcot foot is a very serious condition that can lead to severe deformity, disability, and even amputation

Charcot’s arthropathy

Charcot’s Arthropathy

Charcot foot symptoms may include:

Warmth to the touch (the footfeels warmer than the other) Redness in the foot Swelling in the area Pain or soreness

Management of Charcot’s Foot

Treatment for Charcot foot consists of:Immobilization. Because the foot and

ankle are so fragile during the early stage of Charcot, they must be protected so the soft bones can repair themselves.

Complete non-weightbearing is necessary to keep the foot from further collapsing. The patient will not be able to walk on the affected foot until the surgeon

Management of Charcot’s Foot

During this period, the patient may be fitted with a cast, removable boot, or brace, and may be required to use crutches or a wheelchair. It may take the bones several months to heal, although it can take considerably longer in some patients.

Custom shoes and bracing. Shoes with special inserts may be

needed after the bones have healed Surgery. In some cases, surgery may be

required.

DIABETIC FOOT INFECTIONS

Some facts about Diabetic foot Ulcer

Diabetic foot problems such as ulceration, infections and gangrene are the most common cause of hospitalization among Diabetic patients

Evaluating the Patient with a DFI

Patient◦Systemic response Fever, chills, sweats, cardiovascular status

◦Metabolic status Hyperglycaemia, electrolyte imbalance, hyperosmolality, renal impairment

◦Cognitive function Delirium, depression, dementia, psychosis

◦Social situation Support, self-neglect

· Limb/Foot Wound

Evaluating the Patient with a DFI

Limb or Foot ◦Vascular (Ischaemia , Venous

insufficiency)◦Neuropathy◦Infection

Wound ◦Size, depth ◦Necrosis, gangrene◦Infection

DIABETIC FOOT ULCERS

Diabetic Foot Ulcer

The enormity of the global burden of diabetic foot disease…this much neglected, but potentially devastating, complication of a disease that is reaching epidemic proportions…Someone, somewhere, loses a leg because of diabetes every 30 seconds of everyday…”

Lancet. 2005;366:1674

Prevalence of Diabetic foot ulcer

25 % of diabetics will develop a foot

ulcer

40-80% of these ulcers will become infected

25 % of these will become deep

10-30 % of patients with a diabetic foot ulcer will go on to amputation

Etiology of Diabetic Foot Ulcer

The majority of foot ulcers appear to result from minor trauma in the presence of sensory neuropathy

The critical triad is most commonly seen in patients with diabetic foot ulcers are peripheral sensory neuropathy, deformity and trauma

Hyperglycemia remains the mainstay in the onset and progression of neuropathy

Causal Pathways for Foot Ulcers

Neuropathy

Deformity

ULCER

% Causal Pathways

Neuropathy: 78%

Minor trauma: 79%

Deformity: 63%

Behavioral ?

Diabetes Care. 1999; 22:157

Poor self-foot care

Minor Trauma- Mechanical (shoes)- Thermal- Chemical

Pre-ulcer Cutaneous Pathology

Persistent erythema after shoe removal

Callus with subcutaneous hemorrhage

FissureInterdigital maceration, fungal

infectionNail pathology

AJM Boulton, H Connor, PR Cavanagh, The Foot in Diabetes, 2002

Pre-ulcer

A patient comes with the complain of pre-ulcer (callus with subcutanoeus hemorrhage on the tip of the third digitThis pre-ulcer (callus with subcutaneous hemorrhage) on the tip of the third digit with its claw-toe deformity could easily go undetected. Pre-ulcers must be promptly and carefully debrided to determine if there is already an underlying ulcer.

Case Study

Treatment

In this patient debridement did not reveal an underlying ulcer.

Debridement of callus reduces subcutaneous pressure and helps to prevent subcutaneous hemorrhage and progression to an ulcer. This patient’s socks and shoe gear will have to be modified to accommodate his claw-toe deformities.

Case Study (Cont..d)

Case Study

64-year-old obese man

Type 2 DM (15 yrs)◦ BP (18 yrs)◦ Dyslipidemia (18 yrs)◦ CABG (10 yrs ago)◦ Claudication (today; 25 yds)

Insulin/Metformin/Statin/ACEI/HCTZ/ASAComes with the complain “Sore on my

left foot, Doc”

Case Study (continued)

Clinical evaluation of heel ulcer:◦Probe reached bone◦Extensive subcutaneous abscess

MRI: extensive osteomyelitis

ABI: 0.2

Angiography: Inoperable severe vascular disease

Uncontrolled infection

Amputation necessary

Tragic “Rule of 50”

50% ofamputations

50% of patients

50% of patients

Transfemoral/transtibial level

2nd amputation in 5 years

Die in 5 years

Clinical Care of the Diabetic Foot, 2005

Tragic “Rule of 15”

15% of diabetes Foot ulcer in lifetimepatients

15% of foot ulcers Osteomyelitis

15% of foot ulcers Amputation

Clinical Care of the Diabetic Foot, 2005

Evaluation of Diabetic Foot Ulcer

Documentation of the wound’s size, shape, location, depth, base and border.

A sterile stainless steel probe is used to assess the depth of wound up till the bone, tendon or joint

X-rays should be done MRI is also useful for detecting

osteomyelitis, and deep abscess

Team Care

Identification of high-risk patients Detection of early problemsEducate/motivate self-care

behaviorsProphylactic nail/skin careTherapeutic footwearPrompt, multidisciplinary treatment

of ulcers

Lancet. 2005;366:1676

Team Care Reduces Ulcers/Amputations

50%-80% reductions in ulcers/amputations possible with Team Care

Economic modeling studies◦Cost-effective if 25%-40% reduction in

ulcer rate◦Cost-saving if > 40% reduction in ulcer

rateLancet. 2005;366:1719

Diabetes Care. 2004;27:901

Treatment of Diabetic Foot Ulcers

Debridement:

Removal of all necrotic tissue, peri wound callus, and foreign bodies down to viable tissue

After debridement, wound is irrigated with saline or cleanser and a dressing is applied

Dressings available are hydrogels, foams, calcium alginates and skin replacement

Treatment of Diabetic Foot Ulcers

Debridement:

In case of abscess, incision and drainage are essential with debridement

Treating a deep abscess with antibiotics alone leads to delayed therapy and further mortality and morbidity

Treatment of Diabetic Foot Ulcers

Offloading Proper offloading remains the biggest

challenge for HCPs Having patients use a wheelchair or

crutch is the most effective method of offloading

Total contact Casts (TCC) are difficult but significantly reduce pressure on wounds

Post operative shoes or wedge shoes are also used but proper fitting is necessary

Treatment of Diabetic Foot Ulcers

Infection Control Coverage of gram positive and gram

negative organisms like methicillin resistant Staph. Aureus, B-hemolytic Strep. Pseudomonas and enterococci

Patients should be hospitalised and and treated with IV antibiotics

Mild to moderate infection can be treated as OPD with Cephalexin, Amoxicillin with Clavulanate Potassium, Moxifloxacin or Clindamycin

Detecting Feet-at-risk

History:◦Prior amputation or foot ulcer◦Peripheral artery disease (PAD)

Exam:◦Insensate ◦Foot deformities◦Absent pulses◦Prolonged venous filling time◦Reduced ABI◦Pre-ulcerative cutaneous pathology

Arch Intern Med. 1998;158:157

Prevalence of Amputation

50 % of patients with cellulitis will have another episode within 2 years

25-50 % of diabetic foot infections lead to minor amputations

10-40 % require major amputations

Cause of diabetic amputation

Trauma

Ulcer

Failure to heal

Infection

Amputation

Neuropathy or vascular disease

Physical Examination of the Feet in Persons with Diabetes

Risk categorization system

Category Risk profile Check-up frequency

0 No sensory neuropathy Once a year

1 Sensory neuropathy Every 6 months

2 Sensory neuropathy /peripheral vascular disease/ foot deformities

Every 3 months

3 Previous ulcer Every 1-3 months

Outcomes By IDSA DFI Severity Classification

Armstrong, Lavery, Peters, Lipsky. Clin Infect Dis 2007

3% 3%

46%

78%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No infection Mild Moderate Severe

LE AmputationX2 trend = 108, p < 0.0001

None Mild Moderate Severe

6%10%

54%

89%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No infection Mild Moderate Severe

HospitalizationX2 trend = 118.6, <0.0001

None Mild Moderate Severe

1666 patients enrolled in prospective diabetic foot study

Diabetic Foot Education

Most foot problems are preventable

Upto 85% of foot problems are preventable through early identification and prompt treatment by skilled health professionals.

Diabetic Voice, March 2005, Volume 50, Issue 1

Targeting education according to level of risk

Wide spectrum of foot risk; people require different levels of education

Should be considered when providing footcare education

Lifestyle changes only required for those at high risk

Evidence-based stratification of services

Ulcer

High

Low

High-risk foot clinic

Intensive foot education and podiatry

Neuropathy, previous amputation or ulcer

Peripheral vascular diseaseUnable to feel monofilamentNeuropathy, no previous amputation or ulcer

General information

No neuropathy

Which people should we target for footcare education?

Footcare education

Low risk◦simple advice◦no lifestyle change◦annual foot assessment

High risk◦intensive education◦practical demonstrations◦significant behavioural changes

◦focus on prevention

Footcare education

Which behaviour- and lifestyle-changing strategies do we teach people with diabetes when they are at high risk?

Wash, touch and look at feet every day

Do not soak feetTest water temperatureWash and dry between

toesAvoid herbs and

ointmentsExamine feet in good

light

Learn to look for:

Bruises

Cuts

Blisters

Learn to look for:

Cracked heels Callus

Learn to look for:

Hammer toe Clawed toes

Learn to look for:

Bunion Charcot’s arthropathy

Learn to look for:

Foot infection

Learning to care for skin

Moisturiser – preferably in a pump bottle

Massage with cream – not in open sores or between toes

Without perfume

How to care for toenails

Do not to let nail grow too long

Cut straight across

File sharp edges

Ask a friend or relative

How to treat tinea

Anti-fungal lotion between toes

Anti-fungal cream on feet

Treat affected area and surrounding skin

What to do about fungal nails

Difficult to treatThick nails should be

filed

What to look for in socks

Wool or cottonPadded socksNo tight topsNo rough seamsKnee-high stockings not

advisable

What to look for in a shoe

Wide and deep at the toe

Thick rubber soleNo high heelsFirm heel counterLace-up or velcro Smooth lining

Footwear

When buying shoes

Buy in the afternoon

Measure both feet

Stand up to fit

Wear in slowly

Never wear new shoes all day

Being extra careful

Before putting on shoes, check for

rough spots or loose objects

Preventing burns

Use sunblock on exposed skin

At least 3 m from heater

Turn off electric blankets

No hot water bottles

Never walk barefoot

Exercise

Walk only as far as is absolutely necessary

Non-walking exercises

Basic Footwear Education

DontsPointed

toesSlip-onsOpen

toesHigh

heelsPlasticBlack

colorToo small

Dos

Broad-round toesAdjustable (laces,

buckles, Velcro)Athletic shoes,

walking shoesLeather, canvasWhite/light colors½” between longest

toe and end of shoeDiabetes Self-Management. 2005;22:33

Identify problem and act quickly

If no sign of improvement,

contact doctor or emergency

servicesRemember,

people with neuropathy

do not feel pain!

Footcare educational material

Written material complements education

Written at average reading age

Large font for visually impaired

Pictures should be relevant to text

Evaluating the foot education program

Evaluate behavioural change – not knowledge

‘How many times have you checked your feet this week?’ ‘How many times have you put cream on your feet this week?’

Key messages

Stratify people according to level of risk

Educate those at high riskShoes are the most common

cause of ulcerationIdentify problems early and treat

promptlyHealth professionals need to be

trained in diabetic foot care

Key messages

Get regular check-ups from a foot and ankle surgeon

Check both feet every day—and see a surgeon immediately if there are signs of Charcot foot

Be careful to avoid injury, such as bumping the foot or overdoing an exercise program

An amputation occurs every 30 seconds due to diabetes