Diabetic Foot Exam – inosteo.org
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Diabetic Foot Exam
By Patrick A. DeHeer, DPM
Hoosier Foot & Ankle
Lancet. 2005;366:1674
“…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…”
Global Projections for the Number of
People With Diabetes for 2010 and 2030
AT A GLANCE
2010
2030
Total world population (billions)
7.0
8.4
Adult population (20-79 years, billions)
4.3
5.6
Global prevalence (%)
6.6
7.8
Comparative prevalence (%)
6.4
7.7
Number of people with diabetes (millions)
285
438
DIABETES AND IGT (20-79 years)
Diabetes
IDF Diabetes Atlas, 4th ed. ©International Diabetes Federation, 2009.
Source: IDF Diabetes Atlas, 4th ed. International Diabetes Federation, 2009.
http://www.diabetesatlas.org/sites/default/files/At%20a%20Glance_WORLD.jpg. Accessed 01
March 2011.
Patients who develop a foot infection have a
55.7 times greater risk of hospitalization that
those who do not. –Lavery 2006
Costs to Treat a Diabetic Foot Ulcer
Over a 2-Year Period Following Detection
60,000
$48,156
50,000
$40,786
Cost in US Dollars
40,000
$33,046
30,000
$27,987
20,000
10,000
0
1995
2000
2005
2010
Cost analyses based on percent change in the medical component of the US consumer price index.
Ramsey et al. Diabetes Care. 1999;22:382.
Healing of Neuropathic Ulcers:
Results of a Meta-analysis
These data provide clinicians with a realistic assessment of
their chances of healing neuropathic ulcers
Even with good, standard wound care, healing neuropathic
ulcers in patients with diabetes continues to be a challenge
Margolis et al. Diabetes Care. 1999;22:692.
Tragic “Rule of 50”
50% of amputations Transfemoral/Transtibial level
50% of patients - 2nd amputation in 5 years
50% of patients - Die in 5 years
Clinical Care of the Diabetic Foot, 2005
Tragic “Rule of 15”
15% of diabetics will develop a foot ulcer in
their lifetime
15% of foot ulcers will develop
osteomyelitis
15% of foot ulcers will lead to an
amputation
Pathways for Foot Ulcers
Neuropathy
Foot Deformities (from motor neuropathy)
Minor trauma
Mechanical/Shoes (tight/ill-fitting)
Thermal (heat inside shoes)
Chemical (corn removal pads)
ULCER
Diabetes Care. 1999; 22:157
Patient Ulcer Risk
Risk Level
3: Prior
amputation
Prior ulcer
2: Insensate and
foot deformity
or
absent pedal
pulses
1: Insensate
0: All normal
Foot
Ulcer
%/yr
% Office
Patients
(diabetes
clinics)
28.1%
18.6%
7%
6.3%
10%
4.8%
1.7%
17%-30%
66%
History for the Diabetic Foot
Chief Complaint
HPI –
NLDOCATS
Medications
Allergies
Past Medical History
Diabetes – NIDDM/IDDM
Control?
How long?
Family History
Surgical History
Amputation
Revascularization
Social History
ROS –
CV – IC, edema, change in color or
temperature of LE, PAD, venous
disease
Neuro – burning, numbness,
paresthesia, neuropathy, weakness
MSK – amp, foot deformity, Charcot,
injury, ambulatory, OA/RA
Derm – prior ulcer Hx, nail fungus,
dry and cracking skin, local or
systemic signs or symptoms of
infection
Neurological Exam
Deep Tendon Reflexes –
Patellar
Achilles
Clonus
Babinski
Vibratory
Sharp/Dull
Loss of protective sensation – 5.07/10 g Semmes-Weinstein
monofilament wire
Neurological Exam
Monofilament Wire 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
Demonstrate on forearm or
hand
Place monofilament
perpendicular to test site
Bow into C-shape for 1
second
Test 4 sites/foot
Heel testing does not
predict ulcer
Avoid calluses, scars,
and ulcers
J Fam Pract. 2000;49:S30
Diabetes Care. 1992;15:1386
Monofilament Wire Testing
Insensate at 1 site =
insensate feet
Falsely insensate with
edema, cold feet
Test annually when
sensation normal
Monofilament
< 100 times day
Replace if bent
Replace every 3 months
Neurological Exam
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
Motor Neuropathy and Foot
Deformities
Hammer toes
Claw toes
Prominent metatarsal
heads
Hallux valgus
Collapsed plantar arch
Motor Neuropathy and Foot
Deformities
Motor Neuropathy and Foot
Deformities - Diabetic Charcot
Arthropathy
Pre-Ulcer Cutaneous Pathology
Persistent erythema after
shoe removal
Callus
Callus with subcutaneous
hemorrhage
Fissure
Interdigital maceration,
fungal infection
Nail pathology
Pre-Ulcer Cutaneous Pathology
Pre-Ulcer Cutaneous Pathology
Equinus and the Diabetic Patient
Grant et al JFAS1997
Electron microscope
investigation of the effects
of diabetes on the Achilles
tendon
All patients had diabetic
neuropathy and had an
ulcer or/and Charcot
neuroarthropathy
12 diabetic patients and 5
non-diabetic patients
Changes noted in diabetic
patients –
Increased packing density
of collagen fibrils
Decreased fibrillar diameter
Abnormal fibril morphology
Equinus and the Diabetic Patient
Grant et al JFAS1997
Foci in which collagen fibrils
appeared twisted, curved,
overlapping, and otherwise
highly disorganized were
common in specimens from
most patients (11 of 12)
Structural reorganization that
may be the result of
nonenzymatic glycation
expressed over many years
Leads to tightening of Achilles
tendon
The fine structure of the Achilles
tendon appears normal,
consistent with the finding that
the ultrastructural changes result
from diabetes rather than
neuropathy
Equinus and the Diabetic Patient
Lavery, Armstrong, Boulton
Study JAPMA 2002
Relationship between in
equinus and peak plantar
pressures in diabetic
patients
1,666 patients
Definition 0° AJ DF with KE
Pressure measured with
force-plate gait analysis
system
Mean Age 69.1 +/- 11.1
(years)
Men 50.3%
Weight 83.8 +/- 19.7 (Kg)
Diabetes duration 11.1 +/9.5 (years)
Lavery, Armstrong, Boulton Study
JAPMA 2002
P = 0.007
140
120
100
80
60
40
20
0
92.7
P = 0.0001
Risk for elevated
PPP %
High PP
85.7 N/cm²
60
Low PP
N/cm²
40
20
Mean
PP
N/cm²
0
Risk for
elevated
PPP %
Lavery, Armstrong, Boulton Study
JAPMA 2002
No statistical
significant difference –
Weight
Sex difference
Absence or
presence of
neuopathy
Statistical significant
difference –
Equinus patients had
longer duration of
diabetes
Equinus prevalence in
this population =
10.3%
Lavery, Armstrong, Boulton Study
JAPMA 2002
“A high index of
suspicion should lead
to earlier surgical or
nonsurgical treatment
of these deformities.
This increased
vigilance, coupled with
intervention, may lower
the risk of ulceration
and amputation in this
high-risk population.”
Peripheral Artery Disease
Prevalence (ABI < 0.9):
10%-20% in type 2 diabetes
at diagnosis
30% in diabetics age 50
years
40%-60% in diabetics with
foot ulcer
Complications:
Claudication
Associated coronary and
cerebral vascular disease
Delayed ulcer healing
Diabet Med. 2005;22:1310
Diabetes Care. 2003;26:3333
Absent pedal pulses
predicts severe PAD
Absence of a single pedal
pulse does not predict PAD
Presence of pedal pulses
does not rule out PAD!
Hand held doppler – good
initial evaluation
Multiphasic
Monophasic
Arch Intern Med.
1998;158:1357
Diabetes Care. 2003;26:3333
Adapted from: Norman PE, Eikelboom JW, Hankey GJ. Peripheral arterial disease: prognostic significance and
prevention of atherothrombotic complications. Medical Journal of Australia 2004; 181:150-154. Figure 1, p.151
Ankle-Brachial Index
Screening: 2004 ADA
recommendation
“Consider” at age 50 years
and every 5 years
Diagnosis:
Claudication, absent DP/PT
pulses, foot ulcer
Limitations:
Underestimates severity in
calcified arteries
Interpretation
ABI
Normal
0.90-1.30
Mild obstruction
0.70-0.89
Moderate obstruction*
0.40-0.69
Severe obstruction*
<0.40
Poorly compressible**
>1.30
2° to medial calcification
*Poor ulcer healing with ABI < 0.50
**Further vascular evaluation needed
Foot Care Based on Risk Factors
Low Risk
Annual comprehensive foot
examination
Questionnaire completed by
patient
Examination
Self-management and
footwear education
Brief counseling
Written handout
High Risk
Annual comprehensive foot
exam
Inspect feet every office visit
Podiatry care as needed
Intensive patient education
Detect/manage barriers to
foot care
Therapeutic footwear, as
needed
Foot Care Based on Risk Factors
High Risk: Nursing Tasks
Place “High-Risk Feet” stickers
on each chart
Remove patient’s shoes/socks
Determine if patient can
reach/see soles of feet
Stock 10-g monofilament in each
room
Consider training to perform
monofilament exam
Provide patient education forms
J Gen Intern Med.
2003;18:258
High Risk: Patient
Education
Reinforce frequently – low
retention
Patient demonstrates selfcare knowledge
Evidence:
May reduce foot
ulcer/amputation rates
Cochrane Database Syst Rev. 2005 Jan
25;(1)CD001488
Foot Ankle Int. 2005;26:38
Diabetic Foot Care
High Risk: Podiatry Care
Provide nail and skin care
Assess footwear needs
Visit frequency not
evidence-based
Equinus management
Diabetes Care.
2003;26:1691
J Fam Practice.
2000;49(Suppl):S30
Basic Foot Care Concepts
Daily foot inspection
May require mirror,
magnification, or caregiver
Patient able to
recognize/report:
Persistent erythema
Enlarging callus
Pre-ulcer (callus with
hemorrhage)
Diabetic Foot Care
Basic Foot Care Concepts
Commitment to self-care
Wash/dry daily
Lubricate daily (not between
toes)
Debride callus/corn (low-risk
patients)
No self-cutting of nails if:
Neuropathy
PAD
Poor vision
Basic Foot Protective
Behaviors
Avoid temperature extremes
No walking
barefoot/stocking-footed
Appropriate exercise for
insensate feet
Inspect shoes for foreign
objects
Optimal footwear at all times
Basic Footwear Education
Avoid:
Pointed toes
Slip-ons
Open toes
High heels
Plastic
Black color
Too small
Diabetes Self-Management.
2005;22:33
Favor:
Broad-round toes
Adjustable (laces, buckles,
Velcro)
Athletic shoes, walking
shoes
Leather, canvas
White/light colors
½” between longest toe and
end of shoe
Therapeutic Footwear Efficacy
Protect feet
Reduce plantar pressure, shock, and shear
Accommodate, stabilize, support deformities
Suitable for occupation, home, leisure
Padded socks (e.g., CoolMax, Duraspun, others)
Shoe inserts/insoles (closed-cell foam, viscoelastic)
Therapeutic shoes
Decreases plantar pressure 50%-70%
Uncertain reduction in ulcer rate
Diabetes Care. 2004;27:1774
Thomson Rueters Study JAPMA
2011
Thomson Reuters Healthcare carried out the study utilizing its
MarketScan Data Base examining claims from 316,527 patients with
commercial insurance (64 year of age and younger) and 157,529
patients with Medicare and an employer sponsored secondary
insurance.
The study focused on one specific aspect of diabetic foot care: those
patients who developed a foot ulcer. For those who developed a foot
ulcer, the year preceding their development of a foot ulcer was
examined to see if they had seen a podiatrist. Those who saw a
podiatrist were compared to those who did not over a three year time
period.
A comparison was then made between those who had at least one visit
to a podiatrist prior to developing the foot ulcer to those who had no
podiatry care in the year prior to developing the foot ulceration.
Thomson Rueters Study JAPMA
2011
Average savings over a three-year time period (year before ulceration and
two years after ulceration occurred):
Commercial Insurance: Savings of $19,686 per patient if they had at least
one visit to a podiatrist in the year preceding their ulceration
Medicare Insured: Savings of $4,271 per patient
Amputation Rates:
Commercial Insurance:
Podiatry care amputation rate – 5.82%
Non-podiatry care amputation rate – 8.49%
Medicare Insured:
Podiatry care amputation rate – 4.69%
Non-podiatry care amputation rate – 6.04%
Duke Study – Health Services
Research
Medicare‐eligible patients with diabetes were less likely to
experience a lower extremity amputation if a podiatrist was a
member of the patient care team.
Patients with severe lower extremity complications who only
saw a podiatrist experienced a lower risk of amputation
compared with patients who did not see a podiatrist.
A multidisciplinary team approach that includes podiatrists
most effectively prevents complications from diabetes and
reduces the risk of amputations.
Thank You!!!!
Any Question???
Patrick A. DeHeer, DPM
Hoosier Foot & Ankle
317-346-7722
Hoosierfootandankle.com