Diabetic Foot
An Overview
Foot team
• Prof.Mamdouh El Nahas
• Prof.Hanan Gawish
• Dr. Manal Tarshoby
• Dr.Omnia State
World Diabetes Day 2005
Diabetes and Foot Care
Put Feet First
Prevent Amputations
2005: a Year-long Campaign
Campaign Objectives
• Inform people of the extent of diabetic foot
problems worldwide.
• Persuade people that action is both possible
and affordable.
• Warn people of the consequences of not
taking action.
FOOT FACTS (1)
• Every 30 seconds a leg is lost to diabetes
somewhere in the world.
• Up to 70% of all leg amputations happen to
people with diabetes.
• DF problems are the commonest cause of
hospital admission. (by us?)
FOOT FACTS (2)
• Most amputations begin with a foot ulcer.
• One in every six people with diabetes will have
a foot ulcer during their lifetime.
• Good News
Up to 85% of amputations can be avoided.
Egypt Representative
Mansoura University
Prof.Mamdouh El Nahas.
Dr.Hanan Gawish
Dr. Manal Tarshoby
Dr.Omnia Stat
Levels of foot management
• Level 1 General practitioner, diabetic
nurse and podiatrist
• Level 2 Diabetologist, surgeon (general
and/or vascular and/or orthopedic),
diabetic nurse and podiatrist
• Level 3 Specialized foot center
Value of Podiatric Care
14
% Amputations
12
•KINGS COLLEGE HOSPITAL.
10
8
•1984 establishment of
DIABETIC FOOT CLINIC.
6
4
2
0
84
85
86
Year
87
•Amputation decreased 50% in
3 years.
Diabetic Foot
Diabetic Foot Disease
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Ischaemia
Neuropathy
Infection
Structural deformity
Ulcer
Amputation
Five cornerstones of the management
of the diabetic foot
Regular inspection and examination of the foot.
Identification of the foot at risk.
Education of patient, family and healthcare providers.
Appropriate footwear.
Treatment of non ulcerative pathology
Five cornerstones of the management
of the diabetic foot
Regular inspection and examination of the foot.
Identification of the foot at risk.
Education of patient, family and healthcare providers.
Appropriate footwear.
Treatment of non ulcerative pathology
Regular inspection and
examination of the foot
• All diabetic patients should be
examined at first presentation then at
least once a year
• Patients with risk factors should be
examined every 1-6 months
• Absent symptoms does not mean that
the feet are healthy
• Examine the patient on lying down and
standing up
• Shoe and socks should be inspected
History
• Previous ulcer , amputation
• Previous foot education
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Bare-foot walking
Poor access to healthcare
Smokimg , alcohol
Nephropathy,Retinopathy
• Hypertension
• Ischemic heart disease
Foot examination
1. Nails
Thick
too long
ingrown
fungal infection
wrongly cut nails
Foot Examination
2.Foot deformity:
Foot Examination
2.Foot deformity:
Toe deformity
• Hammer toe
• Claw toe
Toe Deformity:– Hammer Toe
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Increased pressure on 2ndmetatarsal head
Increased pressure on prox. IPJ
Increased pressure on distal IPJ
Increased pressure on apex
Increased pressure on nail fold
Foot Examination
2.Foot deformity:
Toe deformity
Forefoot deformity
• Hallux valgus
• Hallux rigidus
Hallux Valgus
Hallux Rigidus
Osteoarthritic Degeneration 1st MTP Joint
Limitation of Dorsiflexion
Overloading 2nd MTP Joint / 1st IPJoint
Foot Examination
2. Foot deformity:
Toe deformity
Forefoot deformity
Wholefoot Deformities
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•
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Pes Cavus - High arched foot
Pes Planus - Flat foot
Charcot foot
Diagnosis of Acute Charcot
 Painless
 Redness, swelling, and more than 2°C skin
temperature difference when compared with the
contralateral foot.
 Dorsalis pedis pulses are often bounding.
 The patient is afebrile unless a systemic infection
is present.
Foot Examination
2.Foot deformity:
Toe deformity
Forefoot deformity
Whole foot Deformities
Prominent metatarsal heads
Foot Examination
3.Skin condition:
Callus
Redness
Fissure
Swelling
Fungal infection
Bunions
Warmth
Dryness
Maceration
Callus
• Presence of callus is a
significant marker for
the development of foot
ulceration
• The hyperkeratosis is a
result of hypertrophy
under the influence of
intermittent
compression .
• the callus is either a
reaction to abnormal
pressure or an
abnormality of the area
to handle normal
pressure.
Tenia Pedis
Foot Examination
4.Vascular assessment:
History
Intermitent claudication
Rest pain
Colour of the skin
Temperature gradient
Foot Examination
4.Vascular assessment:
Pedal pulse
Dorsalis pedis
Posterior tibial
Foot Examination
4.Vascular assessment:
Pedal pulse
Dorsalis pedis
Posterior tibial
Ankle Brachial Pressure Index
Foot Examination
5. Neurological assessment:
Neurologic assessment
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Temperature
Vibration Sense
Pressure Sense
Light Touch
Proprioception
Reflexes
Neurologic assessment
Neurologic assessment
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Temperature
Vibration Sense
Pressure Sense
Light Touch
Proprioception (Romberg’s Sign)
Superficial Pain
Reflexes
TEMPERATURE TESTING
 Two test tubes, hot/cold.
 Therm-tip
 Subjective, crude tests
Neurologic assessment
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Temperature
Vibration Sense
Pressure Sense
Light Touch
Proprioception
Superficial Pain
Reflexes
VIBRATION SENSE
NEUROTHESIOMETER
Neurologic assessment
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Temperature
Vibration Sense
Pressure Sense
Light Touch
Proprioception
Superficial Pain
Reflexes
MONOFILAMENTS
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10 gm
Sites tested
Technique
Significance
Neurologic assessment
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Temeprature
Vibration Sense
Pressure Sense
Light Touch
Proprioception
Superficial Pain
Reflexes
LIGHT TOUCH TEST
Neurologic assessment
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Temperature
Vibration Sense
Pressure Sense
Light Touch
Proprioception
Superficial Pain
Reflexes
PROPRIOCEPTION TEST
Tested by dorsiflexing
and plantarflexing the
hallux. Can the patient
determine the position
of the hallux?
Neurologic assessment
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Temperature
Vibration Sense
Pressure Sense
Light Touch
Proprioception
Superficial Pain
Reflexes
SUPERFICIAL PAIN TEST
Neurologic assessment
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Temperature
Vibration Sense
Pressure Sense
Light Touch
Proprioception
Superficial Pain
Reflexes
ANKLE REFLEX
Five cornerstones of the management
of the diabetic foot
Regular inspection and examination of the foot.
Identification of the foot at risk.
Education of patient, family and healthcare providers.
Appropriate footwear.
Treatment of non ulcerative pathology
Risk Categorization
Risk categorization system
Category
Risk profile
Checkup frequency
0
no sensory neuropathy
once a year
1
sensory neuropathy
once every 6
months
sensory neuropathy and signs of
peripheral vascular disease and/or
foot deformities.
once every 3
months
2
3
previous ulcer
once every
month
Five cornerstones of the management
of the diabetic foot
Regular inspection and examination of the foot.
Identification of the foot at risk.
Education of patient, family and healthcare providers.
Appropriate footwear.
Treatment of non ulcerative pathology
Five cornerstones of the management
of the diabetic foot
Regular inspection and examination of the foot.
Identification of the foot at risk.
Education of patient, family and healthcare providers.
Appropriate footwear.
Treatment of non ulcerative pathology
Five cornerstones of the management
of the diabetic foot
Regular inspection and examination of the foot.
Identification of the foot at risk.
Education of patient, family and healthcare providers.
Appropriate footwear.
Treatment of non ulcerative pathology
What is going on??
Foot care team
• ??Podiatrists
• Orthotists.
• Diabetologists.
• Vascular Surgeon.
• Educators.
• Microbiologist.
Ulcer assessment
1.Establish the ulcer's etiology
2.Measure its size
3.Establish its depth and involvement of deep
structures
4.Examine it for purulent exudates, necrosis,
sinus tracts, and odor
5.Assess the surrounding tissue for signs of
edema, cellulitis, abscess, and fluctuation
6.Exclude systemic infection
7.Perform a vascular evaluation.
8.The ability to gently probe through the ulcer to
bone has been shown to be highly predictive of
osteomyelitis.
(should be recorded at base line and every subsequent
visits ± digital photo)
• A multidisciplinary approach
providing debridement, meticulous
wound care, adequate vascular
supply, metabolic control,
antimicrobial treatment and relief of
pressure (offloading) is essential in
the treatment of foot ulcer.
Dressing
Do not put anything on the ulcer that you
wouldn’t put in your eye!!
No evidence from large trials
Debridement
Sharp
Larval
Enzymatic (Lytic)
Indication & Contraindication??
Offloading
Offlaoding
• What is meant by offloading
• Different offloading modalities
Key Message
• Of all late complications of diabetes, foot problems
are the most easily detectable and easily
preventable.
• Relatively simple interventions can reduce
amputations by 50 - 80%. (Bakker et al 1994).
• Strategies aimed at preventing foot ulcers are cost
effective and cost saving.
• Only champions willing to act are needed.
Don’t Forget to take your copy!
Thanks for sharing!!!!