Diabetic Foot Exam

By Patrick A. DeHeer, DPM

Hoosier Foot & Ankle
Lancet. 2005;366:1674
the enormity of the global burden of
diabetic foot diseasethis much
neglected, but potentially devastating,
complication of a disease that is reaching
epidemic proportionsSomeone,
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

DIABETES AND IGT (20-79 years)

Diabetes
Global prevalence (%) 6.6 7.8

Comparative prevalence (%) 6.4 7.7

Number of people with diabetes (millions) 285 438

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.
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The Hard Facts
55.7 times greater risk of hospitalization
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Costs to Treat a Diabetic Foot Ulcer
Over a 2-Year Period Following Detection

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
% Office
Foot
Patients
Risk Level Ulcer
(diabetes
%/yr
clinics)
3: Prior
28.1%
amputation 7%
Prior ulcer 18.6%
2: Insensate and
foot deformity
or 6.3% 10%
absent pedal
pulses
1: Insensate 4.8% 17%-30%
0: All normal 1.7% 66%
History for the Diabetic Foot
Chief Complaint Surgical History
Amputation
HPI Revascularization
NLDOCATS Social History
Medications ROS
CV IC, edema, change in color or
Allergies temperature of LE, PAD, venous
disease
Past Medical History Neuro burning, numbness,
Diabetes NIDDM/IDDM paresthesia, neuropathy, weakness
Control? MSK amp, foot deformity, Charcot,
injury, ambulatory, OA/RA
How long?
Derm prior ulcer Hx, nail fungus, dry
Family History 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: Demonstrate on forearm or
Negative predictive value = hand
90%-98% Place monofilament
Positive predictive value = perpendicular to test site
18%-36% Bow into C-shape for 1
Prospective observational second
study: Test 4 sites/foot
80% of ulcers and 100% of
Heel testing does not
amputations occur in
insensate feet predict ulcer
Superior predictive value vs. Avoid calluses, scars,
other test modalities 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 Mean Age 69.1 +/- 11.1
equinus and peak plantar (years)
pressures in diabetic Men 50.3%
patients Weight 83.8 +/- 19.7 (Kg)
1,666 patients Diabetes duration 11.1 +/-
Definition 0 AJ DF with KE 9.5 (years)
Pressure measured with
force-plate gait analysis
system
Lavery, Armstrong, Boulton Study
JAPMA 2002
P = 0.007 P = 0.0001
140
Risk for elevated PPP %
120
100 60
50
80 Risk for
Mean PP 40
60 elevated
N/cm 30 PPP %
40 20
20 10
0 0
DM + Equinus DM + Equinus
Lavery, Armstrong, Boulton Study
JAPMA 2002
No statistical Statistical significant
significant difference difference
Weight Equinus patients had
Sex difference longer duration of
Absence or presence diabetes
of neuopathy 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 patients 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 self-
care 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 Protective
Basic Foot Care Concepts Behaviors
Commitment to self-care Avoid temperature extremes
Wash/dry daily No walking barefoot/stocking-
Lubricate daily (not between footed
toes) Appropriate exercise for
Debride callus/corn (low-risk insensate feet
patients)
Inspect shoes for foreign
No self-cutting of nails if:
objects
Neuropathy
PAD
Optimal footwear at all times
Poor vision
Basic Footwear Education
Avoid: Favor:
Pointed toes Broad-round toes
Slip-ons Adjustable (laces, buckles,
Open toes Velcro)
High heels Athletic shoes, walking shoes
Plastic Leather, canvas
Black color White/light colors
Too small between longest toe and
end of shoe
Diabetes Self-Management.
2005;22:33
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
Medicareeligible 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