The Foot in Diabetes

1
The Foot in Diabetes

• Nurse Education

Start
2
Feet in Diabetes
Economics of Diabetes
NICE Guidelines
Foot Assessments
Read Codes for Foot Assessments
3
Why worry about Diabetic Feet?

• Counting the cost of diabetes
• NHS expenditure on diabetes projected on the
  basis of nine per cent (Currie CJ et al 1997) of
  NHS costs in 2000 5,185,314,000
• This is equivalent to
• 99,717,567 a week
• 14,245,367 a day
• 593,560 an hour
• 9,893 a minute
• 165 a second

4
Diabetic Feet

• Foot ulceration 'diabetic foot' is the
  commonest reason for people with diabetes to be
  admitted to hospital in the UK. (Young MJ et al
  1994) Diabetic Foot problems take up more bed
  days than all the other complications put
  together (Waugh NR 1988)
• It is a result of nerve damage (neuropathy) and
  lack of blood supply (ischaemia). If an ulcer
  becomes infected and gangrenous this can
  necessitate amputation. According to one widely
  cited study, people with diabetes are 15 times
  more likely to need amputation than people
  without the condition. (Bild DE et al 1989)

5
The NICE Guidelines

• The National Institute for Clinical Excellence
  (NICE) has produced guidelines to help prevent a
  person with diabetes develop the complications
  that can lead to amputation and hospitalisation
• A Foot assessment can also recognise the
  complications affecting the feet and establish
  protocols for education, review and onward
  referral.

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The NICE Guidelines

• A General Management approach
• Decision making shared between patient and
  professionals
• Recall and annual review
• Feet Examination as part of Annual review by
  trained personnel to assess risk
• Examination Pulses sensation deformity and
  footwear
• Classify Risk low increased high ulcer.

7
Low Risk Foot

• Foot Pulses are Present so no Ischaemia
• No Loss of Sensation so no Neuropathy

8
Increased Risk Foot

• Either Pulses are Absent
• Or there is Neuropathy
• Or there is Foot deformity

9
High Risk Foot

• Previous History of Foot Ulceration
• Or Pulses are Absent
• Or there is Neuropathy
• and there is Foot deformity, or other risk factor

10
Read Codes used in Foot Assessments

• Diabetic Foot Risk Assessment 66AW
• Read Codes for Low Risk Feet
• Right Foot 2G5E
• Left Foot 2G5I
• Read Codes for Increased Risk Feet
• Right Foot 2G5F
• Left Foot 2G5J
• Read Codes for High Risk Feet
• Right Foot 2G5G
• Left Foot 2G5K

11
Foot Assessment

• The assessment is vital to establish a level of
  risk in the Diabetic Foot
• This assessment is normally performed in a
  primary care setting by Practice nurses, but may
  also be performed by Podiatrists, GPs and
  Consultant Physicians

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Foot Assessment

• The risk groups the assessment is designed to
  place people in are
• Low Risk
• Increased Risk
• High Risk
• Ulcerated
• (Ref NICE Guidelines 2005)

13
Foot Assessment

• The assessment can be divided into three parts
• History
• Examination
• Investigations
• Remember all these can be done at the same time
  in a busy clinic otherwise you will run behind
  and people will start getting annoyed with you in
  the waiting room!

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History

• Presenting complaint if there is one
• Past Foot History
• Diabetes History
• Past Medical History
• Family History
• Drug History
• Psychosocial History

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Presenting Foot Complaint

• Foot problem could be
• Skin breakdown swelling colour changes pain
  callosity toenail problem or footwear problem
• Ask questions
• Where is the problem?
• When did it start?
• How did it start?
• How has it been treated so far?

16
Presenting Foot Complaint

• Consider who is the best team member to deal with
  the current problem and refer when necessary.
• Pain as a symptom may be due to localised trauma
  infection ischaemia or neuropathy
• The next slide will help you distinguish between
  pain from ischaemia and neuropathy

17
Ischaemic or Neuropathic Pain?

• Ischaemic Pain
• Persistent pain
• Worse on elevation
• Relieved by dependency
• Pain in calf on exercise (claudication) relieved
  by rest

• Neuropathic Pain
• Burning pains
• Contact pains due to sheets or other touch
• Sharp short shooting pains
• Pain relieved by cold
• Pain worse during rest

18
Past Foot History

• Note previous ulceration and treatments
• Note any previous amputations
• Major
• Minor
• Reasons for amputations
• Osteomyelitis Necrosis Trauma
• Peripheral Angioplasties
• Peripheral Arterial Bypasses

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Diabetes History

• Type of Diabetes
• Type 1
• Type 2
• Duration of Diabetes
• Treatment of Diabetes
• Insulin
• Oral Hypoglycaemics

20
Diabetes History

• Complications
• Retinopathy
• Nephropathy
• Cardiovascular
• Angina, Heart Failure, Myocardial Infarction
• Coronary artery angioplasty or bypass
• Cerebrovascular
• Transient Ischaemic attack (TIA)
• Stroke (CVA)

21
Past Medical History

• Severe systemic conditions
• Cancer, Rheumatoid Arthritis etc
• Neurological conditions
• Epilepsy, Parkinsons disease etc
• Accidents
• Injuries
• Hospital Admissions
• Operations

22
Drug History

• Present Medication
• Steroids, Anti-coagulants etc.
• Known Allergies or sensitivities
• Antibiotics
• Medications
• Dressings
• Adhesive dressings

23
Family History

• Familial History of Diabetes
• Other serious illness
• Cause of death of near relatives
• Obesity

24
Psychosocial History

• Occupation
• Smoker?
• Number of cigarettes smoked daily
• Drink Alcohol?
• Number of units drunk daily
• Psychiatric illness
• Home circumstance
• Type of accommodation Lives alone?

25
Foot Examination

• Explain what you are doing for each test
• Look at the feet and legs from a distance away
  and note any differences between the right and
  left in terms of Deformity, Colour and Volume
• Ask the patient whether they have any worries
  about their feet
• Take a short history of any relevant operations,
  injuries, medication, that may impact on their
  feet. (See History)

26
Foot Examination

• Feel with the back of the hand the temperature of
  the skin surface from the distal part of the foot
  up the leg and then compare to the other foot and
  leg.
• Are there any differences? Cold spots or areas of
  heat? (May lead you to think about ischaemia or
  infection)
• Note the absence of hair growth on the toes and
  legs (non conclusive sign of ischaemia)

27
Foot Examination

• Note any colour differences
• Redness (erythema) may lead to conclusions about
  presence of infection.
• Oedema may or may not be present in infection
  dependant on how ischaemic the foot is.
• Any suspicion of infection should be referred on
  to an appropriate team member to decide on the
  necessity for antibiotic therapy
• Now go on to check the foot pulses

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Check the Foot Pulses

• Dorsalis Pedis Pulse
• Use index, middle and ring fingers together and
  palpate the dorsum of the foot over the bony
  prominence of the tarsal bones 4-5 cm proximal to
  the space between the first and second toe just
  lateral to the Extensor Hallucis longus tendon
• Posterior Tibial Pulse
• Found below and behind the medial malleolus

29
Check the Foot Pulses

• If you palpate either of these pulses it is
  unlikely there is any significant ischaemia in
  the foot
• If both pulses are not palpable then check the
  popliteal and femoral pulses
• ABPI (Ankle Brachial Pressure Index) can be
  undertaken but calcification of arteries in
  Diabetes can lead to falsely high ABPI readings
  so toe pressures could be undertaken (TBPI)
• Pulse Oximetry comparison between finger and toe
  can also be very useful (Parameswaran et al Arch
  Intern Med Feb 2005 Vol1654 442-446)

30
Check for Neuropathy

• The method of choice is the 10gm monofilament
  applied perpendicular to the foot and pressure
  applied until it bends
• Sites to test
• Apex of first, third, and fifth toes and the ball
  of the foot (MTP joints) of the same toes, dorsum
  of foot and heel
• Vibration sense tested on dorsum of first toe and
  a site further proximal such as the lateral
  malleolus using a 128-Hz tuning fork

31
Check for Neuropathy

• When testing get the person to close their eyes
• Repeat the test three times at each site
• One of those three tests should be a non test
  where the foot is not touched
• This is to ascertain whether the person being
  tested is telling you what they feel you want
  to hear

32
Foot Examination

• Next examine each foot more closely
• Check each toe and in between each toe
• Check the Toenails
• Check the skin
• Check for areas of deformity or swelling
• Check joint mobility
• Check colour signs of necrosis or ischaemia
• Check Footwear

33
Toes

• Toes should be checked for shoe pressures and
  callosities
• Toes should be checked for deformities and advice
  given as appropriate on footwear

34
Toenails

• Toenails should be checked for infections
• Fungal Nail infections
• Toenails should be checked for ulceration
• Ulceration under the nail
• (sub ungual ulceration)

35
Toenails

• Toenails should be checked for thickening
  (Onychogryphosis)
• Check for ingrown Toenails

36
Skin

• Skin should be checked for any wounds or entry
  points for infections
• Skin should be checked for callosity and signs of
  pressure

37
Deformity and Oedema

• Check deformities are not under pressure from
  footwear
• Be aware of any oedema and its possible causes
• venous insufficiency
• infection

38
Joint Mobility

• Check joint mobility as this may impact on
  possible pressure points
• Other conditions complicating Diabetes such as
  Rheumatoid arthritis can result in poor joint
  mobility and gross deformity

39
Necrosis and Ischaemia

• Buergers Test
• Elevate the limb above heart level Turns White
• Then lower the limb to dependency Turns Purple
• Is a Indicator for Ischaemia
• Find Pulse with doppler then raise leg if pulse
  sound reduces or stops then ischaemia is indicated

40
Necrosis and Ischaemia

• Wet necrosis
• Usually appears as yellow/grey slough with
  grey/pale pink base
• Dry Necrotic Lesions should be noted and left dry
  but monitor demarcation lines for signs of
  infection

41
Examine Footwear

• Check Footwear for
• Length, width depth
• Template Test
• Internal seams or rough edges
• Fastenings
• Fastenings to keep shoe on
• No fastenings means shoe is too tight or person
  has to claw toes to keep shoes on
• Heels
• Wide stable heel
• Not higher than 2.5cm

42
Footwear Template Test

• To check for length and width
• Place foot on thin card (cereal pack will do)
• Draw around barefoot
• Cut out template
• Place inside shoes
• This will show if any edges of the template need
  to deform to get the shoe on
• Repeat for the other foot
• Show the person your findings

43
Stages of Diabetic Foot

• Stage 1 Normal or Low Risk Foot
• Stage 2 High-Risk Foot
• Stage 3 Ulcerated Foot
• Stage 4 Infected Foot
• Stage 5 Necrotic Foot
• Stage 6 Unsalvageable Foot
• (Stages of Diabetic Foot Ref Edmonds, Foster,
  Sanders 2004)

44
Normal Foot

• No risk factors present
• Foot sensation good
• Foot pulses palpable
• No foot deformities
• No pathological callus
• No swelling
• Foot Assessment

45
High Risk Foot

• Neuropathy and Ischaemia
• are the main risk factors for ulceration.
• Deformity, oedema and callus
• are risk factors that will not necessarily lead
  to ulceration unless either or both of the main
  risk factors are present

46
High Risk Foot

• The Foot has developed one or more or the
  following risk factors for ulceration
• Neuropathy
• Ischaemia
• Deformity
• Oedema
• Callus

47
Ulcerated Foot

• Foot ulcers can be less than 1mm or cover most of
  the foot surface
• But all foot ulcers large or small should be
  taken very seriously
• As they can deteriorate rapidly

48
Infected Foot

• Managing Infection is a vital in treating foot
  ulceration
• Tissue samples are better than swabs to send for
  culture and sensitivity, but if swabs are used
  take from the base of the ulcer.

Spreading erythema from L/4th toe would strongly
suggest infection
49
Necrotic Foot

• Necrosis can be wet or dry
• Wet Necrosis has slough which is soft, yellow or
  grey in colour
• Dry Necrosis has slough which is hard and black

Wet Necrotic Slough
Dry Necrotic Slough
50
Unsalvageable Foot

• Sometimes when there is a great risk of Spreading
  Osteomyelitis and or necrosis or the patients
  life is in danger from Septicaemia then
  Amputation is the only recourse

Ulcer probes to bone Necrosis and osteomyelitis
present
Amputation was performed within days
51
Investigations

• Laboratory Tests
• Full Blood Count (FBC) to detect anaemia or
  polycythaemia
• Serum Electrolytes, urea and creatinine to assess
  Renal function
• Serum bilirubin, alkaline phosphatase, gamma
  glutamyl transferase, and aspartame transaminase
  to assess Liver function
• Blood Glucose HbA1c to assess diabetes control
• Serum cholesterol and triglycerides to assess
  arterial disease risk factors

52
Investigations

• Radiological determined by clinical presentation
  and not always necessary
• X-ray to detect
• Osteomyelitis
• Fracture
• Charcot Foot
• Gas in soft tissues
• Foreign Body

53
Investigations

• Foot Pressures
• These techniques measure pressure distributions
  of the foot either out of shoe by walking across
  pressure plates or by in shoe pressure
  templates which are placed in the shoes and then
  foot pressures recorded over time.

54
Foot Risk Factors
55
Neuropathy
56
Ischaemia
57
Callus

• Callus is an indication that an area of skin is
  working harder than it is designed for.
• In poor tissue viability the callus can ulcerate.
• Try to remove the causes of the callus
• Footwear can be a major cause of callus
• So can deformities or poor gait patterns

58
Foot Deformity
One month later ulcer improved and infection
treated with antibiotics
Ulcer over exostosis deformity with infection
59
Foot or Toe Deformities

• Deformities under the foot can add to pressures
  when the patient is ambulant
• Deformities to the top or the sides of the foot
  can add to pressures from footwear
• If surgical treatment of the deformity is
  unwanted then accommodate the deformity by
  referring for therapeutic footwear

60
Oedema
This patients Lymphoedema has caused pressure
from footwear on the lateral border of the foot
61
Foot Ulceration
62
Ischaemia

• Ischaemia is the result of poor arterial supply
  to the foot and leg.
• Without a good blood supply skin will not heal
  well and can lead to necrosis (gangrene)

Necrosis of the apex of toe
63
Foot Health Education
64
Self Assessment Tests

• Are you ready to take a self assessment test of
  this module?
• If not then press the button to go back to review
  the material again
• However if you feel ready to be questioned then
  press this button instead

Test
65
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66
Neuropathy

• Diabetic Peripheral Neuropathy is the presence of
  symptoms and/or signs of peripheral nerve
  dysfunction in people with diabetes, after
  exclusion of other causes e.g. Multiple Sclerosis
  (Boulton et al 1998)
• This can be sub divided into
• Motor Neuropathy
• Painful Neuropathy
• Autonomic Neuropathy
• Sensory Neuropathy
• Charcot Neuroarthropathy

67
Motor Neuropathy

• Diabetic amyotrophy
• This is a rare and unusual manifestation which
  results in poor motor control of the leg muscles
  usually bilateral leading to muscle weakness and
  muscle wasting
• Usually affects the quadriceps (anterior thigh)
• May also affect hamstrings (posterior thigh)
• Not always associated with sensory loss
• (Ref Kaplan Abourizk 1981)

68
Painful Neuropathy

• A small number of people with diabetes complain
  of
• Burning pains or Shooting pains in the legs
• Sensation of overtight skin
• Toes can feel larger than they actually are
• Heightened awareness of sensations
• Feeling of walking on stones
• Warm/cold sensations in the feet

69
Painful Neuropathy

• This is a nasty complication of diabetes that can
  be underestimated by healthcare professionals as
  it presents with little sign that anything is
  wrong.
• However patients in pain do not sleep well become
  disturbed, confused and depressed as constant
  unexplained pain can be miserable to bear.

70
Painful Neuropathy

• Can be provoked when insulin is first started and
  gradually improves if tight blood sugars are
  maintained
• Distribution usually bilateral (both legs)
• Usually worse at night and is not improved with
  foot dependency unlike ischaemic rest pain which
  is improved if the foot is lowered out of the bed
  

71
Painful Neuropathy

• Management is reassurance as this condition
  usually resolves within 2 years but may be
  replaced with numbness
• Therapies include
• Topical therapy
• Glycaemic control
• Drug therapy
• Physical treatments

72
Painful Neuropathy

• Topical Therapy
• Some patients find relief from burning pains or
  contact dysaesthesia with opsite film dressings
  or opsite sprays though clingfilm worn on the
  unbroken skin of the legs at night may be an
  alternative.
• Capsaicin applied as a cream

73
Painful Neuropathy

• Glycaemic Control
• High blood sugars (Hyperglycaemia) is known to
  lower the threshold for pain
• So with diabetic painful neuropathy due regard
  should be taken to HbA1c levels noting the normal
  range to be 3.8 to 6.4
• Diabetic therapies should then be optimised

74
Painful Neuropathy

• Drug Therapy
• This consists of analgesics, hypnotics, tricyclic
  antidepressants, anticonvulsants and
  antiarrythmics (used rarely)
• Burning pain Tricyclic antidepressants e.g.
  Amitriptyline or Imipramine (but be aware of
  postural hypotension)
• Anticonvulsants e.g. Gabapentin

75
Painful Neuropathy

• Physical Therapy
• Transcutaneous electrical nerve stimulation TENS
  
• Can be used to block the pain stimulus with
  electrodes either side of painful area
• Acupuncture
• Anecdotally reported as useful

76
Autonomic Neuropathy

• This is very common in the diabetic foot as the
  autonomic nervous system controls the sweat
  glands.
• This type of neuropathy produces dry skin which
  is liable to fissure and could lead to infections
  and/or ulceration

77
Autonomic Neuropathy

• As we can see from this picture of a heel, dry
  skin can easily lead to fissuring and ulceration

78
Autonomic Neuropathy

• So people with autonomic neuropathy should be
  encouraged to use emollients on a daily basis
• A small amount daily is much better than a big
  dollop once a week
• Aqueous Cream B.P. is very good and generally
  more affordable that branded products such as
  E45,Vaseline Intensive Care or Atrixo

79
Sensory Neuropathy

• This is the most common form of Neuropathy in
  diabetes.
• Leads to a numb, painless foot insensitive to one
  or all of
• light touch deep touch heat and cold pain
  sensation and vibration sensation
• This can lead to problems of patients being
  unaware of trauma to the feet.

80
Sensory Neuropathy

• This type of neuropathy can lead to problems of
  ulceration caused by
• Mechanical Trauma
• Chemical Trauma
• Thermal Injury

81
Sensory Neuropathy

• Mechanical Trauma
• Skin can be subject to shearing and compressive
  mechanical stresses leading to corns or callus
• Further stresses can then lead to tissue
  breakdown under the callosity

82
Sensory Neuropathy

• Mechanical Trauma
• The pain and/or pressure response is absent and
  the pressure causing the lesions continues
  without rest and leads to ulceration beneath the
  callosity

83
Sensory Neuropathy

• Chemical Trauma
• People are tempted to use medicated corn and
  callus plasters which contain salicylic acid
  which breaks down the keratin molecules within
  the skin and theoretically softening the
  callosity unfortunately this acid varies in
  concentration and can lead to ulceration

84
Sensory Neuropathy

• Thermal Injury
• This example is of a person with diabetic sensory
  neuropathy who burnt his toe on the metal side of
  a radiant heater.
• As he felt no pain he did not realise the damage
  that was occurring. So as he watched television
  the skin was burnt then blistered and took 7
  months to heal

85
Sensory Neuropathy

• Sensory Neuropathy when recognised as present in
  a person with diabetes should lead to an
  education of that person by healthcare
  professionals in how to care for themselves.
• The main point of that education is DAILY FOOT
  EXAMINATIONS by the patient or their carer.

86
Sensory Neuropathy

• Prevention and recognition of any foot problem is
  the primary responsibility of the person with
  diabetes and their carers.
• The daily foot examination is vital in the high
  risk foot as injuries may have occurred without
  the patient realising so they must look for any
  wounds, injuries or blistering which may give an
  access point to opportunist infections.
• Then a immediate regime of antiseptic dressings
  should be instituted by the patient or carer with
  daily wound checking
• If any sign of infection is present or if the
  wound is large an immediate GP appointment should
  be sought for antibiotic therapy with support
  from the community nursing team instituted

87
Foot Risk Factors
Ischaemia
Neuropathy
Callus
Deformity
88
Economics of Diabetes