five cornerstones of the management of the diabetic foot 1. regular inspection and examination of...

Five cornerstones of the management of the diabetic foot

Five cornerstones of the management of the diabetic foot

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

Foot examination

1. Nails2. Foot deformity3. Skin condition4. Vascular assessment5. Neurological assessment

Foot examination

1. Nails Thick Too long Ingrown Fungal infection Wrongly cut nails

Foot Examination 2. Foot deformity: Toe deformity Hammer toeHammer toe Claw toeClaw toe

Forefoot deformity Hallux valgusHallux valgus Hallux rigidusHallux rigidus

Wholefoot Deformities Pes Cavus - High arched foot Pes Planus - Flat foot Charcot foot

Foot Examination

3.Skin condition:

Callus Bunions Redness Warmth Fissure Dryness Swelling Maceration Fugal infection

Foot Examination

4.Vascular assessment5.Neurological assessment

10/5/2008 Mansoura DF 2nd International Training Course

Does your patient have neuropathy?

Manal TarshobyAssistant Professor of Medicine Diabetes and Endocrinology unit Diabetic Foot TeamMansoura University EGYPT

Clinical Assessment History:

Review diabetes history, managementReview diabetes history, management Daily glycemic records, previous A1cDaily glycemic records, previous A1c Review medical historyReview medical history Review other causes of neuropathy Review other causes of neuropathy

(10%)(10%) 50% has no symptoms50% has no symptoms

Mansoura DF 2nd International Training Course 10/5/2008

History Michigan neuropathy screening questionnaire

Are your feet numbBurning painFeet sensitive to touchMuscle crampCan you tell hot from

cold waterHave you had an ulcerDr diagnosed neuropathyDo you feel weak

Symptom worse at nightLegs hurt when you walkPrickling feelingAble to sense feet when

walkingBed covers hurt your skin Your skin crack openUnsteadinessPrevious amputation

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Feldman, Diabetes care,199410/5/2008

Paradox ?

Mansoura DF 2nd International Training Course

Mansoura DF 2nd International Training Course 10/5/2008

Painful-Painless LegOne doesn’t need to have intact sensation to

experience pain.

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Physical ExaminationInspectionVibration sense Tuning fork 128Reduced protective sensation such as

pressure, hot and cold, painSharp, dull, light touchMotor strengthDiminished ability to sense position of toes

and feetDeep tendon reflex

Mansoura DF 2nd International Training Course 10/5/2008

InspectionMuscle atrophy

Intrinsic minus foot

Dry skin

Mansoura DF 2nd International Training Course 10/5/2008

Neurologic assessment

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Physical Examination Inspection

Vibration sense Tuning fork 128neurothesiometer

Mansoura DF 2nd International Training Course 10/5/2008

Vibration Sense

Tuning fork is held against a bony prominence:• Medial aspect 1st MTP Joint• Plantar Hallux• Med/Lat MalleolusPatients should be reminded that it is the vibration they are required to detect not the sound.

Mansoura DF 2nd International Training Course 10/5/2008

10/5/2008 Mansoura DF 2nd International Training Course

NEUROTHESIOMETER

•Vibration threshold is strongly linked with age •Males have slightly higher thresholds than females

Age 15 35 55

Males 8.8 volts 12.9 volts 19.9 volts

Females 8.3 volts 10.8 volts 14.6 voltsMansoura DF 2nd International Training Course 10/5/2008

NEUROTHESIOMETER

•At the distal pulp of the hallux, over bony prominence•Voltage is increased until the patient can perceive vibration

Mansoura DF 2nd International Training Course 10/5/2008

NEUROTHESIOMETER

Foot ulcer risk increased by 5.6% per volt Abott, Diabetes care, 1998

Mansoura DF 2nd International Training Course 10/5/2008

Physical Examination Inspection Vibration sense

Reduced protective sensation pressure hot and cold pain

Mansoura DF 2nd International Training Course 10/5/2008

TEMPERATURE TESTING

• Two test tubes, hot/cold.• Therm-tip• Subjective, crude tests

Mansoura DF 2nd International Training Course 10/5/2008

MONOFILAMENTS

Which monofilament ?

•10 mg, 1mg•Calibrated

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MONOFILAMENTS

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HOW TO USE IT?

How many sites to be tested?10/5/2008

Mansoura DF 2nd International Training Course 10/5/2008

MONOFILAMENTS

Mansoura DF 2nd International Training Course

How many lost sites to diagnose LOPS

410/5/2008

1

Monofilament Failure

Variability within and between brandsRequire frequent replacementShould be calibratedGive-away devices are of uncertain

quality ,durabilityRepetitive loading?

Mansoura DF 2nd International Training Course 10/5/2008

SUPERFICIAL PAIN TEST

• Neuro - tip• Areas tested• Patient response• Significance

Mansoura DF 2nd International Training Course 10/5/2008

Physical Examination Inspection Vibration sense Reduced protective sensation

Sharp, dull, light touch

Mansoura DF 2nd International Training Course 10/5/2008

LIGHT TOUCH TEST

Wisp of cotton wool Subjective Can be painful if neuropathy

exists

Mansoura DF 2nd International Training Course 10/5/2008

Mansoura DF 2nd International Training Course 10/5/2008

Physical Examination Inspection Vibration sense Reduced protective sensation Sharp, dull, light touch

Motor strength

Mansoura DF 2nd International Training Course 10/5/2008

Physical Examination Inspection Vibration sense Tuning fork 128 Reduced protective sensation such as pressure, hot and cold, pain Sharp, dull, light touch Motor strength

Diminished ability to sense position of toes and feet

Mansoura DF 2nd International Training Course 10/5/2008

Physical Examination Inspection Vibration sense Tuning fork 128 Reduced protective sensation such as pressure, hot and cold, pain Sharp, dull, light touch Motor strength Diminished ability to sense position of toes and feet

Deep tendon reflex

Mansoura DF 2nd International Training Course 10/5/2008

Deep tendon reflex

Mansoura DF 2nd International Training Course 10/5/2008

Neuro Disability score3 sensory modality

VibrationPin prick (neurotip)Hot-cold rodScoredNormal=0Abnormal=1

Ankle reflex

ScoredNormal=0Reinforcement=1Absent=2

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Max total 5 for each legTotal out of 10

10/5/2008

2 minutesPatient should take off his shoes and socksShould inspect his shoes Watch the patient as he walksPlease turnGet up from a chairStand on one leg

10/5/2008 Mansoura DF 2nd International Training Course

Resnick, Vinik et al. Muscle and Nerve, 2001

Risk categorization system categor

yRisk profile Check up

frequency

0 no sensory neuropathy

Once a year

1 sensory neuropathy Once every 6 months

2sensory neuropathy and signs of peripheral vascular disease

and/or foot deformities..Once every 3

months

3 previous ulcer Once every 1-3 months

Mansoura DF 2nd International Training Course 10/5/2008

Thank you

10/5/2008 Mansoura DF 2nd International Training Course