Diabetic Foot ExamBy 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 GLANCE2010 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.

Presence of a DFU for 30 days or longer carries

an 8-Fold risk for infection. – Lavery 2006

24% of all DFU cases require inpatient care -Harrington et al.

2000

Patients who develop a foot infection have a 55.7 times greater risk of hospitalization that those who do not. –Lavery 2006

$72,775 – Cost of a leg amputation/ per amputation

procedure- Bureau of Labor Statistics, 2010

$20,300 – DFU inpatient cost per episode,

Harrington et al. 2000

The Hard Facts

Costs to Treat a Diabetic Foot Ulcer Over a 2-Year Period Following Detection

$27,987

$33,046

$40,786

$48,156

0

10,000

20,000

30,000

40,000

50,000

60,000

1995 2000 2005 2010

Co

st in

US

Do

llars

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 yearsClinical 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 LevelFoot Ulcer %/yr

% Office Patients

(diabetes clinics)

3: Prior amputationPrior ulcer

28.1%18.6% 7%

2: Insensate andfoot deformity orabsent pedalpulses

6.3% 10%

1: Insensate 4.8% 17%-30%0: All normal 1.7% 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 ulcersJ Fam Pract. 2000;49:S30Diabetes 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):S25Diabetes 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

Grant et al JFAS1997

Equinus and the Diabetic Patient

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

Grant et al JFAS1997

Equinus and the Diabetic Patient

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

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 P = 0.0001

Lavery, Armstrong, Boulton Study JAPMA 2002

DM +

Equ

inus

DM -

Equinu

s0

40

80

120

Mean PP N/cm²

DM +

Equ

inus

Dm -

Equinu

s0

30

60

Risk for elevated PPP %

Risk for elevated PPP %

Lavery, Armstrong, Boulton Study JAPMA 2002No statistical

significant difference –Weight Sex differenceAbsence 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

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

Diabet Med. 2005;22:1310Diabetes Care. 2003;26:3333

Arch Intern Med. 1998;158:1357Diabetes 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

InterpretationABI

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

Low Risk High Risk

Foot Care Based on Risk Factors

Annual comprehensive foot examination Questionnaire completed by

patient Examination

Self-management and footwear education Brief counseling Written handout

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

High Risk: Nursing Tasks High Risk: Patient Education

Foot Care Based on Risk Factors

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

Reinforce frequently – low retention

Patient demonstrates self-care knowledge

Evidence: May reduce foot

ulcer/amputation rates

J Gen Intern Med. 2003;18:258

Cochrane Database Syst Rev. 2005 Jan 25;(1)CD001488

Foot Ankle Int. 2005;26:38

High Risk: Podiatry Care Basic Foot Care Concepts

Diabetic Foot Care

Provide nail and skin care Assess footwear needs Visit frequency not

evidence-based Equinus management

Daily foot inspection May require mirror,

magnification, or caregiver Patient able to

recognize/report: Persistent erythema Enlarging callus Pre-ulcer (callus with

hemorrhage)

Diabetes Care. 2003;26:1691J Fam Practice. 2000;49(Suppl):S30

Basic Foot Care ConceptsBasic Foot Protective Behaviors

Diabetic Foot Care

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

Avoid temperature extremes No walking barefoot/stocking-

footed Appropriate exercise for

insensate feet Inspect shoes for foreign

objects Optimal footwear at all times

Avoid: Favor:

Basic Footwear Education

Pointed toes Slip-ons Open toes High heels Plastic Black color Too small

Broad-round toes Adjustable (laces, buckles,

Velcro) Athletic shoes, walking shoes Leather, canvas White/light colors ½” 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 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