1. Diabetes and Your Feet (Physician’s Name Here) (Practice Name Here)
(Practice Address Here)
(Practice Phone Number Here)
(Practice Website Here)
Courtesy of Dr. Barbara J. Aung, DPM,CWS

2. Expected Increase in Diabetes From 2000 to 2030
2000: 151 million patients
2030: 370 million patients (~145% increase)
84.5 M
14.2 M
26.5 M
+57%
+23%
+24%
9.4 M
+50%
15.6 M
1.0 M
+44%
+33%
Zimmet P, et al. Nature. 2001;414:
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3. Prevalence of Diabetes in the US Now up to 18 Million
TYPE 2 DIABETES IS 95 AND TYPE 1 IS 5, AND EQUALLY NUMBER IS PRE DIABETES
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4. The Facts About Diabetes
Diabetes affects minority populations disproportionately:
-2.3 million African Americans age 20 or older have diabetes
-1.2 million Mexican Americans age 20 and older have diabetes
-diabetes can affect up to 50 percent of some Native American populations
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5. Diabetic Complications Affect Every Part of The Body
Diabetic Retinopathy
Leading cause
of blindness
in working age
adults
Cardiovascular Disease
Stroke
2 to 4 fold
increase in
cardiovascular
mortality
and stroke
Diabetic
Nephropathy
Leading cause of
end-stage renal disease
Diabetic Neuropathy
Leading cause of nontraumatic
lower extremity amputations
Diabetes mellitus is associated with a wide variety of microvascular and macrovascular complications.
Diabetic microvascular complications are most commonly manifested in the eyes, kidneys, and nerves.
Diabetic retinopathy and diabetic macular edema: Diabetes is the leading cause of new cases of blindness in adults between the ages of 20 and 74 years.1 After 15 years of diabetes, 2% of patients become blind and 10% develop severe visual disability.4
Diabetic nephropathy: In end-stage renal disease, diabetes accounts for about 35% to 40% of new cases.1 People with diabetes make up the fastest-growing group of renal dialysis and transplant recipients.3
Diabetic neuropathy and amputations: Diabetes is the leading cause of nontraumatic lower-extremity amputations, accounting for 50% of amputations in the United States. About 60% to 70% of people with diabetes have some degree of diabetic nerve damage.4
There is also a high frequency of atherosclerosis (macrovascular disease) leading to increased risk of stroke and/or heart attack.
Cardiovascular disease: People with diabetes are 2 to 4 times more likely to die from heart disease than people without diabetes. Cardiovascular disease is responsible for 50% of diabetes-related deaths.2
Stroke: A person with diabetes is 2 to 4 times more likely to suffer a stroke than a person without diabetes.1
1. National Diabetes Information Clearinghouse. Diabetes Statistics–Complications of Diabetes. Accessed May 1, 2001.
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6. How do diabetic foot problems compare with other diabetes-complications?
Infected wounds: most common reason for hospital admission
Infection:Ulcer ratio = 0.56
1 in 5 leads to lower extremity amputation
Trautner, et al, Invest Opthalmol Vis Sci, 2003
Lavery, Armstrong, et al, Diabetes Care, 2003
Fedele, et al, J Urol, 2001
Bruno, Diabetes Care, 2003
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7. Financial implications
7th leading cause of death
Direct and indirect costs 2002 was $132 billion
25% of all Medicare expenditures
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8. Diabetes Can Be Controlled
Diabetes treatment includes “food management” to control blood sugar, getting regular physical activity, taking oral medications and/or insulin, and monitoring blood glucose levels.
By keeping blood sugar levels in the normal range, people with diabetes lower their risk of long-term complications of diabetes, such as eye disease, kidney disease, and nerve damage.
UKPDS, NDEP
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9. Blood Sugar/Glucose Monitoring Patient Home & Office Setting
Patient education & encouragement in maintaining good glucose control is essential in avoiding complications; both in a primary care and specialist clinic setting.
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10. A1c An Indication For Healing
HbA1C (Now simply A1c)
Reveals a combination/average; reflects mean of fasting and post-meal glucose levels for past 2-3 months
Good indicator of how a patient will heal, as well as how well the blood sugar is controlled on a daily basis
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11. Reduced Risk of Diabetes Complications Risk Reduction per 1% Decrease in A1C
Eye
Kidney
Nerve
Heart
DCCT
27-38%
22-28%
29-35%
40%
Kumamoto
28%
50%
↑NCV
25%
UKPDS
19%
26%
18%
14%
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12. Patient Education
Ask the patient if they know how diabetes affects the foot and if they have ever had their foot examined. This question can provide information on the presence or absence of effective behaviors to institute prevention through appropriate self-maintenance.and recognition of pivotal events
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13. Patient Education (continued)
Helping patients recognize pivotal events that require professional medical attention.
Knowing the duration of diabetes and level of control (A1c #) would indicate level of risk of developing co morbid systemic disease involving the foot since manifestations of complications are time and control dependent.
Checking your own feet everyday and seeing a podiatrist at the earliest sign of redness, skin breakdown
UKPDS, DCCT, CDC, ADA, UTHSC-San Antonio
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14. Risk Factors Leading to Ulceration
Neuropathy
Foot deformities
History of foot ulcers/amputations
Adapted from Armstrong et al, 1991; Pecoraro et al, 1990; Mayfield et al, 1996.
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15. Neuropathy
The presence of subjective complaints : tingling, burning, numbness or formication (sensation of bugs crawling on skin) may indicate the clinical presence of peripheral sensory neuropathy.
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16. Neuropathy in People with Diabetes
Neuropathy is present in >80% of diabetic patients with foot ulcers
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17. Neurosensory Testing
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18. Neurosensory Testing Slide 8 2 3 4 1 5 6 7 8 9 Neurosensory Testing
Neuropathy is detected by neurosensory testing, which is easy to perform in the office setting. One neurosensory test is the Semmes-Weinstein monofilament. The 5.07 monofilament is the one most commonly used.1 [Levin, Diabetic Foot, p43] Patients should turn their heads when the test is being performed. The tip of the monofilament is gently placed on various standardized locations of the foot, including the plantar surface (bottom of the foot). Pressure is exerted until the monofilament buckles. The presence of the monofilament should be detectable by the patient at the time of buckling.1 [Levin, Diabetic Foot, p43] Diabetic patients who cannot feel the 5.07 monofilament (equivalent to 10g of linear force) when it buckles are considered to have lost protective sensation.1 [Levin, Diabetic Foot, p43]
Because patients are typically unaware that they have neuropathy, it can go undetected unless the clinician tests for it. Therefore, simply asking if sensation is decreased or absent is inadequate without actual assessment.
Reference
1. Levin ME: Pathogenesis and management of diabetic foot lesions, in Levin ME, O’Neal LW, Bowker JH (eds): The Diabetic Foot, ed 5. St. Louis, Mosby, 1993, pp 10
Left
Placement of Semmes-Weinstein monofilament
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19. Ulcerations Are Pivotal Events In Limb Loss
Portal for infection
Necrosis in the presence of critical ischemia
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20. Etiology of Neuropathic Diabetic Foot Ulcers
Pressure x Cycles of Repetitive
Stress = Wound
A PRESSURE-ACTIVITY IMBALANCE
Lavery, Armstrong, et al, Diabetes, Care, 2003
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21. Diabetic Amputation Ulceration usually precedes an amputation
Amputation 15 times more likely in people with diabetes
50% have contralateral amputation within 3-5 years
3-year mortality rate 20-50%
Adapted from reiber et al, 1995; CDC, 1997; Jiwa, 1997; Glover et al, 1997.
Courtesy of Dr. Barbara J. Aung, DPM,CWS

22. Musculoskeletal
Biomechanical changes in the diabetic foot develop in conjunction with muscle-tendon imbalances as a result of motor neuropathy. These deformities include the presence of hammertoes, bunions, high arched foot, or flatfoot, all of which increase the potential for focal irritation of the foot within the shoe.
Courtesy of Dr. Barbara J. Aung, DPM,CWS

23. Example of Shoe Pressure
This photo shows the results of shoe pressure on the foot where the shoe in not properly fitted to accommodate an individual’s foot size.
Courtesy of Dr. Barbara J. Aung, DPM,CWS

24. Foot Deformities
Corns and calluses (hyperkeratotic lesions) of the feet are a result of elevated areas of focal mechanical pressure and shearing of the skin. This focal build-up often precedes breakdown of skin forming either a blister or ulceration.
Courtesy of Dr. Barbara J. Aung, DPM,CWS

25. Charcot Arthropathy
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26. Structural Deformities
Bunions
Hammertoes
Arthritis
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27. Calluses
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28. Skin – Athletes Fee & Psoriasis with Fungal Infection in wound
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29. Skin Infections
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30. Toenail Infections
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31. Courtesy of Dr. Barbara J. Aung, DPM,CWS

32. Toenails – Treated
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33. Vascular Disease P.V.D. Reduced Peripheral Circulation
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34. Perpheral Arterial Disease
Symptoms of cramping of the calf when walking the requires frequent periods of rest- “intermitant claudication”
Intense cramping and aching to the toes only at night characteristically relieved with hanging the feet down or with walking
Courtesy of Dr. Barbara J. Aung, DPM,CWS

35. PAD This symptom signifies the end-stage disease.
Though poor blood supply is not an dependent risk factor for the development of ulceration, it is a significant risk factor for amputation.
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36. Non-Invasive Vascular Test
A non-invasive vascular test was performed in order to determine blood flow levels in a diabetic patient with a leg wound. Good vascular status aids in healing potential.
Courtesy of Dr. Barbara J. Aung, DPM,CWS

37. Offloading Its Importance for Reducing Foot Pressure Points
Slide 24
Pressure
Desquamation
Blisters
Callus
Offloading: Its Importance for Reducing Foot Pressure Points
Pressure is the degree of force exerted on a specific area.1 [Boulton, Med Clin, p1516] A pressure point is a localized area on the foot subjected to abnormally high pressure. In the foot that has intact sensory perception, areas of extrinsic pressure can be felt and corrective action taken (eg, shoes that fit too tightly are not worn). This is true even in patients with nondiabetic foot pathologies, such as rheumatoid arthritis. Although the foot deformities are present in these patients, pain perception is generally intact and ulceration is rare.2 [Boulton, Diabetic Foot, p239] In the patient with a diabetic neuropathic foot, however, such trauma cannot be felt. Similarly, motor neuropathy can alter the way the foot is put down (i.e., “planted,” referred to as “foot plant”), thus creating increased pressure in certain parts of the plantar surface. Repetitive stress on these abnormal pressure points can cause callus build-up, hematoma formation, and eventually ulceration.2 [Boulton, p233] The presence of a pre-callus irritation, pressure point, or callus should alert the patient and clinician to the need to take measures to correct any problem of abnormal pressure points.3,4 [Murray, Clin Podiatr Med Surg, 1995, p10; Janisse, p43]
Offloading is any measure to eliminate abnormal pressure points and promote healing or prevent recurrence. Foot pressures, shock, and
Ulcer
Adapted from Janisse, 1995.
Courtesy of Dr. Barbara J. Aung, DPM,CWS

38. Off-loading : For Healing & Prevention
Total contact casting
Removable walker
Felt and foam
Half-shoe
Scotch cast boot
For Prevention
Extra-depth shoe
Custom-molded shoe
Custom Insoles
Oxford type athletic shoe
Adapted from Janisse, 1995; Lavery et al, 1996
Courtesy of Dr. Barbara J. Aung, DPM,CWS

39. Examples of Off-Loading Devices
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40. Example of Off-loading Treatment
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41. “Instant Total Contact Cast”
Armstrong, et al, J Amer Podiatr Med Assn, 2002
Boulton & Armstrong, Diabetes Care, 2003
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42. “How might I prevent recurrence?”
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43. Computerized Gait Analysis
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44. Custom Orthotics
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45. Appropriate Footwear
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46. Additional Methods/Aids In Reducing Footwear Friction
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47. Surgical Intervention

48. Diabetic Foot Screening
L.E.A.P.
Lower Extremity Amputation Prevention
Proactive Screen
Low Risk
Moderate Risk
High Risk
(Refer to Handout)

49. Thank You!!!!!
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