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Diabetic Foot Exam By Patrick A. DeHeer, DPM Hoosier Foot & Ankle.

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Presentation on theme: "Diabetic Foot Exam By Patrick A. DeHeer, DPM Hoosier Foot & Ankle."— Presentation transcript:

1 Diabetic Foot Exam By Patrick A. DeHeer, DPM Hoosier Foot & Ankle

2 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…

3 Global Projections for the Number of People With Diabetes for 2010 and 2030 AT A GLANCE Total world population (billions) Adult population (20-79 years, billions) DIABETES AND IGT (20-79 years) Diabetes Global prevalence (%) Comparative prevalence (%) Number of people with diabetes (millions) IDF Diabetes Atlas, 4 th ed. ©International Diabetes Federation, Source: IDF Diabetes Atlas, 4th ed. International Diabetes Federation, Accessed 01 March 2011.

4 Presence of a DFU for 30 days or longer carries an 8-Fold risk for infection. – Lavery % of all DFU cases require inpatient care -Harrington et al 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

5 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.

6 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.

7 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

8 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

9 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

10 Patient Ulcer Risk Risk Level Foot Ulcer %/yr % Office Patients (diabetes clinics) 3: Prior amputation Prior ulcer 28.1%18.6%7% 2: Insensate and foot deformity or absent pedal pulses 6.3%10% 1: Insensate 4.8%17%-30% 0: All normal 1.7%66%

11 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

12 Neurological Exam Deep Tendon Reflexes – Patellar Achilles Clonus Babinski Vibratory Sharp/Dull Loss of protective sensation – 5.07/10 g Semmes-Weinstein monofilament wire

13 Neurological Exam

14 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 ulcers J Fam Pract. 2000;49:S30 Diabetes Care. 1992;15:1386

15 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

16 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

17 Motor Neuropathy and Foot Deformities Hammer toes Claw toes Prominent metatarsal heads Hallux valgus Collapsed plantar arch

18 Motor Neuropathy and Foot Deformities

19 Motor Neuropathy and Foot Deformities - Diabetic Charcot Arthropathy

20 Pre-Ulcer Cutaneous Pathology Persistent erythema after shoe removal Callus Callus with subcutaneous hemorrhage Fissure Interdigital maceration, fungal infection Nail pathology

21 Pre-Ulcer Cutaneous Pathology


23 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

24 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

25 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 / (years) Men 50.3% Weight / (Kg) Diabetes duration /- 9.5 (years) Lavery, Armstrong, Boulton Study JAPMA 2002

26 P = 0.007P = Lavery, Armstrong, Boulton Study JAPMA 2002

27 No statistical significant difference – Weight Sex difference Absence or presence of neuopathy Statistical significant difference – Equinus patients had longer duration of diabetes Equinus prevalence in this population = 10.3%

28 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.

29 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;22:1310 Diabetes Care. 2003;26:3333 Arch Intern Med. 1998;158:1357 Diabetes Care. 2003;26:3333

30 Adapted from: Norman PE, Eikelboom JW, Hankey GJ. Peripheral arterial disease: prognostic significance and prevention of atherothrombotic complications. Medical Journal of Australia 2004; 181: Figure 1, p.151

31 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 Interpretation ABI Normal Mild obstruction Moderate obstruction* Severe obstruction* <0.40 Poorly compressible** >1.30 2° to medial calcification *Poor ulcer healing with ABI < 0.50 **Further vascular evaluation needed

32 Low RiskHigh 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

33 High Risk: Nursing Tasks High Risk: Patient Education Foot Care Based on Risk Factors 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 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 Jan 25;(1)CD Foot Ankle Int. 2005;26:38

34 High Risk: Podiatry CareBasic 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;26:1691 J Fam Practice. 2000;49(Suppl):S30

35 Basic Foot Care Concepts Basic 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

36 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

37 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

38 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.

39 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%

40 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.

41 Thank You!!!! Any Question??? Patrick A. DeHeer, DPM Hoosier Foot & Ankle

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