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By Patrick A. DeHeer, DPM Hoosier Foot & Ankle

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1 By Patrick A. DeHeer, DPM Hoosier Foot & Ankle
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 IDF Diabetes Atlas, 4th ed. ©International Diabetes Federation, 2009.
Global Projections for the Number of People With Diabetes for 2010 and 2030 AT A GLANCE 2010 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. It is estimated that 285 million people, or 6.6% of adults 20 to 79 years of age had diabetes in The worldwide estimate is expected to increase to 438 million, or 7.8% of the adult population, by 2030. Source: IDF Diabetes Atlas, 4th ed. International Diabetes Federation, Accessed 01 March 2011.

4 24% of all DFU cases require inpatient care -Harrington et al. 2000
Presence of a DFU for 30 days or longer carries an 8-Fold risk for infection. – Lavery 2006 The Hard Facts 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 Go through this slide to help them convince potential referring doctors that there is little time to waste. Stakes are high and risks are unacceptable. $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
Diabetic foot ulcers result in a marked increase in healthcare costs. Ramsey and colleagues (1999) found that the direct, attributable cost over the first 2 years following the development of a DFU was approximately $28,000 (1995 US dollars). This slide displays these costs for 2000, 2005, and 2010 adjusted for medical care increases based on the percent change in the medical component of the US consumer price index.1  This initial 1995 cost analysis was based on retrospective data from a large staff-model HMO and compared diabetic patients with newly diagnosed DFU to age and sex-matched controls with diabetes and no DFU history. The higher costs for patients with DFU are attributed to the increased health service utilization by these patients compared with controls. DFU patients averaged 0.24 more emergency room visits, 22 more outpatient appointments, and 4.6 more hospital stays within the first year. Additionally the DFU group had a greater risk for osteomyelitis and amputation, which added to overall healthcare costs. 15 to 20% increase each year. 1Source: Bureau of Labor Statistics, Consumer Price Index, Archived Consumer Price Index Detailed Report Information, 2009 CPI Index Detailed Report Tables, December Accessed March 3, 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
A 1999 meta-analysis by Margolis and colleagues evaluated the rate of neuropathic ulcer healing in 10 control groups from clinical trials. These control groups used standard good wound care, which included debridement and off-loading, and either saline-moistened gauze or placebo gel and gauze. A total of 622 patients were assessed; 172 in the 20-week end point group and 450 in the 12-week end point group. Weighted mean healing rates were 24.2% (95% CI 19.5–28.8%) for the 12-week end point and 30.9% (95% CI 26.6–35.1%) for the 20-week end point. These data provide clinicians with a realistic assessment of their chance of healing neuropathic ulcers over 20 weeks. Further, this emphasizes that even with good, standard wound care, the healing of neuropathic ulcers in patients with diabetes continues to be a challenge. 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) Prospective studies have investigated the causal pathways leading to diabetic foot ulcer. The most common pathway involved a combination of sensory neuropathy, foot deformities secondary to motor neuropathy, and minor trauma caused by poor self-foot care practices. Sources of minor trauma included ill-fitting shoes, thermal trauma (hot water, sand, or pavement) and chemical trauma (over-the-counter corn plasters). ULCER Diabetes Care. 1999; 22:157

10 Patient Ulcer Risk 28.1% 18.6% 7% 6.3% 10% 4.8% 17%-30% 1.7% 66%
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% Diabetic patients can be stratified into one of four risk levels for subsequent foot ulceration. Risk level 3 patients with either a prior lower extremity amputation or foot ulcer are at greatest risk as their annual risk of foot ulceration is 18-28%; about 7% of office patients are at this level of risk. Risk level 2 patients are insensate to the 10g monofilament, and in addition, they have either major foot deformities or absent pedal pulses; annual risk of foot ulcer is about 6%. Risk level 1 patients are insensate to the 10g monofilament; annual risk of foot ulcer is 4.8%/year risk; they comprise 17-30% of the diabetic patients seen in the office practice. Note that risk level 0 patients who have no risk factors may still have an increased risk of foot ulceration of 1-2%/year.

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 – Clonus Babinski Vibratory
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 Diabetes Care. 2006;29(Suppl 1):S25
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

22 Pre-Ulcer Cutaneous Pathology

23 Equinus and the Diabetic Patient
Grant et al JFAS1997 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 Equinus and the Diabetic Patient
Grant et al JFAS1997 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
Lavery, Armstrong, Boulton Study JAPMA 2002 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)

26 Lavery, Armstrong, Boulton Study JAPMA 2002

27 Lavery, Armstrong, Boulton Study JAPMA 2002
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 Arch Intern Med. 1998;158:1357 Diabetes Care. 2003;26:3333 Diabet Med. 2005;22:1310 Diabetes Care. 2003;26:3333

30 A much more useful noninvasive test to diagnose PAD in diabetes is the Ankle-Brachial Index (ABI). The (ABI) is performed with a handheld Doppler Flow meter to measure systolic blood pressure in both arms and in the DP and PT arteries. The ABI is calculated by dividing the highest pressure measured at the ankle by the highest brachial pressure. [PATRICK AND TED: DO NOT HAVE PERMISSION TO USE. REFERENCE IS: 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 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 Diagnosis:
“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 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 Foot Care Based on Risk Factors
Low Risk High Risk 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 Foot Care Based on Risk Factors
High Risk: Nursing Tasks High Risk: Patient Education 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 Cochrane Database Syst Rev Jan 25;(1)CD001488 Foot Ankle Int. 2005;26:38 J Gen Intern Med. 2003;18:258

34 Diabetic Foot Care High Risk: Podiatry Care Basic Foot Care Concepts
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 Diabetic Foot Care Basic Foot Protective Behaviors
Basic Foot Care Concepts Basic Foot Protective Behaviors 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 Basic Footwear Education
Avoid: Favor: 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 Hoosierfootandankle.com


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