1. DM - FOOT EVALUATION IN THE PRIMARY CARE SETTING
“An ounce of prevention is worth a pound of cure.” – Benjamin Franklin
Bernadette Pendergraph, Gloria Sanchez, MDs
Cindy Mayeda, RN
Department of Family Medicine, Harbor-UCLA

2. Learning Objectives Medical Knowledge
a. Perform Comprehensive DM Foot Exam
b. Implement ADA DM Foot Guidelines
c. Classify DM Foot Ulcers Accurately
d. List indications for imaging
Patient Care
a. Offloading Devices for DM Ulcers
b. Utilize consultants in timely fashion
No conflicts of interest

3. Learning Objectives System Based Practice
a. Utilize resources for patients
b. Expedite pt work up & tx PRN
Interpersonal & Communication Skills
a. Teach pts DM foot care & precautions
b. Collaborate with HC team to examine & treat pts
Professionalism
a. Take “ownership” of DM foot ulcer

4. IMPORTANCE OF FOOT EXAMS
National Hospital Discharge survey ,000 with DM under went > 1 amputation
DM leading cause of amputation in lower extremities
> 50% preventable
Triad: neuropathy, deformity, trauma
Absence of nerve and vascular complaints is not protective
Incidence of:
Foot ulcers up to 25% lifetime risk, annual risk 2%
~50% infected
14-24% amputation
Lower extremity amputation
50% in same/opposite extremity in 5 yrs.
Mortality all cause at 5 yr %
Diabetic Foot Infections
Last Updated: May 2, 2006
Burke A Cunha, MD, MACP, Professor of Medicine, State University of New York at Stony Brook School of Medicine; Chief, Infectious Disease Division, Winthrop-University Hospital

5. IMPORTANCE OF FOOT EXAMS
Healthy People 2020 goals
Increase # of persons receiving at least an annual foot exam
Decrease amputations related to DM
Ethnic risk for amputation per 10,000 persons with DM
African-Americans 95.3
Hispanic 44.4
Caucasians 56
Annual foot exams (55-75%)
Decrease amputations 11-5 per 1000

6. IMPORTANCE OF FOOT EXAMS
% amputations related to DM
Hispanics
African-Americans 61.6
Caucasians
Foot exam frequency
By patient
Daily 52%
Never 22%
By provider
Type 1 66%
Type 2 52%

7. COST OF DM FOOT DISEASE Amputations > $1.1 billion
Ulcer in male y.o. $28,000 over 2 yr

8. RISK FACTORS FOR AMPUTATION
Arterial insufficiency: DM > 10 yrs, Tobacco use
Disease control: high FBS, high A1c, duration = two fold increase
Sex: male
Eng Organ Damage:
Retinopathy
Nephropathy
Cardiovascular disease
Peripheral neuropathy: absent Achilles reflex, decreased vibratory sensation = 2 x likely in amputees
Abnormal gait 15x more likely to injure
Abnormal monofilament exam 60% develoed ulcers, 21% amputations over 32 months

9. RISK FACTORS FOR AMPUTATION
Abnormal foot anatomy
Nail – Onycholysis, Ingrown
Skin – Xerosis, Corn, Callus, Hair loss
Bone – Hallux valgus, hammer toes, prominent metatarsal heads, Charcot foot
Previous ulcer or amputations
Loss of monofilament perception – 18 fold increase risk of ulcer

10. PRECIPITATING EVENTS FOR AMPUTATION
Injury from new shoes
Improper toe nail trimming
Accidental wounds
Thermal injury
1/3 of injuries self induced in PVD

11. ADA GUIDELINES Everyone with DM gets a foot exam Prerequisite history
Starts at diagnosis
Frequency: At least annual – stratify high vs low risk
Visual inspection every visit if neuropathy
Prerequisite history
Previous ulceration, amputation, Charcot joint, vascular surgery, angioplasty, tobacco use
Symptoms of claudication or neuropathy
DM complications: renal, visual
Metabolic theory
This theory proposes that hyperglycemia causes increased levels of intracellular glucose in nerves, leading to saturation of the normal glycolytic pathway. Extra glucose is shunted into the polyol pathway and converted to sorbitol and fructose by the enzymes aldose reductase and sorbitol dehydrogenase. Accumulation of sorbitol and fructose lead to reduced nerve myoinositol, decreased membrane Na+/K+-ATPase activity, impaired axonal transport, and structural breakdown of nerves, causing abnormal action potential propagation. This is the rationale for the use of aldose reductase inhibitors to improve nerve conduction.
Vascular (ischemic-hypoxic) theory
According to this theory, endoneurial ischemia develops because of increased endoneurial vascular resistance to hyperglycemic blood. Various metabolic factors, including formation of advanced glycosylation end products, also have been implicated. The end results are capillary damage, inhibition of axonal transport, reduced Na+/K+-ATPase activity, and finally axonal degeneration.
Altered neurotrophic support theory
Neurotrophic factors are important in the maintenance, development, and regeneration of responsive elements of the nervous systems. Nerve growth factor (NGF) is the best studied. This protein promotes survival of sympathetic and small-fiber neural crest–derived elements in the peripheral nervous system. In animals with diabetes, both production and transport of NGF are impaired. Antioxidants have been used to enhance the effects of NGF.
Laminin theory
Laminin is a large, heteromeric, curariform glycoprotein composed of a large alpha chain and two smaller beta chains, beta 1 and beta 2. In cultured neurons, laminin promotes neurite extension. Lack of normal expression of the laminin beta 2 gene may contribute to the pathogenesis of diabetic neuropathy.
Autoimmune theory
Autoimmune diabetic neuropathy is postulated to result from immunogenic alteration of endothelial capillary cells. This is the basis for the use of intravenous immunoglobulin (IVIg) to treat some variants of diabetic neuropathy.

12. ADA GUIDELINES FOR FOOT CARE
Foot exam components
Visual inspection: dermatologic, musculoskeletal, shoe
Neurological assessment: 10g Monofilament + 1 of the following:
Vibration
Pinprick
Ankle reflexes
VPT
Vascular: Pulses, consider ABI

13. DERMATOLOGIC INSPECTION
Nails
Shape/length
Ingrown, paronychia
Onycholysis
Skin
Xerosis
Callus/Corn/Ulcer
Temperature
Pumice stone okay for DM without peripheral neuropathy

14. MUSCULOSKELETAL ASSESSMENT
Deformities
Toe deformities-claw , hammer
Bunions
Charcot foot

15. SHOE EVALUATION
Look at the patient’s shoes (Are these shoes appropriate for these feet?)
Type of material?
Good: canvas, suede, leather, elastic
Bad: plastic
Any foreign objects?
Depth appropriate?
Width appropriate?
Size?
How old?

16. NEUROLOGIC ASSESSMENT
Peripheral neuropathy most common cause of DM foot ulceration
Identify loss of protective sensation (LOPS)
10 g monofilament
128 Hz turning fork: vibratory sensation-tip of great toe bilaterally
Pinprick: disposable pin proximal to nail of great toe
Ankle reflexes
Vibration perception threshold testing: mean of 3 readings; VPT > 25V
Analgesics: acetaminophen, NSAIDs, capsician, TCAs, anticonvulsants, TENS
w/U: CBC/LYTES/LFTS/B12/THIAMINE/TSH/ESR/SPEP….CONSIDER ANA/RF/PARANEOPLASTIC ANTIBODIES
STAGING: NO - No neuropathy
N1a - Asymptomatic neuropathy detected as nerve conduction abnormality in at least 2 nerves
N1b - N1a and abnormal neurologic examination
N2a - Symptomatic mild diabetic polyneuropathy; sensory, motor, or autonomic symptoms; patient able to heel walk
N2b - Severe symptomatic diabetic polyneuropathy (as in N2a, but patient unable to heel walk)
N3 - Disabling diabetic polyneuropathy
EmEDICINE Diabetic Neuropathy
Last Updated: September 28, 2006

17. MONOFILAMENT TESTING Patient should close the eyes
Check patient on proximal site to demonstrate
Instruct the patient to tell you when he feels the monofilament
Push the monofilament until it bends, then hold for 1-2 seconds
Lift the monofilament from skin
Retest the area where the patient did not feel the monofilament (Avoid callus)
Mark the areas of the foot using a plus sign (+) if they can feel the monofilament and a minus sign (-) if they cannot
Single use monofilaments or Booth and Young study

18. VASCULAR ASSESSMENT PAD is a component cause in 1/3 of ulcers
Risk factor for recurrent wound
Palpate dorsalis pedis and posterior tibialis
If pulses are absent or symptoms of PAD, do ABI
DM > 50 yo
DM < 50 with multiple PAD risk factors

19. ABI Readings Abnormal >1.2 (medial calcinosis) Normal 0.9-1.2
Moderate Vascular Dz
Severe Vascular Dz <0.4

20. TOE PRESSURE TESTING (TBI)
Consider doing if ABI > 1.2
Cut off are different than ABI
TBI > 0.5 or > 70 mm Hg = normal
TBI < 0.2 or < 30mm Hg = severely ischemic
The cut-off values of toe pressure and TBI are arbitrary and vary in the literature. In general, a toe pressure of 70 to 110 mmHg or TBI > 0.5 to 0.75 is considered normal and anything below is diagnostic of PAD. A toe pressure lower than 30 mmHg or TBI < 0.2 is considered severely ischemic and diagnostic of critical limb ischemia (CLI). Wound healing potential drops as TBI decreases from the normal values

21. RISK CLASSIFICATION

22. FOOT CONDITIONS TO WATCH OUT FOR
Diabetic foot infections: inframalleolar infection in a person with DM
Acute: Predominantly g+ cocci
Clindamycin
Keflex
Bactrim
Augmentin
Chronic: g-rods
2nd generation cephalosporin
Linezolid
Daptomycin
Account for the greatest number of diabetes related hospital days

23. DIABETIC FOOT INFECTIONS
Ischemia: obligate anaerobes
Vascular evaluation
Fluoroquinolone + clindamycin
Imipenem
Vancomycin + Ceftazidime + metronidazole

24. Afp 2008
G CSF: does not speed resolution of infection but decreases need for surgical intervention
Hyerbaric oxygen: decreased risk of amputation

25. ULCERS Venous stasis ulcer Arterial insufficiency ulcer
Medial malleolar area
Irregular borders
Red-brown staining
Lower extremity edema/varicose veins
Arterial insufficiency ulcer
Tip of the toe
Punched out (clear demarcation)
Pale, dry base without edema
Arterial Insufficiency and Ulceration: Diagnosis and Treatment Options
ADVANCES IN SKIN & WOUND CARE,  Jun 2004  by Sieggreen, Mary Y,  Kline, Ronald A

26. WAGNER ULCER CLASSIFICATION
Grade 0 = no ulcer in high risk foot
Grade 1 = ulcer involving full skin thickness
Grade 2 = ulcer to ligament and muscle
Grade 3 = ulcer with cellulitis/abscess
Grade 4 = localized gangrene
Grade 5 = extensive gangrene involving whole foot

28. ULCER TREATMENT
Patients should never walk out in the same shoe wear they walked in…
Offload ulcer
Modify shoe insert – cut out area under ulcer
Healing boot
Total contact cast
Assess vascularity
Wound care
Inciting event – shoe, foreign body = xray
Debridement
Assess if Infected
Close follow-up

29. FOOT CONDITIONS Charcot foot
Neuropathic joint – progressive destruction of bone and soft tissues at weight bearing joints
Rocker bottom foot with continued ambulation
Incidence in DM: %
Recurrence 5%
Bilateral disease 10%
Men = Women

31. PATHOGENESIS OF CHARCOT

32. STAGING

33. WHICH ONE IS CHARCOT FOOT?

34. NORMAL FOOT

35. CHARCOT FOOT Acute Chronic
Inflammatory: swelling, increased temperature (3-7°F), redness, bony resorption
Intact skin and pulses
Insensate foot
Treatment
Immobilization: total contact cast
Reduce stress: non-weight bearing
r/o infection
Chronic
Protection: orthotics, surgery
Neurotraumatic theory - This theory states that Charcot arthropathy is caused by an unperceived trauma or injury to an insensate foot. The sensory neuropathy renders the patient unaware of the osseous destruction that occurs with ambulation. This microtrauma leads to progressive destruction and damage to bone and joints.
Neurovascular theory - This theory suggests that the underlying condition leads to the development of autonomic neuropathy, causing the extremity to receive an increased blood flow. This in turn results in a mismatch in bone destruction and synthesis, leading to osteopenia.
anatomic system is described by Saunders and Mrdjencovich
Pattern 1 involves the forefoot, which includes the interphalangeal joints, the phalanges, and the metatarsophalangeal joint.
Pattern 2 involves the tarsometatarsal joint.
Pattern 3 involves the cuneonavicular, talonavicular, and calcaneocuboid articulations.
Pattern 4 involves the talocrural, or ankle, joint, which is the articulation of the tibia, the fibula, and the talus.
Pattern 5 involves the posterior calcaneus.
emedicine. Charcot Arthropathy
Article Last Updated: Aug 29, 2007  Mrugeshkumar Shah, MD, MPH, Walter Panis, MD

36. TREATMENT OVERVIEW

37. OTHER ORTHOSIS Charcot foot
AFO: offload bottom of foot and reduce ankle motion
Total contact cast: transfer weight away from foot
Pneumatic walker brace
Fillers-foam or cork
Special Report: Orthotic and Pedorthic Care Neuropathy, Charcot Joint Disease and Partial-Foot Amputations
Volume 16 · Issue 3 · May/June 2006

38. OTHER ORTHOSIS Charcot foot Toe amputations
AFO: offload bottom of foot and reduce ankle motion
Total contact cast: transfer weight away from foot
Toe amputations
Toe filler
Forefoot amputations: custom shoes
Fillers-foam or cork
Special Report: Orthotic and Pedorthic Care Neuropathy, Charcot Joint Disease and Partial-Foot Amputations
Volume 16 · Issue 3 · May/June 2006

39. Achilles lengthening
Transmetatarsal amputation

40. SHOE PRESCRIPTIONS Healing shoes: post op or heat molded shoes
Depth in-lay: toe deformities, prescription inserts
Extra wide: bunions
Rocker sole: reduce pressure on metatarsal heads; hallux rigidis
Custom molded: severe feet deformities

41. SHOE PRESCRIPTIONS
Medicare covers custom shoes for persons with DM, in a comprehensive DM care program and one of the following:
H/o amputation
H/o ulcer
H/o preulcerative callus
Peripheral neuropathy with callus
Poor circulation
Foot deformity
Products for the year
One pair of depth shoes with 3 inserts
One pair of custom-molded shoes/inserts with 2 inserts

42. FOOT CARE INSTRUCTIONS
Good sugar control
Daily visual exam
Moisturize your feet
Appropriate shoe wear – never barefoot, no open toe box
Firm heel counters and uppers – to prevent excessive motion and rolling
A firm and wide outsole – to provide a stable base for the foot
An extra-depth construction with a removable inlay – to provide added cushion; allow room for a custom foot orthosis

43. HOW TO DEAL WITH PROBLEMS
Thermal injury
Shoe color (8-13°)
Bony abnormalities
Mild deformities: Appropriate depth and width
Athletic shoes
Soft insoles: plastazote/urethrane viscoelastic
Laces or Velco strap
Severe deformities or amputation: Shoe prescription
Relieve excessive pressure
Decrease shock, sheer pressures
Accommodate, stabilize, and support deformities

44. Medicare pays 80% of what is allowed
Depth shoes $126
Custom molded shoes $378
Inserts $64

45. RISK FACTORS FOR FOOT ULCER
Poor glycemic control
Visual impairment
Previous foot ulcer/amputation
Peripheral neuropathy
PAD
Foot deformity
DM nephropathy
Cigarette smoking

46. High risk: amputation, ulcer
Elevated A1c doubles risk of amputation