2Diabetic FootAny foot pathology that results directly from diabetes or its long term complications ( Boulton 2002)The foot of a diabetic patient that has the potential risk of pathologic consequences including infection, ulceration and or destruction of deep tissues associated with neurologic abnormalities, various degrees of peripheral vascular disease and/or metabolic complications of diabetes in the lower limb
4Epidemiology DM is the largest cause of neuropathy 50% patients don’t know that they have diabetesFoot ulcerations is most common cause of hospital admissions for DiabeticsExpensive to treat, may lead to amputation and need for chronic institutionalized care
7Neuropathy Sensory Neuropathy Disorders of proprioception Loss of touch and temperatureMinor trauma goes unnoticesDisorders of proprioceptionAbnormal weight bearingCallus formation, ulcerationMotor and sensory neuropathyAbnormal foot biomechanicsStructural changes
8Neuropathy Autonomic neuropathy Anhidrosis in lower limbs Drying of feetFissure formation
10Hammer ToesDiabetic motor neuropathy leads to atrophy of the intrinsic musculature of the foot with consequent dorsiflexion of the proximal phalanx to form a hammer toe.Dorsiflexion of the middle phalanx and a flexion contracture of the distal phalanx convert the hammer toe into a claw toe.Note the increasingly prominent metatarsal heads with these two deformities. These deformities result in areas of high pressure and subsequent callus formation over the metatarsal head and the tip of the toe when walking, and over the distal end of the proximal phalanx from shoe gear.[PATRICK AND TED: I DO NOT HAVE PERMISSION TO USE THIS DIAGRAM IN A MONOGRAPH THAT IS FOR SALE, AND I DOUBT IT WILL BE GRANTED BY THE AMERICAN DIABETES ASSOCIATION. DO YOU HAVE ARTISTS TO DRAW A SIMILAR PICTURE?]Claw Toes
11Hallux ValgusHallux valgus deformities are more common in persons with diabetes and result in high pressure points from shoe gear at the distal end of the proximal phalanx.[PATRICK AND TED: FROM SAME REFERENCE, NO PERMISSION]
12A marked Hallux valgus deformity and early hammer-toe deformities from diabetic motor neuropathy. Note the areas of persistent erythema over pressure points on the first MTP joint and on the dorsum of the proximal phalanges.This patient requires a modification of shoe gear to relieve pressure and prevent callus and ulcer formation.
13Severe hammer and claw-toe deformities. There are areas of persistent erythema on the dorsum of the fourth and fifth toes.The consequences of the ill-fitting shoe gear have now progressed to marked callus formation at the peak of the hammer toe deformities on the dorsum of the second and third toes.
14Diabetic motor neuropathy has resulted in hammer and claw-toe deformities and very prominent metatarsal heads on the plantar surface of the foot.Excessive pressure on the metatarsal heads and inadequate shoe gear have resulted in marked callus build-up that is further accelerated by the dry skin.The patient is at high risk for ulceration at these sites.Ted: Can we remove background and put neutral color or blue background instead so foot shows up better?
15This patient has a pes cavus or high plantar arch deformity that has resulted in pressure points and callus formation over the heels, metatarsal heads, and along the medial aspect of the great toe.Extensive callus increases the subcutaneous pressure immediately beneath the callus and can result in a subcutaneous hemorrhage, the so-called “pre-ulcer.”Note the extensive nail pathology.Ted: Can you provide a color background?
16Other factors Impaired wound healing Does not allow resolution of fissures and minor injuriesIncreased chances of infection
17Peripheral arterial disease 30 times more prevalent in diabeticsDiabetics get arteriosclerosis obliterans or “lead pipe arteries”Calcification of the mediaOften increased blood flow with lack of elastic properties of the arteriolesNot considered to be a primary cause of foot ulcers
29Interpretation of ABI Interpretation ABI Normal 0.90-1.30 Mild obstructionModerate obstructionSevere obstruction <0.40Poorly compressible >1.302° to medial calcification*Poor ulcer healing with ABI < 0.50**Further vascular evaluation needed
38Treatment Prevention Identification of high risk patients Patient educationCareful selection of foot wearDaily inspection of feetDaily foot hygieneKeep foot clean, moistAvoidance of self treatment of foot abnormalities and high risk behavior ( walking barefoot)Prompt consultation with health care providerOrthotic shoes and devicesCallus managementNail care
39Identifying at risk patient History:Prior amputation or foot ulcerPeripheral artery disease (PAD)Exam:InsensateFoot deformitiesAbsent pulsesProlonged venous filling timeReduced ABIPre-ulcerative cutaneous pathology
40Risk stratification for ulcer risk Risk LevelFoot Ulcer%/yr3: Prior amputation Prior ulcer28.1%18.6%2: Insensate and foot deformity or absent pedal pulses6.3%1: Insensate4.8%0: All normal1.7%
41Treatment Attention to other risk factors Glycemic control Smoking HypertensionDyslipidemiaGlycemic control
42Treatment Plantar surface of the foot is the most common site Ulcer may bePrimarily neuropathica/w surrounding cellulitis/ ostemyelitisCellulitis without ulceration may occur