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Five cornerstones of the management of the diabetic foot 1. Regular inspection and examination of the foot. 2.Identification of the foot at risk. 3.Education.

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Presentation on theme: "Five cornerstones of the management of the diabetic foot 1. Regular inspection and examination of the foot. 2.Identification of the foot at risk. 3.Education."— Presentation transcript:

1 Five cornerstones of the management of the diabetic foot 1. Regular inspection and examination of the foot. 2.Identification of the foot at risk. 3.Education of patient, family and healthcare providers. 4.Appropriate footwear. 5.Treatment of non ulcerative pathology

2 Five cornerstones of the management of the diabetic foot 1. Regular inspection and examination of the foot. 2.Identification of the foot at risk. 3.Education of patient, family and healthcare providers. 4.Appropriate footwear. 5.Treatment of non ulcerative pathology

3 Regular inspection and examination of the foot All diabetic patients should be examined at first presentation then at least once a year Patients with risk factors should be examined every 1-6 months Absent symptoms does not mean that the feet are healthy Examine the patient on lying down and standing up Shoe and socks should be inspected

4 Foot examination 1. Nails 2. Foot deformity 3. Skin condition 4. Vascular assessment 5. Neurological assessment

5 Foot examination 1. Nails  Thick  Too long  Ingrown  Fungal infection  Wrongly cut nails

6 Foot Examination 2. Foot deformity: Toe deformity Hammer toe Hammer toe Claw toe Claw toe Forefoot deformity Hallux valgus Hallux valgus Hallux rigidus Hallux rigidus Wholefoot Deformities Pes Cavus - High arched foot Pes Planus - Flat foot Charcot foot

7 Foot Examination 3. Skin condition: Callus Bunions Redness Warmth Fissure Dryness Swelling Maceration Fugal infection

8 Foot Examination 4. Vascular assessment 5. Neurological assessment

9 10/5/2008Mansoura DF 2nd International Training Course Does your patient have neuropathy?

10 Manal Tarshoby Assistant Professor of Medicine Diabetes and Endocrinology unit Diabetic Foot Team Mansoura University EGYPT

11 Clinical Assessment  History:  Review diabetes history, management  Daily glycemic records, previous A1c  Review medical history  Review other causes of neuropathy (10%)  50% has no symptoms Mansoura DF 2nd International Training Course10/5/2008

12 History Michigan neuropathy screening questionnaire Are your feet numb Burning pain Feet sensitive to touch Muscle cramp Can you tell hot from cold water Have you had an ulcer Dr diagnosed neuropathy Do you feel weak Symptom worse at night Legs hurt when you walk Prickling feeling Able to sense feet when walking Bed covers hurt your skin Your skin crack open Unsteadiness Previous amputation Mansoura DF 2nd International Training Course Feldman, Diabetes care, /5/2008

13 Paradox ? Mansoura DF 2nd International Training Course

14 10/5/2008

15 Painful-Painless Leg One doesn’t need to have intact sensation to experience pain. Mansoura DF 2nd International Training Course

16 Physical Examination Inspection Vibration sense Tuning fork 128 Reduced protective sensation such as pressure, hot and cold, pain Sharp, dull, light touch Motor strength Diminished ability to sense position of toes and feet Deep tendon reflex Mansoura DF 2nd International Training Course10/5/2008

17 Inspection Muscle atrophy Intrinsic minus foot Dry skin Mansoura DF 2nd International Training Course10/5/2008

18 Neurologic assessment Mansoura DF 2nd International Training Course10/5/2008

19 Physical Examination Inspection Vibration sense Tuning fork 128 neurothesiometer Mansoura DF 2nd International Training Course10/5/2008

20 Vibration Sense Tuning fork is held against a bony prominence: Medial aspect 1 st MTP Joint Plantar Hallux Med/Lat Malleolus Patients should be reminded that it is the vibration they are required to detect not the sound. Mansoura DF 2nd International Training Course10/5/2008

21 Mansoura DF 2nd International Training Course

22 NEUROTHESIOMETER Vibration threshold is strongly linked with age Males have slightly higher thresholds than females Age Males8.8 volts12.9 volts19.9 volts Females8.3 volts10.8 volts14.6 volts Mansoura DF 2nd International Training Course10/5/2008

23 NEUROTHESIOMETER At the distal pulp of the hallux, over bony prominence Voltage is increased until the patient can perceive vibration Mansoura DF 2nd International Training Course10/5/2008

24 NEUROTHESIOMETER Foot ulcer risk increased by 5.6% per volt Abott, Diabetes care, 1998 Mansoura DF 2nd International Training Course10/5/2008

25 Physical Examination Inspection Vibration sense Reduced protective sensation pressure hot and cold pain Mansoura DF 2nd International Training Course10/5/2008

26 TEMPERATURE TESTING Two test tubes, hot/cold. Therm-tip Subjective, crude tests Mansoura DF 2nd International Training Course10/5/2008

27 MONOFILAMENTS Which monofilament ? 10 mg, 1mg Calibrated Mansoura DF 2nd International Training Course10/5/2008

28 MONOFILAMENTS Mansoura DF 2nd International Training Course HOW TO USE IT? How many sites to be tested? 10/5/2008

29 Mansoura DF 2nd International Training Course10/5/2008

30 MONOFILAMENTS Mansoura DF 2nd International Training Course How many lost sites to diagnose LOPS 4 10/5/2008 1

31 Monofilament Failure Variability within and between brands Require frequent replacement Should be calibrated Give-away devices are of uncertain quality,durability Repetitive loading? Mansoura DF 2nd International Training Course10/5/2008

32 SUPERFICIAL PAIN TEST Neuro - tip Areas tested Patient response Significance Mansoura DF 2nd International Training Course10/5/2008

33 Physical Examination Inspection Vibration sense Reduced protective sensation Sharp, dull, light touch Mansoura DF 2nd International Training Course10/5/2008

34 LIGHT TOUCH TEST  Wisp of cotton wool  Subjective  Can be painful if neuropathy exists Mansoura DF 2nd International Training Course10/5/2008

35 Mansoura DF 2nd International Training Course10/5/2008

36 Physical Examination Inspection Vibration sense Reduced protective sensation Sharp, dull, light touch Motor strength Mansoura DF 2nd International Training Course10/5/2008

37 Physical Examination Inspection Vibration sense Tuning fork 128 Reduced protective sensation such as pressure, hot and cold, pain Sharp, dull, light touch Motor strength Diminished ability to sense position of toes and feet Mansoura DF 2nd International Training Course10/5/2008

38 Physical Examination Inspection Vibration sense Tuning fork 128 Reduced protective sensation such as pressure, hot and cold, pain Sharp, dull, light touch Motor strength Diminished ability to sense position of toes and feet Deep tendon reflex Mansoura DF 2nd International Training Course10/5/2008

39 Deep tendon reflex Mansoura DF 2nd International Training Course10/5/2008

40 Neuro Disability score 3 sensory modality Vibration Pin prick (neurotip) Hot-cold rod Scored Normal=0 Abnormal=1 Ankle reflex Scored Normal=0 Reinforcement=1 Absent=2 Mansoura DF 2nd International Training Course Max total 5 for each leg Total out of 10 10/5/2008

41 2 minutes Patient should take off his shoes and socks Should inspect his shoes Watch the patient as he walks Please turn Get up from a chair Stand on one leg 10/5/2008Mansoura DF 2nd International Training Course Resnick, Vinik et al. Muscle and Nerve, 2001

42 Risk categorization system category Risk profile Check up frequency 0 no sensory neuropathy Once a year 1sensory neuropathy Once every 6 months 2. sensory neuropathy and signs of peripheral vascular disease and/or foot deformities. Once every 3 months 3 previous ulcer Once every 1-3 months Mansoura DF 2nd International Training Course10/5/2008

43 Thank you 10/5/2008Mansoura DF 2nd International Training Course


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