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Five cornerstones of the management of the diabetic foot

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Presentation on theme: "Five cornerstones of the management of the diabetic foot"— 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 Appropriate footwear 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 Nails Foot deformity Skin condition
Vascular assessment Neurological assessment

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

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

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

8 Foot Examination Vascular assessment Neurological assessment

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

10 Neuropathy assessment
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 10/5/2008 Mansoura DF 2nd International Training Course

12 History Michigan neuropathy screening questionnaire
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 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 Feldman, Diabetes care,1994 10/5/2008 Mansoura DF 2nd International Training Course

13 Paradox ? Mansoura DF 2nd International Training Course

14 10/5/2008 Mansoura DF 2nd International Training Course

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 10/5/2008 Mansoura DF 2nd International Training Course

17 Inspection Muscle atrophy Dry skin Intrinsic minus foot 10/5/2008
Mansoura DF 2nd International Training Course

18 Neurologic assessment
10/5/2008 Mansoura DF 2nd International Training Course

19 Physical Examination Vibration sense Tuning fork 128 neurothesiometer
Inspection Vibration sense Tuning fork 128 neurothesiometer 10/5/2008 Mansoura DF 2nd International Training Course

20 Vibration Sense Tuning fork is held against a bony prominence:
Medial aspect 1st MTP Joint Plantar Hallux Med/Lat Malleolus Patients should be reminded that it is the vibration they are required to detect not the sound. 10/5/2008 Mansoura DF 2nd International Training Course

21 10/5/2008 Mansoura DF 2nd International Training Course

22 NEUROTHESIOMETER Vibration threshold is strongly linked with age
Males have slightly higher thresholds than females Age Males 8.8 volts volts volts Females 8.3 volts volts volts 10/5/2008 Mansoura DF 2nd International Training Course

23 NEUROTHESIOMETER At the distal pulp of the hallux, over bony prominence Voltage is increased until the patient can perceive vibration 10/5/2008 Mansoura DF 2nd International Training Course

24 Foot ulcer risk increased by 5.6% per volt
NEUROTHESIOMETER Foot ulcer risk increased by 5.6% per volt Abott, Diabetes care, 1998 10/5/2008 Mansoura DF 2nd International Training Course

25 Physical Examination Reduced protective sensation pressure
Inspection Vibration sense Reduced protective sensation pressure hot and cold pain 10/5/2008 Mansoura DF 2nd International Training Course

26 TEMPERATURE TESTING Two test tubes, hot/cold. Therm-tip
Subjective, crude tests 10/5/2008 Mansoura DF 2nd International Training Course

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

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

29 10/5/2008 Mansoura DF 2nd International Training Course

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

31 Monofilament Failure Variability within and between brands
Require frequent replacement Should be calibrated Give-away devices are of uncertain quality ,durability Repetitive loading? 10/5/2008 Mansoura DF 2nd International Training Course

32 SUPERFICIAL PAIN TEST Areas tested Patient response Significance
Neuro - tip Areas tested Patient response Significance 10/5/2008 Mansoura DF 2nd International Training Course

33 Physical Examination Sharp, dull, light touch Inspection
Vibration sense Reduced protective sensation Sharp, dull, light touch 10/5/2008 Mansoura DF 2nd International Training Course

34 LIGHT TOUCH TEST Wisp of cotton wool Subjective
Can be painful if neuropathy exists 10/5/2008 Mansoura DF 2nd International Training Course

35 10/5/2008 Mansoura DF 2nd International Training Course

36 Physical Examination Motor strength Inspection Vibration sense
Reduced protective sensation Sharp, dull, light touch Motor strength 10/5/2008 Mansoura DF 2nd International Training Course

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 10/5/2008 Mansoura DF 2nd International Training Course

38 Physical Examination Deep tendon reflex 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 10/5/2008 Mansoura DF 2nd International Training Course

39 Deep tendon reflex 10/5/2008 Mansoura DF 2nd International Training Course

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 Max total 5 for each leg Total out of 10 10/5/2008 Mansoura DF 2nd International Training Course

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 Resnick, Vinik et al. Muscle and Nerve, 2001 10/5/2008 Mansoura DF 2nd International Training Course

42 Risk categorization system
category Risk profile Check up frequency no sensory neuropathy Once a year 1 sensory 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 10/5/2008 Mansoura DF 2nd International Training Course

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

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