1. 1 Louise Maye Podiatrist Podiatry and Footcare Services Greater Newcastle Cluster Care of the diabetic foot A podiatrist’s perspective

2. Diabetes & Feet  “Diabetic foot complications are the single most common cause of non-traumatic lower limb amputations in the industrialised world” Armstrong D, Lavery L & Harkless L (1998) Who is at risk for diabetic foot ulceration? Clinics in Podiatric Medicine and Surgery, 15 pp 11-19  Foot problems are the most common reason for hospital admissions for people with diabetes and approximately 50% of all amputations are attributable to diabetes National Report to Health Ministers on Diabetes 1998 p124 and ABS 1997

3. Diabetes & Feet  It has been suggested that as many as 75% of amputations due to diabetes could be prevented by appropriate foot care Larsson J, Apelqvist J, Agardh C & Stenstrom A (1995) Decreasing the incidence of major amputation in diabetic patients: a consequence of multi-disciplinary foot care team approach? Diabetic Medicine 12, 770

4. Most foot problems are preventable when: they are identified early they are treated appropriately people are educated to avoid these problems

5. Role of the Podiatrist in Diabetes  provide … wound care biomechanical assessment footwear / orthotic prescription palliative care ingrown toenail surgery  Conduct diabetes foot assessments  Provide education to clients and their families

6. Diabetes Foot Assessment  Should be performed every 6-12 months  Risk factors to be assessed: peripheral vascular disease peripheral neuropathy dermatological conditions and skin integrity abnormal lower limb biomechanics inappropriate footwear poor self care

7. Education: Client needs to …  Standard holistic advice regarding blood pressure, BGLs, smoking, diet and exercise  But the main points that need to get across from our behalf are to:  Be aware of potential foot problems  Check feet DAILY!  Wear appropriate footwear at all times

8. Aetiology of Foot Wounds Primary Factors Peripheral neuropathy Peripheral vascular disease Secondary Factors Limited joint mobility Bony deformity Trauma  Immune response Australian National Association of Diabetes Centres, The National Diabetes Foot Care Project

9. Assessment of Foot Wounds Aetiology Neuropathic ulcer Ischaemic ulcer Neuroischaemic ulcer Infection Local Cellulitis Osteomyelitis Investigations X-ray Swab Bone scans MRI Referral Endocrinologist Vascular Consultant Orthopaedic Consultant Rehabilitation Consultant Dietitian

10. Treatment of Foot Wounds  Debridement Conservative sharp Mechanical Autolytic Enzymatic Surgical  Dressings  Pressure management  Surgery  Infection management  Oedema management

11. Off-Loading Options  total contact cast  soft cast shoes  removable cast walkers  post-op shoes / all purpose boots  orthoses  felt padding  combination of the above

12. Total Contact Casts  Gold standard for offloading plantar neuropathic foot wounds  Traditionally plaster of paris with fibreglass shell – minimally padded, contact with entire plantar surface and lower leg  Compression and pressure relief  Pressure transferred from forefoot to the cast walls and rear foot  Forces compliance Armstrong, D. and Stacpoole-Shea, S. 1999. Total contact casts and removable cast walkers: mitigation of plantar heel pressure. JAPMA, (89), pp 50-53.

13. Charcot Neuroarthropathy Is a rapid destructive arthropathy associated with peripheral neuropathy. Long standing diabetes is the most common cause (Approx 15%). The foot is the most common site. Other predisposing conditions include  Alcoholism  Spinal Cord lesions  Other  Any condition that involves a degeneration of sensory, motor and autonomic nerve function Aetiology is unclear.

14. Charcot Neuroarthropathy  Suggested aetiology: Autonomic neuropathy increases blood flow to the extremity and bones, resulting in osteopenia amking it more prone to fractures Motor neuropathy results in muscle imbalance Sensory neuropathy means that patient in unaware of the osseous destruction that is taking place Armstrong DG, Todd WF, Lavery LA, Harkless LB, Bushman TR (1997). The Natural Histroy of Acute Charcot’s Arthropathy in a Diabetic Foot Specialty Clinic. Diabetic Medicine, 14 pp 357-363.

15. Charcot Neuroarthropathy Acute Aim – Maintain normal foot structure  Off load -TCC -Air cast -Crutches, compliance?? Chronic Hopefully no deformity  Orthosis  Custom made footwear Management

16. Case Study Eight  75 yo male with type 2 diabetes referred to podiatry department by GP  Seven years ago client fell off a ladder and was diagnosed simply with a foot fracture  Since this time, his foot has progressively changed shape into a rocker-bottom foot type  Until his podiatry appointment, no diagnosis of Charcot Neuroarthropathy was ever made  No medical intervention was initiated during the acute phase

17. Footwear  Protects feet and skin integrity  Can be … Off-the-shelf Medical grade Custom made  Orthoses / accommodative insoles are important in patients with biomechanical abnormalities to prevent ulceration

18. Footwear All footwear should have the following features… 1.Fastenings 2.A firm heel counter 3.Heel height of less than 2cm 4.A firm sole 5.A wide and deep toe-box 6.One thumbs-width from the longest toe to the end of the shoe 7.Preferably a leather upper and lining