Foot problems are an important cause of morbidity in diabetes mellitus. vascular and neurologic disease contribute to this problem.

 15% of patients with type 1 and type 2 diabetes will develop one or more foot ulcerations in their lifetime

Assessment of risk factors Diabetic peripheral neuropathy Peripheral vascular disease Skin condition Foot deformity Footware

Facts Amputation rates are 15 – 40 times higher for diabetic than non-diabetic patients.

Assessment of Risk Factors  Diabetic peripheral neuropathy  Peripheral vascular disease  Skin condition  Foot deformity  Footware

DETECTING FEET-AT-RISK  Prior LEA  Prior foot ulcer  Known PAD or claudication < 1 block  Major foot deformities  Pre-ulcer cutaneous pathology  Insensate to 5.07/10g monofilament  PAD

Screening  All patients with diabetes should be screened at regular intervals to identify those at risk for foot ulceration

Foot ULCER RISKS  Decrease adherence to self-foot care  Emotional maladaptive responses  Depression, anxiety  Cognitive dysfunction  Decrease self-foot care – Can’t see feet (retinopathy)  Not access to foot care centers

Visual Inspection  Colour of Skin  Trauma/Ulceration  Callus  Swelling  Nail deformities  Signs of pressure  General hygiene/self care

FOOT DEFORMITIES  Hammer toes  Claw toes  Prominent metatarsal heads  Hallux valgus  Collapsed plantar arch

Neuropathy  Neuropathy promotes ulcer formation by decreasing pain sensation and perception of pressure, by causing muscle imbalance that can lead to anatomic deformities and by impairing the microcirculation and the integrity of the skin.

Symptom of Neuropathy  What is the sensation felt ? burning, numbness, or tingling (2 points); fatigue, cramping, or aching (1 point). Maximum is 2 points  What is the location of symptoms ? feet (2 points); calves (1 point); elsewhere (no points). Maximum is 2 points.  Have the symptoms ever awaken you at night ? yes (1 point).

Symptom of Neuropathy  What is the timing of symptoms ? worse at night (2 points); present day and night (1 points); present only during the day (no points). Maximum is 2 points.  How are symptoms relieved ? walking around (2 points); standing (1 point); sitting or lying or no relief (no points). Maximum is 2 points.

Diabetic symptoms score  0 to 2 — normal  3 to 4 — mild  5 to 6 — moderate  7 to 9 — severe

Neuropathy Sign  What is the Achilles tendon reflex ? absent (2 points for each foot); present with reinforcement (1 point for each foot).  What is the vibration sense ? absent or reduced (1 point for each foot).  What is the pinprick sensation ? absent or reduced (1 point for each foot).  What is the temperature sensation ?  reduced (1 point for each foot).

Neuropathy Sign  0 to 2 — normal  3 to 5 — mild  6 to 8 — moderate  9 to 10 — sever

Neuropathy  Peripheral neuropathy is considered to be present if there are moderate or severe signs (6 or more) even in the absence of symptoms.  Mild signs (3 to 5) in the presence of moderate symptoms.  A neurologic signs score of 8 or more is indicative of a high-risk foot.