1. MANAGING THE FOOT IN DIABETES
Tracey Arkle
Diabetes Foot Protection Lead
Emma Lewis
Diabetes Specialist Podiatrist

2. Foot examination Risk status Referral Case study Questions
PRESENTATION CONTENT
Foot examination
Risk status
Referral
Case study
Questions

3. Half of people who undergo major amputation will die within two years.
STATISTICS
Diabetes leads to more than 169 toe, foot and leg amputations each week in the UK.
Half of people who undergo major amputation will die within two years.
More than 4 in 10 people who have a foot ulcer will die in 5 years.
Studies suggest between 70,000 and 90,000 people with diabetes have a foot ulcer in any given week.

4. MAJOR AMPUTATION RATES IN PEOPLE DIABETES
Stats a true reflection?
South West
High amputation rates attributed to :
Ethnicity and ageing population
Rural location
Lack of awareness of foot risk amongst service users
Delay in presentation of foot ulcers
Delay in referral to podiatry
Absence of foot care pathways
Delay in referral to the multidisciplinary foot clinic.
Lack of administrative support for the foot service.
All of these issues were addressed and a significant reduction in the rate of major amputation was achieved over the following 8 years, however an increase in no. of minor procedures was noted.
RCA [Root Cause Analysis]for major amputations [Plymouth and East Cornwall ], results:
Pt’s non concordance.
Delayed referral to podiatry.
False interpretation of ABPI results.
Delayed vascular intervention.
-False interpretation of ABPI- Many diabetic patients have medial arterial calcification giving an artificially elevated systolic pressure even in the presence of ischaemia.

5. PREVENTION OF ULCERS IN PEOPLE WITH DIABETES
Working knowledge of Diabetes Foot care Pathway for Western Devon and NICE NG19.
Foot assessment – vascular, neurological, foot deformities.
Appropriate risk status classification as per NICE NG19.
Appropriate prompt further referrals.
Correct frequency of foot health reviews.
Advice and education on foot care, footwear, life style etc.

6. When diabetes is diagnosed and at least yearly thereafter.
DIABETIC FOOT PROBLEMS:
PREVENTION AND MANAGEMENT(NG19)
For adults with diabetes assess their risk of foot problems at the following times:
When diabetes is diagnosed and at least yearly thereafter.
If any foot problems arise.
On any admission to hospital and if there is any change in status in hospital.

7. Remove shoes, socks, bandages and dressings and examine both feet for:
FOOT EXAMINATION
Remove shoes, socks, bandages and dressings and examine both feet for:
Neuropathy (using a 10g monofilament)
Peripheral arterial disease
Ulceration
Callous
Deformity

8. Ask about previous ulceration/amputation/renal replacement therapy.
Foot examination
Ask about previous ulceration/amputation/renal replacement therapy.
Ask about pain.
Check footwear.
Classify foot risk and advise patient.
Provide foot care education.
Refer according to the Diabetes Foot care Pathway for Western Devon.

9. neuropathy
Up to 35% of all patients have asymptomatic neuropathy only detected by clinical examination.
10g monofilament detects if protective pain sensation has been lost increasing risk of ulceration.
A properly calibrated device should be used to ensure that 10g of linear pressure is being applied (Owen Mumford Neuropen or Baileys monofilament).

10. 10g monofilament testing
Explain the test to the patient.
Use on inside of patient wrist or so they know what to expect and to take any stiffness out of the monofilament.
The patient must close their eyes so they cannot see when the monofilament is applied.
Five sites to be tested on each foot.
No agreed set sites nationally.
Ask the patient to respond with a ‘yes’ every time pressure is detected.

11. 10g monofilament testing
Apply sufficient force to enable the 10g monofilament to bend by 1cm.
The duration of contact, bend and removal of the monofilament should be 2 seconds.
One or more sites missed = Neuropathy

12. Replace after using 10,000 times or if becomes damaged or bent.
Resting and replacement
Do not allow the monofilament to slide or make repetitive contact at the same site.
Do not apply the monofilament at sites of ulceration, callous, scar tissue or necrosis.
If a monofilament is used 100 times in 24 hours it should be rested for 24 hours.
Replace after using 10,000 times or if becomes damaged or bent.

13. Palpation of foot pulses
Dorsalis pedis pulse is lateral to the extensor hallucis longus tendon on the dorsum of the foot.
Posterior tibial pulse is above and behind the medial malleolus.
In addition observe for hair loss, brittle slow growing toenails, open sores slow to heal, changing skin colour and shiny skin.

14. Inspection for ulceration
Search for breaks in the skin over the entire surface of foot and ankle not forgetting between the toes and back of the heel.
Some lesions are obvious but others make their presence known by complications:
Discharge
Colour changes
Pain or discomfort
Swelling
Warmth
Erythema

15. callus Plantar callus characteristic feature in neuropathic foot.
If becomes too thick will result in ulceration.
Speckles of blood or deep layer of white tissue indicate the foot is close too or ulcerated requiring urgent treatment.
Dangers of corn and callous removers.

16. deformity
Deformities lead to bony prominences associated with high mechanical pressures on overlying skin.
This results in ulceration particularly in the absence of protective pain sensation and when shoes are unsuitable.
Ideally the deformity should be recognised early and accommodated in properly fitting shoes.

17. Questions to ask…
Previous amputation?
Previous ulceration?
On renal replacement therapy?
All of the above class your patient as high risk automatically.
Pain in feet?
Neuropathic pain
Claudication pain
Rest pain
Infection
Previous trauma

18. Footwear assessment Is the shoe long enough?
Is the toe box broad and deep enough?
Are the heels low ( below 5cm)?
Does the shoe have a fastening?
Are there foreign bodies in the shoe?
Are there bulky seams inside the shoe which may cause rubbing?

19. Classify risk Low risk: High risk
No risk factor present except callous.
Moderate:
deformity or
neuropathy or
non-critical limb ischaemia.
previous ulceration or
previous amputation or
on renal replacement therapy or
neuropathy and non-critical limb ischaemia together or
neuropathy in combination with callus and/or deformity or
non-critical limb ischaemia in combination with callus and/or deformity.

20. Diabetes foot care pathway for western devon

21. referral
Moderate risk and high risk- Refer to Community Podiatry.
Ulceration/Infection/Charcot- Refer to Multidisciplinary Foot care Team, Derriford Hospital.
Severe infection/Sepsis- Emergency admission Medical Assessment Unit.
Critical ischaemia-Direct to vascular surgery via Surgical Assessment Unit FAO Duty Vascular Consultant.
Referral information in pathway.

22. Foot care education
Sites for information and leaflets:
1. Diabetes UK:
2. College of Podiatry:
3. Livewell Southwest Podiatry:

23. CASE STUDY 1- CHARCOT
Patient with midfoot charcot.
Developed ulceration after wearing regular footwear instead of bespoke boots and insoles.
Treated for infection with co-amoxiclav.

24. Deteriorated on antibiotics.
CASE STUDY…
One week later.
Deteriorated on antibiotics.
Admitted for incision and drainage of collection.
SFA angioplasty.

25. CASE STUDY..
Put into total contact cast.
Changed on a weekly basis in Fracture clinic with podiatry input to assess, treat and redress the ulcer.

26. Any Questions
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