Diabetic foot

 Foot problems are common in type-1 and type-2 diabetics

 20-40% of diabetics have peripheral neuropathy
 Many also have features of peripheral vascular disease
 15% of diabetics develop foot ulceration
 Diabetes is the leading cause of non-traumatic lower limb amputation

How do the pathophysiological features of diabetes put the foot at

increased risk for tissue damage?

 A number of  precipitating events can initiate damage in the foot in those with

diabetes that is at increased risk for tissue damage:
- Accidental cuts
- Shoe trauma
- Repetitive stress
- Thermal trauma
- Iatrogenic
- Vascular occlusion
- Skin or nail conditions
 Demographic risk factors
- Age (older at greater risk)
- Gender (male is at 2x greater) (mechanism for gender diferences is not clear -
maybe behavioural; maybe physiological)
- Ethnicity (some ethnic groups are at signifcantly increased risk for foot
complications) (mechanism not clear - maybe behavioural; maybe cultural; maybe
physiological; may be linked to socio-economic status; maybe access to health care)
- Social situation (living alone 2x greater risk)
 Other risk factors
 - Body weight (higher prevalance in those with type 2 diabetes) - however the link
to increased plantar pressure is inconsistent; could be related to other DM
complications (eg dyslipidaemia)
- Smoking (not linked to foot ulcer in multivariate analysis; Why??)
 - Footwear - can be protective (if appropriate) or precipitating (if inappropriate)
 Diabetes related risk factors 
- Duration of diabetes - highly related to diabetic foot complications; it is highly
correlated to other diabetes complications – so which one is really the risk factor?)
- Glycaemic control (univariate studies show a link; multivariate either don’t show a
link or a weak link; why?)
 - Loss of protective sensation - main risk factor; permissive of unperceived injury
- Motor neuropathy (muscle wasting and gait changes; the “intrinsic minus foot” –
high arched, claw toes, intrinsic muscle wasting)
- Autonomic neuropathy - microvascular dysfunction; Anhidrotic, dry, cracked skin
- Peripheral vascular disease (4x more common in those with diabetes)
 - Increased plantar pressures
- Limited joint mobility (AGE’s/glycation of collagen; restricts movement of key
joints; related to increased plantar pressures; mechanism of increase in plantar
pressures unclear; stronger relationship to foot ulcers and pressure in univariate
than in multivariate studies)
 - Immune/Defence mechanisms (infections are more common; the immune
responses are impaird due to vascular supply factors, chemotatic factors and a
reduced neutrophil response)
 - Previous ulceration (this is THE main risk factor for ulceration)

Pathophysiology

 The diabetic foot results from a combination of neuropathy and ischaemia

 Neuropathy has sensory, motor and autonomic components
 Sensory loss results in loss of protective sensation and unnoticed foot injuries
 Loss of motor control to the small muscles of the feet results in a claw foot deformity
 Autonomic neuropathy leads to vasomotor denervation and arteriovenous shunting
 This compromises the ability to direct blood flow to the capillary beds
 Ischaemia can affect both the large and small vessels
 Large vessels disease results in atheroma of the femoral, popliteal and tibial vessels
 Small vessel disease affects the microcirculation
 Other contributing factors include:
o Poor vision
o Limited joint mobility
o Cerebrovascular disease
o Peripheral oedema
 In patients with foot ulceration healing is impaired
 This results from:
o Impaired fibroblast function
o Deficiency in growth factors
o Abnormalities of the extracellular matrix

 Diabetic foot lesions frequently result from two or more risk factors occurring  
Fig 1. Illustration of ulcer due to
together. In the majority of patients, diabetic peripheral neuropathy plays a repetitive stress
central role: up to 50% of people with diabetes with type 2 diabetes have
neuropathy and at-risk feet.
Neuropathy leads to an insensitive and sometimes deformed foot, often with an
abnormal walking pattern. In people with neuropathy, minor trauma - caused
for example by ill-fitting shoes, walking barefoot or an acute injury - can
precipitate a chronic ulcer. Loss of sensation, foot deformities, and limited joint
mobility can result in abnormal biomechanical loading of the foot. Thickened 1. Callus formation

skin (callus) forms as a result. This leads to a further increase of the abnormal
loading and, often, subcutaneous haemorrhage.

2.

Subcutaneous hemorrhage

Whatever the primary cause, the patient continues walking on the insensitive
foot, impairing subsequent healing (see Figure 1). Peripheral vascular disease,
3.
usually in conjunction with minor trauma, may result in a painful, purely
ischaemic foot ulcer. 
However, in patients with both neuropathy and ischaemia (neuro-ischaemic Breakdown of skin

ulcer), symptoms may be absent, despite severe peripheral ischaemia. Micro-

angiopathy should not be accepted as a primary cause of an ulcer.

4.

Deep foot infection with

osteomyelitis

Management

INSPECTION

Hard skin and callused areas are signs that high pressures are occurring. If a callus is not reduced, the
skin itself becomes hard enough to cause injury and the skin breaks down beneath the callus and
ulcerates.

At this stage there may be no external sign of ulceration visible to the patient. However, close
inspection of callused areas may alert a healthcare professional to imminent ulceration. Skin becomes
discoloured in various ways. Sometimes a yellowish, halo-like appearance occurs and occasionally
there will be signs of blood staining within the skin. With ischaemic ulcers, the skin usually reddens
before ulcerating (Edmonds and Foster, 2005).

VASCULAR ASSESSMENT

Taking a good history from the patient may highlight symptoms that will aid clinical decision-making.
For example, a patient with resting pain (indicating advanced disease) would require a more urgent
vascular referral than a patient with stable intermittent claudication.

The initial practical step in assessing the contribution of ischaemia to a diabetic foot ulcer is palpation
of two foot (pedal) pulses. The dorsalis pedis can be located by placing the fingers between the first
and second toes and moving up to the area over the arch of the foot. The posterior tibial pulse is
located in the hollow behind the medial malleolus. Absence of a pulse should be noted.

The next stage of vascular assessment is to perform an ankle brachial pressure index using doppler
ultrasound.

NEUROLOGICAL ASSESSMENT

It is useful to begin a neurological assessment by taking a patient history with the emphasis on
assessing pain sensation (Prodigy, 2006). For a useful practical guide, see Baker et al (2005).

Practitioners wishing to perform a neurological assessment should ensure that they have access to the
relevant equipment. Tuning forks have been superseded by the neurothesiometer/biothesiometer.
These are expensive items and not usually found in primary care.

It is likely that primary care practitioners will use the 10g monofilament. Although there is contention
about the number of sites on the foot that should be tested with the 10g monofilament, my opinion is
that it is better for a novice assessor to begin with the simplest method as described by the
International Working Group on the Diabetic Foot (1999). This restricts the test to three sites on the
forefoot. Inability of the patient to detect that the 10g monofilament is in contact with the foot
signifies a neuropathic component to any presenting ulcer.

ADVICE FOR PREVENTION (Pwede din to discharge management)

Education

Patients need to be actively supported to self-manage their feet. This can involve daily checking of
feet and awareness of the signs of infection (Berendt and Lipsky, 2003).

However, many patients at risk of diabetic foot ulcers will have other complications such as
retinopathy, and this must be taken into account.

It may be necessary to engage relatives/carers in the self-management process (International

Working Group on the Diabetic Foot, 1999).

Regular podiatry

Foot protection programmes (FPP) offering regular podiatry for patients who are at risk of foot
ulceration, as well as footwear, hosiery checks and education have been shown to limit the effects of
diabetic foot ulcers (McCabe et al, 1998). Health professionals in primary care have an important role
to play in referring patients to FPPs and reinforcing the importance of regular attendance.
 Skin care

Skin changes such as dry skin should be identified. Patients may need advice on the use of
moisturising or emollient preparations.

Such products should not be applied between the toes as they can cause the skin in this area to
become too moist. This may lead to splitting and fissuring, making it easy for bacteria to enter and the
foot to become infected.

The effects of tinea pedis (athlete’s foot) can lead to breaks in the skin that become infected by
bacteria. Tinea pedis should always be treated in people with neuropathy or ischaemia.

Footwear

In the early stages of diabetic foot disease when neuropathy or ischaemia are diagnosed but there is
no ulceration, general footwear advice may be all that is required. This should be reinforced with
leaflets (Edmonds and Foster, 2005). Details of local stockists can be useful. When deformity or
ulceration have occurred referral to a podiatrist or orthotist for a specialist opinion is recommended
(NICE, 2004).

PRINCIPLES OF TREATMENT

Treatment of diabetic foot ulcers depends on whether they are neuropathic or predominantly
ischaemic. Detailed guidelines on treatment (Prodigy, 2006) recommend immediate referral to a
multidisciplinary foot clinic. Basic principles of treatment include assessment for:

 Peripheral arterial disease;

 Infection;
 Pressure relief;
 Wound care;
 Blood glucose control;
 Education.
If tissue damage has occurred and the wound is non-healing or deteriorating, this increases the
urgency of the referral. A pink or pale, painful, pulseless foot can indicate a critically ischaemic foot
and hospital admission may be necessary (Prodigy, 2006). In patients with peripheral arterial disease,
diabetic foot ulcers are at risk of rapid deterioration. This should be considered when deciding on
treatment intervals or review appointments.

Infection

Infection in the diabetic foot already complicated by neuropathy or ischaemia will cause major tissue
destruction if left untreated (Edmonds and Foster, 2005). An accurate appraisal of the wound and
commencing appropriate treatment can often prevent a critically colonised wound from deteriorating
into spreading infection.

PRESSURE RELIEF

Every attempt should be made to offload the ulcer and redistribute pressure away from the affected
area. This often begins with reducing a callus using scalpel techniques. Callus contributes to increased
pressure on the insensate foot (Steed et al, 1996). Other treatments vary from adapting patients’ own
footwear to specialist plaster casts.

WOUND CARE
 Tissue viability nurses are a source of advice on wound care products. There is a wide range of
products available.

Many of the more interactive/advanced products have been of benefit to patient care but there
remains a lack of robust evidence that one product is superior to another. Products used to treat
diabetic foot ulcers should be chosen for their ability to:

 Protect against contamination of the wound by potential pathogens;

 Minimise bulk and reduce pressure;
 Handle wound exudate.
In neuropathic ulcers, drainage of wound exudate can be facilitated by debridement of the wound.
Debridement of slough and necrotic tissue from the wound margins and within the wound bed reduces
sites for micro-organisms and lessens the chances of infection.

Hyperglycaemia and wound healing

Hyperglycaemia affects many of the biochemical pathways of the body. The ability of an ulcer to
progress through the phases of wound healing involves a number of complex cellular processes,
actions and interactions.

Patients with continually high blood glucose levels have impaired white blood cell activity, which leads
to delayed wound healing (Senior, 2000). Part of diabetic foot ulcer treatment should be aimed at
optimal blood glucose control.

Education

Instruction in dressing technique is necessary if the patient is caring for a foot ulcer. It is important
that both patient and healthcare professional recognise the signs of deterioration and infection and
always check for these when re-dressing ulcers:

 Change in the colour of the foot, for example, redness signifying infection or
blue/black signifying necrosis;
 Change in wound bed from viable tissue to friable granulation tissue or slough
(European Wound Management Association, 2005);
 Swelling of the foot;
 Increased discharge or change in viscosity;
 Fever or flu-like symptoms.

Diabetic Foot Care (Kat, preventive measures to.)

Diabetic foot complications are the No. 1 cause of non-traumatic foot amputations in the United States and cause one
in five people with diabetes to enter the hospital. Learning to do proper foot care can help prevent or delay this
occurrence.

What causes foot problems with diabetes? 

In patients with diabetes, blood flow to the feet may be impaired. This means that your foot is less able to fight
infection or heal itself.

Nerve damage (neuropathy) may be present, causing a lack of sensation in the feet. Pain may not be felt even with
injury, predisposing you to foot ulcers and infection. The skin may also become dry, cracking and peeling easily,
since neuropathy may cause sweating to be impaired.
The following guidelines will help you protect your feet and should be done daily.

1. Good Blood Sugar Control 

Keeping your blood sugar under good control can help prevent or delay foot complications as well as other diabetes-
related problems. This will mean self-management of blood sugars with diet, exercise medication, monitoring blood
glucoses, and education in other techniques of controlling blood sugar.

2. Inspect Your Feet Daily 

Visually checking your feet is important, since you may not feel injuries if you have neuropathy. Look for cuts, sores,
red spots, infection, swelling or unusual appearing areas. You can use a mirror to help see the bottom of your feet, or
ask a family member or caregiver for help. Set a time daily (such as after your bath or shower) to perform this check.

3. Wash and Moisturize Your Feet Daily 

Warm (about 90-95 degrees) water is best, instead of hot. You can use a thermometer or your elbow to assess the
temperature. Dry your feet afterwards, with special attention between the toes (to prevent athlete's feet). Rub a think
layer of a good moisturizer or lotion that does not contain alcohol (which can be drying), avoiding the area between
the toes. Moisturizing will help prevent your skin from drying and cracking, which can lead to infection. Also, do not
soak your feet, since this will also dry out the skin.

4. Smooth Corns and Calluses 

After your bath or shower, when the skin is soft, use a pumice stone to gently rub in one direction, smoothing off
corns or calluses. Avoid tearing the skin, and never cut corns or calluses. Never use liquid corn and callus removers,
since they can create a chemical burn. If the calluses become thick, see your health care provider for a referral to a
podiatrist (foot doctor) who can trim these for you. They may indicate a pressure area, and the need for special shoes
or inserts to relieve the pressure.

5. Trim Your Toenails Regularly 

Once a week is usually enough. After washing and drying your feet, trim your toenails straight across, then smooth
them with an emery board so there are no sharp edges. Do not rip off hangnails, and don't cut into the corners, or
trim into the quick. You may need a podiatry consult if the nails are thickened and yellow.

6. Never Go Barefoot 
Even going barefoot indoors can cause injury. Good fitting shoes and socks are one of your feet's best protection.
Choose socks made of cotton or wool, since they will "wick" moisture away from your skin, and make sure there are
no seams or bumps. Be sure to check inside your shoes before putting them on for objects, rough spots or exposed
nails.

It is best to break in new shoes slowly (one hour a day the first week, increasing time gradually). Choose shoes made
of canvas or leather, that let your feet "breathe," with good support at the ankles. Don't buy pointed toes or high
heels, which put pressure on the feet. Keep slippers with good soles by your bed to use at night if you get up.

7. Avoid Thermal Injury 

Never use hot water bottles or heating pads on your feet, which cause tissue injury or burns. Wear socks at night if
your feet get cold.

Put sunscreen on the top of your feet to prevent sun burn. In the winter, lined boots can help keep your feet warm.
Check for frostbite if exposed to the cold.

8. Don't Constrict Circulation 

Avoid crossing your legs, or wearing tight socks, garters or constricting garments.

9. Exercise 
Exercise helps promote blood flow. Check with your health care provider as to which activities are best for you.
Walking, swimming and bicycling can help blood flow and do not put pressure on the feet. Avoid high impact
exercises such as running or jumping. Wear good fitting, supportive athletic shoes.
10. Have Your Health Care Provider Check Your Feet at Every Visit 
At minimum, a yearly foot check of pulses, sensation and visual inspection should be done by a health care
professional. If you are at higher risk, the foot-check should be done more frequently.

Any time infection, inflammation, an ingrown toenail or a foot ulcer occur, see your health care provider immediately.

Every ulcer should be seen by your health care provider immediately, even if there is not pain. If sensation in your
feet changes, if you develop severe pain, or the color changes, tell your health care provider.