Diabetic Foot
Diabetic foot problems and its prevention.
 |
Foot ulcers and other foot problems are one of the commonest causes of morbidity (disability), and even mortality (high death rate), amongst the diabetics in our country. |
|
|
Diabetics account for the second largest group of people undergoing lower limb amputations (after accidents) in our country. |
|
|
Foot problems are also the reason for repeated hospital admissions and prolonged indoor stay. |
|
|
The frequency and the severity of foot problems can be decreased with adequate foot evaluation and, as importantly, patient education about foot care |
|
|
All patients at the time of diagnosis and annually, must undergo a comprehensive foot evaluation which includes a complete vascular, neurological, musculo-skeletal, skin and soft tissue examination. |
|
|
This comprehensive evaluation does not necessarily involve the use of sophisticated, complex and costly equipment; the use of a simple point based protocol ( given below) allows delineation of most people at high, or increasing, risk for the development of foot problems; some patients may require more sophisticated evaluation. |
|
|
Patients at high, or increasing, risk may require more frequent evaluations and proactive management. |
Patients with high risk:
|
|
Patients who walk barefoot. |
|
|
Patients with diabetic neuropathy. (nerve damage) |
|
|
Patients with significant diabetic peripheral vascular disease. (damage to vessels supplying the limbs). |
|
|
Patients who smoke or use tobacco in any form. |
|
|
Those with a foot deformity. |
|
|
Diabetics with a history of previous ulcers or foot infections. |
|
|
Patients with abnormal gait. (walk in unbalanced manner). |
|
|
Those with significant skin and nail infections or deformities. |
|
|
Blind/partially sighted persons. (increase chances of repeated injuries to foot) |
|
|
Elderly patients; especially those living alone. |
|
|
Diabetics with chronic renal failure. (kidney failure). |
|
|
Patients with high alcohol intake. |
Importantly,
|
|
The prognosis (long term outcome) for the second limb is poor in those who have had an amputation of the contra lateral (opposite) limb . |
Foot problems presentations
Ulceration-superficial . Ulceration-deep. Gangrene of digit (toes).
Stages and classification
|
|
Ulceration-superficial. |
|
|
Ulceration-deep. |
|
|
Ulceration-deep with exposure of bone, muscles, ligaments, tendons. |
|
|
Osteitis (bone inflammation), abscesses, osteomyelitis (infection of bone) |
|
|
Gangrene of digit (toes). |
|
|
Gangrene of foot requiring amputation. |
Screen tests for diabetic foot problems.
Inspection
|
|
For evidence of dry, or excessively moist, skin, hair and nail abnormalities corns, calluses and infection |
|
|
For presence of deformities, heel spurs, flat arches, etc. |
Sensation
|
|
Inquire for symptoms (numbness in the periphery, etc.) |
Large nerve fiber function.
-
vibratory perception at dorsum of the great toe and deep tendon reflexes
-
light touch
-
position sense
Small nerve fiber function.
Temperature and pain perception thresholds.
Vascular.
|
|
Inquire for symptoms of intermittent claudication (pain limbs while walking a fixed distance, which can disappear after walking further-due to damaged blood vessels) |
|
|
Palpation of pedal pulses. (pulses of feet) |
|
|
Brachial to ankle systolic pressure ratio. |
|
|
If foot pulses are absent examine proximal pulses (popliteal and femoral) |
If necessary, the following tests should be considered :
|
|
Doppler studies for blood flow. |
|
|
Arteriography. |
|
|
All these investigations may not be necessary in every patient and the range of investigations should be individualized. |
Simple protocol for judging potential for foot problems | ||
(Basic Point Based Protocol) | ||
Paraesthesia (increased sensations ) |
no (0) |
yes (2) |
Hypoesthesia (decreased sensations) |
no (0) |
yes (4) |
Anesthesia |
no (0) |
yes (6) |
Veins on dorsum of foot |
| |
|
(0)+ (3) (6) | |
H/O intermittent claudication |
no (0) |
moderate (3) |
severe (6) |
|
H/O rest pain |
no (0) |
moderate (3) |
severe (6) |
|
H/O nocturnal leg pain |
no (0) |
moderate (3) |
severe (6) |
|
Peripheral pulses |
normal (0) |
feeble (4) |
absent (6) |
|
Filling time after blanching of |
< 5(0) |
5-10(1) |
11-15(2) |
>15(4) |
Skin and Nail Changes: |
| |
Skin: cold/dry/thickened/atrophic/shining/loss of hair |
no(0) |
yes(2) |
Nails: thickened/ingrown/ fungal infections |
no(0) |
yes(2) |
Presence of corns |
no(0) |
yes(2) |
Presence of calluses |
no(0) |
yes(2) |
Based on the points scored, patients are classified into categories A to E with increasing risk for developing foot problems. | ||||||||||||
A < 5; | B 5-10; | C 11-15; | D 15-20; | E >20; | ||||||||
NOTE:
| ||||||||||||
Foot problems
|
|
Foot problems can develop quickly in people with diabetes because of poor circulation, hardening of the arteries, or nerve damage. |
|
|
Poor circulation can lead to symptoms such as cold feet, leg cramps, shiny or dry skin, loss of hair, and slow healing. |
|
|
Nerve damage can cause pain, numbness, loss of feeling, burning, and tingling in the legs or feet. |
|
|
If you have nerve damage and poor circulation, you are vulnerable to even more serious complications. You may not be able to feel a small cut or blister on your foot. If the cut or blister becomes infected, this can lead to a more serious infection called gangrene. |
|
|
If gangrene is not treated soon enough, a section of the foot may need to be amputated to save the rest of the foot or leg. |
|
|
Your feet will be more prone to dryness, peeling, and cracking, so always keep them clean and dry. |
|
|
After bathing, dry your feet carefully, especially between the toes, and apply a thin coating of baby oil or lotion. |
|
|
Do not put baby oil or lotion between your toes. |
|
|
Similar complications can develop from ingrown toenails, plantar warts, and puncture wounds. |