Diabetic Foot Exam
By Patrick A. DeHeer, DPM
Hoosier Foot & Ankle
Lancet. 2005;366:1674
 “…the enormity of the global burden of
diabetic foot disease…this much
neglected, but potentially devastating,
complication of a disease that is
reaching epidemic
proportions…Someone, somewhere,
loses a leg because of diabetes every 30
seconds of everyday…”
Global Projections for the Number of
People With Diabetes for 2010 and 2030
AT A GLANCE
2010
2030
Total world population (billions)
7.0
8.4
Adult population (20-79 years, billions)
4.3
5.6
Global prevalence (%)
6.6
7.8
Comparative prevalence (%)
6.4
7.7
Number of people with diabetes (millions)
285
438
DIABETES AND IGT (20-79 years)
Diabetes
IDF Diabetes Atlas, 4th ed. ©International Diabetes Federation, 2009.
Source: IDF Diabetes Atlas, 4th ed. International Diabetes Federation, 2009.
http://www.diabetesatlas.org/sites/default/files/At%20a%20Glance_WORLD.jpg. Accessed 01
March 2011.
Patients who develop a foot infection have a
55.7 times greater risk of hospitalization that
those who do not. –Lavery 2006
Costs to Treat a Diabetic Foot Ulcer
Over a 2-Year Period Following Detection
60,000
$48,156
50,000
$40,786
Cost in US Dollars
40,000
$33,046
30,000
$27,987
20,000
10,000
0
1995
2000
2005
2010
Cost analyses based on percent change in the medical component of the US consumer price index.
Ramsey et al. Diabetes Care. 1999;22:382.
Healing of Neuropathic Ulcers:
Results of a Meta-analysis
 These data provide clinicians with a realistic assessment of
their chances of healing neuropathic ulcers
 Even with good, standard wound care, healing neuropathic
ulcers in patients with diabetes continues to be a challenge
Margolis et al. Diabetes Care. 1999;22:692.
Tragic “Rule of 50”
50% of amputations Transfemoral/Transtibial level
50% of patients - 2nd amputation in 5 years
50% of patients - Die in 5 years
Clinical Care of the Diabetic Foot, 2005
Tragic “Rule of 15”
15% of diabetics will develop a foot ulcer in
their lifetime
15% of foot ulcers will develop
osteomyelitis
15% of foot ulcers will lead to an
amputation
Pathways for Foot Ulcers
 Neuropathy
 Foot Deformities (from motor neuropathy)
 Minor trauma
 Mechanical/Shoes (tight/ill-fitting)
 Thermal (heat inside shoes)
 Chemical (corn removal pads)
ULCER
Diabetes Care. 1999; 22:157
Patient Ulcer Risk
Risk Level
3: Prior
amputation
Prior ulcer
2: Insensate and
foot deformity
or
absent pedal
pulses
1: Insensate
0: All normal
Foot
Ulcer
%/yr
% Office
Patients
(diabetes
clinics)
28.1%
18.6%
7%
6.3%
10%
4.8%
1.7%
17%-30%
66%
History for the Diabetic Foot
 Chief Complaint
 HPI –
 NLDOCATS
 Medications
 Allergies
 Past Medical History
 Diabetes – NIDDM/IDDM
 Control?
 How long?
 Family History
 Surgical History
 Amputation
 Revascularization
 Social History
 ROS –
 CV – IC, edema, change in color or
temperature of LE, PAD, venous
disease
 Neuro – burning, numbness,
paresthesia, neuropathy, weakness
 MSK – amp, foot deformity, Charcot,
injury, ambulatory, OA/RA
 Derm – prior ulcer Hx, nail fungus,
dry and cracking skin, local or
systemic signs or symptoms of
infection
Neurological Exam
 Deep Tendon Reflexes –
 Patellar
 Achilles
 Clonus
 Babinski
 Vibratory
 Sharp/Dull
 Loss of protective sensation – 5.07/10 g Semmes-Weinstein
monofilament wire
Neurological Exam
Monofilament Wire Testing
 Test characteristics:
 Negative predictive value =
90%-98%
 Positive predictive value =
18%-36%
 Prospective observational
study:
 80% of ulcers and 100% of
amputations occur in
insensate feet
 Superior predictive value vs.
other test modalities
 Demonstrate on forearm or
hand
 Place monofilament
perpendicular to test site
 Bow into C-shape for 1
second
 Test 4 sites/foot
 Heel testing does not
predict ulcer
 Avoid calluses, scars,
and ulcers
J Fam Pract. 2000;49:S30
Diabetes Care. 1992;15:1386
Monofilament Wire Testing
 Insensate at 1 site =
insensate feet
 Falsely insensate with
edema, cold feet
 Test annually when
sensation normal
 Monofilament
 < 100 times day
 Replace if bent
 Replace every 3 months
Neurological Exam
 Biothesiometer
 Best predictor of foot ulcer
risk
 128-Hz tuning fork at
halluces
 Equivalent to 10-g
monofilament
 Newly recommended by
ADA
Diabetes Care. 2006;29(Suppl 1):S25
Diabetes Res Clin Pract. 2005;70:8
Motor Neuropathy and Foot
Deformities
 Hammer toes
 Claw toes
 Prominent metatarsal
heads
 Hallux valgus
 Collapsed plantar arch
Motor Neuropathy and Foot
Deformities
Motor Neuropathy and Foot
Deformities - Diabetic Charcot
Arthropathy
Pre-Ulcer Cutaneous Pathology
 Persistent erythema after
shoe removal
 Callus
 Callus with subcutaneous
hemorrhage
 Fissure
 Interdigital maceration,
fungal infection
 Nail pathology
Pre-Ulcer Cutaneous Pathology
Pre-Ulcer Cutaneous Pathology
Equinus and the Diabetic Patient
Grant et al JFAS1997
 Electron microscope
investigation of the effects
of diabetes on the Achilles
tendon
 All patients had diabetic
neuropathy and had an
ulcer or/and Charcot
neuroarthropathy
 12 diabetic patients and 5
non-diabetic patients
 Changes noted in diabetic
patients –
 Increased packing density
of collagen fibrils
 Decreased fibrillar diameter
 Abnormal fibril morphology
Equinus and the Diabetic Patient
Grant et al JFAS1997
 Foci in which collagen fibrils
appeared twisted, curved,
overlapping, and otherwise
highly disorganized were
common in specimens from
most patients (11 of 12)
 Structural reorganization that
may be the result of
nonenzymatic glycation
expressed over many years
 Leads to tightening of Achilles
tendon
 The fine structure of the Achilles
tendon appears normal,
consistent with the finding that
the ultrastructural changes result
from diabetes rather than
neuropathy
Equinus and the Diabetic Patient
Lavery, Armstrong, Boulton
Study JAPMA 2002
 Relationship between in
equinus and peak plantar
pressures in diabetic
patients
 1,666 patients
 Definition 0° AJ DF with KE
 Pressure measured with
force-plate gait analysis
system
 Mean Age 69.1 +/- 11.1
(years)
 Men 50.3%
 Weight 83.8 +/- 19.7 (Kg)
 Diabetes duration 11.1 +/9.5 (years)
Lavery, Armstrong, Boulton Study
JAPMA 2002
P = 0.007
140
120
100
80
60
40
20
0
92.7
P = 0.0001
Risk for elevated
PPP %
High PP
85.7 N/cm²
60
Low PP
N/cm²
40
20
Mean
PP
N/cm²
0
Risk for
elevated
PPP %
Lavery, Armstrong, Boulton Study
JAPMA 2002
 No statistical
significant difference –
 Weight
 Sex difference
 Absence or
presence of
neuopathy
 Statistical significant
difference –
 Equinus patients had
longer duration of
diabetes
 Equinus prevalence in
this population =
10.3%
Lavery, Armstrong, Boulton Study
JAPMA 2002
 “A high index of
suspicion should lead
to earlier surgical or
nonsurgical treatment
of these deformities.
This increased
vigilance, coupled with
intervention, may lower
the risk of ulceration
and amputation in this
high-risk population.”
Peripheral Artery Disease
 Prevalence (ABI < 0.9):
 10%-20% in type 2 diabetes
at diagnosis
 30% in diabetics  age 50
years
 40%-60% in diabetics with
foot ulcer
 Complications:
 Claudication
 Associated coronary and
cerebral vascular disease
 Delayed ulcer healing
Diabet Med. 2005;22:1310
Diabetes Care. 2003;26:3333
 Absent pedal pulses
predicts severe PAD
 Absence of a single pedal
pulse does not predict PAD
 Presence of pedal pulses
does not rule out PAD!
 Hand held doppler – good
initial evaluation
 Multiphasic
 Monophasic
Arch Intern Med.
1998;158:1357
Diabetes Care. 2003;26:3333
Adapted from: Norman PE, Eikelboom JW, Hankey GJ. Peripheral arterial disease: prognostic significance and
prevention of atherothrombotic complications. Medical Journal of Australia 2004; 181:150-154. Figure 1, p.151
Ankle-Brachial Index
 Screening: 2004 ADA
recommendation
 “Consider” at age 50 years
and every 5 years
 Diagnosis:
 Claudication, absent DP/PT
pulses, foot ulcer
 Limitations:
 Underestimates severity in
calcified arteries
 Interpretation
ABI
Normal
0.90-1.30
Mild obstruction
0.70-0.89
Moderate obstruction*
0.40-0.69
Severe obstruction*
<0.40
Poorly compressible**
>1.30
2° to medial calcification
*Poor ulcer healing with ABI < 0.50
**Further vascular evaluation needed
Foot Care Based on Risk Factors
Low Risk
 Annual comprehensive foot
examination
 Questionnaire completed by
patient
 Examination
 Self-management and
footwear education
 Brief counseling
 Written handout
High Risk
 Annual comprehensive foot
exam
 Inspect feet every office visit
 Podiatry care as needed
 Intensive patient education
 Detect/manage barriers to
foot care
 Therapeutic footwear, as
needed
Foot Care Based on Risk Factors
High Risk: Nursing Tasks
 Place “High-Risk Feet” stickers
on each chart
 Remove patient’s shoes/socks
 Determine if patient can
reach/see soles of feet
 Stock 10-g monofilament in each
room
 Consider training to perform
monofilament exam
 Provide patient education forms
J Gen Intern Med.
2003;18:258
High Risk: Patient
Education
 Reinforce frequently – low
retention
 Patient demonstrates selfcare knowledge
 Evidence:
 May reduce foot
ulcer/amputation rates
Cochrane Database Syst Rev. 2005 Jan
25;(1)CD001488
Foot Ankle Int. 2005;26:38
Diabetic Foot Care
High Risk: Podiatry Care
 Provide nail and skin care
 Assess footwear needs
 Visit frequency not
evidence-based
 Equinus management
Diabetes Care.
2003;26:1691
J Fam Practice.
2000;49(Suppl):S30
Basic Foot Care Concepts
 Daily foot inspection
 May require mirror,
magnification, or caregiver
 Patient able to
recognize/report:
 Persistent erythema
 Enlarging callus
 Pre-ulcer (callus with
hemorrhage)
Diabetic Foot Care
Basic Foot Care Concepts
 Commitment to self-care
 Wash/dry daily
 Lubricate daily (not between
toes)
 Debride callus/corn (low-risk
patients)
 No self-cutting of nails if:
 Neuropathy
 PAD
 Poor vision
Basic Foot Protective
Behaviors
 Avoid temperature extremes
 No walking
barefoot/stocking-footed
 Appropriate exercise for
insensate feet
 Inspect shoes for foreign
objects
 Optimal footwear at all times
Basic Footwear Education
Avoid:
 Pointed toes
 Slip-ons
 Open toes
 High heels
 Plastic
 Black color
 Too small
Diabetes Self-Management.
2005;22:33
Favor:
 Broad-round toes
 Adjustable (laces, buckles,
Velcro)
 Athletic shoes, walking
shoes
 Leather, canvas
 White/light colors
 ½” between longest toe and
end of shoe
Therapeutic Footwear Efficacy
 Protect feet
 Reduce plantar pressure, shock, and shear
 Accommodate, stabilize, support deformities
 Suitable for occupation, home, leisure
 Padded socks (e.g., CoolMax, Duraspun, others)
 Shoe inserts/insoles (closed-cell foam, viscoelastic)
 Therapeutic shoes
 Decreases plantar pressure 50%-70%
 Uncertain reduction in ulcer rate
Diabetes Care. 2004;27:1774
Thomson Rueters Study JAPMA
2011
 Thomson Reuters Healthcare carried out the study utilizing its
MarketScan Data Base examining claims from 316,527 patients with
commercial insurance (64 year of age and younger) and 157,529
patients with Medicare and an employer sponsored secondary
insurance.
 The study focused on one specific aspect of diabetic foot care: those
patients who developed a foot ulcer. For those who developed a foot
ulcer, the year preceding their development of a foot ulcer was
examined to see if they had seen a podiatrist. Those who saw a
podiatrist were compared to those who did not over a three year time
period.
 A comparison was then made between those who had at least one visit
to a podiatrist prior to developing the foot ulcer to those who had no
podiatry care in the year prior to developing the foot ulceration.
Thomson Rueters Study JAPMA
2011
 Average savings over a three-year time period (year before ulceration and
two years after ulceration occurred):
 Commercial Insurance: Savings of $19,686 per patient if they had at least
one visit to a podiatrist in the year preceding their ulceration
 Medicare Insured: Savings of $4,271 per patient
 Amputation Rates:
 Commercial Insurance:
 Podiatry care amputation rate – 5.82%
 Non-podiatry care amputation rate – 8.49%
 Medicare Insured:
 Podiatry care amputation rate – 4.69%
 Non-podiatry care amputation rate – 6.04%
Duke Study – Health Services
Research
 Medicare‐eligible patients with diabetes were less likely to
experience a lower extremity amputation if a podiatrist was a
member of the patient care team.
 Patients with severe lower extremity complications who only
saw a podiatrist experienced a lower risk of amputation
compared with patients who did not see a podiatrist.
 A multidisciplinary team approach that includes podiatrists
most effectively prevents complications from diabetes and
reduces the risk of amputations.
Thank You!!!!
Any Question???
 Patrick A. DeHeer, DPM
 Hoosier Foot & Ankle
 317-346-7722
 Hoosierfootandankle.com