What is happening and how to treat it
Helen Moakes
Specialist Diabetes Podiatrist
National Guidelines and Statistics
Diabetes annual foot review – the foot assessment
How do problems start?
Types of diabetic foot
Acute foot problems
Charcot foot
What to do with them!
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NICE CG10 – Prevention and Management of
Foot Problems in Type 2 Diabetes
NICE CG119 – Inpatient Management of
Diabetic Foot Problems
Putting Feet First – NHS Diabetes
National Minimum Skills Framework for
Commissioning of Foot Care Services for
People with Diabetes
NSF Diabetes – DoH document
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1 in 7 people with diabetes will develop a foot
ulcer
1 in 12 ulcers results in an amputation
8-10% of inpatients have a pressure sore and
50% of these have diabetes
25% of diabetic patients are admitted to
hospital with foot ulceration as primary
diagnosis
Direct relationship between the time to healing
and the time to assessment
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70 amputations per week, of which 80% are
potentially preventable
In 2007/2008 nearly a quarter (23 per cent) of
people did not have a foot check
Diabetes complications of the foot estimated to
account for 20% of total cost of diabetes care in
UK
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On newly diagnosed patients and annually
thereafter
Identifies risk factors (neuropathy, ischaemia,
deformity, previous ulceration, smoking, poor
glucose control, callosities)
Assessment will result in a Risk Classification
or Status – QOF indicator DM29
Risk classification informs education needs and
further care planning
What to check?
Foot pulses (Dorsalis Pedis & Posterior Tibial)
- Check by hand
- Doppler if unable to palpate
- Oedema
-
Also an indicator of vascular problems
elsewhere
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What to check?
Protective pain sensation (neuropathy)
- 10g Monofilament (Bailey/Owen Mumford)
- Test sites
- Tell patient result!
Diagnosis of neuropathy means greatly
increased chance of developing foot ulcer due
to inability to sense pain
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When undertaking the diabetes foot
assessment, look at:
Foot shape
Deformity
Footwear
Smoking
Glucose control
Callosities
Risk status – NICE guidelines and QOF
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Low Risk
- Normal sensation, palpable pulses
Increased Risk or At Risk
- Neuropathy OR absent pulses
High Risk
- Neuropathy AND/OR absent pulses AND
pathology
Ulcerated foot
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High blood glucose
levels
Start of damage to
nerves and blood
vessels
Diabetes may not be
diagnosed
Once diagnosed, poor
control of BG levels
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Lack of education and
knowledge
Fear
Injury/trauma
Painless!
Ischaemia - pain
Painful neuropathy
Amputations
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Neuropathic
Pink and warm
Good pulses
Abnormal
monofilament result
Dry
Callus
High arch, claw toes
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Neuro-ischaemic
Dusky/Blueish and
cool/cold
Non-palpable pulses
Abnormal
monofilament (?)
Little callus, glassy
Pain
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Common
Look ‘normal’
Education of paramount importance
Protection – footwear, insoles, not barefoot!
Podiatry care if required – varies with area
BG control
Painful neuropathy
Swift referral
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Less common
Fragile
Life expectancy reduced
Often painful
Poor healing
Protection essential to prevent injury/trauma
Podiatry care
Swift referral
Don’t leave it!
Find out your nearest hospital Foot Clinic contact
details
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Assess urgency
(pyrexic, BG level,
wound)
Get a history
Will almost always
require referral to
Foot Clinic
Often requires
admission
If unsure, get advice
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Blisters
Callus with tissue
breakdown
underneath
Ingrowing toenail
Accidental trauma –
stubbing toe,
cuts/grazes
ANYTHING
INFECTED
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Process affecting the
bony structure of the
feet
Rare but underdiagnosed
Affects neuropaths
with good blood
supply
Diagnosis difficult –
differentials?
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Neuropathic –
insensate
Bones within
foot/ankle soften due
to arterio-venous
shunting
Bounding foot pulses
TRAUMA ??
Bones begin to
fracture within
foot/ankle
Foot may swell,
redden, increased
temperature
 Mostly unilateral, 20%
bilateral involvement
 Pain/discomfort??
 Foot/ankle changes
shape
(collapse/rocker
bottom)
...but we can avoid this...
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REFER TO FOOT
CLINIC
X-ray – not as useful
in early stages but
gives a baseline
Bone scan – detects
heat
HbA1c, Hb, ESR &
CRP
Rule out infection,
DVT, etc
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TOTAL CONTACT PLASTER CAST – gold
standard
Time in cast varies – couple of months to 18
months
Transition to Aircast, then custom footwear
Can take 3 years
Prevent by good BG control, lessen
complications, education
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If in doubt with any diabetic foot problem...
SEEK ADVICE.......FAST!
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Hospital MDT foot clinics are there to help
Diabetic feet can deteriorate fast, especially
with infection
Prevention is key
Any Questions?