In the Name of ALLAH, Ever
Beneficent, Infinitely Merciful
Dr Muhammad Farhatullah
Khan
M.B.B.S, DDM
INCHARGE
FOOT CLINIC AND PEDOGRAPH DEPTT
BAQAI INSTITUTE OF DIABETOLOGY AND
ENDOCRINOLOGY
Foot Care
INTRODUCTION
Diabetes mellitus is a syndrome characterized by
hyperglycemia due to
Absolute insulin deficiency - Type 1 DM
Relative insulin deficiency – Type 2 DM
One of leading causes of increased morbidity &
mortality worldwide.
Number of people with diabetes (20-79
years), 2010 and 2030
Estimated number of people with
diabetes worldwide (millions)
Global diabetes epidemic (20-79 years)
450
400
350
300
250
200
150
100
50
0
1980
438
285
150
30
1990
2000
2010
2020
2030
Year
IDF atlas 4th edition 2009
So, there is urgent
need for strategies to
be implemented to prevent the emerging
global epidemic of diabetes ( mainly T2DM)
Complications of
Diabetes
Macrovascular
Brain
Cerebrovascular disease
• Transient ischemic
attack
• Cerebrovascular
accident
• Cognitive
impairment
Heart
Coronary artery disease
• Coronary syndrome
• Myocardial infarction
• Congestive heart failure
Extremities
Peripheral vascular
disease
• Ulceration
• Gangrene
• Amputation
Microvascular
Eye
Retinopathy
Cataracts
Glaucoma
Kidney
Nephropathy
• Microalbuminuria
• Gross albuminuria
• Kidney failure
Nerves
Neuropathy
• Peripheral
• Autonomic
Incidence of Diabetic
Foot Ulcer
 Annual incidence ranges between1.0 to 2.0%1
 Prevalence of foot ulcer is reported between
5.3 to 10.5%1
 Life time risk diabetic foot ulcer is 25%1
 85% of amputation in diabetic are preceded by
foot ulcer
 Local prevelance is 10% at BIDE ,276000
1 Boulton et al..Comprehensive Foot Examination
and Risk Assessment.Diabetes Care.August
2008
Who will develop foot
ulcer/amputation
Age between 45-64
More male than female
Long duration of diabetes
Neuropathy
Peripheral vascular disease
Who will develop foot
ulcer/amputation
 Smoking
 Elevated level of HbA1c
 Prior history of ulcer/amputation
 Structural foot abnormalities, hammer toes,
claw toes
 Foot with dry and cracked skin
 Tight shoes, pointed toes
Precipitating Events
 Trauma
 Improper Foot Wear
 Blisters
 Fissures
 Puncture Wounds
 Thermal Injury
 Infection
 Vascular Event
Types of diabetic
leisons
 Ulcer
 Cellulitis
 Corn
 Callus
 Abscess
 Gangrene
 Nail disorder
 Foot edema
MOST COMMON TRIAD OF CAUSES1
1. NEUROPATHY
2. DEFORMITY
3. TRAUMA
1 Boulton et al..Comprehensive Foot Examination and Risk Assessment.Diabetes Care.August 2008
Site of ulcers
Toe
16%
45%
5%
11%
Sole/Met
Malleoli
Heel
Kissing Ulcers
Others
18%
5%
S.M.Ali et.al, Diabetic Foot Ulcer- a Prospective Study, 2001: 51(2); 78-81
Types of ulcers
Neuropathic
Neuro ischaemic
43%
Ischaemic
56%
1%
Accepted as a “Poster Display” Presentation for the 18th IDF Congress to be held in Paris, France.
Why We Do Foot
Assessments?
1. To Prevent foot ulcers with associated risk of
lower leg amputation
2. To have Early intervention for foot problems.
3. To Improve wound outcomes.
4. To Reduce severity of complications.
5. To Improve quality of life.
ASSESSMENT OF DIABETIC
FOOT
HISTORY OF PATIENT
CLINICAL EXAMINATION
INPECTION
PALPATION
SENSORY EXAMINATION
VASCULAR EXAMINATION
ESSENTIAL FEATURES HX
PAST HISTORY
ULCERATION
AMPUTATION
CHARCOT JOINT
VASCULAR SURGERY
ANGIOPLASTY
CIGARETTE SMOKING
ESSENTIAL FEATURES HX
NEUROPATHIC SYMPTOMS
Positive (e.g. burning and shooting, pain, electrical or
Sharp sensation etc)
Negative (e.g. numbness, feet, feel dead)
Vascular System
Claudication
Rest Pain
nonhealing ulcer
Other Diabetic Complications
renal (dialysis, transplant)
retinal (visual impairment)
INSPECTIION
Shape of the foot
Skin color, thickness, dryness, cracking,
sweating, pigmentation
Foot deformity, claw toes, prominent metatarsal
head, charcot joint,
Muscle wasting
Ulcer
Callus
INSPECTIION
INSPECTIION
CALLOSITY
ABSCESS
CELLULITIS
VESICLE
SWELLING
GANGRENE
NAIL DEFORMITY
INSPECTIION
PALPATION
 FEEL CONTOUR OF FOOT
 TEMPERATURE (DORSUM OF HAND)
 SENSORY/MOTOR SYSTEM
 VASCULAR ASSESSMENT
 EXAMINATION OF
LEISON,ULCER,ABSCESS,CELLULITIS
SENSORY
NEUROPATHY
 Burning, pin and needle, numbness of the foot
and nocturnal leg pain indicate cutaneous
sensory neuropathy
 35% of patients who are asymptomatic,are
found to have neuropathy on examination
 Primary cause of unrecognised injury
SENSORY
NEUROPATHY
 To identify LOPS
 For pain,pin prick with common pin
 For temperature
 For touch,cotton, monofilament
 For vibration,tunning fork,neurothesiom
 Propioception,sense of position of joint which
affect gait and stability,cause of freq fall
Using the Monofilament
Place
monofilament
perpendicular to
test site
Bow into C-shape
for 1 second
Test 3 sites/foot
Identify 90% of
neuropathic foot
Thermal Sensation
Heat & cold perception
Noted as
 Present
 absent
Neurothesiometer
 A biothesiometer is a portable
device that measures the
vibration perception threshold. A
vibration threshold of more than
25V has a sensitivity of 83%.
 Either an abnormal 10g
monofilament test or vibration
threshold of more than 25v
predicts foot ulceration with a
sensitivity of 100% hence the
rationale for combining these
two tests in clinical practice
MOTOR NEUROPATHY
 ATROPHY OF INTRINSIC MUSCLES
 INCREASED PRESSURE TO METATARSAL
HEADS AND TOES
 CALLUS FORMATION AND ULCERATION
 DIAGNOSIS: ABSENT ANKLE REFLEX
 S1-2 Ankle
L3-4 Knee
AUTOMATIC
NEUROPATHY
 DRY AND FISSURED SKIN DUE DYSHYROSIS
 A.V SHUNTING AND ALTERED PERFUSION
 DIAGNOSIS: POSTURAL HYPOTENTION,LOSS
OF VARIATION IN RR INTERVAL
VASCULAR ASSESSMENT
 TEMPERATURE
 PALPATION OF PERIPHRAL PULSES
 ABI
 ANGIOGRAPHY
Peripheral Vascular Disease
(PVD)
History : claudication (calf pain after walking a specific
distance) that is relieved by rest. However this is
uncommon in people with diabetes due the concomitant
neuropathy.
Examination: Palpate the foot for temperature (cool in PVD);
palpate the dorsalis pedis pulse and, if absent, the
posterior tibial pulse, than popliteal and femoral
Palpation of the dorsalis pedis pulse
Palpation of the posterior tibial pulse
Investigations: ankle
brachial pressure index
 Measure the blood pressure (BP)
in the arm using a sphygmanometer
 Measure the blood pressure in the
foot. Place a BP cuff around the calf
and detect the dorsalis pedis pulse
using a small hand-held doppler.
Inflate the cuff and slowly deflate
until the pulse appears.
 The ankle brachial pressure index
(ABPI) is the ratio of the ankle
systolic pressure to brachial systolic
pressure.
Doppler being used to detect
the dorsalis pedis pulse
Ankle Brachial Pressure Index
 ABI is usually between 0.9 -1.3. value <0.9
ischemia,value above 1.3 calcification. Normal
ABI effectively excludes significant arterial
disease in >90% of limbs.
 Absence of pulses and an ABI of <0.9 confirms
significant ischaemia. An exception is in artery
calcification, in which the ABPI can be falsely
elevated due to the simultaneously lower blood
pressure (BP) in the limb
.
Management
General measures
 To have good glycaemic control
 To Address cardiovascular risk factors such as
smoking, dyslipidaemia and hypertension so that
risks of PVD, acute coronary syndrome and
chronic renal failure can be minimised
 Education of patients on proper foot care and on
the importance of seeking medical advice early is
very important
Thank You