Diabetes and the foot

1. Diabetes and the foot What is happening and how to treat it Helen Moakes Specialist Diabetes Podiatrist

2. Overview 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!

3. National Guidelines • 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

4. National Statistics(Putting Feet First and Fast – NHS Diabetes summary doc) • 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

5. National Statistics(Putting Feet First National Skills Framework – NHS Diabetes) • 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

6. Foot Assessment • 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

7. Foot Assessment 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

8. Foot assessment continued • 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

9. What else? • When undertaking the diabetes foot assessment, look at: • Foot shape • Deformity • Footwear • Smoking • Glucose control • Callosities • Risk status – NICE guidelines and QOF

10. Risk Classification(NICE guideline CG10, QOF indicator DM29 • 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

11. How do problems start? • High blood glucose levels • Start of damage to nerves and blood vessels • Diabetes may not be diagnosed • Once diagnosed, poor control of BG levels • Lack of education and knowledge • Fear • Injury/trauma • Painless! • Ischaemia - pain • Painful neuropathy • Amputations

12. Types of Diabetic Foot • Neuropathic • Pink and warm • Good pulses • Abnormal monofilament result • Dry • Callus • High arch, claw toes • Neuro-ischaemic • Dusky/Blueish and cool/cold • Non-palpable pulses • Abnormal monofilament (?) • Little callus, glassy • Pain

13. Neuropathic Feet

14. Neuropathic Feet(typical features) • 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

15. Neuro-Ischaemic Feet

16. Neuro-Ischaemic Feet (typical features) • Less common • Fragile • Life expectancy reduced • Often painful • Poor healing • Protection essential to prevent injury/trauma • Podiatry care • Swift referral

17. INFECTION IS A KILLER OF DIABETIC FEET Don’t leave it! Find out your nearest hospital Foot Clinic contact details

18. Acute Foot Problems • Assess urgency (pyrexic, BG level, wound) • Get a history • Will almost always require referral to Foot Clinic • Often requires admission • If unsure, get advice

19. Acute Foot Problems – possible examples • Blisters • Callus with tissue breakdown underneath • Ingrowing toenail • Accidental trauma – stubbing toe, cuts/grazes • ANYTHING INFECTED

20. Acute Foot Problems

21. Acute Foot Problems

22. Acute Foot Problems

23. Charcot foot • Process affecting the bony structure of the feet • Rare but under-diagnosed • Affects neuropaths with good blood supply • Diagnosis difficult – differentials?

24. Charcot foot – the process • 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...

25. Charcot foot - diagnosis • 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

26. Charcot Foot - treatment • 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

27. What to Do! • If in doubt with any diabetic foot problem... SEEK ADVICE.......FAST! • Hospital MDT foot clinics are there to help • Diabetic feet can deteriorate fast, especially with infection • Prevention is key

28. And finally...

29. Thank you! Any Questions?