Five cornerstones of the management of the diabetic foot

1. 1. Regular inspection and examination of the foot.2.Identification of the foot at risk.3.Education of patient, family and healthcare providers.4.Appropriate footwear.5.Treatment of non ulcerative pathology Five cornerstones of the management of the diabetic foot

2. 1.Regular inspection and examination of the foot.2.Identification of the foot at risk.3.Education of patient, family and healthcare providers. 4.Appropriate footwear. 5.Treatment of non ulcerative pathology Five cornerstones of the management of the diabetic foot

3. Regular inspection and examination of the foot • All diabetic patients should be examined at first presentation then at least once a year • Patients with risk factors should be examined every 1-6 months • Absent symptoms does not mean that the feet are healthy • Examine the patient on lying down and standing up • Shoe and socks should be inspected

4. Foot examination • Nails • Foot deformity • Skin condition • Vascular assessment • Neurological assessment

5. Foot examination • Nails • Thick • Too long • Ingrown • Fungal infection • Wrongly cut nails

6. Foot Examination • Foot deformity: Toe deformity • Hammer toe • Claw toe Forefoot deformity • Halluxvalgus • Halluxrigidus Wholefoot Deformities • PesCavus - High arched foot • PesPlanus - Flat foot • Charcot foot

7. Foot Examination • Skin condition: Callus Bunions Redness Warmth Fissure Dryness Swelling Maceration Fugal infection

8. Foot Examination • Vascular assessment • Neurological assessment

9. Does your patient have neuropathy? Mansoura DF 2nd International Training Course

10. Neuropathy assessment Manal Tarshoby Assistant Professor of Medicine Diabetes and Endocrinology unit Diabetic Foot Team Mansoura University EGYPT

11. Clinical Assessment • History: • Review diabetes history, management • Daily glycemic records, previous A1c • Review medical history • Review other causes of neuropathy (10%) • 50% has no symptoms Mansoura DF 2nd International Training Course

12. HistoryMichigan neuropathy screening questionnaire • Are your feet numb • Burning pain • Feet sensitive to touch • Muscle cramp • Can you tell hot from cold water • Have you had an ulcer • Dr diagnosed neuropathy • Do you feel weak • Symptom worse at night • Legs hurt when you walk • Prickling feeling • Able to sense feet when walking • Bed covers hurt your skin • Your skin crack open • Unsteadiness • Previous amputation Feldman, Diabetes care,1994 Mansoura DF 2nd International Training Course

13. Paradox ? Mansoura DF 2nd International Training Course

14. Mansoura DF 2nd International Training Course

15. Painful-Painless Leg • One doesn’t need to have intact sensation to experience pain. Mansoura DF 2nd International Training Course

16. Physical Examination • Inspection • Vibration sense Tuning fork 128 • Reduced protective sensation such as pressure, hot and cold, pain • Sharp, dull, light touch • Motor strength • Diminished ability to sense position of toes and feet • Deep tendon reflex Mansoura DF 2nd International Training Course

17. Inspection • Muscle atrophy • Intrinsic minus foot • Dry skin Mansoura DF 2nd International Training Course

18. Neurologic assessment Mansoura DF 2nd International Training Course

19. Physical Examination • Inspection • Vibration sense • Tuning fork 128 • neurothesiometer Mansoura DF 2nd International Training Course

20. Vibration Sense • Tuning fork is held against a bony prominence: • Medial aspect 1st MTP Joint • Plantar Hallux • Med/Lat Malleolus • Patients should be reminded that it is the vibration they are required to detect not the sound. Mansoura DF 2nd International Training Course

21. Mansoura DF 2nd International Training Course

22. NEUROTHESIOMETER • Vibration threshold is strongly linked with age • Males have slightly higher thresholds than females Age 15 35 55 Males 8.8 volts 12.9 volts 19.9 volts Females 8.3 volts 10.8 volts 14.6 volts Mansoura DF 2nd International Training Course

23. NEUROTHESIOMETER • At the distal pulp of the hallux, over bony prominence • Voltage is increased until the patient can perceive vibration Mansoura DF 2nd International Training Course

24. NEUROTHESIOMETER Foot ulcer risk increased by 5.6% per volt Abott, Diabetes care, 1998 Mansoura DF 2nd International Training Course

25. Physical Examination • Inspection • Vibration sense • Reduced protective sensation • pressure • hot and cold • pain Mansoura DF 2nd International Training Course

26. TEMPERATURE TESTING • Two test tubes, hot/cold. • Therm-tip • Subjective, crude tests Mansoura DF 2nd International Training Course

27. MONOFILAMENTS Which monofilament ? 10 mg, 1mg Calibrated Mansoura DF 2nd International Training Course

28. MONOFILAMENTS HOW TO USE IT? How many sites to be tested? Mansoura DF 2nd International Training Course

29. Mansoura DF 2nd International Training Course

30. MONOFILAMENTS How many lost sites to diagnose LOPS 4 1 Mansoura DF 2nd International Training Course

31. Monofilament Failure • Variability within and between brands • Require frequent replacement • Should be calibrated • Give-away devices are of uncertain quality ,durability • Repetitive loading? Mansoura DF 2nd International Training Course

32. SUPERFICIAL PAIN TEST • Neuro - tip • Areas tested • Patient response • Significance Mansoura DF 2nd International Training Course

33. Physical Examination • Inspection • Vibration sense • Reduced protective sensation • Sharp, dull, light touch Mansoura DF 2nd International Training Course

34. LIGHT TOUCH TEST • Wisp of cotton wool • Subjective • Can be painful if neuropathy exists Mansoura DF 2nd International Training Course

35. Mansoura DF 2nd International Training Course

36. Physical Examination • Inspection • Vibration sense • Reduced protective sensation • Sharp, dull, light touch • Motor strength Mansoura DF 2nd International Training Course

37. Physical Examination • Inspection • Vibration sense Tuning fork 128 • Reduced protective sensation such as pressure, hot and cold, pain • Sharp, dull, light touch • Motor strength • Diminished ability to sense position of toes and feet Mansoura DF 2nd International Training Course

38. Physical Examination • Inspection • Vibration sense Tuning fork 128 • Reduced protective sensation such as pressure, hot and cold, pain • Sharp, dull, light touch • Motor strength • Diminished ability to sense position of toes and feet • Deep tendon reflex Mansoura DF 2nd International Training Course

39. Deep tendon reflex Mansoura DF 2nd International Training Course

40. Neuro Disability score • 3 sensory modality • Vibration • Pin prick (neurotip) • Hot-cold rod Scored Normal=0 Abnormal=1 • Ankle reflex Scored Normal=0 Reinforcement=1 Absent=2 Max total 5 for each leg Total out of 10 Mansoura DF 2nd International Training Course

41. 2 minutes • Patient should take off his shoes and socks • Should inspect his shoes • Watch the patient as he walks • Please turn • Get up from a chair • Stand on one leg Resnick, Vinik et al. Muscle and Nerve, 2001 Mansoura DF 2nd International Training Course

42. Risk categorization system Mansoura DF 2nd International Training Course

43. Thank you Mansoura DF 2nd International Training Course