Diabetic Foot Exam By Patrick A. DeHeer, DPM Hoosier Foot & Ankle.
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Transcript of Diabetic Foot Exam By Patrick A. DeHeer, DPM Hoosier Foot & Ankle.
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Diabetic Foot ExamBy Patrick A. DeHeer, DPM
Hoosier Foot & Ankle
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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…”
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Global Projections for the Number of People With Diabetes for 2010 and 2030
AT A GLANCE2010 2030
Total world population (billions) 7.0 8.4
Adult population (20-79 years, billions) 4.3 5.6
DIABETES AND IGT (20-79 years)
Diabetes
Global prevalence (%) 6.6 7.8
Comparative prevalence (%) 6.4 7.7
Number of people with diabetes (millions) 285 438
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.
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Presence of a DFU for 30 days or longer carries
an 8-Fold risk for infection. – Lavery 2006
24% of all DFU cases require inpatient care -Harrington et al.
2000
Patients who develop a foot infection have a 55.7 times greater risk of hospitalization that those who do not. –Lavery 2006
$72,775 – Cost of a leg amputation/ per amputation
procedure- Bureau of Labor Statistics, 2010
$20,300 – DFU inpatient cost per episode,
Harrington et al. 2000
The Hard Facts
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Costs to Treat a Diabetic Foot Ulcer Over a 2-Year Period Following Detection
$27,987
$33,046
$40,786
$48,156
0
10,000
20,000
30,000
40,000
50,000
60,000
1995 2000 2005 2010
Co
st in
US
Do
llars
Cost analyses based on percent change in the medical component of the US consumer price index.Ramsey et al. Diabetes Care. 1999;22:382.
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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.
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Tragic “Rule of 50”50% of amputations - Transfemoral/Transtibial level
50% of patients - 2nd amputation in 5 years
50% of patients - Die in 5 yearsClinical Care of the Diabetic Foot, 2005
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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
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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
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Patient Ulcer Risk
Risk LevelFoot Ulcer %/yr
% Office Patients
(diabetes clinics)
3: Prior amputationPrior ulcer
28.1%18.6% 7%
2: Insensate andfoot deformity orabsent pedalpulses
6.3% 10%
1: Insensate 4.8% 17%-30%0: All normal 1.7% 66%
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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
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Neurological Exam Deep Tendon Reflexes –
Patellar Achilles
Clonus Babinski Vibratory Sharp/Dull Loss of protective sensation – 5.07/10 g Semmes-Weinstein
monofilament wire
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Neurological Exam
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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 ulcersJ Fam Pract. 2000;49:S30Diabetes Care. 1992;15:1386
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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
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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):S25Diabetes Res Clin Pract. 2005;70:8
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Motor Neuropathy and Foot Deformities Hammer toes
Claw toes
Prominent metatarsal heads
Hallux valgus
Collapsed plantar arch
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Motor Neuropathy and Foot Deformities
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Motor Neuropathy and Foot Deformities - Diabetic Charcot Arthropathy
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Pre-Ulcer Cutaneous Pathology Persistent erythema after
shoe removal Callus Callus with subcutaneous
hemorrhage Fissure Interdigital maceration,
fungal infection Nail pathology
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Pre-Ulcer Cutaneous Pathology
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Pre-Ulcer Cutaneous Pathology
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Grant et al JFAS1997
Equinus and the Diabetic Patient
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
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Grant et al JFAS1997
Equinus and the Diabetic Patient
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
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Equinus and the Diabetic Patient
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
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P = 0.007 P = 0.0001
Lavery, Armstrong, Boulton Study JAPMA 2002
DM +
Equ
inus
DM -
Equinu
s0
40
80
120
Mean PP N/cm²
DM +
Equ
inus
Dm -
Equinu
s0
30
60
Risk for elevated PPP %
Risk for elevated PPP %
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Lavery, Armstrong, Boulton Study JAPMA 2002No statistical
significant difference –Weight Sex differenceAbsence or presence
of neuopathy
Statistical significant difference –Equinus patients had
longer duration of diabetes
Equinus prevalence in this population = 10.3%
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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.”
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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
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
Diabet Med. 2005;22:1310Diabetes Care. 2003;26:3333
Arch Intern Med. 1998;158:1357Diabetes Care. 2003;26:3333
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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
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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
InterpretationABI
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
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Low Risk High Risk
Foot Care Based on Risk Factors
Annual comprehensive foot examination Questionnaire completed by
patient Examination
Self-management and footwear education Brief counseling Written handout
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
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High Risk: Nursing Tasks High Risk: Patient Education
Foot Care Based on Risk Factors
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
Reinforce frequently – low retention
Patient demonstrates self-care knowledge
Evidence: May reduce foot
ulcer/amputation rates
J Gen Intern Med. 2003;18:258
Cochrane Database Syst Rev. 2005 Jan 25;(1)CD001488
Foot Ankle Int. 2005;26:38
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High Risk: Podiatry Care Basic Foot Care Concepts
Diabetic Foot Care
Provide nail and skin care Assess footwear needs Visit frequency not
evidence-based Equinus management
Daily foot inspection May require mirror,
magnification, or caregiver Patient able to
recognize/report: Persistent erythema Enlarging callus Pre-ulcer (callus with
hemorrhage)
Diabetes Care. 2003;26:1691J Fam Practice. 2000;49(Suppl):S30
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Basic Foot Care ConceptsBasic Foot Protective Behaviors
Diabetic Foot Care
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
Avoid temperature extremes No walking barefoot/stocking-
footed Appropriate exercise for
insensate feet Inspect shoes for foreign
objects Optimal footwear at all times
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Avoid: Favor:
Basic Footwear Education
Pointed toes Slip-ons Open toes High heels Plastic Black color Too small
Broad-round toes Adjustable (laces, buckles,
Velcro) Athletic shoes, walking shoes Leather, canvas White/light colors ½” between longest toe and
end of shoe
Diabetes Self-Management. 2005;22:33
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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
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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.
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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%
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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.
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Thank You!!!!Any Question??? Patrick A. DeHeer, DPM Hoosier Foot & Ankle 317-346-7722 Hoosierfootandankle.com