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Five cornerstones of the management of the diabetic foot
Five cornerstones of the management of the diabetic foot
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
Foot examination
1. Nails2. Foot deformity3. Skin condition4. Vascular assessment5. Neurological assessment
Foot examination
1. Nails Thick Too long Ingrown Fungal infection Wrongly cut nails
Foot Examination 2. Foot deformity: Toe deformity Hammer toeHammer toe Claw toeClaw toe
Forefoot deformity Hallux valgusHallux valgus Hallux rigidusHallux rigidus
Wholefoot Deformities Pes Cavus - High arched foot Pes Planus - Flat foot Charcot foot
Foot Examination
3.Skin condition:
Callus Bunions Redness Warmth Fissure Dryness Swelling Maceration Fugal infection
Foot Examination
4.Vascular assessment5.Neurological assessment
10/5/2008 Mansoura DF 2nd International Training Course
Does your patient have neuropathy?
Manal TarshobyAssistant Professor of Medicine Diabetes and Endocrinology unit Diabetic Foot TeamMansoura University EGYPT
Clinical Assessment History:
Review diabetes history, managementReview diabetes history, management Daily glycemic records, previous A1cDaily glycemic records, previous A1c Review medical historyReview medical history Review other causes of neuropathy Review other causes of neuropathy
(10%)(10%) 50% has no symptoms50% has no symptoms
Mansoura DF 2nd International Training Course 10/5/2008
History Michigan neuropathy screening questionnaire
Are your feet numbBurning painFeet sensitive to touchMuscle crampCan you tell hot from
cold waterHave you had an ulcerDr diagnosed neuropathyDo you feel weak
Symptom worse at nightLegs hurt when you walkPrickling feelingAble to sense feet when
walkingBed covers hurt your skin Your skin crack openUnsteadinessPrevious amputation
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Feldman, Diabetes care,199410/5/2008
Paradox ?
Mansoura DF 2nd International Training Course
Mansoura DF 2nd International Training Course 10/5/2008
Painful-Painless LegOne doesn’t need to have intact sensation to
experience pain.
Mansoura DF 2nd International Training Course
Physical ExaminationInspectionVibration sense Tuning fork 128Reduced protective sensation such as
pressure, hot and cold, painSharp, dull, light touchMotor strengthDiminished ability to sense position of toes
and feetDeep tendon reflex
Mansoura DF 2nd International Training Course 10/5/2008
InspectionMuscle atrophy
Intrinsic minus foot
Dry skin
Mansoura DF 2nd International Training Course 10/5/2008
Neurologic assessment
Mansoura DF 2nd International Training Course 10/5/2008
Physical Examination Inspection
Vibration sense Tuning fork 128neurothesiometer
Mansoura DF 2nd International Training Course 10/5/2008
Vibration Sense
Tuning fork is held against a bony prominence:• Medial aspect 1st MTP Joint• Plantar Hallux• Med/Lat MalleolusPatients should be reminded that it is the vibration they are required to detect not the sound.
Mansoura DF 2nd International Training Course 10/5/2008
10/5/2008 Mansoura DF 2nd International Training Course
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 voltsMansoura DF 2nd International Training Course 10/5/2008
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 10/5/2008
NEUROTHESIOMETER
Foot ulcer risk increased by 5.6% per volt Abott, Diabetes care, 1998
Mansoura DF 2nd International Training Course 10/5/2008
Physical Examination Inspection Vibration sense
Reduced protective sensation pressure hot and cold pain
Mansoura DF 2nd International Training Course 10/5/2008
TEMPERATURE TESTING
• Two test tubes, hot/cold.• Therm-tip• Subjective, crude tests
Mansoura DF 2nd International Training Course 10/5/2008
MONOFILAMENTS
Which monofilament ?
•10 mg, 1mg•Calibrated
Mansoura DF 2nd International Training Course 10/5/2008
MONOFILAMENTS
Mansoura DF 2nd International Training Course
HOW TO USE IT?
How many sites to be tested?10/5/2008
Mansoura DF 2nd International Training Course 10/5/2008
MONOFILAMENTS
Mansoura DF 2nd International Training Course
How many lost sites to diagnose LOPS
410/5/2008
1
Monofilament Failure
Variability within and between brandsRequire frequent replacementShould be calibratedGive-away devices are of uncertain
quality ,durabilityRepetitive loading?
Mansoura DF 2nd International Training Course 10/5/2008
SUPERFICIAL PAIN TEST
• Neuro - tip• Areas tested• Patient response• Significance
Mansoura DF 2nd International Training Course 10/5/2008
Physical Examination Inspection Vibration sense Reduced protective sensation
Sharp, dull, light touch
Mansoura DF 2nd International Training Course 10/5/2008
LIGHT TOUCH TEST
Wisp of cotton wool Subjective Can be painful if neuropathy
exists
Mansoura DF 2nd International Training Course 10/5/2008
Mansoura DF 2nd International Training Course 10/5/2008
Physical Examination Inspection Vibration sense Reduced protective sensation Sharp, dull, light touch
Motor strength
Mansoura DF 2nd International Training Course 10/5/2008
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 10/5/2008
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 10/5/2008
Deep tendon reflex
Mansoura DF 2nd International Training Course 10/5/2008
Neuro Disability score3 sensory modality
VibrationPin prick (neurotip)Hot-cold rodScoredNormal=0Abnormal=1
Ankle reflex
ScoredNormal=0Reinforcement=1Absent=2
Mansoura DF 2nd International Training Course
Max total 5 for each legTotal out of 10
10/5/2008
2 minutesPatient should take off his shoes and socksShould inspect his shoes Watch the patient as he walksPlease turnGet up from a chairStand on one leg
10/5/2008 Mansoura DF 2nd International Training Course
Resnick, Vinik et al. Muscle and Nerve, 2001
Risk categorization system categor
yRisk profile Check up
frequency
0 no sensory neuropathy
Once a year
1 sensory neuropathy Once every 6 months
2sensory neuropathy and signs of peripheral vascular disease
and/or foot deformities..Once every 3
months
3 previous ulcer Once every 1-3 months
Mansoura DF 2nd International Training Course 10/5/2008
Thank you
10/5/2008 Mansoura DF 2nd International Training Course