Assessment of the diabetic foot; how I assess Dr. Nalaka Gunawansa 08.07.2015

Why perform a foot assessment? Identify “the foot at risk” Prevention of: foot ulceration gangrene amputation Assist in the maintenance of: Mobility Independence Healthy active lifestyle DPMI Workforce Development – The Alfred Workforce Development Team June 2005

DIABETIC FOOT ASSESSMENT COMPLETE HISTORY MUSCULO-SKELETAL ASSESSMENT - deformities NEUROLOGICAL ASSESSMENT VASCULAR ASSESMENT – pedal pulses DERMATOLOGICAL ASSESSMENT – tissues, callus, ulcers, necrosis etc. INVESTIGATION – IMAGING, MICROBIOLOGICAL etc.

COMPLETE HISTORY Duration of diabetes, type of treatment, Quality of glycaemic control Other diabetes complications : Renal / visual impairment, hypertension, Ischaemic heart disease, strokes Wound history Functional impact of the wound Previous foot ulceration/amputation Neuropathic symptoms Vascular symptoms Social history & support

1. THE MUSCULO-SKELETAL ASSESSMENT Claw toes, hammertoe, Pes Cavus rocker bottom foot, Hallux Rigidus bunions and Charcot changes

2. NEUROLOGICAL ASSESSMENT Pain –Pin Prick Sensation Pressure -10g Monofilaments Vibration --128Hz Tuning Fork Ankle Reflexes

NEUROLOGICAL ASSESSMENT Designed to identify loss of protective sensation (LOPS) rather than early neuropathy. Loss of sensation to the 10-g monofilament was associated with a 10-fold risk of foot ulceration and a 17-fold risk of amputation over a 32-month follow-up period MONOFILAMENTS At 6 sites on the sole in each foot, avoiding callus perpendicular to the skin pressure applied until the Monofilament buckles. It should be held in place for <1 s and then released.

3. VASCULAR ASSESSMENT Absence / weak pulse mottling, dusky colour cold foot, shiny thin dry skin, atrophic nails, loss of hair on lower limbs

VASCULAR ASSESSMENT Taking temperature of the foot Palpate for pulses Check the ABPI : Normal 0.9 -1.2 Risk of foot ulcer is small Definite vascular disease 0.6 -0.9 Risk of ulcer is moderate and depends on other risk factors Severe vascular disease < 0.6 High risk of developing foot ulcer Check the ToeBrachial Index <0.5 - Peripheral V Dis Transcutaneous O2 tension Duplex Scan

4. DERMATOLOGICAL ASSESSMENT Callus / ulcers Location & dimensions Look for sinus track, evidence of osteomyelitis and abscess Assess the ulcer base : Black : necrotic / Yellow : slough Pink : granulation tissue Take note of slough, necrotic/gangrene tissue, dry exposed tendons/ligaments/fascia/joint capsule

STAGES OF ULCER DEVELOPMENT

 Assess depth of ulcer - probe - radiograph

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EXAMINE THE ULCER Check for evidence of infection : Redness, swelling discharge/pus Culture and Sensitivity : Ulcer swab – of limited value Tissue – deep tissue biopsy Bone fragments Pus – after drainage of abscess

Interpreting Results

LABORATORY ASSESSMENT PEDOGRAPHY Pedographyis a dynamic measurement tool for the early recognition of the altered pressure patterns in the foot of diabetic patient Patient walks barefoot across a platform with thousands of calibrated pressure sensors, each sensor will scan up to 400 times/sec and data is transmitted to the computer for analysis

GAIT ANALYSIS –SEE HOW THE PATIENT WALKS Three dimensional analysis : > Comprehensive, Multisegment models Detect imbalances which may be contributing towards the foot problems

WAGNER CLASSIFICATION The most widely recognized classification is the Wagner system, which grades ulcers from 0 to 5 based largely on ulcer depth and severity Although easy to remember, this system fails to address critical parameters like foot ischaemia, peripheral neuropathy, ulcer dimensions

DIABETIC FOOT ASSESSMENT COMPLETE HISTORY MUSCULO-SKELETAL ASSESSMENT - deformities NEUROLOGICAL ASSESSMENT VASCULAR ASSESMENT – pedal pulses DERMATOLOGICAL ASSESSMENT – tissues, callus, ulcers, necrosis etc. INVESTIGATION – IMAGING, MICROBIOLOGICAL etc.