What is happening and how to treat it Helen Moakes Specialist Diabetes Podiatrist

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!

 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

 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

 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

 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

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

 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

 When undertaking the diabetes foot assessment, look at:  Foot shape  Deformity  Footwear  Smoking  Glucose control  Callosities  Risk status – NICE guidelines and QOF

 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

 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

 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

 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

 Less common  Fragile  Life expectancy reduced  Often painful  Poor healing  Protection essential to prevent injury/trauma  Podiatry care  Swift referral

Don’t leave it! Find out your nearest hospital Foot Clinic contact details

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

 Blisters  Callus with tissue breakdown underneath  Ingrowing toenail  Accidental trauma – stubbing toe, cuts/grazes  ANYTHING INFECTED

 Process affecting the bony structure of the feet  Rare but under- diagnosed  Affects neuropaths with good blood supply  Diagnosis difficult – differentials?

 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...

 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

 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

 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

Any Questions?