Practical Guidelines for the Management of the Diabetic Foot Gerda van Rensburg PODIATRIST Area 556 Johannesburg Hospital

Practical Guidelines for the Management of the Diabetic Foot Standardise the assessment and management of the diabetic foot. To increase awareness at all levels of care. Set up a diabetic foot referral pathway

Pathophysiology Two or more risk factors present Peripheral neuropathy plays a central role Peripheral vascular disease may result in painful ischemic foot Neuro-ischemic foot symptoms may be absent despite severe peripheral ischemia Infection complicates situation Pathophysiology Two or more risk factors present Peripheral neuropathy plays a central role

Pathophysiology Two or more risk factors present Peripheral neuropathy plays a central role Peripheral vascular disease may result in painful ischemic foot Neuro-ischemic foot symptoms may be absent despite severe peripheral ischemia Infection complicates situation Pathophysiology Peripheral vascular disease may result in painful ischemic foot

Pathophysiology Two or more risk factors present Peripheral neuropathy plays a central role Peripheral vascular disease may result in painful ischemic foot Neuro-ischemic foot symptoms may be absent despite severe peripheral ischemia Infection complicates situation Pathophysiology Neuro-ischemic foot symptoms may be absent despite severe peripheral ischemia

Pathophysiology Two or more risk factors present Peripheral neuropathy plays a central role Peripheral vascular disease may result in painful ischemic foot Neuro-ischemic foot symptoms may be absent despite severe peripheral ischemia Infection complicates situation Pathophysiology Infection complicates situation

Five Cornerstones of the Management of the Diabetic Foot Regular inspection and examination of the foot at risk Identification of the foot at risk Education of patient, family and healthcare providers Appropriate footwear Treatment of non-ulcerative pathology

Regular Inspection and Examination HistoryPrevious ulcer/amputation Previous foot education Social isolation Poor access to healthcare Barefoot walking

Regular Inspection and Examination NeuropathySymptoms: pain, tingling Loss of sensation

Testing for Neuropathy

Vascular Status Claudication Rest pain Pedal pulses Rubor on dependency

Regular inspection and Examination SkinColour, Temperature, Oedema Nail pathologyWrongly cut nails Ingrown nails Infection

Regular inspection and Examination Bone / jointDeformities Bony prominence Loss of mobility

Risk Areas

Regular inspection and Examination Footwear Stockings

Identification of the foot at risk Each patient to be assigned to a risk category Presence of one or more risk factors = HIGH RISK Sensory neuropathyIschemia Foot deformityCallus History of ulceration/amputation

Education of patient, family and HCP

Appropriate footwear

Treatment of non ulcerative pathology High risk patient: callus, nail, skin pathology should be treated regularly Treatment by a trained foot care specialist

Ulcer treatment Relief of pressure Restoration of skin perfusion Treatment of infection Metabolic control and treatment of co- morbidity Local wound care Instruction of patient and relatives Determining the cause and preventing recurrence

Illustration of ulcer due to repetitive stress

Pressure Relief

Restoration of skin perfusion

Treatment of infection Superficial with extensive cellulitis Deep limb- threatening infection

Metabolic control and treatment of co-morbidity Blood glucose < 10mmol/l Treat oedema Treat malnutrition

Local wound care

Instruction of patient and relatives Determining the cause and preventing recurrence