In the Name of ALLAH, Ever Beneficent, Infinitely Merciful

Dr Muhammad Farhatullah Khan M.B.B.S, DDM INCHARGE FOOT CLINIC AND PEDOGRAPH DEPTT BAQAI INSTITUTE OF DIABETOLOGY AND ENDOCRINOLOGY

Foot Care

INTRODUCTION Diabetes mellitus is a syndrome characterized by hyperglycemia due to Absolute insulin deficiency - Type 1 DM Relative insulin deficiency – Type 2 DM One of leading causes of increased morbidity & mortality worldwide.

Number of people with diabetes (20-79 years), 2010 and 2030 5

Global diabetes epidemic (20-79 years) Estimated number of people with diabetes worldwide (millions) Year 30 150 285 438 50 100 200 250 300 350 400 1980 1990 2000 2010 2020 2030 450 Global diabetes epidemic We face a global epidemic of type 2 diabetes in the coming decades. The latest projection of the prevalence of diabetes from the International Diabetes Federation (IDF) is shown here. The number of people worldwide who have diabetes will increase from 194 million to 385 million by 2025. Ninety per cent or more of cases of diabetes will be the type 2 form of the disease. International Diabetes Federation. http://www.idf.org IDF atlas 4th edition 2009 6

So, there is urgent need for strategies to be implemented to prevent the emerging global epidemic of diabetes ( mainly T2DM)

Complications of Diabetes Macrovascular Microvascular Brain Cerebrovascular disease Transient ischemic attack Cerebrovascular accident Cognitive impairment Eye Retinopathy Cataracts Glaucoma Kidney Nephropathy Microalbuminuria Gross albuminuria Kidney failure Heart Coronary artery disease Coronary syndrome Myocardial infarction Congestive heart failure Extremities Peripheral vascular disease Ulceration Gangrene Amputation Nerves Neuropathy Peripheral Autonomic

Incidence of Diabetic Foot Ulcer Annual incidence ranges between1.0 to 2.0%1 Prevalence of foot ulcer is reported between 5.3 to 10.5%1 Life time risk diabetic foot ulcer is 25%1 85% of amputation in diabetic are preceded by foot ulcer Local prevelance is 10% at BIDE ,276000 1 Boulton et al..Comprehensive Foot Examination and Risk Assessment.Diabetes Care.August 2008

Who will develop foot ulcer/amputation Age between 45-64 More male than female Long duration of diabetes Neuropathy Peripheral vascular disease

Who will develop foot ulcer/amputation Smoking Elevated level of HbA1c Prior history of ulcer/amputation Structural foot abnormalities, hammer toes, claw toes Foot with dry and cracked skin Tight shoes, pointed toes

Precipitating Events Trauma Improper Foot Wear Blisters Fissures Puncture Wounds Thermal Injury Infection Vascular Event

Types of diabetic leisons Ulcer Cellulitis Corn Callus Abscess Gangrene Nail disorder Foot edema

MOST COMMON TRIAD OF CAUSES1 NEUROPATHY DEFORMITY TRAUMA 1 Boulton et al..Comprehensive Foot Examination and Risk Assessment.Diabetes Care.August 2008

Site of ulcers S.M.Ali et.al, Diabetic Foot Ulcer- a Prospective Study, 2001: 51(2); 78-81

Types of ulcers Accepted as a “Poster Display” Presentation for the 18th IDF Congress to be held in Paris, France.

Why We Do Foot Assessments? To Prevent foot ulcers with associated risk of lower leg amputation To have Early intervention for foot problems. To Improve wound outcomes. To Reduce severity of complications. To Improve quality of life.

ASSESSMENT OF DIABETIC FOOT HISTORY OF PATIENT CLINICAL EXAMINATION INPECTION PALPATION SENSORY EXAMINATION VASCULAR EXAMINATION

ESSENTIAL FEATURES HX PAST HISTORY ULCERATION AMPUTATION CHARCOT JOINT VASCULAR SURGERY ANGIOPLASTY CIGARETTE SMOKING

ESSENTIAL FEATURES HX NEUROPATHIC SYMPTOMS Positive (e.g. burning and shooting, pain, electrical or Sharp sensation etc) Negative (e.g. numbness, feet, feel dead) Vascular System Claudication Rest Pain nonhealing ulcer Other Diabetic Complications renal (dialysis, transplant) retinal (visual impairment)

INSPECTIION Shape of the foot Skin color, thickness, dryness, cracking, sweating, pigmentation Foot deformity, claw toes, prominent metatarsal head, charcot joint, Muscle wasting Ulcer Callus

INSPECTIION

INSPECTIION CALLOSITY ABSCESS CELLULITIS VESICLE SWELLING GANGRENE NAIL DEFORMITY

INSPECTIION

PALPATION FEEL CONTOUR OF FOOT TEMPERATURE (DORSUM OF HAND) SENSORY/MOTOR SYSTEM VASCULAR ASSESSMENT EXAMINATION OF LEISON,ULCER,ABSCESS,CELLULITIS

SENSORY NEUROPATHY Burning, pin and needle, numbness of the foot and nocturnal leg pain indicate cutaneous sensory neuropathy 35% of patients who are asymptomatic,are found to have neuropathy on examination Primary cause of unrecognised injury

SENSORY NEUROPATHY To identify LOPS For pain,pin prick with common pin For temperature For touch,cotton, monofilament For vibration,tunning fork,neurothesiom Propioception,sense of position of joint which affect gait and stability,cause of freq fall

Using the Monofilament Place monofilament perpendicular to test site Bow into C-shape for 1 second Test 3 sites/foot Identify 90% of neuropathic foot Test with the monofilament using the following protocol: Place the patient in the supine position with shoes and socks removed. Demonstrate sensation of the filament on the patient’s forearm or hand, bowing the monofilament into a C-shape for one second. Ask the patient to close their eyes. Proceed to bow the monofilament into a C-shape for one second at each of four test sites on the plantar surface of each foot: the plantar surface of the distal phalanx of the great toe and the plantar surfaces of the 1st, 3rd, and 5th metatarsal heads. In one study testing these four sites as compared to eight sites still detected 95% of ulcer formers; in particular, heel testing does not discriminate ulcer formers. Avoid testing calluses, scars, or ulcers; if these lesions are present, test at adjacent sites on the plantar surface of the foot.

Thermal Sensation Heat & cold perception Noted as Present absent

Neurothesiometer A biothesiometer is a portable device that measures the vibration perception threshold. A vibration threshold of more than 25V has a sensitivity of 83%. Either an abnormal 10g monofilament test or vibration threshold of more than 25v predicts foot ulceration with a sensitivity of 100% hence the rationale for combining these two tests in clinical practice

MOTOR NEUROPATHY ATROPHY OF INTRINSIC MUSCLES INCREASED PRESSURE TO METATARSAL HEADS AND TOES CALLUS FORMATION AND ULCERATION DIAGNOSIS: ABSENT ANKLE REFLEX S1-2 Ankle L3-4 Knee

AUTOMATIC NEUROPATHY DRY AND FISSURED SKIN DUE DYSHYROSIS A.V SHUNTING AND ALTERED PERFUSION DIAGNOSIS: POSTURAL HYPOTENTION,LOSS OF VARIATION IN RR INTERVAL

VASCULAR ASSESSMENT TEMPERATURE PALPATION OF PERIPHRAL PULSES ABI ANGIOGRAPHY

Peripheral Vascular Disease (PVD) History : claudication (calf pain after walking a specific distance) that is relieved by rest. However this is uncommon in people with diabetes due the concomitant neuropathy. Examination: Palpate the foot for temperature (cool in PVD); palpate the dorsalis pedis pulse and, if absent, the posterior tibial pulse, than popliteal and femoral Palpation of the dorsalis pedis pulse Palpation of the posterior tibial pulse

Investigations: ankle brachial pressure index Measure the blood pressure (BP) in the arm using a sphygmanometer Measure the blood pressure in the foot. Place a BP cuff around the calf and detect the dorsalis pedis pulse using a small hand-held doppler. Inflate the cuff and slowly deflate until the pulse appears. The ankle brachial pressure index (ABPI) is the ratio of the ankle systolic pressure to brachial systolic pressure. Doppler being used to detect the dorsalis pedis pulse

Ankle Brachial Pressure Index ABI is usually between 0.9 -1.3. value <0.9 ischemia,value above 1.3 calcification. Normal ABI effectively excludes significant arterial disease in >90% of limbs. Absence of pulses and an ABI of <0.9 confirms significant ischaemia. An exception is in artery calcification, in which the ABPI can be falsely elevated due to the simultaneously lower blood pressure (BP) in the limb .

Management General measures To have good glycaemic control To Address cardiovascular risk factors such as smoking, dyslipidaemia and hypertension so that risks of PVD, acute coronary syndrome and chronic renal failure can be minimised Education of patients on proper foot care and on the importance of seeking medical advice early is very important

Thank You