1. In the Name of ALLAH, Ever Beneficent, Infinitely Merciful

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

3. Foot Care

4. 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.

5. Number of people with diabetes (20-79 years), 2010 and 20305

6. 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 Ninety per cent or more of cases of diabetes will be the type 2 form of the disease.
International Diabetes Federation.
IDF atlas 4th edition 2009 6

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

8. 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

9. 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

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

11. 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

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

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

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

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

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

17. 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.

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

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

20. 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)

21. 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

22. INSPECTIION

23. INSPECTIION CALLOSITY ABSCESS CELLULITIS VESICLE SWELLING GANGRENE
NAIL DEFORMITY

24. INSPECTIION

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

27. 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

28. 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

29. 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.

30. Thermal Sensation
Heat & cold perception
Noted as
Present
absent

31. 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

32. 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

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

35. VASCULAR ASSESSMENT TEMPERATURE PALPATION OF PERIPHRAL PULSES ABI
ANGIOGRAPHY

36. 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

37. 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

38. Ankle Brachial Pressure Index
ABI is usually between 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 .

39. 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

40. Thank You