You can help avoid foot problems. First, control your blood sugar levels. Good foot hygiene is also crucial:. Diabetic Foot. On this page Basics Summary Start Here. See, Play and Learn Images. Research Clinical Trials Journal Articles. Resources Find an Expert. For You Patient Handouts. Due to the peripheral nerve dysfunction associated with diabetes diabetic neuropathy , patients have a reduced ability to feel pain.
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This means that minor injuries may remain undiscovered for a long while. People with diabetes are also at risk of developing a diabetic foot ulcer. In diabetes, peripheral nerve dysfunction can be combined with peripheral artery disease PAD causing poor blood circulation to the extremities diabetic angiopathy.
Screening and management of The Diabetic Foot - BPJ Issue 31 October
Around half of patients with a diabetic foot ulcer have co-existing PAD. Where wounds take a long time to heal, infection may set in and lower limb amputation may be necessary. Foot infection is the most common cause of non-traumatic amputation in people with diabetes.
Prevention of diabetic foot may include optimising metabolic control via the regulation of blood glucose levels; identification and screening of people at high risk for diabetic foot ulceration; and patient education in order to promote foot self-examination and foot care knowledge. Patients would be taught routinely to inspect their feet for hyperkeratosis , fungal infection , skin lesions and foot deformities. Control of footwear is also important as repeated trauma from tight shoes can be a triggering factor,  especially where peripheral neuropathy is present.
There is however only limited evidence that patient education has a long-term impact as a preventative measure. Treatment of diabetic foot can be challenging and prolonged; it may include orthopaedic appliances, antimicrobial drugs and topical dressings. Most diabetic foot infections DFIs require treatment with systemic antibiotics.
The development of peripheral vascular disease and neuropathy, leading to foot complications, may be able to be avoided or delayed with optimal management of diabetes and cardiovascular risk factors. This includes:. The three main aspects of foot care education have been identified as foot hygiene, awareness of fungal infections and appropriate actions required for skin injuries.
The following points can be discussed with patients in regards to the care of their feet: 4. Organisations such as Diabetes New Zealand have websites with downloadable patient information and resources that can be helpful to reinforce advice: www. Due to limited mobility or visual impairment, many people will be unable to adequately inspect and care for their feet. Discuss methods to help self-examination such as the use of a mirror or the possibility of a family member or carer being involved in regular foot care.
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One of the most important aspects of preventing diabetic foot complications is wearing appropriate footwear. Patients should be advised to always wear well-fitting, cushioned footwear including slippers to protect their feet from injuries. Loose-fitting or open-toed footwear such as gumboots, jandals or sandals, and going barefoot should be avoided. Patients especially those at high risk can be custom-fitted with specialised shoes and orthoses insoles by a podiatrist.
Specialised shoes for people with diabetes are usually made with extra depth and room to accommodate foot deformities and orthoses. They have increased cushioning and reduce the pressure on certain parts of the foot, therefore reducing the potential for ulcers to occur. There is a lack of evidence of the superiority of custom-made therapeutic footwear to off-the-shelf varieties in reducing the occurrence of ulcers.
Orthoses specially made insoles can provide cushioning and redistribution of pressure loading. They may be worn in specially designed or regular shoes. Padded hosiery may protect the feet, reduce plantar pressure and reduce calluses. Community diabetes specialist podiatrists hold contracts with their DHBs in most regions around New Zealand and undertake primary care podiatry screening, assessment and treatment for the management of diabetic foot complications.
Secondary care hospital-based podiatrists are employed in most hospitals and can receive referrals for the acute management of diabetes-related complications. Contact your local DHB for details of funding for these services and referral criteria. In many areas, people with diabetes related foot complications are able to access fully-funded podiatry services including supply of customised therapeutic footwear and orthoses. Follow us on facebook.
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Login to my bpac. Remember me. Key concepts Foot ulceration and damage is a common complication of diabetes Feet should be checked at least once per year in every person with diabetes and more regularly in those who are at higher risk of developing foot complications Educate about foot care, appropriate foot wear and foot hygiene at every opportunity Refer to, or consult with, a podiatrist, diabetologist or vascular specialist if foot complications develop or if there are any concerns.
Performing a foot check Examine the foot to identify deformity e. Assess the skin status i. Check if the foot is fixed or flexible by asking the patient to stand and observe whether the toes straighten.
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Assess how well the patient cares for their feet by checking for cleanliness and trimmed nails. Examine carefully between the toes for tinea pedis. Check whether the patient can both reach and see their feet. Ask the patient if they experience numbness or pain, including what type of pain e. Ask about the normal temperature of the foot. Assess for neuropathy using a 10 g monofilament see below. A vibration test, using a Hz tuning fork or a biothesiometer may also be performed.
Assess peripheral circulation with thorough palpation of pedal pulses dorsalis pedis and posterior tibial. If there are no palpable pulses, and if a Doppler machine is available, calculate ankle brachial index see below or consider referral to a vascular specialist see sidebar. Absent pulses, calf claudication, absence of hair on the feet, altered temperature a cold foot and thin, bluish skin are suggestive of peripheral arterial disease.
Calculating ankle brachial index 7 Equipment : Blood pressure cuff and hand-held Doppler machine Take the blood pressure in the arm brachial pressure Take the blood pressure in the ankle using the Doppler machine ankle pressure Calculate ankle brachial index by dividing systolic ankle pressure by systolic brachial pressure e. Performing a test using a monofilament 3 A test using a 10 g monofilament is the recommended method for assessing for neuropathy of the foot. Place the filament on one of the designated sites on the foot Figure 1 , press it against the skin until the patient indicates they can feel it, or a C shape is formed, and then lift it off.
This should take approximately three seconds. Repeat this sequence at each of the designated sites on the feet and record findings Repeat again in the areas in which the patient did not indicate feeling the monofilament If evidence of neuropathy is detected, further assessment is required Tips: Avoid tapping the filament against the skin or using rapid movements Choose the sites on the foot at random and try not to test sites in a predictable pattern that will allow the patient to anticipate when and where the monofilament is likely to be positioned next Do not apply the filament directly on an ulcer, callous, scar or necrotic tissue.
Apply the filament on near-by normal tissue. The filament should be cleaned after use with an alcohol swab or dilute bleach solution and returned to its case Filaments should not be used for more than ten patients in 24 hours, as they may buckle Figure 1 : Monofilament bent to form a C shape. Treatment of ulcers Clean, debride and dress the wound The wound may be cleaned, e. Osteomyelitis Osteomyelitis is common in infected diabetic foot ulcers.
Treatment of painful neuropathy Pain associated with neuropathy is a common feature of diabetic foot complications. After beginning any medicine or medicine regimen for treating neuropathic pain, the following aspects should be regularly reviewed: 12 Pain control Adverse effects Mood Daily functioning Sleep patterns Consider dose adjustment or adding or substituting another medicine if optimum control of these factors is not being achieved. First-line pain management Paracetamol may be trialled as first-line management for neuropathic pain and may be continued throughout any regimen.
Second-line pain management If paracetamol alone is not adequate for controlling pain, a tricyclic antidepressant TCA may be added to the regimen or paracetamol substituted for a TCA. Avoid propping feet up with a pillow during a foot examination or treatment. Encourage the use of slippers or socks to protect feet when inside, if outdoor shoes are considered unacceptable. Preventing diabetic foot complications The two main factors in preventing diabetic foot complications are: Maintaining optimal control of risk factors Educating about appropriate care of the feet Optimal control of risk factors The development of peripheral vascular disease and neuropathy, leading to foot complications, may be able to be avoided or delayed with optimal management of diabetes and cardiovascular risk factors.
Educating about foot care The three main aspects of foot care education have been identified as foot hygiene, awareness of fungal infections and appropriate actions required for skin injuries. Selecting appropriate footwear One of the most important aspects of preventing diabetic foot complications is wearing appropriate footwear. Referral criteria for podiatry services Community diabetes specialist podiatrists hold contracts with their DHBs in most regions around New Zealand and undertake primary care podiatry screening, assessment and treatment for the management of diabetic foot complications.
Did you know there is an audit related to this topic? See "Following up people with diabetes" , bpac nz References Ministry of Health. Diabetes Surveillance: Population-based estimates and projections for New Zealand, Wellington: Ministry of Health, Available from: www.
Ministry of Health. Management of type 2 diabetes. Wellington: NZGG,