1 Louise Maye Podiatrist Podiatry and Footcare Services Greater Newcastle Cluster Care of the diabetic foot A podiatrist’s perspective.

1

Louise Maye

PodiatristPodiatry and Footcare Services

Greater Newcastle Cluster

Care of the diabetic foot

A podiatrist’s perspective

Diabetes & Feet

“Diabetic foot complications are the single most common cause of non-traumatic lower limb amputations in the industrialised world”

Armstrong D, Lavery L & Harkless L (1998) Who is at risk for diabetic foot ulceration? Clinics in Podiatric Medicine and Surgery, 15 pp

11-19

Foot problems are the most common reason for hospital admissions for people with diabetes and approximately 50% of all amputations are attributable to diabetesNational Report to Health Ministers on Diabetes 1998 p124 and ABS 1997

Diabetes & Feet

It has been suggested that as many as 75% of amputations due to diabetes could be prevented by appropriate foot care

Larsson J, Apelqvist J, Agardh C & Stenstrom A (1995) Decreasing the incidence of major amputation in diabetic patients: a

consequence of multi-disciplinary foot care team approach? Diabetic Medicine 12, 770

• Most foot problems are preventable when:

they are identified early

they are treated appropriately

people are educated to avoid these problems

Role of the Podiatrist in Diabetes

provide … wound care

biomechanical assessment

footwear / orthotic prescription

palliative care

ingrown toenail surgery

Conduct diabetes foot assessments

Provide education to clients and their families

Diabetes Foot Assessment

Should be performed every 6-12 months

Risk factors to be assessed:

peripheral vascular disease

peripheral neuropathy

dermatological conditions and skin integrity

abnormal lower limb biomechanics

inappropriate footwear

poor self care

Education: Client needs to …

Standard holistic advice regarding blood pressure, BGLs, smoking, diet and exercise

But the main points that need to get across from our behalf are to:

Be aware of potential foot problems

Check feet DAILY!

Wear appropriate footwear at all times

Aetiology of Foot Wounds

Primary Factors

Peripheral neuropathy

Peripheral vascular disease

Secondary Factors

Limited joint mobility

Bony deformity

Trauma

Immune responseAustralian National

Association of Diabetes Centres, The National Diabetes Foot Care

Project

Assessment of Foot Wounds

Aetiology

Neuropathic ulcer

Ischaemic ulcer

Neuroischaemic ulcer

Infection

Local

Cellulitis

Osteomyelitis

Investigations

X-ray

Swab

Bone scans

MRI

Referral

Endocrinologist

Vascular Consultant

Orthopaedic Consultant

Rehabilitation Consultant

Dietitian

Treatment of Foot Wounds

Debridement

Conservative sharp

Mechanical

Autolytic

Enzymatic

Surgical

Dressings

Pressure management

Surgery

Infection management

Oedema management

Off-Loading Options

total contact cast

soft cast shoes

removable cast walkers

post-op shoes / all purpose boots

orthoses

felt padding

combination of the above

Total Contact Casts

Gold standard for offloading plantar neuropathic foot wounds

Traditionally plaster of paris with fibreglass shell – minimally padded, contact with entire plantar surface and lower leg

Compression and pressure relief

Pressure transferred from forefoot to the cast walls and rear foot

Forces compliance

Armstrong, D. and Stacpoole-Shea, S. 1999. Total contact casts and removable cast walkers: mitigation of plantar heel pressure.

JAPMA, (89), pp 50-53.

Charcot Neuroarthropathy

• Is a rapid destructive arthropathy associated with peripheral neuropathy.

• Long standing diabetes is the most common cause (Approx 15%).

• The foot is the most common site.

• Other predisposing conditions include

Alcoholism Spinal Cord lesions Other Any condition that involves a

degeneration of sensory, motor and autonomic nerve function

• Aetiology is unclear.

Charcot Neuroarthropathy

Suggested aetiology:

Autonomic neuropathy increases blood flow to the extremity and bones, resulting in osteopenia amking it more prone to fractures

Motor neuropathy results in muscle imbalance

Sensory neuropathy means that patient in unaware of the osseous destruction that is taking place

Armstrong DG, Todd WF, Lavery LA, Harkless LB, Bushman TR (1997). The Natural Histroy of Acute Charcot’s Arthropathy in a Diabetic Foot Specialty

Clinic. Diabetic Medicine, 14 pp 357-363.

Charcot Neuroarthropathy

• Acute

Aim – Maintain normal foot structure

Off load

- TCC

- Air cast

- Crutches, compliance??

• Chronic

Hopefully no deformity

Orthosis

Custom made footwear

Management

Case Study Eight 75 yo male with type 2 diabetes referred to podiatry department by

GP

Seven years ago client fell off a ladder and was diagnosed simply with a foot fracture

Since this time, his foot has progressively changed shape into a rocker-bottom foot type

Until his podiatry appointment, no diagnosis of Charcot Neuroarthropathy was ever made

No medical intervention was initiated during the acute phase

Footwear

Protects feet and skin integrity

Can be …

Off-the-shelf

Medical grade

Custom made

Orthoses / accommodative insoles are important in patients with biomechanical abnormalities to prevent ulceration

Footwear

All footwear should have the following features…

1. Fastenings

2. A firm heel counter

3. Heel height of less than 2cm

4. A firm sole

5. A wide and deep toe-box

6. One thumbs-width from the longest toe to the end of the shoe

7. Preferably a leather upper and lining