Why are diabetic foot examinations important?

Why are diabetic foot examinations important?

All patients with diabetes are at risk for developing a diabetic foot ulcer (DFU) (Bartus & Margolis, 2004).  There are simple interventions patients with diabetes can perform at home to reduce the risk of DFU.  An important component of diabetes self-management plans is a daily foot examination (Video 1). In addition to self-examinations, all patients with diabetes should have professional foot examinations on a regular basis (Miller, Salloum, Button, Giovinco, & Armstrong, 2014; Yetzer, 2004).  Professional examinations should include an inspection of the skin as well as assessment of neurologic, vascular, and musculoskeletal functions (Miller et al., 2014).

Any break in the skin can potentially develop into a DFU. Patients with diabetes should maintain proper foot hygiene, including daily cleaning, moisturizing, and proper footwear.  Patients should inspect their feet daily to identify any skin breaks, blisters, swelling, or redness.  Skin lesions should be aggressively treated to prevent complications and/or development of a DFU.

Neuropathy means a disease of the nerves.  There are many different types of neuropathy.  Approximately 50% of patients with diabetes have at least one form of neuropathy (Bakker, Apelqvist, & Schaper, 2012).  The most common form of neuropathy in patients with diabetes is distal symmetric polyneuropathy.  Distal symmetric polyneuropathy presents with numbness and/or tingling sensations that develop in the lower extremities and then extend to more proximal areas of the body.  Neuropathy can lead to loss of protective sensation, foot deformities, and limited joint mobility (Bakker et al., 2012).  Effective screening tools for diabetic neuropathy include monofilament pressure testing (Figure 1), measurement of vibratory perception threshold (Figure 2), subjective symptom assessment, and diminished ankle reflexes (Armstrong, Lavery, Vela, Quebedeaux, & Fleischli, 1998).  Treatment can be started once neuropathy is diagnosed and can include use of protective measures such as appropriate footwear.

Figure 1: Caring for Diabetes Educational Forum (n.d.) Retrieved from http://www.caringfordiabetes.com/activity/23455/article/http://www.caringfordiabetes.com/activity/23455/article/.

Monofilament Pressure Testing: A monofilament is applied to various areas on a patient’s foot to determine if the patient has loss of sensation.

Figure 2: Cameron Kippen (2012).  Retrieved from http://foottalk.blogspot.com/2012/05/diabetes-peripheral-neuropathy-and-foot.html.

Vibratory Perception Threshold (VPT): VPT can be performed using a variety of instruments and is helpful to identify loss of sensation in the lower extremity (Garrow & Boulton, 2006)

Peripheral vascular disease (PVD) refers to a group of diseases that affect blood vessels.  PVD is a well-known complication of diabetes and one-third of patients with DFU have peripheral vascular disease (Miller et al., 2014).  PVD can present with symptoms such as, cold extremities and lower extremity pain with exertion.  PVD can also present asymptomatically, which is why screening is critical.  Effective screening for peripheral vascular disease includes measurement of the ankle-brachial index (Figure 3), measurement of transcutaneous oxygen pressures (Figure 4), and assessment of pedal pulses (Bartus & Margolis, 2004).  Once PVD has been diagnosed, both pharmaceutical therapies, such as antiplatelets and anticoagulation, and surgical interventions including revascularization procedures can be initiated (Bartus & Margolis, 2004).

Figure 3: CI Medical Center (2010).  Retrieved from http://www.cimedicalcenter.com/ankle-brachial-index-test-p210.

Ankle Brachial Index (ABI):  Simple procedure in which the blood pressure of the upper extremities is compared to the blood pressure of the lower extremities.  ABI is useful to diagnose PVD.

Figure 4: BaroMedical Hyperbaric Oxygen Therapy (n.d.)  Retrieved from http://baromedical.ca/services/hyperbaric-oxygen/assessment-procedures/

Measurement of transcutaneous oxygen pressure: Non-invasive method to measure oxygenation of peripheral tissues.

      There are other factors that make it more likely for a patient to develop DFU.  Musculoskeletal deformities can lead to abnormal biomechanics, or foot movements, and subsequently increase the risk for DFU.  Musculoskeletal deformities can be treated with non-surgical methods, such as orthotic devices, and surgical interventions.  Poor glycemic control and uncontrolled co-morbidities are both associated with increased risk of DFUs (Bartus & Margolis, 2004).  Regular healthcare with a primary care provider is essential to maintain optimal control of diabetes and to prevent associated complications.

Video 1: https://www.youtube.com/watch?v=qXUcqVnqnYM

References

Bakker, K., Apelqvist, J., & Schaper, N. (2012).  Practical guidelines on the management

and prevention of the diabetic foot.  Diabetes/Metabolism Research and Reviews, 28(S1), 225-231.  http://dx.doi/10.1002/dmrr.2253.

Bartus, C. & Margolis, D. (2004).  Reducing the incidence of foot ulceration and

amputation in diabetes.  Current Diabetes Reports, 4, 413-318.  http://dx.doi.10.1007/s11892-004-0049-x.

Garrow, A. & Boulton, A. (2006).  Vibration perception threshold: A valuable

assessment of neural dysfunction in people with diabetes.  Diabetes Metabolism Research and Reviews, 22, 411-419.  http://dx.doi.org/10.1002/dmrr.657.

Miller, J., Salloum, M., Button, A., Giovinco, N., & Armstrong, D. (2014).  How can I

maintain my patient with diabetes and history of foot ulcer in remission?  The International Journal of Lower Extremity Wounds, 13(4), 371-377. http://dx.doi.org/10.1177/1534734614545874.

Yetzer, E. (2004).  Incorporating foot care education into diabetic foot screening. 

Rehabilitation Nursing, 29(3), 80-84.  http://dx.doi.org/10.1002/j.2048-7940.2004.tb00315.x