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Diabetes - Screening and Management of Foot Complications

Diabetes - Screening & Management of Foot Complications

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Introduction

Diabetic foot disease is the single most important cause of major amputation in the developed world. More bed days are utilised by foot problems than any other diabetes complication in the UK. There is strong evidence to show that good care will prevent ulceration and amputation (up to 50% reduction). 15% of patients with diabetes will develop a foot ulcer at some point.

The diabetic foot may be defined as a group of syndromes in which neuropathy, ischaemia, and infection lead to tissue breakdown resulting in morbidity and possible amputation (World Health Organisation, 1995).

Peripheral neuropathy in feet leads to loss of sensation and autonomic and motor dysfunction and abnormalities of gait. Peripheral vascular disease in diabetes is often bilateral, multisegmental, and distal. Both of these conditions increase the risk of ulceration.

Infection often complicates neuropathic and neuroischaemic ulcers and is responsible for considerable damage in diabetic feet. Overwhelming infection is the main reason for major amputation in neuropathic feet.

Risk Factors associated with increased risk of foot complications include:

Poor glycaemic control

Duration of disease

Cardiovascular risk factors inc. smoking

Ethnic background (lower in some Asian populations)

Strategies to minimise the sequelae of foot complications include:

Patient education in foot care (see - Useful Resources and Links)

Early recognition of the 'at risk' foot

Prompt use of preventative measures

Rapid and intensive treatment of foot complications in specialist multidisciplinary foot clinics

View

Putting Feet First  Diabetes UK Campaign provides useful information and resources about all aspects of foot care for professionals and patients

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Foot Assessment

Essential foot care in diabetic patients involves adequate monitoring and the opportunity to reinforce messages of self-care. Many patients with poor eyesight and reduced mobility find it difficult to inspect their own feet: education of family and carers is essential.

All patients need a minimum of an annual foot inspection by a competent health care professional which should detect risk factors for ulceration and include:

Inspection: legs, dorsal, plantar and posterior surfaces of the foot and between the toes, looking for foot deformity, callus, skin and nail condition and trauma.

Vascular: palpation of the pulses (dorsalis pedis – DP, posterior tibial – PT) and look for evidence of ischaemic changes.

Neurological: ask for symptoms and assess sensation using a 10 gram monofilament Peripheral neuropathy

Assessment of footwear and gait.

See - Putting Feet First - Footcare Pathway

Monofilament Testing

Reduced sensitivity to the 10g monofilament predicts ulceration and places into an ‘at risk group’. Sensitivity should be tested on at least 5 peripheral sites on the foot, avoiding callus. The filament tip should be pressed into the skin until the filament just bends. A stroking movement should not be used. The monofilament deteriorates with use and should not be used to test more than 10 people in one session and should be then left for at least 24 hours to recover. It should be replaced according to manufacturer’s recommendations.

Monofilaments should be purchased from recognised suppliers and be of assured quality and calibration.

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Foot Risk Classification

The foot risk of ulceration should be classified each year, the patient informed of their risk classification and the appropriate action followed. If patients are currently under review by the podiatric services the annual foot assessment will be done by the podiatrist. Patient leaflets are available for each risk classification.

Low Current Risk

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Normal sensation
Palpable pulses (PT and DP)
No previous foot ulcer

Increased / Moderate Risk

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Neuropathy or
Absent pulses or
Other risk factor

High Risk PDF File

Neuropathy or absent pulses plus
Deformity or
Skin changes or
Previous foot ulcer

Emergency / Active PDF File

Foot ulcer, swelling, discolouration

 
 

CATEGORIES

 

ASSESSMENT

 

MANAGEMENT

 

TREATMENT PLAN

 
 

 

 

 

 

 

 

 

 
 

Low Risk

 

Protective sensation intact (10 g mono)

 

Primary Care - self care

 

Referral to Podiatry only for problems *

 
 

 

 

Normal pulses

 

 

 

 

 
      No deformity          
      No callus          
 

 

 

No previous ulcer

 

 

 

 

 
 

 

 

 

 

 

 

 

 
 

 

 

 

 

 

 

 

 
 

Increased / Moderate Risk

 

Loss of protective sensation (10g mono)

 

Community Podiatry

 

Foot education

 
 

 

 

or

 

 

 

Optimise diabetic control

 
 

 

 

Absent  pulses

 

 

 

Footwear assessment

 
 

 

 

No deformity

 

 

 

Podiatry as required

 
 

 

 

No callus

 

 

 

 

 
 

 

 

No previous ulcer

 

 

 

 

 
                 

 

 

 

 

 

 

 

 

 

 

High Risk

 

Previous Ulcer

or

2 of the following

Loss of protective sensation

No pulses

Deformity

Other risk factors

 

Community Podiatry

 

Foot education

 

 

 

 

 

 

 

Optimise control

 

 

 

 

 

 

 

Shoe review/referral for prescribed footwear

 

 

 

 

 

 

 

Regular podiatry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Emergency / Active

 

Ulcer present

or

Unilateral

Sudden swelling

Erythema

Change of shape

 

Community/ Hospital Podiatry

 

Foot education

 

 

 

 

 

 

 

Optimise diabetes control

 

 

 

 

 

 

 

Consultant opinion

 

 

 

 

 

 

 

Prescribed footwear

 
 

 

 

 

 

 

Regular podiatry

 
                 

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Referral Guidelines for Foot Problems

Emergency admission is necessary if any of the following are present:

Critical ischaemia (pale, pulseless, reduced capillary refill, weakness, painful foot – unless neuropathic when pain may not be a prominent feature)

Necrosis or gangrene

Spreading cellulitis or lymphangitis

Crepitus

Systemic symptoms of infection

Lack of response of infection to oral antibiotics

Suspicion of osteomyelitis

Contact numbers for referral - Bedford - Luton

 

Urgent Referral to a specialist multidisciplinary foot care team for any of the following:

New ulceration

New unilateral foot swelling (could indicate Charcot’s)

New discolouration

Signs or symptoms of infection

Contact numbers for referral - Bedford - Luton

 

Routine referral to podiatry

Increased and high risk of foot ulceration

Other specific foot care issues

(Referral Forms see - Useful Resources and Links)

 

Vascular referral is indicated for:

Rest pain (which is not neuropathic) or disabling claudication

Evidence of peripheral vascular disease in the presence of an ulcer

Revascularisation needs to be considered early or healing may be delayed.

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Risk Management

Low Risk of Foot Ulceration

Agree a management plan including Foot Care Education Leaflet with each person(see leaflet in  - Useful Resources and Links)

Foot Care Advice

General foot care advice should be given to all patients as follows:

Inspect feet daily

Wash feet daily, drying well between toes

Use a moisturising cream (but not between toes)

Do not use hot water bottles or electric blankets on feet.

Clean and cover any minor cuts and abrasions.

Footwear advice

If any neuropathy:

 

do not go barefoot

 

appropriate and properly fitted footwear

 

caution with new shoes

 

test bath and shower water with elbow

Provide all newly diagnosed patients and those with problems with foot care advice leaflet. These are available on other languages from Diabetes UK Website

Moderate/Increased Risk of Foot Ulceration

Refer to community podiatry for 3-6 monthly review:

Optimise all other risk factors (glycaemia, vascular, smoking)

(see leaflet in  - Useful Resources and Links)

High Risk of Foot Ulceration

Frequent review by community podiatry (1-3 monthly):

Ensure special arrangements for those people with disabilities or immobility.

Optimise all other risk factors (glycaemia, vascular, smoking)

(see leaflet in  - Useful Resources and Links)

Emergency/Active

Refer to specialist diabetes foot care team at the hospital urgently or as an emergency to A&E if clinically appropriate e.g. critical limb ischaemia or severe sepsis.

(see leaflet in  - Useful Resources and Links)

Rapid correction of hyperglycaemia is critical for limb salvage.

Contact numbers for referral - Bedford - Luton

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Foot Ulcers: Action for Primary Care Team

All diabetic patients with new foot ulcers should be referred to the multidisciplinary foot care team within 24 hours. If in doubt refer / discuss as an emergency.

Contact numbers for referral - Bedford - Luton

Principles of Management

If evidence of infection take swab / tissue sample if available prior to starting antibiotics. Take swab, after initial cleaning, from as deep as possible into the wound to try to minimise the risk of surface contamination.

Optimise diabetes control - if suboptimal glycaemic control may need additional  specialist input.

If hot swollen foot consider acute Charcot’s

Leg ulcers (ankle or above) should be referred to the appropriate service - not podiatry or diabetes foot clinic

Inspect footwear possible causes for the ulceration (e.g. foreign bodies)

Risk Factors for developing Diabetic Foot Ulcers

Peripheral Neuropathy

Peripheral vascular disease

Foot deformity (including hallux valgus, hallux rigidus and clawed toes)

Callus

Poorly fitting or inappropriate footwear

Poor eyesight resulting in injury and reduced foot care

Previous foot ulceration

Previous major or minor amputation of the lower limb

Other orthopaedic problems which alter gait (e.g. osteoarthritis of the knee, rheumatoid arthritis)

Increased duration of diabetes (>10years)

Neuropathic Foot Ulcers

Neuropathic feet (50%), where good circulation remains, are warm, numb, dry, usually painless and pulses remain palpable. Neuropathic ulcers, found mainly on the soles of feet, and neuropathic (or Charcot’s ) joints are the two main complications which may result.

Foot ulcers are susceptible to infection and polymicrobial infection may spread rapidly causing overwhelming tissue destruction. This process is the main reason for major amputation in neuropathic feet.

Neuro-Ischaemic Foot Ulcers

Neuro-ischaemic feet (50%) are cool and pulses are absent. Pain at rest, ulceration at the edges of the foot from localised pressure damage, and gangrene may occur in addition to neuropathic complications. Purely ischaemic feet, where these occur, are managed identically to neuro-ischaemic feet

Foot Ulcers: Microbiology and Antibiotics

If there is evidence of infection or cellulitis, then antibiotics should be started.

Routine use of antibiotics for all foot ulcers is not recommended, as there is no evidence of benefit.

Patients with diabetes are relatively immunocompromised and unless the infection is very minor the course of treatment should be at least 2 weeks or as advised by the specialist foot care team.

Common pathogenic bacteria are Staph aureus, streptococcus, anaerobes (which may be difficult to isolate) and coliforms, the latter especially if there is vascular insufficiency.

If there is only minor cellulitis without any deeper tissue involvement (tracking) and the patient has not previous had antibiotics for the ulcer a short course of flucloxacillin 500mg qds for 7-14 days can be used

   Otherwise:
 

Empirical treatment with amoxicillin and flucloxacillin (both 500mg to 1G) with addition of metronidazole if heavy exudate or malodorous, until the results of microbiological cultures are known.

If the patient is allergic to penicillin, a macrolide can be used instead.

The antibiotic regime should be reviewed as soon as the results of microbiological culture are known.

Foot Ulcers: Dressings

For an established foot ulcer dressing advice (type and frequency) will be given by the specialist diabetes foot service.

No single dressing is suitable for all types and locations of ulcers. The requirements of the ulcer and the patient need to be assessed regularly to match the appropriate dressing. Consider size, depth, location, infection, slough and amount of exudates.

Choice of dressing depends on nature of ulcer:

Flat, shallow, low exudative wounds: Low adherent dressing – (Inadine, Bactigras, Atrauman, Melolin)

Dry necrosis/ eschar – Non adherent / Inadine

Exudative ulcers Alginates and Hydrofibres – (Aquacel, Sorbsan)

Sloughy: Hydrogels – (honey dressings: Algivon, Activon Tulle, Actilite),

Infected or colonised wounds Antimicrobial – (Inadine, silver dressing, honey based dressing)

 

Foams – secondary dressing to the above to manage exudates levels and provide some pressure relief (Allevyn, Biatain)

Highly exuding ulcers may have to be dressed daily to avoid maceration otherwise dressings should be changed every 2-3 days to avoid missing aggressive infection or necrosis. Home visits are necessary if non weight bearing.

Dry gangrenous/necrotic tissue (eg autoamputation of toes/tips) should be kept dry and covered to reduce the risk of infection.

Occlusive/ primary adhesive dressings should be avoided to reduce risk of maceration and fluid build-up causing pressure related tissue necrosis.

Cavities should be packed with saline soaked gauze ribbon or other – eg Aquacel ribbon to ensure ulcers heal from the base upwards.

Podiatric Services

In addition to assessment and treatment of increased and high risk patients with or without foot ulcers the podiatrists provide a range of additional services such as biomechanics, nail and foot surgery.

Access to this service is by healthcare professional referral only. (see - Useful Resources and Links)

Once referred and assessed, patients can access the service on a regular return period advised by their podiatrist depending upon risk status.

Biomechanics Patients with foot pain or deformity should be referred for assessment for corrective footwear / insoles.

Nail care is provided to increased risk/high risk patients. Those at low risk will be advised on safe self management or gain assistance from family.

Nail surgery If phenolisation is not appropriate, surgical removal can be done by the Podiatric Surgeon. Referral by the podiatrist or GP.

Foot Surgery The Podiatric Surgeon can provide surgery to correct bunions, minor toe deformities and chronic plantar lesions. Referral via Podiatrist or GP.

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Peripheral Neuropathy

This is defined as the symptoms or signs of peripheral nerve dysfunction in patients with diabetes when other causes have been excluded. Diabetic peripheral neuropathy typically affects the feet much more than the hands and normally symmetrical in a ‘glove and stocking’ distribution

Symptoms:

Dysaesthesia / paraesthesia (tingling/pins and needles/numbness)

allodynia (painful sensation resulting from a normally non-painful stimulus)

pain in foot typically lancinating / burning pains

Signs:

dry skin

loss of ankle reflexes

sensory loss of more than one modality (loss/reduced vibration sensation, proprioception, temperature and/or pain sensation)

warm peripheries with bounding pulses (unless vascular disease present)

foot deformity (e.g. clawed toes)

callus

Most patients will only have a few of the above. The condition can be temporary following rapid improvement of diabetes control or permanent with long standing diabetes. Deterioration in glycaemic control can lead to an exacerbation of neuropathic symptoms.

Management

Prevention of foot ulcers with good foot care and daily surveillance by the patient.

Provide foot care advice and advice about suitable footwear.(see - Useful Resources and Links)

Arrange regular monitoring by the podiatrist.

Drugs for painful peripheral neuropathy:
Duloxetine is first line management according to NICE recommendations
 Second line therapy:

 

Amitriptyline 10-100mg

 

Gabapentin 300-600mg tds

 

Pregabalin 75-600mg daily in divided doses

 

Tramadol 50-100mg tds

These drugs all take up to 4-6 weeks to be effective (except tramadol) and are unlikely to remove pain altogether but a reduction of 50% on a pain scale may be considered a clinical response.

Topical

 

OpSite® spray before bed for nocturnal hyperaesthesia

 

Capsaicin cream (0.075%) apply sparingly to small area proximal to painful part tds.

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Charcot’s Arthropathy

This should be considered in any patient with diabetes presenting with a hot, swollen foot or part of foot and referred urgently to the specialist diabetes footcare team. It normally arises in patients with some degree of peripheral neuropathy following minor trauma (e.g. a trip).

Management includes the exclusion of infection (normal inflammatory markers), monitoring with temperature and x rays and non-weight bearing or the use of total contact casts or similar off-loading device.

Early appropriate treatment is associated with better prognosis. Delayed treatment can result in permanent deformity or major amputation.

(see leaflet in - Useful Resources and Links)

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Useful External Links & Resources

NICE | Type 2 diabetes: Prevention and Management of Foot Problems
NICE | Clinical Guideline 15, Type 1 Diabetes July 2004
Diabetes UK leaflets in other languages
Putting Feet first Skills Framework
‘National Patient Safety Suite – Safe management of diabetic foot– e-learning module’
PDF File Putting feet first Diabetes UK Campaign
PDF File Putting Feet First - Foot Care Pathway
PDF File Low risk foot in diabetes
PDF File Moderate risk foot in diabetes
PDF File High risk foot in diabetes
PDF File Emergency/ Active Ulcer in diabetes
PDF File Looking after your diabetic foot ulcer
PDF File Charcot foot
PDF File Holiday feet

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Advice about your Footwear

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Podiatry Referral Form
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