DM - FOOT EVALUATION IN THE DM - FOOT EVALUATION IN THE PRIMARY CARE SETTINGPRIMARY CARE SETTING

Bernadette Pendergraph, Gloria Sanchez, MDsBernadette Pendergraph, Gloria Sanchez, MDsCindy Mayeda, RNCindy Mayeda, RNDepartment of Family Medicine, Harbor-UCLADepartment of Family Medicine, Harbor-UCLA

“An ounce of prevention is worth a pound of cure.”– Benjamin Franklin

Learning ObjectivesLearning Objectives

Medical KnowledgeMedical Knowledgea. Perform Comprehensive DM Foot Exama. Perform Comprehensive DM Foot Examb. Implement ADA DM Foot Guidelinesb. Implement ADA DM Foot Guidelinesc. Classify DM Foot Ulcers Accuratelyc. Classify DM Foot Ulcers Accuratelyd. List indications for imagingd. List indications for imaging

Patient CarePatient Carea. Offloading Devices for DM Ulcersa. Offloading Devices for DM Ulcersb. Utilize consultants in timely fashionb. Utilize consultants in timely fashion

No conflicts of interest

Learning ObjectivesLearning Objectives System Based PracticeSystem Based Practice

a. Utilize resources for patientsa. Utilize resources for patientsb. Expedite pt work up & tx PRNb. Expedite pt work up & tx PRN

Interpersonal & Communication SkillsInterpersonal & Communication Skillsa. Teach pts DM foot care & precautionsa. Teach pts DM foot care & precautionsb. Collaborate with HC team to examine & b. Collaborate with HC team to examine & treat ptstreat pts

ProfessionalismProfessionalisma. Take “ownership” of DM foot ulcera. Take “ownership” of DM foot ulcer

IMPORTANCE OF FOOT EXAMSIMPORTANCE OF FOOT EXAMS

National Hospital Discharge survey 1996 86,000 National Hospital Discharge survey 1996 86,000 with DM under went with DM under went >> 1 amputation 1 amputation

DM leading cause of amputation in lower DM leading cause of amputation in lower extremitiesextremities > 50% preventable> 50% preventable Triad: neuropathy, deformity, trauma Triad: neuropathy, deformity, trauma

Absence of nerve and vascular complaints is not Absence of nerve and vascular complaints is not protectiveprotective

Incidence of:Incidence of: Foot ulcers up to 25% lifetime risk, annual risk 2%Foot ulcers up to 25% lifetime risk, annual risk 2%

~~50% infected50% infected 14-24% amputation14-24% amputation

Lower extremity amputationLower extremity amputation 50% in same/opposite extremity in 5 yrs.50% in same/opposite extremity in 5 yrs. Mortality all cause at 5 yr 39-68%Mortality all cause at 5 yr 39-68%

IMPORTANCE OF FOOT EXAMSIMPORTANCE OF FOOT EXAMS

Healthy People 2020 goalsHealthy People 2020 goals Increase # of persons receiving at least an Increase # of persons receiving at least an

annual foot examannual foot exam Decrease amputations related to DMDecrease amputations related to DM

Ethnic risk for amputation per 10,000 Ethnic risk for amputation per 10,000 persons with DMpersons with DM African-Americans 95.3African-Americans 95.3 Hispanic 44.4Hispanic 44.4 Caucasians 56Caucasians 56

IMPORTANCE OF FOOT EXAMSIMPORTANCE OF FOOT EXAMS

% amputations related to DM% amputations related to DM HispanicsHispanics 82.782.7 African-AmericansAfrican-Americans 61.661.6 CaucasiansCaucasians 56.856.8

Foot exam frequencyFoot exam frequency By patientBy patient

DailyDaily 52%52% NeverNever 22%22%

By providerBy provider Type 1 66%Type 1 66% Type 2 52%Type 2 52%

COST OF DM FOOT DISEASECOST OF DM FOOT DISEASE

Amputations > $1.1 billionAmputations > $1.1 billion Ulcer in male 40-65 y.o. $28,000 Ulcer in male 40-65 y.o. $28,000

over 2 yrover 2 yr

RISK FACTORS FOR RISK FACTORS FOR AMPUTATIONAMPUTATION

Arterial insufficiency: DM > 10 yrs, Tobacco useArterial insufficiency: DM > 10 yrs, Tobacco use Disease control: high FBS, high A1c, duration = Disease control: high FBS, high A1c, duration =

two fold increasetwo fold increase Sex: maleSex: male Eng Organ Damage: Eng Organ Damage:

RetinopathyRetinopathy NephropathyNephropathy Cardiovascular diseaseCardiovascular disease Peripheral neuropathyPeripheral neuropathy: absent Achilles reflex, : absent Achilles reflex,

decreased vibratory sensation = 2 x likely in amputeesdecreased vibratory sensation = 2 x likely in amputees Abnormal gait 15x more likely to injureAbnormal gait 15x more likely to injure Abnormal monofilament exam 60% develoed ulcers, 21% Abnormal monofilament exam 60% develoed ulcers, 21%

amputations over 32 monthsamputations over 32 months

RISK FACTORS FOR RISK FACTORS FOR AMPUTATIONAMPUTATION

Abnormal foot anatomyAbnormal foot anatomy Nail – Onycholysis, Ingrown Nail – Onycholysis, Ingrown Skin – Xerosis, Corn, Skin – Xerosis, Corn, CallusCallus, Hair loss, Hair loss BoneBone – Hallux valgus, hammer toes, – Hallux valgus, hammer toes,

prominent metatarsal heads, Charcot prominent metatarsal heads, Charcot footfoot

Previous ulcer or amputationsPrevious ulcer or amputations Loss of monofilament perception – 18 Loss of monofilament perception – 18

fold increase risk of ulcerfold increase risk of ulcer

PRECIPITATING EVENTS FOR PRECIPITATING EVENTS FOR AMPUTATIONAMPUTATION

Injury from new shoesInjury from new shoes Improper toe nail trimmingImproper toe nail trimming Accidental woundsAccidental wounds Thermal injuryThermal injury

1/3 of injuries self induced in PVD1/3 of injuries self induced in PVD

ADA GUIDELINESADA GUIDELINES Everyone with DM gets a foot examEveryone with DM gets a foot exam

Starts at diagnosisStarts at diagnosis Frequency: At least annual – stratify high Frequency: At least annual – stratify high

vs low riskvs low risk Visual inspection every visit if Visual inspection every visit if

neuropathyneuropathy Prerequisite historyPrerequisite history

Previous ulceration, amputation, Charcot Previous ulceration, amputation, Charcot joint, vascular surgery, angioplasty, joint, vascular surgery, angioplasty, tobacco use tobacco use

Symptoms of claudication or neuropathySymptoms of claudication or neuropathy DM complications: renal, visualDM complications: renal, visual

ADA GUIDELINESADA GUIDELINESFOR FOOT CAREFOR FOOT CARE

Foot exam componentsFoot exam components Visual inspection: dermatologic, Visual inspection: dermatologic,

musculoskeletal, shoemusculoskeletal, shoe Neurological assessment: 10g Neurological assessment: 10g

Monofilament + 1 of the following:Monofilament + 1 of the following: VibrationVibration PinprickPinprick Ankle reflexesAnkle reflexes VPTVPT

Vascular: Pulses, consider ABIVascular: Pulses, consider ABI

DERMATOLOGIC INSPECTIONDERMATOLOGIC INSPECTION

NailsNails Shape/lengthShape/length Ingrown, paronychiaIngrown, paronychia OnycholysisOnycholysis

SkinSkin XerosisXerosis Callus/Corn/UlcerCallus/Corn/Ulcer

TemperatureTemperature

MUSCULOSKELETAL ASSESSMENTMUSCULOSKELETAL ASSESSMENT DeformitiesDeformities

Toe deformities-Toe deformities-claw , hammerclaw , hammer

BunionsBunions Charcot footCharcot foot

SHOE EVALUATIONSHOE EVALUATION Look at the patient’s shoes Look at the patient’s shoes (Are (Are

these shoes appropriate for these feet?)these shoes appropriate for these feet?) Type of material?Type of material?

Good: canvas, suede, leather, Good: canvas, suede, leather, elasticelastic

Bad: plasticBad: plastic Any foreign objects?Any foreign objects? Depth appropriate?Depth appropriate? Width appropriate?Width appropriate? Size?Size? How old?How old?

NEUROLOGIC ASSESSMENTNEUROLOGIC ASSESSMENT Peripheral neuropathy most common cause of Peripheral neuropathy most common cause of

DM foot ulcerationDM foot ulceration Identify loss of protective Identify loss of protective sensation (LOPS)sensation (LOPS)

10 g monofilament10 g monofilament 128 Hz turning fork: vibratory 128 Hz turning fork: vibratory sensation-tip of sensation-tip of

great toe bilaterallygreat toe bilaterally Pinprick: disposable pin proximal toPinprick: disposable pin proximal to nail of nail of

great toegreat toe Ankle reflexesAnkle reflexes Vibration perception threshold testing: mean of 3 Vibration perception threshold testing: mean of 3

readings; VPT > 25Vreadings; VPT > 25V

MONOFILAMENT TESTINGMONOFILAMENT TESTING Patient should close the eyes Check patient on proximal site to

demonstrate Instruct the patient to tell you when he

feels the monofilament Push the monofilament until it bends, then

hold for 1-2 seconds Lift the monofilament from skin Retest the area where the patient did not

feel the monofilament (Avoid callus) Mark the areas of the foot using a plus

sign (+) if they can feel the monofilament and a minus sign (-) if they cannot

VASCULAR ASSESSMENTVASCULAR ASSESSMENT

PAD is a component cause in 1/3 of ulcersPAD is a component cause in 1/3 of ulcers Risk factor for recurrent woundRisk factor for recurrent wound

Palpate dorsalis pedis and posterior Palpate dorsalis pedis and posterior tibialistibialis

If pulses are absent or symptoms of PAD, If pulses are absent or symptoms of PAD, do ABIdo ABI DM > 50 yoDM > 50 yo DM < 50 with multiple DM < 50 with multiple

PAD risk factorsPAD risk factors

ABI ReadingsABI Readings

AbnormalAbnormal >1.2>1.2(medial calcinosis)(medial calcinosis)

NormalNormal 0.9-1.20.9-1.2

Moderate Vascular DzModerate Vascular Dz 0.4-0.80.4-0.8

Severe Vascular DzSevere Vascular Dz <0.4<0.4

TOE PRESSURE TESTING (TBI)TOE PRESSURE TESTING (TBI)

Consider doing if ABI Consider doing if ABI >> 1.21.2

Cut off are different Cut off are different than ABIthan ABI TBI > 0.5 or > 70 mm TBI > 0.5 or > 70 mm

Hg = normalHg = normal TBI TBI << 0.2 or < 30mm 0.2 or < 30mm

Hg = severely ischemicHg = severely ischemic

RISK CLASSIFICATIONRISK CLASSIFICATION

FOOT CONDITIONS TO FOOT CONDITIONS TO WATCH OUT FORWATCH OUT FOR

Diabetic foot infections: Diabetic foot infections: inframalleolar infection in a inframalleolar infection in a person with DMperson with DM Acute: Predominantly g+ cocciAcute: Predominantly g+ cocci

ClindamycinClindamycin KeflexKeflex BactrimBactrim AugmentinAugmentin

Chronic: g-rodsChronic: g-rods 22ndnd generation cephalosporin generation cephalosporin LinezolidLinezolid DaptomycinDaptomycin

DIABETIC FOOT INFECTIONSDIABETIC FOOT INFECTIONS

Ischemia: obligate anaerobesIschemia: obligate anaerobes Vascular evaluationVascular evaluation Fluoroquinolone + clindamycinFluoroquinolone + clindamycin ImipenemImipenem Vancomycin + Ceftazidime Vancomycin + Ceftazidime ++ metronidazole metronidazole

ULCERSULCERS Venous stasis ulcerVenous stasis ulcer

Medial malleolar areaMedial malleolar area Irregular bordersIrregular borders Red-brown stainingRed-brown staining Lower extremity edema/varicose veinsLower extremity edema/varicose veins

Arterial insufficiency ulcer Arterial insufficiency ulcer Tip of the toeTip of the toe Punched out (clear demarcation)Punched out (clear demarcation) Pale, dry base without edemaPale, dry base without edema

WAGNER ULCER CLASSIFICATION

Grade 0 = no ulcer in high risk foot Grade 1 = ulcer involving full skin

thickness Grade 2 = ulcer to ligament and muscle Grade 3 = ulcer with cellulitis/abscess Grade 4 = localized gangrene Grade 5 = extensive gangrene involving

whole foot

ULCER TREATMENTULCER TREATMENT Patients should never walk out in the same shoe Patients should never walk out in the same shoe

wear they walked in…wear they walked in… Offload ulcerOffload ulcer

Modify shoe insert – cut out area under ulcerModify shoe insert – cut out area under ulcer Healing bootHealing boot Total contact castTotal contact cast

Assess vascularityAssess vascularity Wound careWound care

Inciting event – shoe, foreign body = xrayInciting event – shoe, foreign body = xray DebridementDebridement Assess if InfectedAssess if Infected Close follow-upClose follow-up

FOOT FOOT CONDITIONSCONDITIONS

Charcot footCharcot foot Neuropathic joint – Neuropathic joint –

progressive destruction of progressive destruction of bone and soft tissues at bone and soft tissues at weight bearing jointsweight bearing joints

Rocker bottom foot with Rocker bottom foot with continued ambulationcontinued ambulation

Incidence in DM: 0.15-Incidence in DM: 0.15-2.5%2.5%

Recurrence 5%Recurrence 5% Bilateral disease 10%Bilateral disease 10% Men = WomenMen = Women

PATHOGENESIS OF PATHOGENESIS OF CHARCOTCHARCOT

STAGINGSTAGING

WHICH ONE IS WHICH ONE IS CHARCOT FOOT?CHARCOT FOOT?

NORMAL FOOTNORMAL FOOT

CHARCOT FOOTCHARCOT FOOT AcuteAcute

Inflammatory: swelling, increased Inflammatory: swelling, increased temperature (3-7temperature (3-7°F), redness, bony °F), redness, bony resorptionresorption

Intact skin and pulsesIntact skin and pulses Insensate footInsensate foot

TreatmentTreatment Immobilization: total contact castImmobilization: total contact cast Reduce stress: non-weight bearingReduce stress: non-weight bearing r/o infectionr/o infection

ChronicChronic Protection: orthotics, surgeryProtection: orthotics, surgery

TREATMENT OVERVIEWTREATMENT OVERVIEW

OTHER ORTHOSISOTHER ORTHOSIS Charcot footCharcot foot

AFO: offload bottom of foot and AFO: offload bottom of foot and reduce ankle motionreduce ankle motion

Total contact cast: transfer Total contact cast: transfer weight away from footweight away from foot

Pneumatic walker bracePneumatic walker brace

OTHER ORTHOSISOTHER ORTHOSIS

Charcot footCharcot foot AFO: offload bottom of foot and AFO: offload bottom of foot and

reduce ankle motionreduce ankle motion Total contact cast: transfer Total contact cast: transfer

weight away from footweight away from foot Toe amputationsToe amputations

Toe fillerToe filler Forefoot amputations: custom Forefoot amputations: custom

shoesshoes

Achilles lengtheningAchilles lengthening

Transmetatarsal amputationTransmetatarsal amputation

SHOE PRESCRIPTIONSSHOE PRESCRIPTIONS

Healing shoes: post op or heat molded Healing shoes: post op or heat molded shoesshoes

Depth in-lay: toe deformities, Depth in-lay: toe deformities, prescription insertsprescription inserts

Extra wide: bunionsExtra wide: bunions Rocker sole: reduce pressure on Rocker sole: reduce pressure on

metatarsal heads; hallux rigidismetatarsal heads; hallux rigidis Custom molded: severe feet Custom molded: severe feet

deformitiesdeformities

SHOE PRESCRIPTIONSSHOE PRESCRIPTIONS Medicare covers custom shoes for persons with Medicare covers custom shoes for persons with

DM, in a comprehensive DM care program and DM, in a comprehensive DM care program and one of the following:one of the following: H/o amputationH/o amputation H/o ulcerH/o ulcer H/o preulcerative callusH/o preulcerative callus Peripheral neuropathy with callusPeripheral neuropathy with callus Poor circulationPoor circulation Foot deformityFoot deformity

Products for the yearProducts for the year One pair of depth shoes with 3 insertsOne pair of depth shoes with 3 inserts One pair of custom-molded shoes/inserts with 2 insertsOne pair of custom-molded shoes/inserts with 2 inserts

FOOT CARE INSTRUCTIONSFOOT CARE INSTRUCTIONS Good sugar controlGood sugar control Daily visual examDaily visual exam Moisturize your feetMoisturize your feet Appropriate shoe wear – never barefoot, Appropriate shoe wear – never barefoot,

no open toe boxno open toe box Firm heel counters and uppers – to prevent Firm heel counters and uppers – to prevent

excessive motion and rolling excessive motion and rolling A firm and wide outsole – to provide a stable A firm and wide outsole – to provide a stable

base for the foot base for the foot An extra-depth construction with a removable An extra-depth construction with a removable

inlay – to provide added cushion; allow room inlay – to provide added cushion; allow room for a custom foot orthosis for a custom foot orthosis

HOW TO DEAL WITH HOW TO DEAL WITH PROBLEMSPROBLEMS

Thermal injuryThermal injury Shoe color (8-13Shoe color (8-13°)°)

Bony abnormalitiesBony abnormalities Mild deformities: Appropriate depth and widthMild deformities: Appropriate depth and width

Athletic shoesAthletic shoes Soft insoles: plastazote/urethrane viscoelasticSoft insoles: plastazote/urethrane viscoelastic Laces or Velco strapLaces or Velco strap

Severe deformities or amputation: Shoe Severe deformities or amputation: Shoe prescriptionprescription

Relieve excessive pressureRelieve excessive pressure Decrease shock, sheer pressuresDecrease shock, sheer pressures Accommodate, stabilize, and support deformitiesAccommodate, stabilize, and support deformities

Medicare pays 80% of what is allowedDepth shoes $126Custom molded shoes $378Inserts $64

RISK FACTORS FOR FOOT ULCERRISK FACTORS FOR FOOT ULCER

Poor glycemic controlPoor glycemic control Visual impairmentVisual impairment Previous foot ulcer/amputationPrevious foot ulcer/amputation Peripheral neuropathyPeripheral neuropathy PADPAD Foot deformityFoot deformity DM nephropathyDM nephropathy Cigarette smokingCigarette smoking

High risk: High risk: amputation, amputation, ulcerulcer

Elevated A1c Elevated A1c doubles risk doubles risk of amputationof amputation