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Examine the Diabetic Foot

Posted on February 23, 2018 | No Comments on Examine the Diabetic Foot

Diabetes mellitus is a chronic condition accompanied by a slew of complications, from the head down to the toes. Ask any diabetic what complications they are aware of, and, chances are, ranking among the top answers would be amputations. True enough, diabetes mellitus is the leading cause of non-traumatic amputations of the lower extremities. The presence of poor diabetes control, peripheral neuropathy (nerve damage), peripheral arterial disease, and foot ‘ ulcerations predict a higher risk for having a toe or a foot amputated.

Thus, there is indeed reason to be concerned about a diabetic’s foot and it is of utmost importance that proper attention be given to it, whether in the doctor’s clinic or in the patient’s own home. Serious foot complications are likely to be prevented with proper foot care and early intervention for beginning foot problems.

A diabetic patient is more prone to developing foot problems because of their tendency to have vascular (blood vessel) and ierve complications related to their diabetes, Darticularly in those who are poorly controlled and have had the disease for quite some time. Nerve damage may lead to sensory loss that can predispose the patient to foot injuries, while vascular damage could lead to poor circulation impairing the healing of foot ulcers. The proper evaluation of the foot is an important part of the care of a diabetic patient and this starts with the patient learning how to care for his feet properly on a daily basis, supported by the patient’s health care provider who performs a thorough evaluation of the foot at least annually in low risk patients and during every visit in high risk patients.

A proper foot evaluation starts with the patient’s medical history. The duration of diabetes may give an idea as to the likelihood of having diabetes-related complications. Usually, the longer the duration of the diabetes,the more likely it is for complications to be present. The presence of peripheral neuropathy, as well as peripheral vascular disease, puts the patient at risk for having foot problems. The presence of a foot ulcer, or a prior amputation, would put the patient in the high risk category. The patient should be questioned about pain or numbness in the feet, which if present, could be indicative of peripheral neuropathy. Impairment in circulation may be suggested by pain over the calf muscles during walking which disappears after a period of rest.

The first step in the foot examination is a visual inspection of the whole foot, including the area between each toe. The over-all condition and appearance of the skin should be noted, as well as the presence or absence of hair. Poor circulation may lead to a shiny, thin skin devoid of hair. Overly dry skin can lead to skin cracks which may predispose to infections. Note areas of redness and hype rpigmentation. Redness may be the first sign of a beginning infection, while hyperpigmentation may occur in those who have frequent or prolonged swelling of the lower extremities. The nails should also be inspected for the presence of fungal infection and deformities. Ingrown toenails could lead to infections. Bluish nailbeds may be seen in those with poor circulation. During the visual inspection, musculoskeletal deformities may be seen. These deformities may happen in , those who have peripheral neuropathy. More severe deformities would include Charcot foot, hammer and claw toe deformities.

The next part of the foot exam involves touching and getting a feel for the temperature of the foot. A foot cold to the touch may indicate poor circulation, whereas warmth in I some areas could accompany inflammation I or infection. Diminished pulses may be the result of peripheral arterial disease, hence it is important that both the dorsalis pedis and posterior tibia] pulses be checked during the foot exam.

Sensory examination of the foot can be done via several methods. A simple way of doing this would be to use a 10 gram nylon monofilament applied over certain areas of the foot (see figure). The monofilament should be applied at the indicated test sites, perpendicular to the skin, with sufficient force that would cause the filament to bend for one second. The inability to feel the monofilament at any of the areas indicates sensory loss leading to a higher risk for foot ulcers.

Vibration testing using a 128 Hz tuning fork applied to both big toes may be similar in sensitivity and specificity to the 10 gram monofilament test. A reduced vibration sense increases the risk for getting a foot ulcer.

Those patients who had a history of foot ulcers, prior amputations, foot deformities, absent pedal pulses, and sensory loss are considered high-risk patients. They would warrant an annual comprehensive foot exam and at least a visual examination of the feet during each visit to the clinic.

The patient should be made a partner in the care of their feet. Foot evaluations should not only be done in the clinic but also in the patient’s home. Patients should be encouraged to make it a habit to do a quick visual examination of the foot on a daily basis and to report to their health care provider any problem that would arise. With the patient and the health care provider working together, it would be possible to avoid, or even prevent, serious foot complications enabling the patient to lead a more pleasant and fruitful life.

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