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Foot Exam Basics for Diabetes Educators

Diabetes is a chronic disease which can lead to serious complications such as heart disease, kidney disease, retinopathy, stroke, peripheral arterial occlusive disease and diabetic neuropathy which diabetic foot is a part of. These complications are quite preventable with healthy lifestyle, good compliance to prescribed medications, proper education and regular visits to a doctor. However, among these complications, diabetic foot is one complication which is very much preventable with proper education on foot care.

Over time, poorly controlled blood sugar can damage the nerves and the blood vessels. Diabetes can lead to many different types of foot complications, including athlete’s foot (a fungal infection), calluses, bunions and other foot deformities, or ulcers that can range from a surface wound to a deep infection. Nerve damage from diabetes can cause loss of sensation of feet. A cut, a blister or a sore may not be felt and the wound remains unnoticeable until a foul-smelling discharge comes out of it. Serious cases may even lead to amputation. Poor wound healing of the stump can still happen because of poor blood flow, more so, if one has poorly controlled blood sugars.

Feet and legs are examined once a year by someone trained on foot examination. Everything starts with foot inspection. The feet are checked for calluses, corns or changes in their shape. The footwear is also checked to make sure that it is not ill-fitting and will not be the cause of any foot problems.

Secondly, neuropathy testing or testing for the integrity of the nerves is carried out. The examiner will have a range of simple instruments to test for any numbness in the feet. Sensation will be checked with either gentle pressure to the underside of the toes and the ball of the foot using either finger touch or a fine plastic strand called a monofilament or vibration using a tuning fork. The examiner may also test the reflexes to discover if the patient can feel the difference between hot and cold on the skin.

Thirdly, the examiner will do circulation testing or testing for the presence of good blood flow to the legs and feet. The examiner will feel the pulses on the feet and legs to check how well the blood is circulating to the feet. Equipment may be used to listen to the sound of the blood moving in the arteries of the legs and feet.

Blood pressure is taken in the legs the same way blood pressure is taken in the arms. This is the determination of the ankle brachial index. The Ankle Brachial Index (ABI) is the ratio of the blood pressure in the lower legs to the blood pressure in the arms. Compared to the arm, lower blood pressure in the leg is an indication of blocked arteries or what we call as peripheral vascular disease. The ABI is calculated by dividing the systolic blood pressure at the ankle by the systolic blood pressures in the arm.

At the end of the examination, the patient is told of the result and whether the patient is at risk of any foot problems. If all is well, the patient is given general foot care advice until the next annual foot review. If risk for diabetic foot complication is identified, the patient will be referred to see a member of a foot protection team, who will treat any immediate problems and advise the patient on the best ways to look after their feet and keep them healthy. This team is composed of vascular surgeons, endocrinologists/diabetologists, diabetes nurse specialist, vascular nurse specialist, podiatrist (someone who specialized in the study of, diagnosis and treatment of the foot, ankle and lower leg); a diabetes foot health technician and orthotist (someone who custom makes the insoles, shoes, knee brace, splints, ankle boot and other supporting devices that the patient particularly needs).

However, diabetic foot care does not start and end with annual foot evaluation and referral to the foot protection team. Each consultation with a clinician is an opportunity to evaluate the foot and educate patients on proper foot care. Oftentimes, clinicians are asked these questions every time the topic of diabetic foot is brought up. “How often do we need to check our feet?” “How do we generally take care of our feet?” As clinicians, we can start by saying that “inspection of the feet is done every day.”

Self-examination of the foot starts with inspection for puncture wounds, bruises, pressure areas, redness, warmth, blisters, ulcers, cuts and nail problems. We have to look and feel each foot; examine the bottoms of the feet and toes. There are six major locations on the bottom of each foot that we need to examine. These are the tip of the big toe, the base of the little toe, the base of the middle toe, the heel, the outside edge of the foot and across the ball of the foot.

One cardinal rule is to never walk barefoot. Nerve damage decreases sensation, so it may be that objects already stuck on the foot may go unnoticed. Feet have to be washed everyday with mild soap and water. Testing the water temperature with the hand first, prevents burn injuries. When drying, always avoid rubbing the feet vigorously and instead, pat each foot with a towel. Toe nails have to be trimmed straight across; cutting the corners should be avoided. Lubricating lotions maybe applied to the legs and feet since these are generally dry in patients with diabetes. Smoking cessation is encouraged, since smoking damages blood vessels and decreases the ability of the body to deliver oxygen. In combination with diabetes, it significantly increases the risk of amputation—not only of the feet, but can include the hands, as well.

Any trauma, even a minor one, must be given proper attention before it worsens. If the patient has sore spots, blisters, corns, calluses and constant pain associated with wearing shoes, properly fitting footwear must be obtained as soon as possible. If the patient has common foot abnormalities such as flat feet, bunions, or hammertoes, prescription shoes or shoe inserts may be necessary. A limp or difficulty walking can be a sign of joint problems, serious infection or ill-fitting shoes. Fever and chills in association with wounds can be signs of limb-threatening or life threatening infection.

Patients should be made aware of the telltale signs of infection such as fever, redness, warmth, blister formation, swelling of the foot and leg and foul-smelling discharge. Infected wounds should be properly debrided and dressed with sterile gauze. Pain in the legs or buttocks that increases with walking but improves with rest accompanied by purplish discoloration are signs of poor blood flow which may lead to limb amputation.

Diabetes-related foot problems are preventable. It is very important to note that not only are patients with longstanding diabetes at risk of developing foot complications but so are those who are have been recently diagnosed. Proper care and management of the diabetic foot requires a multidisciplinary approach wherein patients play a very active role. The absolute goal of diabetic foot treatment is the prevention of ulceration and ultimately the reduction of amputation. Clinicians have to properly educate their patients on the need for self-evaluation of their feet. This basic foot care can prevent hundreds of wound infections and amputations in the future.

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