bio mechanics of diabetic foot ulcer


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role of physiotherapy managment and prevention for diabetic foot ulcer

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bio mechanics of diabetic foot ulcer

  1. 1. Welcome<br />
  2. 2. Diabetic Foot UlcerRole of Physiotherapist<br />T. Senthilkumar M.P.T (Ortho).,M.I.A.P<br />Asst. Professor<br />Shanmuga College Of Physiotherapy<br />
  3. 3. What is Diabetes Mellitus?<br />Diabetes Mellitus is a group of metabolic disorders characterized by high levels of blood glucose resulting from defects in insulin production,or action, or both.<br />
  4. 4. Types of Diabetes<br /><ul><li> Type 1
  5. 5. Type 2
  6. 6. Gestational Diabetes</li></li></ul><li>The Need<br />India has the largest number of diabetic patient (19.4 Million) - 1995<br />In 2025 this is projected as 57.2 million ie 114.4 million foot are at risk<br />40 – 70%- All lower extremity amputation are related to diabetes mellitus<br />85% - All diabetic related amputation are due to foot ulcers.<br />30 sec - Every 30 sec a leg is lost to diabetes somewhere in the world<br />One in every six people with diabetes will have an ulcer during their life time. Ratio (1:6)<br />Source: WHO Statistics on Diabetic Foot Ulcer<br />
  7. 7. Contd..<br />45% of diabetics will have peripheral vascular disease after 20 years<br />After first below –knee amputation 42% of patients with lose the contra lateral limb within 1 year<br />11-40% of patients will die within first year of their below-knee amputations<br />Source: WHO Statistics on Diabetic Foot Ulcer<br />
  8. 8. Diabetic Foot ?<br />The term diabetic foot has been coined to encompass a multitude of leg / foot presentation where the underlying disease is Diabetes Mellitus.<br />
  9. 9. Clinical triads <br />Peripheral neuropathy<br />Peripheral vascular disease<br />Mechanical factors (deformities)<br />
  10. 10. Anatomy of the Foot<br /><ul><li>26 – bones + (2-sesamoids) = 28
  11. 11. 57- Joints
  12. 12. 42- Muscles
  13. 13. 107- ligaments
  14. 14. In lifetime, its is estimated that a human being walks about 100,000m(1,50,000 KM) equaling to almost 4 times around the world</li></li></ul><li>Why PVD & Peripheral Neuropathy is common in lower limbs than in upper limbs<br />A comparative lengthening of lower extremity<br />Internal rotation to render the foot planti-grade<br />Weight bearing got restricted to two instead of four limbs<br />Our ability to see our plantar decreased significantly<br />Great toe went further away from the body so its needs longest nerves and arteries<br />
  15. 15. Bio & Patho mechanics of Diabetic Foot<br />
  16. 16. Phases of Gait Overview<br />Stance phase (62%)<br /><ul><li>Contact period - heel contact (HC) to forefoot contact (FFC)
  17. 17. Midstance period - forefoot contact (FFC) to heel off (HO)
  18. 18. Propulsion period - heel off (HO) to toe off (TO)</li></ul>Swing phase (38%)<br /><ul><li>early swing, late swing, double and single support</li></li></ul><li>
  19. 19. Normal Foot Function<br />Heel Strike<br /> The foot assists in shock absorption. The foot and leg are required to be a loose chain structure.<br />Mid Stance<br /> The foot supports the entire body. A stable structure is required<br />Propulsion<br /> The foot is required to adapt to the needs for propulsion. A rigid lever is required<br />
  20. 20. Normal Foot Function contd..<br />Heel Strike - Subtalar joint pronates and allows shock absorption<br />Mid Stance – Subtalar joint comes to neutral position and acts as stable structure<br />Propulsion – Subtalar joint supinates and acts as rigid lever<br />
  21. 21. Abnormal Foot Function<br />
  22. 22. Sensory loss<br /> Trauma / Pressure / Stress / Heat<br /> Blisters / <br /> Wound <br /> Ulcer <br /> Tissue loss<br /> Autonomic dysfunction<br /> Dryness <br /> Cracks / Fissures / Callous<br /> Ulcer<br /> Tissue loss<br /> Motor Paralysis<br /> Altered biomechanics<br /> Contractures/Pressure/ blister/ wounds<br /> Ulcer <br /> Tissue Loss<br /> PAD<br /> Ischemia<br /> Ulcer<br /> Infection<br /> Tissue Loss<br />
  23. 23. Factors affecting normal biomechanical loading in diabetic foot<br /><ul><li>Deformities
  24. 24. Abnormal walking pattern
  25. 25. Limited joint mobility
  26. 26. Repeated plantar pressure
  27. 27. Shear stress</li></li></ul><li>PATHOGENESIS OF ULCERATION OF DIABETIC FOOT<br /><ul><li>Impulse loading in diabetic neuropathy is very high at 1st MTP joint
  28. 28. Increasing ground contact time due to LJM, soft and connective tissues changes, already existing deformities and scars of previous ulcers
  29. 29. Due to autonomic neuropathy the recovery from anoxia and ischemia is delayed as the sympathetic denervation of the circulatory bed occurs
  30. 30. This causes increased warmth and Erythema in the region of 1st/3rd/5th metatarsal heads
  31. 31. This leads to progressive inflammation and exudates formed
  32. 32. Continued walking with blisters promotes ulcers formation in the risk areas </li></li></ul><li>Commonest deformities in diabetic foot<br />FLAT FEET (OVER PRONATION OF FEET)<br />PES CALCANEUS<br />PES EQUNIUS<br />CLUB FOOT<br />INSUFFICIENT PUSH OFF<br />ACHILLES TENDINITIS<br />PLANTAR FASCITIS<br />HALLUX ABDUCTO VALGUS (BUNION)<br />HALLUX RIGIDUS <br />METATARSALGIA<br />HAMMER TOE<br />CALLUSES<br />
  33. 33. High risk areas of diabetic foot<br /><ul><li>1st Metatarsal Head
  34. 34. 2nd and 3rd Metatarsal Head
  35. 35. Between 4th and 5th MT Head
  36. 36. Ball of the all toes
  37. 37. Under 1 MTP joint
  38. 38. Under MTP joints
  39. 39. Lateral heel </li></li></ul><li>CAUSATIVE FACTORS FOR NEUROPATHIC ULCERS<br />EXTRINSIC FACTORS<br /><ul><li>Ill fitting footwear
  40. 40. Barefoot walking
  41. 41. Falls/accidents
  42. 42. Objects inside shoes
  43. 43. Thermal trauma
  44. 44. Injury by sharp objects
  45. 45. Home surgery</li></ul>INTRINSIC FACTORS<br /><ul><li>Limited joint mobility
  46. 46. Bony prominences
  47. 47. Foot deformities
  48. 48. Neuro-arthropathy
  49. 49. Plantar callus
  50. 50. Scar tissue
  51. 51. Fissures</li></li></ul><li>Clinical features of diabetic foot <br />SIGNS OF MOTOR NEUROPATHY<br />Clawed toes<br />Raised arch of foot<br />Foot drop<br />Intrinsic muscle wasting<br />Other deformities<br />SIGNS OF AUTONOMIC NEUROPATHY<br />Dry skin<br />Fissuring<br />Distended dorsal veins<br />Warm foot<br />Increased blood flow<br />Bounding pulses<br />
  52. 52. Various Presentations of diabetic foot<br />Fissures<br />Abscesses<br />Cellulitis<br />Ulcers<br />Gangrene<br />Claw Toes<br />Charcot foot<br />
  53. 53. Wagner ulcer classification system<br />
  54. 54. Role of Physiotherapy<br />
  55. 55. “The Whole problem is really one of mechanics not of Medicine”- Dr Paul Brand<br />
  56. 56. Assessment and Investigations<br />History <br />Neurological Examination (sensory)<br />Foot Biomechanical Assessment<br />Wound assessment<br />Radiological Examination<br />Pedobarography<br />F - Scan<br />
  57. 57. Examinations<br />1. Touch and pressure - Semmes Weinstein Nylon Monofilament 10gm<br /> 2. Vibration Perception Threshold (VPT)- by tuning fork<br />3. Thermal thresholds i.e. sensation of heat and cold<br />4. Foot pressure measurements by pedobarograph<br />5.Reflex assessment by using tendon hammer <br />
  58. 58. Foot Functional Assessment<br />Ask the patient to walk on the spot for a few seconds.<br />Ask the patient to stop, stand still and look straight ahead.<br />Look at the heel to see it turns in or out.<br />Everted Heel<br />Normal Heel<br />Inverted Heel<br />
  59. 59. Interventions<br />Prevention<br />Therapeutic Exercises<br />Health Education & Home care activities<br />Splinting<br /> Modalities<br />Footwear<br />Orthosis<br />Prosthesis<br />
  60. 60. Prevention and Education <br />Proper education about insensitive foot<br />Regular examination of the sole of the foot<br />Immediate reporting if there is any change in sensory perception or motor abnormality<br />Checking nails for blood flow or any discoloration<br />Check feet regularly for blood circulation, and blisters, callus, corns, wound<br />
  61. 61. Contd….<br />Soak the feet for 20-30 minutes in cold water to keep the foot supple and smooth (especially those who have fissures and cracks) <br />Dress the wound properly<br />Give adequate rest to the affected part<br />Avoid long distance walking <br />Wear Proper Footwear<br />
  62. 62. Aim of physiotherapist in diabetic foot clinic<br /><ul><li>To control and maintain blood glucose level
  63. 63. To check the area at risk of foot ulcers and give utmost care to that risky areas
  64. 64. To educate the foot care and prevention methods
  65. 65. To advice proper footwear
  66. 66. To educate do’s and don'ts during daily activities properly</li></li></ul><li>Contd..<br />To advice proper foot splints <br />To minimize neuropathic pain<br />To prevent deformities<br />To improve muscle power and prevent muscle wasting<br />To increase range of motions, strength, endurance<br />To prevent limited joint mobility <br />
  67. 67. <ul><li>Physiotherapy can help people to maintain good blood glucose control and achieve optimal weight
  68. 68. Isotonic exercise like jogging, running, walking will benefit a person with diabetes
  69. 69. LMJ mobility is corrected by teach active exercise to toes and foot
  70. 70. Neuropathy pain to be corrected by the TENS and Interferential therapy
  71. 71. HVPC (High voltage pulsed galvanic current) also used to enhance wound healing
  72. 72. Electrical stimulation will enhance wound healing</li></ul>Means <br />
  73. 73. <ul><li>Exercise - Burger-Allen exercises will facilitate and activate the blood circulation in lower extremities
  74. 74. To teach Off Loading techniques that means train crutch walking, wheel chair training
  75. 75. During off loading its necessary to prevent muscle wasting by active physio for leg & foot muscles
  76. 76. To identify the excessive pressure areas and advice suitable foot wears
  77. 77. To concentrate the dry skin to avoid that advice soaking training in cold water</li></ul>Contd..<br />
  78. 78.
  79. 79. Objectives of diabetic foot wear<br />Relief of excessive plantar pressure<br />Reduction of shock <br />Reduction shear (frictional forces) <br />Accommodation of minimal deformity<br />Stabilization of deformity <br />Preventing recurrence of ulcer<br />
  80. 80. Splinting<br />Total contact Cast is the appropriate way of resting the foot with diabetic plantar ulcer<br />It Distributes weight along the entire plantar aspect of the foot. <br />It Reduces shear forces normally present between the foot and shoe. <br />It Produces shortened stride length and a decreased walking velocity. <br />
  81. 81. Various types of Rocker Soles<br />Mid rocker soles – to relieve pressure metatarsal <br />Heel to toe rocker soles – fixed claw toes, hammer toes, calcaneal ulcers<br />Toe only rocker soles – ulcer metatarsal heads<br />Severe angle rocker sole – hallux rigidus, ulcer on the distal part of toe, hammer toe, ulcer metasal heads <br />Negative heel rocker sole – fixed ankle in dorsiflexion<br />
  82. 82. Do’s<br /><ul><li>Inspect the feet daily using mirror (especially b/w toes, pressure areas)
  83. 83. Wash feet daily water
  84. 84. Apply lotion, oil to feet after drying
  85. 85. Avoid extremes of temperature
  86. 86. Have your feet checked at each clinic visit
  87. 87. Inspect shoes daily for defects/foreign bodies
  88. 88. Change shoes often
  89. 89. Regular skin and nail care</li></li></ul><li>DONT’S<br /><ul><li>Walk barefoot
  90. 90. Smoke
  91. 91. Step into the bath before checking water temperature
  92. 92. Use heating pads
  93. 93. Perform bathroom surgery
  94. 94. Use chemical agent to treat corns or calluses
  95. 95. Wear new shoes for more than an hour at a time</li></li></ul><li>Conclusion<br />Physiotherapist are likely to treat patients<br />for diabetes related complications. Therapist<br />may also have a role in preventing<br />complications secondary to diabetes. So we are<br />the peoples more responsible to treat and prevent<br />the diabetic foot ulcers for diabetes patients <br />“PREVENTION IS BETTER THAN CURE”<br />
  96. 96. Thank You<br />