The document provides guidance on managing neuropathic foot ulcers in diabetes patients. It recommends daily foot examination for issues like blisters and increased temperature. Treatment includes good glycemic control, managing infections and edema, and offloading pressure through total contact casts. Preventive measures involve regular inspection, footwear choices, and patient education.

1. 1
Daily Foot ExaminationDaily Foot Examination
• Check For:Check For:
• BlistersBlisters
• BleedingBleeding
• InjuryInjury
• SmellSmell
• Increased temperature at pressure pointIncreased temperature at pressure point

2. 2
Management of NeuropathicManagement of Neuropathic
Ulcer - 1Ulcer - 1
– General measuresGeneral measures
– Specific measuresSpecific measures

3. 3
Management of NeuropathicManagement of Neuropathic
Ulcer - 2Ulcer - 2
• Good glycemic controlGood glycemic control
• Treatment of infectionsTreatment of infections
• Management of neuropathic oedemaManagement of neuropathic oedema

4. 4
Management of NeuropathicManagement of Neuropathic
Ulcer - 3Ulcer - 3
• All ulcers irrespective of their cause willAll ulcers irrespective of their cause will
be slow to heal in presence of oedema,be slow to heal in presence of oedema,
due impairment of local flowdue impairment of local flow
• Neuropathic oedema can be treatedNeuropathic oedema can be treated
withwith
– DiureticsDiuretics
– Ace inhibitorsAce inhibitors
– Ephedrine ( 30 mg tds )Ephedrine ( 30 mg tds )
– D/d: hypoalbuminemia cardiacD/d: hypoalbuminemia cardiac

5. 5
Management of NeuropathicManagement of Neuropathic
Ulcer - 4Ulcer - 4
• ““Over 90% of predominantly neuropathicOver 90% of predominantly neuropathic
• ulcers will heal satisfactorily withulcers will heal satisfactorily with
• conservative measures”conservative measures”

6. 6
Management of NeuropathicManagement of Neuropathic
Ulcer - 5Ulcer - 5
• ““Key to the management is the relief ofKey to the management is the relief of
• pressure that caused the initial lesion”pressure that caused the initial lesion”
• Pressure is off loaded most effectivelyPressure is off loaded most effectively
byby
• encasing the foot in a light plaster ofencasing the foot in a light plaster of
parisparis
• cast.cast.
– *Total contact cast*Total contact cast

7. 7
• You can put almost anything on theYou can put almost anything on the
ulcer except the patients weight – saysulcer except the patients weight – says
the Australian Podiatristthe Australian Podiatrist
Management of NeuropathicManagement of Neuropathic
Ulcer - 6Ulcer - 6

8. 8
Foot at risk - 1Foot at risk - 1
• Our job – look after “NDF at risk”Our job – look after “NDF at risk”
• A: Preventive measuresA: Preventive measures
• Treatment - rapid and intensiveTreatment - rapid and intensive
• RestRest
• Off loadOff load
• AntibioticsAntibiotics
• Foot wearFoot wear
• Patient educationPatient education

9. 9
Foot at Risk - 2Foot at Risk - 2
• B. Metabolic controlB. Metabolic control
– HyperglycemiaHyperglycemia
– HypertensionHypertension
– HyperlipidaemiaHyperlipidaemia
– Cessation of smokingCessation of smoking
• C. Deformity managementC. Deformity management
• D. Callus managementD. Callus management
• E. Debridement and dry skin and fissureE. Debridement and dry skin and fissure

10. 10
Foot at risk - 3Foot at risk - 3
• F. Mechanical controlF. Mechanical control
– Off load, Off load, Off loadOff load, Off load, Off load
• by rest, crutches, walkers, protective shoes,by rest, crutches, walkers, protective shoes,
heel protective pad, decrease plantarheel protective pad, decrease plantar
pressure by removal calluspressure by removal callus
• G. The importance of callus removal in NFUG. The importance of callus removal in NFU
• decrease plantar pressuredecrease plantar pressure
• shows full dimension of the ulcershows full dimension of the ulcer
• deep swab possibledeep swab possible
• drainage of exudate, removal of dead tissuedrainage of exudate, removal of dead tissue
• H. Infection controlH. Infection control
• I. Educational controlI. Educational control

11. 11
Acute Chronic
Assess Assess vascular Status
Vascular status
A/B index > 0.7
Peripheral pulses A/B Index Assess Extent
weak / not palpable > 0.7 of Infection
A/B index < 0.5
Localised wound Deeper Inf. No Charcot Charcot Foot
Colour Doppler CT Scan
Conservative Treatment Dedridement on Rule out MRI Complete rest
Angiography Anatomical Principles Osteomyelitis Nuclear plaster cast
scan antibiotics
Revascularization Revacularization Dressing Contact Surgery
not feasible off loading cast CT. off loading
Strict & POP cast
Surgery Angioplasty Gene Therapy Higher Amputation Rehab Reconstruction off loading Till stage of
Footwear dressing reformation
Ischaemic pain
No ischaemic pain Prolonged Gradual
antibiotic cover Mobilisation
Strict off loading
Gradual Foot wear
Auto amputation Mobilisation restricted
Activity
Foot wear
SURGICAL TREATMENT OF
Assess Neuropathy
Rule out Charcot Foot
WOUND
DIABETIC FOOT
By Dr. Arun Bal

12. 12
Preventing Neuropathic FootPreventing Neuropathic Foot
Ulcers - 1Ulcers - 1
• Regular inspection of foot - annuallyRegular inspection of foot - annually
• Identification of high risk feet – 3 mo / 6moIdentification of high risk feet – 3 mo / 6mo
• Careful choice of foot wearCareful choice of foot wear
• Regular chiropodyRegular chiropody
• Intense educationIntense education

13. 13
Preventing neuropathic footPreventing neuropathic foot
ulcers - 2ulcers - 2
• ““As little as one hour’s educationAs little as one hour’s education
provided by the podiatrist resulted in 70%provided by the podiatrist resulted in 70%
reduction in amputations over thereduction in amputations over the
following 2 years . as compared with afollowing 2 years . as compared with a
control group who did not receive thecontrol group who did not receive the
advice”advice”
 Malone IM et al 1989Malone IM et al 1989

14. 14
Glycemic control and diabeticGlycemic control and diabetic
neuropathyneuropathy
• Diabetes control and complication trialDiabetes control and complication trial
• showed that intensive insulin therapyshowed that intensive insulin therapy
• reduced the incidence of appearance ofreduced the incidence of appearance of
• neuropathy by about 70%neuropathy by about 70%

15. 15
Daily Foot ExaminationDaily Foot Examination
• Check For:Check For:
• BlistersBlisters
• BleedingBleeding
• InjuryInjury
• SmellSmell
• Increased temperature at pressure pointIncreased temperature at pressure point

16. 16
Management of NeuropathicManagement of Neuropathic
Ulcer - 1Ulcer - 1
– General measuresGeneral measures
– Specific measuresSpecific measures

17. 17
Management of NeuropathicManagement of Neuropathic
Ulcer - 2Ulcer - 2
• Good glycemic controlGood glycemic control
• Treatment of infectionsTreatment of infections
• Management of neuropathic oedemaManagement of neuropathic oedema

18. 18
Management of NeuropathicManagement of Neuropathic
Ulcer - 3Ulcer - 3
• All ulcers irrespective of their cause willAll ulcers irrespective of their cause will
be slow to heal in presence of oedema,be slow to heal in presence of oedema,
due impairment of local flowdue impairment of local flow
• Neuropathic oedema can be treatedNeuropathic oedema can be treated
withwith
– DiureticsDiuretics
– Ace inhibitorsAce inhibitors
– Ephedrine ( 30 mg tds )Ephedrine ( 30 mg tds )
– D/d: hypoalbuminemia cardiacD/d: hypoalbuminemia cardiac

19. 19
Management of NeuropathicManagement of Neuropathic
Ulcer - 4Ulcer - 4
• ““Over 90% of predominantly neuropathicOver 90% of predominantly neuropathic
• ulcers will heal satisfactorily withulcers will heal satisfactorily with
• conservative measures”conservative measures”

20. 20
Management of NeuropathicManagement of Neuropathic
Ulcer - 5Ulcer - 5
• ““Key to the management is the relief ofKey to the management is the relief of
• pressure that caused the initial lesion”pressure that caused the initial lesion”
• Pressure is off loaded most effectivelyPressure is off loaded most effectively
byby
• encasing the foot in a light plaster ofencasing the foot in a light plaster of
parisparis
• cast.cast.
– *Total contact cast*Total contact cast

21. 21
• You can put almost anything on theYou can put almost anything on the
ulcer except the patients weight – saysulcer except the patients weight – says
the Australian Podiatristthe Australian Podiatrist
Management of NeuropathicManagement of Neuropathic
Ulcer - 6Ulcer - 6

22. 22
Foot at risk - 1Foot at risk - 1
• Our job – look after “NDF at risk”Our job – look after “NDF at risk”
• A: Preventive measuresA: Preventive measures
• Treatment - rapid and intensiveTreatment - rapid and intensive
• RestRest
• Off loadOff load
• AntibioticsAntibiotics
• Foot wearFoot wear
• Patient educationPatient education

23. 23
Foot at Risk - 2Foot at Risk - 2
• B. Metabolic controlB. Metabolic control
– HyperglycemiaHyperglycemia
– HypertensionHypertension
– HyperlipidaemiaHyperlipidaemia
– Cessation of smokingCessation of smoking
• C. Deformity managementC. Deformity management
• D. Callus managementD. Callus management
• E. Debridement and dry skin and fissureE. Debridement and dry skin and fissure

24. 24
Foot at risk - 3Foot at risk - 3
• F. Mechanical controlF. Mechanical control
– Off load, Off load, Off loadOff load, Off load, Off load
• by rest, crutches, walkers, protective shoes,by rest, crutches, walkers, protective shoes,
heel protective pad, decrease plantarheel protective pad, decrease plantar
pressure by removal calluspressure by removal callus
• G. The importance of callus removal in NFUG. The importance of callus removal in NFU
• decrease plantar pressuredecrease plantar pressure
• shows full dimension of the ulcershows full dimension of the ulcer
• deep swab possibledeep swab possible
• drainage of exudate, removal of dead tissuedrainage of exudate, removal of dead tissue
• H. Infection controlH. Infection control
• I. Educational controlI. Educational control

25. 25
Acute Chronic
Assess Assess vascular Status
Vascular status
A/B index > 0.7
Peripheral pulses A/B Index Assess Extent
weak / not palpable > 0.7 of Infection
A/B index < 0.5
Localised wound Deeper Inf. No Charcot Charcot Foot
Colour Doppler CT Scan
Conservative Treatment Dedridement on Rule out MRI Complete rest
Angiography Anatomical Principles Osteomyelitis Nuclear plaster cast
scan antibiotics
Revascularization Revacularization Dressing Contact Surgery
not feasible off loading cast CT. off loading
Strict & POP cast
Surgery Angioplasty Gene Therapy Higher Amputation Rehab Reconstruction off loading Till stage of
Footwear dressing reformation
Ischaemic pain
No ischaemic pain Prolonged Gradual
antibiotic cover Mobilisation
Strict off loading
Gradual Foot wear
Auto amputation Mobilisation restricted
Activity
Foot wear
SURGICAL TREATMENT OF
Assess Neuropathy
Rule out Charcot Foot
WOUND
DIABETIC FOOT
By Dr. Arun Bal

26. 26
Preventing Neuropathic FootPreventing Neuropathic Foot
Ulcers - 1Ulcers - 1
• Regular inspection of foot - annuallyRegular inspection of foot - annually
• Identification of high risk feet – 3 mo / 6moIdentification of high risk feet – 3 mo / 6mo
• Careful choice of foot wearCareful choice of foot wear
• Regular chiropodyRegular chiropody
• Intense educationIntense education

27. 27
Preventing neuropathic footPreventing neuropathic foot
ulcers - 2ulcers - 2
• ““As little as one hour’s educationAs little as one hour’s education
provided by the podiatrist resulted in 70%provided by the podiatrist resulted in 70%
reduction in amputations over thereduction in amputations over the
following 2 years . as compared with afollowing 2 years . as compared with a
control group who did not receive thecontrol group who did not receive the
advice”advice”
 Malone IM et al 1989Malone IM et al 1989

28. 28
Management involvesManagement involves
• Bed restBed rest
• Pressure offloadingPressure offloading
• Reduction of edemaReduction of edema
• Glycemic controlGlycemic control
• Most important step is the early detectionMost important step is the early detection
• of a high risk foot by simple tests / fewof a high risk foot by simple tests / few
• quantitative testsquantitative tests