Diabetic Foot, Prevalence, how to approach, Assessment of risk factors, Examination, treatment of diabetic foot at Primary Care Center.

1. Diabetic Foot

2. Dr Wafa Sheikh
Consultant Family Medicine
Trainer at Family Medicine Post Graduate Acadmy

3. Reflection 10 min
Learning 40 min
Activity 1 25 min
Activity 2 20 min
Activity 3 10 min
planning 5 min
Sum-up and close 5 min

4. Reflection
• Do I always consider foot care when reviewing a patient with diabetes?
• If not, why?, and is it something I should be doing?
• How often should it be done?
• Can this help make a difference to disease progression / prognosis?
• What do the statistics tell us?
• What are the current guidelines?

5. Learning outcome
1. Take a history to assess risk or extent of diabetic foot disease
2. Undertake a physical examination of lower limbs to assess risk or
extent of foot disease in a diabetic patient
3. Advise a patient living with diabetes about foot care in order to
minimize their risk of foot disease

6. Is it common ?
Global diabetic foot ulcer prevalence was
6.3% (95%CI: 5.4-7.3%), which was higher in
males (4.5%, 95%CI: 3.7-5.2%) than in
females (3.5%, 95%CI: 2.8-4.2%), and
higher in type 2 diabetic patients (6.4%,
95%CI: 4.6-8.1%) than in type 1 diabetics

7. Is it common ? In KSA?
The study Included patients previously
diagnosed with diabetes mellitus who
presented to the hospital with either
diabetic foot ulcers or foot gangrene
Among the participants, 84.9%
underwent amputation.
The most common cause of
amputation was infection (50.3%).

9. How large is the cost?
The overall cost of managing a patient
with DFU/ year is approximately 6684.9
SAR
The highest cost was for admission
expenditure (45.6%),
followed by debridement (14.5%) and
intensive care unit (ICU) admission
(10.4%).

10. A etiology?

12. Comprehensive diabetic foot assessments and foot care,
based on prevention, education and a multi-disciplinary
team approach, may reduce foot complications and
amputations by up to 85%

13. Assessment
According to ADA 2022 recommendations:
Screening for peripheral neuropathy and peripheral arterial disease
can help identify patients at risk of foot ulcers.
Patients with evidence of sensory loss or prior ulceration or
amputation should have their feet inspected at every visit.

14. What to ask?
Does the patient have a history of :
•previous leg/foot ulcer or lower limb amputation/surgery?
•prior angioplasty, stent, or leg bypass surgery?
•foot wound requiring more than 3 weeks to heal?
•smoking or nicotine use ?
•diabetes control ?
Does the patient have :
•burning or tingling in legs or feet?
•leg or foot pain with activity or at rest ?
changes in skin color, or skin lesions?
•loss of lower extremity sensation ?
https://diabetesed.net/wp-content/uploads/2017/05/3-minute-foot-exam.pdf

15. What to look for?

16. FOOT EXAMINATION
VISUAL INSPECTION
Hammer toe
Ingrowing nail

17. VISUAL INSPECTION
Bunions
hallux valgus Blistering

18. Dried and Cracked Foot
VISUAL INSPECTION

19. Onychomycosis & tines pedis
VISUAL INSPECTION

20. Charcot Foot/A rocker-bottom deformity
VISUAL INSPECTION

21. NEUROPATHY ASSESSMENT
Testing vibration sensation by
tuning fork
With a 128 Hz tuning fork applied
to the bony prominence at the
dorsum of the first toe.
Vibration
sensation

22. The 10-g monofilament
it is the most useful test to diagnose LOPS
(loss of protective sensation)
should be performed with at least one other
assessment (pinprick, temperature or
vibration sensation using a 128-Hz tuning fork,
or ankle reflexes).
Retinopathy, Neuropathy, and Foot Care: Standards of Medical
Care in Diabetes—2022
Pressure sensation

23. The 10-g monofilament

24. Ankle reflex

25. Vascular (PAD) ASSESSMENT
✓Palpation of arterial pulses .
✓Ankle brachial index (ABI).

26. PAD is a component cause in approximately one-third of foot ulcers and is
often a significant risk factor associated with recurrent wounds
PAD. ASSESSMENT

27. Taking Brachial pressure: TakingAnkle pressure;
PAD. ASSESSMENT

29. Divide the systolic blood pressure of the ankle by the systolic blood
pressure of the arm. You will calculate the ABI for each leg individually.
Use the highest value from your readings of the left ankle arteries and
divide it by the value of the brachial artery. Then repeat this process
with the results from the right ankle.[8]Example: The systolic blood
pressure of the left ankle is 120 and the systolic blood pressure of the
arm is 100. 120/100=1.20

30. Interpretation of ankle brachial index (ABI)

31. DIABETIC FOOT INFECTION
❖Diabetic patient have poor defense against infection.
❖Minor cut and abrasion can turn into infection.
❖It is essential to distinguish between localized and generalized foot
infection.

32. DIABETIC FOOT INFECTION
● Diabetic foot infection typically take one of the
following forms:
➢Cellulitis
➢Deep-skin and soft-tissue infection
➢Acute osteomyelitis
➢Chronic osteomyelitis.

33. The presence of a diabetic foot infection is usually presumed if these
conditions are present:
At least two of the following – Erythema, warmth, tenderness, or swelling
or
Pus coming out of an ulcer site and/or a nearby sinus tract
Uptodate

34. DIABETIC OSTEOMYELITIS
Suspected if:
Bone can be seen at the floor of a deep ulcer
Ulcer size larger than 2 X2 cm
Difficult ulcer to heal( >2months) despite optimal
treatment.
Unexplained high ESR

35. Wagner classification system

36. ULCER CLASSIFICATION
University of Texas system
It evaluates wound depth, the presence of infection, and peripheral
arterial occlusive disease for every category of the wound assessment .
The UT system was the first diabetic foot ulcer classification to be
validated .
This system updated the Wagner classification
https://www.uptodate.com/contents/management-of-diabetic-foot-
ulcers?search=University%20of%20Texas%2
0system&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H3764347

37. ULCER CLASSIFICATION
University of Texas system
Grade:
Grade 0: Pre- or postulcerative (Stages A to D)
Grade 1: Full-thickness ulcer not involving
tendon, capsule, or bone (Stages A to D)
Grade 2: Tendon or capsular involvement
without bone palpable (Stages A to D)
Grade 3: Probes to bone (Stages A to D)
Stage:
A: Noninfected
B: Infected
C: Ischemic
D: Infected and ischemic

38. local infection with more than 2cm erythema or involving
deeper structures (such as abscess, osteomyelitis, septic
arthritis or fasciitis)
Severity classification of diabetic
foot ulcer
Mild local infection with 0.5 to less than 2cm erythema
Moderate
Severe
local infection with signs of a systemic inflammatory
response

39. TYPES OF ULCERS
Neuropathic
Ischemic
Venous
Sole/ pressure area
Gaiter region
Site
Deep
Superficial
Depth
Punched out
Sloping
Edges
Sloughy &Bloody
Sloughy &Pale
Granulated
Base
Red
Pale
Pink
Colour
Non-painful
Painful
Moderate
Pain
Sensory neuropathy
Loss of peripheral
pulse
Varicose
Venous eczema
Hemosiderin deposit
Other
characteristic

41. TYPES OF ULCERS

42. Management..
Appropriate care of the feet among patients with diabetes can save
them from one of the devastating consequences of diabetes Limb
complications such as amputation.
early detection and effective management is one of major role in
management since prevention may not eradicate all foot problems.
Narrative review: Diabetic foot and infrared thermography - ScienceDirect

43. Can it be treated at PHC?
Type of treatment for diabetic foot ulcer
Reassessment and Follow up plan
Advice given to the patient
prevention

44. Can it be treated at PHC?
Callous or Corn
Fungal infection
ingrown toenails
plantar warts
Mild non infected ulcer
Mild infected ulcer

45. limb-threatening and life-threatening diabetic foot
problems include the following:
ulceration with fever or any signs of sepsis
ulceration with limb ischaemia
clinical concern that there is a deep-seated soft tissue
or bone infection (with or without ulceration)
gangrene (with or without ulceration).
Refer to emergency
for all other active diabetic foot problems
multidisciplinary foot care
service or foot protection
service within 1 working day

47. Off loading DFUs
Total contact cast or irremovable fixed ankle waking boot
Severe foot ischemia, a deep abscess,
osteomyelitis, and poor skin quality
contraindication
Update on management of diabetic foot ulcers (nih.gov)

48. Removable cast walker
surgical sandal or heel
relief shoe
pressure-relieving insoles
Crutch
Off loading DFUs
Wheelchair
Update on management of diabetic foot ulcers (nih.gov)

49. Dressing
Should be free from contaminants,
be able to remove excess exudates and toxic components,
maintain a moist environment at the wound-dressing interface,
be impermeable to microorganisms,
allow gaseous exchange,
easily removed and cost-effective
Management of Diabetic Foot Ulcers (nih.gov)

50. Type of Dressing

51. Debridement
Non surgical
Autolytic debridement Enzymatic debridement
Mechanical
debridement Biosurgery
Surgical
Sharp
Debridement
(Gold Standard)
Hydrogels
dressing
Clostridial
collagenase
ointment (CCO)
is the most
common agent
used
Maggot and larval
debridement
Hydrotherapy
The
Verajet™ hydros
urgery system
Update on management of diabetic foot ulcers (nih.gov)

52. Treatment course of maggot therapy.
(a) Before maggot therapy. Necrotic tissue is seen on the surface of the wound.
(b) After one session (48 h) of treatment, the reduction of necrotic tissues is
seen.
(c) Maggots growing from second to third instar larvae.
(d) After six sessions of treatment, debridement was conducted to the deep
portion from the ulcerated base, and favorable granulation can be seen on the
amputated surface.

53. Treatment of infection

54. Antibiotics for mild diabetic foot
infection in adults

55. • When microbiological results are available:
review the choice of antibiotic and change the antibiotic according to results, using a
narrow-spectrum antibiotic, if appropriate.
• symptoms worsen rapidly or significantly at any time.
• do not start to improve within 1 to 2 days.
• the person becomes systemically very unwell or has severe pain out of proportion to
the infection Take account of:
other possible diagnoses, such as pressure sores, gout or non-infected ulcers
any symptoms or signs suggesting a more serious illness or condition, such as limb
ischemia, osteomyelitis, necrotizing fasciitis or sepsis
previous antibiotic use
Reassessment

57. Prevention of diabetic foot
Good glycemic control
Regular foot assessment
Appropriate footwear
Patient education
Early referral for pre-ulcerative lesions

58. ACTIVITY 1
Physical Examination

59. CASE CENARIO………..
Asma 55-year-old with history of type 2 diabetes mellitus for 15
years presents to the Family Medicine clinic for follow-up visit.
MEDICAL HX: No past medical hx except D.M.
MEDICATION USED: Metformin and sitagliptin.
FAMILY HX: her mother and an older brother both have type 2D.M.
Height:165cm weight:75kg BMI:27.5kg/m2.
Blood pressure:135/80mmHg. pulse:76beats/min.
TASK: How to examine this pt ?

60. • Inspection:
General : Gait & shoes “ Flat , pattern of wear “
Skin : Vascular insufficiency “ hair , pallor “ dry or shiny, muscle wasting , corn , callus ,
fissure
Nail : dystrophic , ingrowing
Webspace : Cracked , infected , ulcer , maceration
Deformity : clow toe , bony prominence , Charcot's joint
Ulceration :( current or previous).
if present describe number, site, size, depth, appearance, any discharge, smell,
exposed underlying structures, as tendons, joint capsule, or bone • Signs of inf:
Erythema, warmth, tenderness, or swelling, Pus coming out of ulcer site
Foot examination :

61. • Palpation : ( ARTEROPATHY)
PAD. ASSESSMENT
Temperature : use dorsum of each hand to feel up to leg
Pulses : dorsalis pedis , posterior tabia ,popliteal and femoral
Capillary refill :
Ankle brachial index (ABI).
Foot examination :

62. • Palpation : ( ARTEROPATHY)
PAD. ASSESSMENT
Buerger’s Test
Foot examination :

63. Palpation : (Neuropathy)
Sensory : show patients how each feels on sternum before
and get them to close their eyes
• Monofilament : Testing touch pressure sensation
Foot examination :

64. Palpation : (Neuropathy)
Sensory
128 Hz Tuning forks : Testing vibration sensation
Foot examination :

65. Palpation : (Neuropathy)
Sensory
proprioception: Testing Position sensation
Foot examination :

66. Palpation : (Neuropathy)
Motor : Charcot's joint
Reflexes : ankle jerk
Foot examination :

67. EXAMINATION OF THE ULCER
 Classification
 Ischemia
 Deformity
 Size depth, location,
 Ulcer bed color
 Exposed bone, necrosis.
 Gangrene
 Infection
 Local pain
 Exudate
 Ulcer edge
Foot examination :

68. CASE SCENARIO….
Asma 55-year-old female with history of type 2 diabetes mellitus for 15 years presents to the
Family Medicine clinic for follow-up visit.
MEDICAL HX: No past medical hx except D.M.
MEDICATION USED: Metformin and sitagliptin.
FAMILY HX: Her mother and an older brother both have type 2D.M.
PHYSICAL EXAMINATION: Height:165cm weight:75kg bmi:27.5kg/m2.
Blood pressure:135/80mmHg. pulse:76beats/min.
Physical examination :otherwise unremarkable except foot examination reveals :
Tinea Pedis.
TASK: COUNSEL PATIENT ACCORDING TO HER FOOT CARE AS A DIABETIC PATIENT.

69. Foot examination :

70. Counseling using 5AS

71.  A-Introduce yourself and establish good rapport.
B-ASK:
-How long have you been diabetic? Treatment used? level of control ?
-Any previous foot injury, infections, nail problems, accidental foreign bodies.
-Any end organ damage :kidney diseases decrease (eGFR) or microalbuminuria,
eye or cardiac diseases.
-Ideas concern expectations.
-Medication used .
-Brief past medical history family hx and social hx.
C-ADVISE:
Foot problem among diabetes mellitus patient are common, treating it early is very
important to prevent serious complications. This is because healing is slow in
diabetes due to decrease blood supply and less sensitive nerve.

72. D-ASSESS:
YOU MUST INSPECT YOUR DIABETIC PATIENT FEET EVERY VISIT.
Current care routine; ability of patient to take care of the foot.
Assess presence of family support.
E-ASSIST:
Most people can prevent any serious foot problem by following some STEPS:
DON’T FORGET THE FIRST THING TO HELP YOURSELF FROM DIBETIC FOOT COMPLICATION
(CONTROL YOUR DIABETES MELLITUS )
THEN we should follow this plane that’s help you:
1-Wash and dry between your toes daily check the warmth of the water before washing your
feet
2-Prevent foot dryness by applying petrolium jelly.
3-Use non _tight foot wear and wear cotton socks and change them daily.

73. 4-Avoid walking on bare feet.
5-Check your feet in front of mirror every night and look for any
complications such as wounds, corns, callosities, soggy skin
between toes like that fungal infection.
6-If you notice any wound you must wash it with tape water ,cover
it with clean gauze and see your doctor within 2 days maximum.
7-Keep the blood flowing to your feet ,put your feet up when sitting.
8-Don’t cross your leg for long period of time.

74. 9-Trim your toenail straight across, and avoid cutting them
down the slides or too short and you can use a nail file to
remove any sharp edges to prevent the toenail from digging
into your skin.
10-NEVER cut your cuticles or allow any one to remove (manicurist)
11-Avoid activities that can injure your feet.
12-Avoid smoking as smoking can worsen heart and vascular
problem.
13-Health education about diet and exercise as she is over weight

75. DON’T FORGET TTT OF CURRENT PROBLEM
TTT of tinea pedis
1st line topical allylamine and azoles antifungal therapy.
E.g. butenafine ,ciclopirox, tolnaftate cream BID for 4 weeks
or terbinafine 1% cream BID for one week.
If local TTT failed we can use oral antifungal.
F-ARRANGE
-FOLLOW up after TTT .tell your patient to revisit you after one week.
-Brief assessment of underlying conditions and age appropriate
screening
-Give away reading material if available.

76. Ask your patient to summarize and check her understanding
and finally thank your patient .
Don’t forget communication skills:
1-Ensure organized approach.
2-Mixed question style (open and closed ended. question)
3-Active listening.
4-Clear language.
5-Reflection on patient ideas, concern and expectations.

77. Awareness of Diabetic Foot Disease Risks
Activity 3

79. A 52-year-old man with history of type 2 diabetes mellitus for 20
years presents to the Family Medicine clinic for follow-up visit. His
current medications are Metformin, Gliclazide and Sitagliptin. Foot
examination reveals poor fitting footwear, callus present on soles of
feet, loss of sensation at great toe and pedal pulses are palpable.
Case Scenario……

80. A 52-year-old man with history of type 2 diabetes mellitus for 20
years presents to the Family Medicine clinic for follow-up visit. His
current medications are Metformin, Gliclazide and Sitagliptin. Foot
examination reveals poor fitting footwear, callus present on soles
of feet, loss of sensation at great toe and pedal pulses are
palpable.
Case Scenario

81. Time for discussion
What additional information is required to complete
foot physical examination in this patient?

82. Time for discussion
What additional information is required to complete foot
physical examination in this patient?
 Evidence of Foot ulcer (a wound that took > 2 weeks to heal)
now or in the past
 Any foot Deformity or Lesions (Deformed nails - Hallux valgus
- Fungal infection)
 Patient able to see the bottom of feet or unable

83. Time for discussion
Identify two factors that might increase risk of foot
ulcer in this patient?

84. Time for discussion
Identify two factors that might increase risk of foot ulcer
in this patient?
 Presence of Callus
 Poor fitting footwear
 Loss of sensation at great toe

85. Time for discussion
How can you classify the level of diabetic foot risk?

86. Time for discussion
How you can classify the level of diabetic foot risk

87. Diabetic foot: Primary care Risk Assessment

88. Diabetic foot: Primary care Risk Assessment

89. Diabetic foot: Primary care Risk Assessment

90. Recommendations:
Awareness of good foot care is essential amongst T2DM patients to
reduce the incidence of foot disease, and this would involve:
 Preventing and managing local trauma and/or infection
 Dealing with foot deformities
 Improving poor glycemic control
 Managing pre-existing vascular damage and/or peripheral neuropathy
 Managing associated cardiovascular diseases
 Improving awareness and self-practice of foot care

91. Planning
• Deciding to review ADA 2022 ,IDF, NICE or other guidelines
• Practicing physical examination skills.
• Learning more about ABPI measurement and using Doppler .
• Making a practical change such a downloading the BMJ visual aid to
their desktop for use as a guide (link provided in Resources section of
this document), or downloading/ordering patient information leaflets
• Discussing options for referral with their trainers
• To review foot care annually in all diabetic patients.

92. THANK YOU