Podiatric Medicine: Your Partner in Patient Care

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1 Podiatric Medicine: Your Partner in Patient Care Craig Herman, D.P.M. Diplomat A.B.P.O.P.P.M. Director of Podiatry, Community Healthcare Network Advanced Foot Care, Bronx, New York; Owner/Operator

2 Diabetes and It s Effects on the Feet: Identification and Prevention of Pedal Problems in the Primary Care Setting Target Audience: Primary Care Providers Nurses Health Educators Quality Improvement Staff

3 Diabetes and It s Effects on the Feet: Identification and Prevention of Pedal Problems in the Primary Care Setting Overview of Program: Podiatric Medicine Overview Diabetes Statistics Potential complications of diabetes manifesting in the feet. Diabetic Peripheral Neuropathy Peripheral Vascular Disease Charcot Arthropothy Ulcerations and Amputations

4 Diabetes and It s Effects on the Feet: Identification and Prevention of Pedal Problems in the Primary Care Setting Overview continued: Screening for pedal complications in Diabetics in the Primary Care setting Medicare Diabetic Shoe Program, Custom Molded Orthotics and Braces; including footwear recommendations. Do s and Don ts for patient s with Diabetes

5 Diabetes and It s Effects on the Feet: Identification and Prevention of Pedal Problems in the Primary Care Setting Goals: Perform a basic pedal exam to screen for complications in the feet related to Diabetes. Identify the signs and symptoms of Diabetic Peripheral Neuropathy and Peripheral Vascular Disease Be aware of the Medicare Diabetic Shoe Program. Have the knowledge and confidence to educate patients on the Do s and Don ts in home foot care for Diabetics.

6 Podiatric Medical Education and Training Four year undergraduate degree: Bachelor of Arts from SUNY at Buffalo Four years of Podiatric Medical School: Doctor of Podiatric Medicine New York College of Podiatric Medicine 2-3 years of Residency (3 years currently required) Jamaica Hospital Medical Center DVAMC East Orange New Jersey

Partnering in Patient Care Diabetes Care Trauma Foot and Ankle Fractures, Soft Tissue Trauma (lacerations, nail injuries), Strains/Sprains, ER call

high school, college and professional, All Ages, Walking, Running, Shoe Recommendations, Orthotics Arthritis Coordinating care, Conservative Care:

7 Partnering in Patient Care Diabetes Care Trauma Foot and Ankle Fractures, Soft Tissue Trauma (lacerations, nail injuries), Strains/Sprains, ER call Dermatology Onychomycosis, Bacterial/Fungals, Blisters, Corns/Calluses, Ingrown Nails Infections, Cysts, Wart Sports Medicine Coordinating care, high school, college and professional, All Ages, Walking, Running, Shoe Recommendations, Orthotics Arthritis Coordinating care, Conservative Care: Orthotics, Shoe Modifications, Physical Therapy, Surgical Care: Joint Fusions, Joint Replacement, Joint Implantation Biomechanics Surgical Interventions

Vascular Rearfoot Pain and Injury Heel Pain

8 Biomechanics Forefoot Pain and Injury Stress Fractures and Injuries Neuromas Bursitis Capsulitis Leg Pain and Cramps Muscular vs. Vascular Rearfoot Pain and Injury Heel Pain Causes Multiple treatment options Orthotics, Physical Therapy, Surgery Achilles Tendonitis

9 Surgical Interventions Bone Deformities and Conditions Bunions Hammertoes Tumors Neuromas/Soft Tissue Lesions Ingrown Nails

10 Diabetes Statistics Diabetes affects 25.8 million people of all ages 8.3 percent of the U.S. population DIAGNOSED 18.8 million people UNDIAGNOSED 7.0 million people Among U.S. residents ages 65 years and older, 10.9 million, or 26.9 percent, had diabetes in 2010

11 Diabetes Statistics Diabetes is the leading cause of kidney failure, non-traumatic lower-limb amputations, and new cases of blindness among adults in the United States Diabetes is a major cause of heart disease and stroke Diabetes is the seventh leading cause of death in the United States. Detailed information about the data sources, methods, and references are available at

12 Diabetic Care Multi-disciplinary Care Identifying Peripheral Vascular Disease Identifying Diabetic Peripheral Neuropathy Diabetic Education and Preventive Care Wound Care Inpatient and Outpatient Diabetic Foot Care Medicare Diabetic Shoe Programs, Custom Orthotics & Braces Footwear Recommendations

13 Complications of Diabetes To decrease potential complications related to Diabetes the patient should have a target HbA1c of 6.5 or less than 7.

14 Potential Complications of Diabetes Manifesting in the Feet Peripheral Vascular Disease (PVD) [Peripheral Arterial Disease (PAD)] Peripheral vascular disease causes poor blood flow in the arms and legs that can affect the ability of a sore or cut to heal, leading to ulcers, gangrene and possible amputation. Risk factors for PVD Smoking Hyperlipidemia Obesity Hypertension Diabetes mellitus Physical Inactivity

15 Peripheral Vascular Disease Symptoms Intermittent claudication Symptoms are precipitated by walking a predictable distance and are relieved by rest. The pain of claudication usually does not occur with sitting or standing Ischemic rest pain pain in the extremity due to a combination of PVD and inadequate perfusion. Relief by placing extremity in a dependent position, so perfusion is enhanced by the effects of gravity. Skin wounds taking more than 8 to 12 weeks to heal.

16 Peripheral Vascular Disease Peripheral signs of peripheral vascular disease are the classic "5 P's": Pulselessness Pain Pallor Paralysis Paraesthesia Paralysis and paraesthesia suggest limb-threatening ischemia.

17 Ankle-brachial index (ABI) Using a Doppler, the pressure at the brachial artery and at the posterior tibialis artery is measured. The ankle systolic pressure is divided by the brachial pressure. The interpretation of ABI is as follows: : Severe peripheral arterial disease sufficient to cause resting pain or gangrene : Peripheral arterial disease sufficient to cause claudication : Normal Greater than 1.30: Noncompressible, severely-calcified vessel

18 Peripheral Vascular Disease Symptomatic patients, patient s with absent pedal pulses or an ABI less than 0.90 Refer to a vascular laboratory or vascular surgeon for further testing. May include Segmental pressures, CT, MRI, or conventional angiography, all of which assess the arterial flow. Patients with an ABI of less than 0.9 have a higher risk of coronary artery disease, stroke, and death.

19 Peripheral Vascular Disease Other Treatment Options: Programs to Stop Smoking Blood pressure control Lowering cholesterol Better management of Diabetes (blood sugar) Medications to prevent clotting Healthy diet Exercise program

20 Potential Complications of Diabetes Manifesting in the Feet Diabetic Peripheral Neuropathy (DPN) The presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes. Affecting up to 50% of patients with type 1 and type 2 DM

21 Diabetic Peripheral Neuropathy Neuropathies can severely decrease patients' quality of life Primary symptoms of neuropathy can be highly unpleasant Secondary complications (eg, falls, foot ulcers and cardiac arrhythmias) are even more serious and can lead to fractures, amputations, and even death in patients with DM. May have Sensory, Motor or Autonomic symptoms

22 Diabetic Peripheral Neuropathy Sensory symptoms May be negative or positive, diffuse or focal. Negative sensory symptoms Feelings of numbness or deadness wearing gloves or socks. Loss of balance Especially with the eyes closed Painless injuries due to loss of sensation

23 Diabetic Peripheral Neuropathy Positive symptoms Burning Prickling pain Tingling Electric shock like feelings Aching Tightness Hypersensitivity to touch.

24 Diabetic Peripheral Neuropathy Motor symptoms May be distal, proximal, or more focal weakness In the upper extremities impaired fine hand coordination difficulty with tasks such as opening jars or turning keys. Foot slapping, toe scuffing, frequent tripping early symptoms of foot weakness. Symptoms of proximal limb weakness difficulty climbing up and down stairs difficulty getting up from a seated or supine position falls due to the knees giving way difficulty raising the arms above the shoulders.

25 Diabetic Peripheral Neuropathy Autonomic symptoms Autonomic neuropathy may involve Cardiovascular Gastrointestinal Genitourinary systems Sweat glands

26 Diabetic Peripheral Neuropathy Physical Examination The first clinical sign is usually a decrease or loss of vibratory and pinprick sensation over the toes. As disease progresses, the level of decreased sensation may move upward into the legs and then from the hands into the arms "stocking and glove" sensory loss Examine for distal intrinsic extremity muscle atrophy Examine the skin for dryness

27 Diabetic Peripheral Neuropathy Vibratory sense 128-Hz tuning fork placed at the 1 st Metatarsal Phalangeal Joint. Protective sensation 5.07 Semmes-Weinstein monofilament Inability to perceive the tuning fork or the monofilament = increased risk of developing a foot ulcer. (ie, 60% in the next 3 years) The 2 tests should be performed at least every year.

28 Diabetic Peripheral Neuropathy Fasting Plasma Glucose HbA1c NCV/EMG Testing Diagnosis Patients with DPN from predominant axonal loss have reduced or absent sensory nerve action potentials, especially in the legs. Conduction velocities are generally within the normal range or only mildly slowed in DPN. Epidermal Nerve Fiber Density Testing

29 Diabetic Peripheral Neuropathy Treatment Tight Glycemic Control Pain Management Medication Physical Therapy (Anodyne Therapy) Surgery (Spinal Cord Stimulator)

30 Diabetic Peripheral Neuropathy Pharmacological Agents Most listed are not approved by the FDA for this use. NSAID (Ibuprofen, Naproxen, Meloxicam) Topical [Capsaicin (Zostrix), Transdermal Lidocaine, NSAID] Anticonvulsant (Gabapentin, Lyrica) Antidepressant - Tricyclic [Amitriptyline (Elavil)] Antidepressant SSRI (Cymbalta) Antidepressant (Other) (Trazodone HCL) Vitamin Supplement (Metanax, Vit. B12)

31 Potential Complications of Diabetes Manifesting in the Feet Charcot Arthropathy (Charcot Joint or Neuropathic Joint) Characterized by joint dislocations, pathologic fractures, and debilitating deformities. Results in progressive destruction of bone and soft tissues at weight-bearing joints Can cause significant disruption of the bony architecture. Most commonly affects the joints in the lower extremity, at the foot and ankle

32 Charcot Arthropathy Etiology Any condition that causes sensory or autonomic neuropathy Diabetes (Most common) Syphilis Chronic alcoholism Leprosy spinal cord injury renal dialysis congenital insensitivity to pain.

33 Charcot Arthropathy Pathophysiology Exact nature remains unknown, Neurotraumatic theory Neurovascular theory Most likely Combination of Both Theories

34 Charcot Arthropathy Presentation Acute Charcot Arthropathy Signs of inflammation Profound Unilateral Swelling Increase in local skin temperature increase of 3-7 º above the non-affected side Erythema Joint effusion Bone resorption

35 Blood Tests Charcot Arthropathy Diagnosis WBC ESR Basic Metabolic Panel Imaging Studies Bone Scan Indium Scan MRI Doppler ultrasound

36 Acute Phase Immobilization Long Term Care Charcot Arthropathy Treatment Total Contact Cast CROW walker Accommodation for Deformity Extra Depth or Custom Molded Shoes Custom or Prefabricated Multidensity Plastizote Inserts or Custom Orthotics. Shoes with Rocker Sole

37 Charcot Arthropathy Treatment Surgery to correct osseous deformities Bisphosphonates Pulsed low-intensity ultrasound Electrical stimulation Earlier Diagnosis = Better Outcome

38 Potential Complications of Diabetes Manifesting in the Feet Ulcerations and Amputation: DPN, contributes to foot deformities and/or ulcers that increase the chance of lowerextremity amputations (LEA) unless treated. Statistics Cost

39 Screening for pedal complications in Diabetics in the Primary Care setting 1. Inspect the foot 2. Look for thin, fragile, shiny, and hairless skin 3. Feel the feet for excessive warmth and dryness. 4. Inspect nails for thickening, ingrown corners, length, and fungal infection. 5. Inspect socks or hose for blood or other discharge. 6. Examine footwear 7. If new foot abnormality found, should be scheduled for a comprehensive foot examination. 8. Document findings in the medical record.

40 Frequency of Inspection Recommendations for visual inspection of feet: At every visit for people who have neuropathy. At least twice a year for people with high risk foot conditions to screen for the development of additional risk factors. At least annually for low risk feet. Where prevalence and incidence of diabetes foot problems are high, consider more often inspection. For all patients with diabetes, remove shoes and socks in preparation for examination.

41 Annual Comprehensive Diabetes Foot Exam A Primary Care Provider should conduct the foot exam. Prepare by having patient remove shoes and socks/hose: I. Presence of Diabetes Complications Question 1: Does the patient have any history of the macroand micro-vascular complications of diabetes or a previous amputation? Question 2: Does the patient have a foot ulcer now or a history of foot ulcer?

42 II. Current History Annual Comprehensive Diabetes Foot Exam Question 1: Is there pain in the calf muscles when walking i.e., pain occurring in the calf or thigh when walking less than one block that is relieved by rest? Question 2: Has the patient noticed any changes in the feet since the last foot exam? Questions 3 and 4: Has the patient experienced any shoe problems? Has the patient noticed any blood or other discharge in socks or hose? Question 5: What is the patient's smoking history? Question 6: What is the patient s most recent hemoglobin A1c test result?

Annual Comprehensive Diabetes Foot Exam III.

43 Annual Comprehensive Diabetes Foot Exam III. Foot Exam (Note all findings in patient chart) Item 1. Condition of the skin, hair and toenails. Questions: Is the skin thin, fragile, shiny and hairless? Are the nails thick, too long, ingrown, or infected with fungal disease? Item 2: Musculoskeletal Deformities

44 Annual Comprehensive Diabetes Foot Exam Item 3: Pedal Pulses Check the pedal pulses (posterior tibial, dorsalis pedis) in both feet and note whether pulses are present or absent. Temperature Gradient

45 Annual Comprehensive Item 4: Sensory Exam Lower Extremity Amputation Prevention (LEAP) Program HRSA/BPHC/DPSP 4350 East-West Highway 9th Floor Bethesda, MD Phone: (888) Internet: Disposable 5.07 (10gm): Free (maximum 50) Diabetes Foot Exam

46 Annual Comprehensive Diabetes Foot Exam IV. Footwear Assessment Question 1. Does the patient wear appropriate shoes? Question 2. Does the patient need inserts? Question 3. Should corrective footwear be prescribed?

47 V. Education Annual Comprehensive Diabetes Foot Exam Question 1: Has the patient had prior foot care and other relevant diabetes education? Question 2: Can the patient demonstrate appropriate foot care? VI. Management Plan

48 Medicare Therapeutic Footwear Program for Diabetics How Do Individuals Qualify? The M.D. or D.O. treating the patient for diabetes must certify that the individual: 1. Has diabetes. 2. Has one or more of the following conditions in one or both feet: history of partial or complete foot amputation history of previous foot ulceration history of pre-ulcerative callus peripheral neuropathy with evidence of callus formation poor circulation foot deformity 3. Is being treated under a comprehensive diabetes care plan and needs therapeutic shoes and/or inserts because of diabetes.

49 Medicare Therapeutic Footwear Program for Diabetics What the Physician Needs to Do 1. The certifying physician (the M.D. or D.O.) overseeing the diabetes treatment must review and sign a Statement of Certifying Physician for Therapeutic Shoes Statement of Certifying Physician for Therapeutic Shoes Patient Name: HIC Number: I certify that all of the following statements are true: 1. This Patient has diabetes mellitus 2. This Patient has one or more of the following conditions (Circle all that apply): History of partial or complete amputation of the foot History of previous foot ulceration History of pre-ulcerative callous Peripheral neuropathy with evidence of callous formation Foot deformity Poor circulation 3. I am treating this patient under a comprehensive plan of care for his/her diabetes. 4. This patient needs special shoes (depth or custom molded shoes) because of his/her diabetes. Physician signature: Physician Name (printed): Date Signed: Physician address: Physician NPI Number:

50 Do's and Don'ts 1. Take care of your diabetes. Work with your health care team to keep your blood sugar within a good range. 2. Check your feet every day. Look at your bare feet every day for cuts, blisters, red spots, and swelling. Use a mirror to check the bottoms of your feet or ask a family member for help if you have trouble seeing. 3. Wash your feet every day. Wash your feet in warm, not hot, water daily. Dry your feet well. Be sure to dry between toes. 4. Keep the skin soft and smooth. Rub a thin coat of skin lotion over the tops and bottoms of your feet, but not between toes. 5. Smooth corns and calluses gently. If your feet are at low risk for problems, use a pumice stone to smooth corns and calluses. Don t use over-the-counter products or sharp objects on corns or calluses. 6. If you can see and reach your toenails, trim them each week or when needed. Trim your toenails straight across and file the edges with an emery board or nail file.

51 Do's and Don'ts 7. Wear shoes and socks at all times. Never walk bare foot. Wear comfortable shoes that fit well, protect feet. Feel inside shoes before putting them on each time to make sure lining is smooth and no objects inside. 8. Protect you feet from hot and cold. Wear shoes at the beach or on hot pavement. Wear socks at night if your feet get cold. Don t test bath water with your feet. Don t use hot water bottles or heating pads. 9. Keep the blood flowing to your feet. Put your feet up when sitting. Wiggle your toes and move your ankles up and down for 5 minutes, 2 or 3 times a day. Don t cross your legs for long periods of time. Don t smoke. 10. Be more active. Plan your physical activity program with your doctor. 11. Check with your doctor. Have your doctor check your bare feet and find out whether you are likely to have serious foot problems. Remember that you may not feel the pain of an injury. Call your doctor right away if you find a cut, sore, blister, or bruise on your foot that does not begin to heal after one day. Follow your doctor s advice about foot care. 12. Get started now. Begin taking good care of your feet today.

52 SUMMARY Prevalence of Diabetes Potential Complications DPN PVD Charcot Arthopathy Ulcerations and Amputations Screening in the Primary Care Setting Medicare Diabetic Shoe Program Do's and Don'ts for Diabetics

53 Diabetes and It s Effects on the Feet: Identification and Prevention of Pedal Problems in the Primary Care Setting Craig Herman, D.P.M. cherman@chnnyc.org (718)

Podiatry in Practice. Alan M. Singer, DPM, FACFAS

Podiatry in Practice. Alan M. Singer, DPM, FACFAS Podiatry in Practice Alan M. Singer, DPM, FACFAS Podiatry in Practice Alan Singer, D.P.M. UNIVERSITY PODIATRY GROUP Onychomycosis Anti-fungals Onychocryptosis (Ingrown Nails) Ingrown Nails Partial Nail