Clinical assessment of diabetic foot in 5 minutes Assoc. Prof. N. Tentolouris, MD 1 st Department of Propaedeutic Internal Medicine Medical School Laiko General Hospital Leading Innovative Vascular Education Symposium - LIVE 2018, Patras, 24-26 May 2018
The problem of diabetic foot Diabetes is common affecting 8-10% of the general adult population. Up to 15% of patients during lifetime with diabetes will develop a foot ulcer (DFU). The 2- to 5-year recurrence rates exceed 50%. Alarmingly, 15%-24% of recurrent ulcerations lead to amputations. In 80% of the non-traumatic lower extremity amputations the cause is a DFU. American Diabetes Association. Fast facts: data and statistics about diabetes. July 2014. http://professional.diabetes.org/admin/userfiles/0 - Sean/14_fast_facts_june2014_final3.pdf Boulton AJ, Armstrong DG, Albert SF, et al; American Diabetes Association; American Association of Clinical Endocrinologists. Comprehensive foot examination and risk assessment: a report of the Task Force of the Foot Care Interest Group of the American Diabetes Association with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care. 2008;31:1679-1685.
The problem of diabetic foot As the diabetic population grows, so does the demand for a more effective screening protocol for the diabetic foot to identify those at risk. Such a protocol should expedite referrals, with the hope of getting patients to a specialist before they face hospitalization or a preventable amputation. The routine foot exam and rapid risk stratification is often difficult to incorporate into a busy primary care exam. Data suggest that the diabetic foot is adequately evaluated in only 12%-20% of patient with diabetes during routine appointments. Bailey TS, Yu HM, Rayfield EJ. Patterns of foot examination in a diabetes clinic. Am J Med. 1985;78:371-374. Lavery LA, Armstrong DG, Vela SA, Quebedeaux TL, Fleischli JG. Practical criteria for screening patients at high risk for diabetic foot ulceration. Arch Intern Med. 1998;158:157-162.
The 5-min foot exam The 5-minute foot exam" was designed to provide healthcare providers with a thorough, yet concise and easily effective and repeatable way to evaluate the lower extremity of the diabetic patient. This exam consists of three components, each performed in 1 minute or less: a patient history, a physical exam, and patient education.
Patient history A complete medical history can help identify certain factors that may increase the risk for the patient to develop a lower-extremity complication. Asking diabetic patients about glucose control and history of lower-extremity conditions, such as wounds or amputations, is crucial when screening for diabetic foot. Patients with previous lower-extremity ulceration or amputation carry a 60% greater risk for re-ulceration. It is also important to inquire about previous vascular procedures and the patient's use of tobacco, which is linked to peripheral artery disease. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293:217-228. Boulton AJ, Armstrong DG, Albert SF, et al; American Diabetes Association; American Association of Clinical Endocrinologists. Comprehensive foot examination and risk assessment: a report of the Task Force of the Foot Care Interest Group of the American Diabetes Association with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care. 2008;31:1679-1685.
Physical Examination The physical exam should include a careful examination of the feet in every patient with suspected or confirmed diabetes. Clinical examination should include: inspection, neurological & myoskeletal exam assess the vascular status of the lower extremity, and evaluate the dermatologic condition of the patient's lower extremity. Up to 50% of patients may be asymptomatic owing to loss of protective sensation (LOPS). Failure to identify any problems early can result in detrimental consequences, including hospitalization and amputation. Including all these systems may sound daunting, but with practice, the provider will be able to accomplish the diabetic foot examination quickly and thoroughly. Boulton AJ, Vinik AI, Arezzo JC, et al; American Diabetes Association. Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care. 2005;28:956-962.
Peripheral neuropathy-inspection N. Katsilambros et al., Atlas of the Diabetic Foot, 2003, Wiley, UK
Orthopedic/Musculoskeletal Examination This portion of the exam should focus on any biomechanical abnormalities of the foot and ankle, including deformities, such as bunions, hammertoes, and enlarged bony prominences. Limitation in range of motion (LJM) of any joint in the foot and ankle can significantly increase the risk for ulceration. Muscle strength should also be evaluated to assess weakness and asymmetry. Musculoskeletal abnormalities of the foot and ankle can lead to problems with properly fitting shoe gear as well as mobility, and contribute to a higher risk for injury. Frykberg RG, Zgonis T, Armstrong DG, et al; American College of Foot and Ankle Surgeons. Diabetic foot disorders. A clinical practice guideline (2006 revision). J Foot Ankle Surg. 2006;45:S1-S66.
Orthopedic/Musculoskeletal Examination DIABETES CARE, VOLUME 31, NUMBER 8, AUGUST 2008
Limited joint mobility
Neurologic Examination The neurologic portion of the exam should focus on the presence or absence of protective sensation. Loss of protective sensation (LOPS) has been linked to 75% of all non-traumatic diabetic foot-related amputations. LOPS can lead to diminished skin integrity and musculoskeletal imbalance, and can increase the risk for ulceration. Various devices exist to test for LOPS and include Semmes-Weinstein monofilaments, vibratory perception threshold, 128-Hz tuning fork. Armstrong DG, Lavery LA, Vela SA, Quebedeaux TL, Fleischli JG. Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration. Arch Intern Med. 1998;158:289-292.
Biothesiometer Incidence of FU in 1 yr VPT < 15 V 2.9% VPT > 25 V 19.8% HR: 7.99 (3.65-17.5) Young MJ et al, Diabetes Care 1994;17:557-60
Semmes-Weinstein monofilaments Insensation of 5.07 monofilament and risk of foot ulceration over 1-4 yrs HR: 2.5-7.9 (95% CI 2.0-14.3) Feng et al, J Vasc Surg. 2010 Aug 7 (meta-analysis)
NDS and risk of foot ulceration North-West study 9,710 people with diabetes FU: 2 years HR for foot ulceration NDS=6-10 2.32 (95% CI 1.61-3.35) Abbott et al Diabet Med 19: 377 384, 2002
Dryness of the skin of the feet Method for the assessment of skin dryness Neuropad testing has high sensitivity and negative predictive value for the diagnosis of neuropathy Zick R et al Klinikarzt 2003;32:192-94 Papanas N et al Exp Clin Endocrinol Diabetes 2005;113:195-98
The performance of combination of various tests for the prediction of foot ulcers Armstrong et al, Arch Intern Med 1998; 158: 289-92
Neurologic Examination-Ipswich Touch Test (IpTT) The is an alternative neurologic test that requires only the examiner's index finger. The IpTT is performed by asking the patient to close his or her eyes while the examiner lightly places an index finger on the patient's first, third, and fifth toes for 2 seconds. The patient is instructed to respond "yes" when they feel the examiner's touch. This method has been found to be as sensitive and specific as Semmes- Weinstein monofilaments for detecting LOPS and does not require the use of any specific device. Rayman G, Vas PR, Baker N, et al. The Ipswich Touch Test: a simple and novel method to identify inpatients with diabetes at risk of foot ulceration. Diabetes Care. 2011;34:1517-1518.
Ipswich Touch Test (IpTT)
Vascular Examination History of intermittent claudication. Palpation of the femoral, popliteal, posterior tibial, and dorsalis pedis pulses. A diminished or absent pulse could serve as an indicator of a more serious underlying problem of vascular compromise. Skin temperature, digital hair growth, capillary refill times, and edema of both lower extremities should also be evaluated and compared. Abnormal findings can also indicate the presence of peripheral artery disease. Substantial data show that compromised circulation leads to the development of impaired healing in up to one half of all foot ulcerations in patients with diabetes. Khan NA, Rahim SA, Anand SS, Simel DL, Panju A. Does the clinical examination predict lower extremity peripheral arterial disease? JAMA. 2006;295:536-546.
Dermatologic Examination The dermatologic exam includes a comprehensive inspection of the skin for abnormal integrity, including dryness, cracking, discoloration, and callous formation, which are probable precursors to ulceration. An abnormal finding should prompt an expedited referral to the specialist for further evaluation and treatment. The toes should be inspected for the presence of thickened, elongated, or ingrowing nails, and check between the toes for any skin maceration or tears, which can be easily missed and lead to detrimental consequences. Bailey TS, Yu HM, Rayfield EJ. Patterns of foot examination in a diabetes clinic. Am J Med. 1985;78:371-374
How often to examine patients DIABETES CARE, VOLUME 31, NUMBER 8, AUGUST 2008
Patient Education Education is power when it comes to helping at risk patients understand their condition and involving them in their care. Education regarding appropriate foot hygiene, skin and nail care, and the use of proper foot wear can help reduce injuries that may lead to foot ulceration. The lack of appropriate education about diabetes has been found to increase recurrent ulcer risk by 90%. Patient education improves knowledge about diabetic foot and may modestly reduce the risk for foot ulcerations and amputations in the short term. More data are needed to determine the long-term benefits of the types of education that are most helpful to the patient. Valk GD, Kriegsman DM, Assendelft WJ. Patient education for preventing diabetic foot ulceration. A systematic review. Endocrinol Metab Clin North Am. 2002;31:633-658
Conclusions Every physician, everywhere can perform a screening test to determine patients with diabetes at risk for DFU. Upon completion of the 5-minute foot examination, the physician can have a firm understanding of the patient's needs and can be able to triage the patient's treatment and follow up appropriately. The examination will help guide the necessary referral to a specialist who can deal with the pathology and ensure successful outcomes of the treatments.
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