Complete Nurse's Guide to Diabetes Care, 3rd Edition

Chapter 17:

Evaluation and Management of the Diabetic Foot

George T. Liu, DPM,1 Caitlin S. Garwood, DPM,1 and John S. Steinberg, DPM1

1Liu is an Associate Professor at the University of Texas Southwestern Medical Center, Department of Orthopaedic Surgery, Dallas, TX. 2Garwood is an Assistant Professor at Georgetown University School of Medicine, Department of Plastic Surgery, Washington, DC. 3Steinberg is an Associate Professor at Georgetown University School of Medicine, Department of Plastic Surgery, Washington, DC.

EPIDEMIOLOGY

The crude prevalence of diabetes worldwide is on the rise. There are 26 million people living with diabetes in the U.S. and 382 million throughout the world. It is estimated that by 2035, 417 million people will be living with diabetes.1Diabetes mellitus is one of the leading causes of death in the world, along with ischemic heart disease, stroke, chronic obstructive pulmonary disease, and HIV/AIDS.2 In 2012, the economic impact of diabetes was estimated at US$471 billion.1,2

Heart disease, blindness, retinopathy, renal disease, neuropathy, and lower-limb amputation are several complications that can significantly challenge the course and outcomes of a patient with diabetes.3 Diabetic peripheral neuropathy leads to diabetic foot ulceration (DFU), which has been shown to increase morbidity and mortality. Reports have estimated that 15–25% of patients with diabetes will develop a diabetic foot ulcer in their lifetime.4–6 Foot complications or ulceration is the leading cause of hospitalization in this population.4,7,8 The initial presence of a foot ulcer not only has been recognized as a local comorbid manifestation of diabetes but also as a marker of the diabetic disease state and the overall health of a patient.6–15 Patients who develop a DFU are at a higher lifetime risk of death, lower-extremity amputation, and contralateral lower-extremity amputation and also have a 50–70% reulceration rate. Diabetes is the leading cause of nontraumatic lower-extremity amputation.3,16–19 A 2014 study found the cumulative incidence among 644 people with diabetes to be 26.6% for DFU, 5.8% for lower-extremity amputation, and 14.0% for death.20They also found that DFU has an independent impact of lower-extremity amputation and mortality.

Ulceration and amputation of lower extremities pose a direct socioeconomic burden to both patients and society. Management of foot ulcers is estimated at $13,179–$27,721 per episode of foot care management for an ulcer,21 and the average hospital cost incurred for diabetes-related lower-extremity amputation ranges from $20,000 to $32,611.22–26 Aside from the large economic cost, studies have demonstrated a relationship between the presence of ulceration or amputation and a negative impact on function, self-perception, emotional health, and quality of life.27–31

PATHOGENESIS OF DIABETIC FOOT PROBLEMS

Several pathological manifestations of diabetes, including neuropathy, hyperglycemia, and peripheral arterial disease, contribute to ulceration and amputation of the diabetic foot. Sensory neuropathy is the most common contributing factor for foot lesions encountered in the diabetic foot. This lack of protective sensation subjects the foot to increased risk of open injuries, undetected trauma, or repetitive low-grade stresses. Motor neuropathy causes muscle atrophy and subsequent imbalances of tendon-pull across the foot joints. The resultant foot deformities, such as hammertoes, claw toes, and prominent plantar metatarsal heads, may serve as areas of irritation and pressure within tight shoes (Figure 17.1). Additionally, abnormal plantar pressures cause callus formation as a result of these foot deformities and altered mechanics. The callus further increases the pressure and along with repeated trauma, can cause inflammation, tissue injury, necrosis, and ulceration (Figure 17.2). Autonomic neuropathy in the foot may manifest as decreased sweating of the feet, predisposing the dorsal and plantar skin to dryness and fissures. A more serious manifestation of autonomic neuropathy in the foot is Charcot neuroarthropathy, in which destruction of the foot joints can cause severe foot deformities and collapsing of the arch (Figure 17.3). Another pathologic manifestation of long-term diabetes is nonenzymatic glycosylation. This process of glycosylation in diabetes stiffens soft tissues such as ligaments and tendons, causing limited joint mobility, which also leads to increased plantar pressures. In addition, peripheral arterial disease (PAD) in patients with diabetes is more advanced and prevalent compared with individuals without diabetes. Micro- and macrovascular disease can be seen in people with diabetes and is critically important to recognize. Poor tissue oxygenation together with impaired blood flow may slow the healing of foot wounds, delay the delivery of antibiotics, and, in severe cases, result in ischemic pain and gangrene.

Figure 17.1—Retracted claw toes with prominent extensor tendons and depressed metatarsal head

Figure 17.1—Retracted claw toes with prominent extensor tendons and depressed metatarsal head are a result of muscular imbalances from motor neuropathy.

Figure 17.2—Depressed metatarsal heads create increased plantar pressures with walking

Figure 17.2—Depressed metatarsal heads create increased plantar pressures with walking. In the insensate foot, these focal pressures predispose skin to ulcerations.

Figure 17.3—Charcot foot

Figure 17.3—Clinically, Charcot foot presents with redness, swelling, heat, and severe deformity. Radiographic pictures demonstrate severe fracture dislocations accompanied with osteolysis and fragmentation in the foot joints.

FOOT ASSESSMENT AND EVALUATION

Assessment of high-risk conditions for ulceration and amputation in the diabetic foot is crucial in reducing the incidence of comorbid complications. A systems-based evaluation of the foot can identify early risk factors and initiate appropriate interventions to prevent the progression toward ulceration and amputation. The essential parts of a thorough diabetic foot evaluation include 1) vascular, 2) neurological, 3) dermatological, 4) orthopedic and biomechanical, and 5) footwear assessments.

VASCULAR ASSESSMENT: ADEQUATE BLOOD FLOW TO THE FOOT

Ischemia to the lower extremities impedes the immune response to infection, delivery of antibiotics, and healing of open wounds. A thorough history and physical exam are vital to obtaining adequate information to help assess the vascular status of a patient with diabetes.

A history should include prior PAD, intermittent claudication, or rest pain. Intermittent calf claudication, as identified by cramping of the calf muscles while walking, is an indication of relative ischemia, wherein the tissue demand for blood exceeds the available supply. Calf claudication is measured by the number of city blocks the patient is able to walk before intense cramping or tiredness of the legs ensues. Also measured is the amount of rest time required before walking can again be comfortably initiated. Calf cramping during sleep (nocturnal leg cramping) is different from intermittent calf claudication. Rest pain occurs in the advanced stages of ischemia and is characterized by intense pain and cramping, primarily in the forefoot, during sleep that is relieved only by placing the limb in a dependent position. Rest pain and claudication may be absent in people with diabetes secondary to peripheral neuropathy.

On physical examination, signs of vascular disease can include skin pallor, dependent rubor, thin, shiny skin, hair loss, or decreased skin temperature. The presence of gangrene is an ominous indication of severe vascular disease and needs immediate attention. Gangrene is ischemic tissue death, which signifies end-stage PAD or absolute ischemia, in which the blood supply is completely inadequate for tissue survival. One should also palpate the pedal pulses, including dorsalis pedis artery and posterior tibial artery, which can be assessed as either “palpable” or “nonpalpable.” A palpable pulse, however, does not entirely exclude PAD. If considered nonpalpable a handheld Doppler examination should be performed.

If signs and symptoms of PAD are present, lower-extremity noninvasive arterial examination consisting of arterial Doppler waveforms, ankle-brachial and toe-brachial indexes, segmental pressures, and digital plethysmography are indicated. Appropriate consultation with a vascular surgeon or interventional cardiologist with specific training in lower-extremity endovascular surgery is made if the noninvasive arterial exam is abnormal (see Table 17.1).

Table 17.1—Examination of Vascular Status

Assessment

Potential indication

Palpate femoral, popliteal, dorsalis pedis, and posterior tibial pulses.

Absent pedal pulse may be an indication of poor inflow to the foot.

Palpating proximal arteries may help identify the level of lower-extremity arterial disease.

If not palpable, perform handheld Doppler examination.

Feel for differences in skin temperature from proximal to distal; compare limbs.

Coolness may indicate diminished circulatory perfusion.

Localized warmth may be an indication of infection or Charcot neuroarthropathy.

Inspect skin for atrophic, shiny, and taut appearance and digital hair growth.

Loss of turgor and digital hair growth may be signs of poor cutaneous perfusion.

Evaluate digital capillary filling time.

Normal refilling should be pink in color in 1–3 s.

Refilling that is 3–5 s may indicate arterial insufficiency.28

Refilling that is immediate and bluish or purplish in color may indicate venous insufficiency.

Evaluate the following:

• Elevational pallor by raising the leg above the level of the heart or 60 degrees above horizontal for 1 min.

• Dependent rubor by lowering and hanging the lower extremity.

In the elevated position, marked pallor to the sole and digits indicates arterial insufficiency.

When lowering the extremity, if it takes >10 s for the pink color to return or vein filling takes >15 s, arterial insufficiency should be suspected.

Inspect for areas of gangrene.

Presence of gangrene is representative of end-stage vascular disease resulting in tissue death.

Neurological Assessment: Absence of Protective Sensation

Indicators of clinical sensory neuropathy may include the subjective presence of tingling, numbness, burning, or stabbing or shooting pain that typically begins at the toes and fingertips. In advanced cases of sensory neuropathy, the symptomatic sensations progress proximally in a “stocking-and-glove” distribution.

Evaluation for sensory neuropathy begins with assessment of protective sensation. The 5.07 Semmes-Weinstein monofilament wire (Figure 17.4) has been the screening tool of choice for determining the loss of protective sensation with sensory neuropathy. This inexpensive and portable device can yield reproducible and predictive information regarding risk of ulcer formation.32 The 5.07 Semmes-Weinstein monofilament is calibrated to deliver 10 g of force to a designated testing site when sufficient force is applied, causing the wire to bend. The examination is performed with the subject’s eyes closed. The patient is asked to respond “yes” if any pressure from the monofilament wire is detected. Demonstrating the monofilament on the patient’s proximal leg or palm may help identify the type of sensation he or she is to detect. Ten sites are tested: plantar first, third, and fifth digits; plantar first, third, and fifth metatarsal heads; plantar medial and lateral midfoot; plantar heel; and dorsal midfoot. A clinical finding of four insensate sites was found to be 97% sensitive and 83% specific for detecting a loss of protective sensation.33,34 Sensory neuropathy is tested using a 128 Hz tuning fork that is placed at the level of the first metatarsal phalangeal joint. Lack or diminished vibratory sensation indicates a component of sensory neuropathy in the lower extremity.35

Figure 17.4—5.07 Semmes Weinstein monofilament wire

Figure 17.4—The 5.07 Semmes-Weinstein monofilament wire is used to detect loss of protective sensation.

Other methods of testing neuropathy can include inspecting for dryness of the skin or fissures, which can indicate autonomic neuropathy. Motor neuropathy is tested by ankle or knee reflexes as well as by inspecting for intrinsic muscle atrophy. Lack of reflexes can indicate early stages of neuropathy.32–37

Dermatological Assessment: Skin Pathology

Among the many vital functions of the integumentary system, the skin serves as a barrier to protect the body from injury and foreign pathogens. In the diabetic foot, the absence of protective sensation and presence of foot deformity leave the skin susceptible to mechanical injury, resulting in skin breakdown. Open lesions to the foot serve as pathways of infection to the body. The presence of an open wound is the pivotal event for development of infection.

Examination of the skin should identify areas of low-grade mechanical irritation, such as that seen with callus or corn. Of particular importance is any hemorrhage or petechiae present underneath calluses or nails as this can indicate preulceration. The nails should be inspected for color, thickness, or deformity. Frequently fungal infections are seen in the nails of patients with diabetes and can be an area of excess pressure or infection. Any area of open injury, such as laceration or ulceration should be fully inspected, including size, drainage, color, and exposure of deep tissues or signs of infection (see Table 17.2 and Figures 17.5–17.7).

Table 17.2—Examination of Dermatologic Status

Assessment

Potential indication

Observe the skin for cutaneous hydration with the skin texture and turgor.

• Dry, rough, and scaling skin may be an indicator of poor cutaneous hydration.

• In severe cases, this loss of moisture may lead to fissures, which can open and serve as a pathway for infection.

• Chronic tinea pedis (athlete’s foot) may cause scaling and thickening of the skin, which also may lead to fissures.

Inspect for corn and callus formation.

• Formation of keratosis indicates areas subjected to repetitive pressure and shear stress.

• Calluses are highly associated with areas of skin breakdown and potential ulcer formation.

Inspect nails.

• Fungal infection of the nails (onychomycosis) presents with hypertrophy, dystrophy, discoloration, brittleness, and subungual debris (Figure 17.5).

• Thick nails may serve as a source of pressure within shoes, subjecting the nail bed to ulceration.

• Inspect nail borders for ingrown toenails and for associated infection (paronychia).

Inspect for hemorrhage beneath calluses and toenails (Figure 17.6).

• Hemorrhage may indicate injury and presence of a preulcerative lesion.

• Anecdotal evidence has indicated that painless bleeding beneath calluses and nails may be considered dermatological signs of clinically significant sensory neuropathy.

Inspect for open wounds.

• Open wounds, such as ulcers, in the diabetic foot are pathways for infection.

• Inspect the foot for abrasions, lacerations, blisters, ingrown nails, and ulcerations.

• Inspect the web spaces between the digits for open lesions. Web space may become macerated, predisposing the skin to breakdown (Figure 17.7).

• Assess wounds for size; depth; location; exposure of tendon, joint capsule, or bone; presence of necrotic tissue; and signs of infection.

Inspect for areas of erythema.

• Erythema may indicate inflammation associated with areas of irritation or pressure from poor-fitting shoes.

• Erythema accompanied with pain, localized heat and swelling, and pus may indicate presence of infection.

Figure 17.5—Fungally infected nails present with thickness, discoloration, and subungual debris

Figure 17.5—Fungally infected nails present with thickness, discoloration, and subungual debris. Thick nails may cause pressure to the nail bed within shoes, creating nail bed ulcerations.

Figure 17.6—Hemorrhage beneath calluses

Figure 17.6—A hemorrhage beneath calluses may indicate the presence of a preulcerative lesion.

Figure 17.7—Web spaces of toes may retain moisture, which causes maceration

Figure 17.7—Web spaces of toes may retain moisture, which causes maceration. Chronic maceration may lead to skin breakdown.

If an ulcer develops, clinical assessment and staging are performed. Several classification schemes exist for diabetic foot ulcers.38–41 The University of Texas wound classification system is the most widely used system among wound care centers and categorizes wounds into four grades and as either noninfected/nonischemic, infected, ischemic, or both (see Table 17.3).

Table 17.3—University of Texas Wound Classification System

Table 17.3—University of Texas Wound Classification System

Source: From Lavery et al.41

Orthopedic and Biomechanical Assessment: Foot Deformity

Structural and functional deformities of the foot may be a source of repetitive low-grade trauma within shoes during walking. In the insensate foot, this continual trauma may lead to ulceration of the skin. It is important to assess for any orthopedic or biomechanical deformities that may be present.

An examination should include inspection of the foot type, identifying high or low arches. This gives a global picture of the structure. It is important to assess any digital deformities such as hammertoes, hallux valgus previous amputations, as these are common causes of ulceration. Any areas of bony prominence should be noted because they also can be areas of high pressure and lead to ulceration. Common areas include the plantar metatarsal heads, heel, and malleoli. Joint range of motion of the ankle, hindfoot, and forefoot should be determined, as this has a biomechanical impact and leads to stress on the feet (see Table 17.4 and Figure 17.8).

Table 17.4—Orthopedic Examination of Musculoskeletal Status

Assessment

Potential indication

Observe for digital deformities (e.g., hammertoes, claw toes, and mallet toes).

• Determine whether the deformity is flexible or rigid. Rigid deformities are more prone to irritation and skin breakdown within shoes.

• Inspect for associated callus or corn formation along the bony prominences, an indication of low-grade irritation within shoe gear.

Identify bunion or Tailor’s bunion (fifth metatarsophalangeal joint) deformity.

• Large bony protrusion of the metatarsal joint causing pressure in the area at risk of ulceration.

Inspect for prominent depressed metatarsal heads with an anteriorly displaced metatarsal fat pad.

• Prominent plantar metatarsal areas with loss of fat pad protection are subject to increased pressures. Diffuse callus formation may be present.

Identify midfoot deformities: low arch and high arch.

• Low arches may be seen with flatfoot deformities (pes planus). Inspect the plantar midfoot for any signs of callus formation or irritation. Collapse of the midfoot arch, with a “rocker bottom” deformity, also may be seen with Charcot neuroarthropathy (Figure 17.8). This condition should be referred to a podiatrist or foot-and-ankle orthopedist for evaluation and treatment.

• High arches may be seen with “intrinsic minus foot,” in which atrophy of the intrinsic muscles of the foot and depression of the metatarsal heads gives a hollow appearance to the arch. This is accompanied with retracted digit and prominent extensor tendons. Observe the plantar metatarsal head area and heels for callus formation and irritation.

Identify rearfoot deformities: varus (inversion) or valgus (eversion).

• Rigid varus or valgus rearfoot deformities at the heel may cause callus formation or irritation.

Identify prominences along joints or bones.

• Bony prominence may be the result of arthritic joint changes or bony injury.

• Severe deformity may be seen in Charcot neuroarthropathy.

Identify previous foot amputations.

• Partial amputations of the foot alter the mechanics of gait and the normal distribution of plantar pressures, predisposing the foot to ulceration.

Assess the range of motion of joints for limited joint mobility.

• First metatarsophalangeal joint: 65 degrees in dorsiflexion in the sagittal plane.

• Subtalar joint: 10-degree eversion and 20-degree inversion in the frontal plane.

• Ankle joint: 10 degrees of dorsiflexion in the sagittal plane.

• Limited joint range of motion of the lower-extremity joints reduces shock absorption capacity and translates increased plantar pressures to the foot. Limited joint mobility has been associated with increased risk of ulcer formation.

Figure 17.8—Collapse of the midfoot in Charcot foot will result ina rocker bottom deformity

Figure 17.8—Collapse of the midfoot in Charcot foot will result in a “rocker bottom” deformity. The plantar bony prominence is subject to increased pressure and ulceration.

Shoe Assessment: Adequate Footwear and COMPLIANCE

Ideally, the role of footwear is to protect the feet from injury. By accommodating deformity and off-loading pressure, proper footwear can prevent ulcer occurrence and recurrence. The use of specialized therapeutic footwear is recommended for high-risk patients with diabetes with foot deformities, severe peripheral neuropathy, or previous amputations. Patients must understand the importance of prevention and the role shoes and activity play. In the diabetic insensate foot, an ill-fitting shoe can be a source of repetitive injury. Examination of the shoe treads may reveal abnormal gait patterns and areas of increased pedal stress. Ideal footwear should be extra deep, with a wide toe box to accommodate digital deformities. The construction and inner lining of the shoe, particularly in the toe box, should be smooth with no ridges or rough stitching to prevent pressure sores. By manually examining the inside of the shoe for smoothness of construction, the nurse can assess the design of the shoe for use with insensate feet. Insoles should be custom molded and redistribute plantar pressures. Shoes should fit well, with little to no pistoning of the foot (see Table 17.5 and Figure 17.9).

Table 17.5—Footwear Evaluation

Assessment

Potential indication

Inspect interior of shoe for foreign objects and exterior of the shoe for impaled sharp objects (Figure 17.9).

• Sharp objects may injure the foot, predisposing to ulceration.

Inspect wear pattern of the shoe.

• Wear patterns may be associated with abnormal gait and deformities of the foot.

Inspect shoe fit.

• Shoes should be well-fitting. Tight shoes may create areas of pressure over the skin of bony prominences. Oversized or loose shoes will create pistoning within the shoe, which may produce areas of shear stress and irritation to the foot.

• Toe box of the shoe should be deep and wide enough to avoid digital pressure and irritation.

• Shoe fitting is best performed by certified pedorthist or health-care professional with foot care training.

Inspect insoles for material fatigue and failure (bottoming out).

• If inner soles cannot be visually inspected, place a hand into the shoe to assess worn spots or areas where padding is weak and worn.

Figure 17.9—Undetected impaled objects in the shoe

Figure 17.9—In the insensate foot, undetected impaled objects in the shoe are sources for repetitive injury.

Compliance issues with therapeutic protective diabetic footwear are often related to shoe appearance.42,43 To address this problem with use, orthopedic shoe manufacturers have introduced various styles of diabetic-compliant footwear to accommodate the social needs of the patient.

LABS AND TESTS

Few laboratory and advance testing modalities are used for routine assessment of the diabetic foot, and most ancillary tests are performed only when clinically indicated. An initial screening laboratory test includes glycated hemoglobin A1c (A1C) to assess long-term blood glucose control. Poor long-term glucose control has been shown to correlate with increased incidence of diabetes-related comorbidities, such as neuropathy, retinopathy, nephropathy, and PAD. The American Diabetes Association has recommended that A1C ≥6.5% is a diagnostic criterion for diabetes.44

Oral temperatures, complete blood counts, and erythrocyte sedimentation rates are appropriate screening tests in cases of infection; however, these tests have been shown to correlate poorly with acute diabetic foot infections. One study demonstrated that in the presence of a clinically infected diabetic foot, oral temperature was elevated in only 18% of all cases and leukocytosis was seen in 46% of all infections.45 C-reactive protein and erythrocyte sedimentation rate may be other lab values that are surrogate indicators for soft tissue or bone infection, but they lack specificity.46–48

Radiographic evaluation for underlying osteomyelitis of the foot should be performed in the presence of chronic foot ulcerations that probe to deep soft tissue or bone. Severe and acute foot deformities should be radiographically evaluated for fracture or dislocation and Charcot neuroarthropathy. In cases of severe clinical infection, foot radiographs can detect soft tissue gas and bone involvement. Additionally, nuclear and advanced diagnostic imaging, such as bone scan, computed tomography, and magnetic resonance imaging, may be used to evaluate the presence of osteomyelitis to better guide treatment plans.

As mentioned, noninvasive vascular evaluation of the lower-extremity arteries (arterial Dopplers, digital plethysmography, pulse volume recordings, and ankle-brachial and toe-brachial indexes) may be used to evaluate the quality of physiological blood flow. This examination is usually performed in patients with diabetes who present with clinical signs and symptoms of ischemia in the lower extremity or an ischemic nonhealing wound. A noninvasive vascular evaluation is commonly performed before an arteriogram, which is an invasive test used to assess arterial runoff and target vessels for lower-extremity arterial bypass surgery.

Nail Care

The following procedures should only be done by a health-care professional with foot care training unless otherwise noted.

• Mycotic and hypertrophic nails should be debrided to relieve potential pressure against the toe box in shoes.

• Ingrowing and ingrown toenails should be treated with debridement of the offending margin or a partial nail avulsion.

• Ingrown nails with an infection (paronychia) often require debridement or avulsion of the offending nail margin and possible oral antibiotic therapy.

• Elongated nails should be trimmed either transversely or along the contours of the distal toe pulp with care to maintain clearance of the nail border from the medial and lateral nail grooves. Patients may perform this nail reduction at home if they have normal nail type, good sensation, and adequate vision. If there is concern of self-injury, this care should be performed by a health-care professional.

Callus Care

• Thick calluses and corns should be reduced to prevent focal areas of pressure against the foot. Reduction performed using a sharp blade must be done by a health-care professional with foot care training. Patients may reduce thinner calluses using a pumice stone if they have sensate feet and have received proper instructions on its use.

• Padding with soft cushioning devices, such as felt, moleskin, or viscoelastic material, may be applied to areas of callus reduction to reduce shear.

• Insole materials may be used to reduce plantar pressures at callus sites.

• Corns associated with rigid digital deformities may be accommodated with extra-depth shoes or diabetic shoes with a soft toe box to reduce digital irritation.

Skin Care

The patient who has been properly instructed can perform most skin care to the feet.

• Application of lotions and creams with mild keratolytics (e.g., 20–40% urea cream) may be used to penetrate and maintain moisture within thick dry skin.

• Clean between digital web spaces. Lamb’s wool placed within the web spaces of toes also may be used to facilitate drying of macerated skin.

• Noninfected, clean ulcers should be gently scrubbed with a noncytotoxic, antiseptic solution and rinsed with normal saline. Debridement of the hyperkeratotic borders and necrotic tissue should be performed by a health-care professional with training in foot care. Multiple dressing materials for wounds are available, but the dressing used should keep the wound site moist and protected from contamination.

Footwear

• The function of shoe gear in the diabetic foot is to reduce abnormal plantar pressures and to protect from external injury. Referral to a podiatrist or foot-and-ankle orthopedist is needed for prescription footwear. Consultation with a certified prosthetist or orthotist or shoe specialist will assist in selecting and developing the specific shoe design and fitting. Shoe selection should be based on level of risk.

—Sensate foot without deformity: commercial footwear.

—Sensory neuropathy: accommodative inserts and possibly a therapeutic shoe if the patient’s foot demonstrates areas of irritation with the present footwear.

—Sensory neuropathy and minor or flexible foot deformity: extra-depth shoe with custom-molded insert (Figure 17.10).

—Severe rigid nonreducible foot deformity (e.g., quiescent Charcot foot): custom-molded shoe with custom-molded insert.

—Partial foot amputation: will often require a custom-molded filler or insert within either an extra-depth or a custom-molded shoe. Depending on the level of amputation, an ankle foot orthosis may be required to assist the patient in stability with walking.

Timing of Follow-up Care

All patients with diabetes should have their feet inspected at every visit.

• Comprehensive foot examination for a well-controlled patient with diabetes without sensory neuropathy, PAD, or deformity should be performed at least annually to screen for high-risk conditions.

• Patients with sensory neuropathy should have their feet examined every 6 months.

• Patients with sensory neuropathy and foot deformity or PAD should have their feet examined every 2–3 months.

• Patients with sensory neuropathy, deformity, and history of ulceration or amputation should have their feet examined every 1–2 months.

Figure 17.10—Extra-depth shoes

Figure 17.10—Custom-molded insert to accommodate minor foot deformities and attenuate focal plantar pressures

Figure 17.10—Extra-depth shoes with custom-molded inserts will accommodate minor foot deformities and attenuate focal plantar pressures.

Practical Point

A culmination of individual factors contributes to the cumulative risk of developing foot ulcers.49–53

• Approximately 85% of all diabetes-related lower-extremity amputations are preceded by a preventable ulceration.

• Patients with sensory neuropathy have a 6–9% incidence of ulceration.

• Patients with neuropathy and deformity have a 8–17% incidence of ulceration.

• Patients with neuropathy, deformity, and history of amputation have a 26–78% incidence of ulceration.

• Presence of a callus in the diabetic foot is strongly associated with the site of ulcer formation.

TREATMENT

The goal of management of the diabetic foot is to address high-risk conditions and potential complications associated with ulceration and amputation. Key treatment modalities include care of the nails, calluses, and skin; therapeutic footwear; and regular follow-up.

Educational AND Behavioral Considerations

Diabetes foot education has been shown to reduce foot complications associated with diabetes. Educating patients on daily monitoring and maintenance of the feet will aid in preventing complications and improve response time to potentially limb-threatening conditions.

Patients should be taught to perform a daily foot inspection as follows:

• Inspect feet, especially the soles, at least once per day for injury, callosities, and areas of redness. If the area of redness is associated with heat, swelling, pain, and drainage accompanied by fever, chills, and night sweats, this condition should be reported immediately to a doctor or nurse. The use of a shatterproof mirror on the floor is recommended if patients cannot bend their legs to visually inspect the feet.

• Inspect web spaces between toes for maceration and fissures.

• Inspect the interior and exterior of shoes for foreign objects before wearing and note areas of wear and tear. Worn-out shoes may not be supportive and therefore may be unable to evenly distribute foot pressure across the sole.

Patients should be taught the following daily maintenance:

• Do not walk barefoot (inside or outside the home). Always wear footwear recommended by a health-care professional.

• Using lotions or creams recommended by a health-care provider will help skin retain moisture and prevent cracking. Do not apply lotions to the web spaces between toes.

• Wash feet daily with mild soap and water. Test water temperature with an elbow before submerging the feet.

• After washing, dry feet well, especially the web spaces between toes, to prevent maceration. Apply lamb’s wool to the web spaces as instructed to facilitate drying of macerated skin.

• Wear cotton socks to absorb perspiration from the skin. Wearing clean, light-colored socks will help identify the presence of pus or blood from an undetected injury. Do not wear tight socks that constrict the circulation to the feet.

• Trim toenails either straight across or along the contours of the toe pulp to maintain nail clearance from adjacent skin and to reduce potential ingrown toenail formation.

• Small calluses may be reduced with a pumice stone, ideally after bathing, when calluses are soft.

• Do not trim or cut nails or calluses if neuropathy is present; refer to a podiatrist or specialist with foot care training.

• Do not use over-the-counter “medicated” corn and callus pads because they contain salicylic acid, which can injure the insensate foot. Nonmedicated corn and callus pads are acceptable as directed by a health-care professional.

• Do not self-treat ingrown nails and associated infections, and do not use sharp objects to reduce calluses. Seek the advice and help of a doctor or nurse.

• Open injuries of the foot should be cleansed with antiseptic solution and dressed. The condition should be reported immediately to the doctor or nurse for evaluation and treatment.

• Ulcer care should be performed as directed by a health-care professional.

ADDRESSING BARRIERS TO TREATMENT AND LIFESTYLE CHANGES

The following are commonly reported reasons for poor patient adherence to treatment regimens:

• Inability to understand physicians’ instructions54

• Difficulty remembering treatment regimen55

• Lack of social support for healthy lifestyle changes56

• Embarrassment when wearing protective therapeutic shoes because of appearance57,58

Detailed explanations of the disease process and the rationale for treatment have been shown to improve compliance rates.54 Therefore, educate both patients and family members regarding diabetes and foot maintenance. Understanding the rationale for the patient’s lifestyle changes will encourage cooperative behavior and improve the support of family members. Enrollment in a diabetes self-management education course (that also provides instruction for foot maintenance),59,,60 provision of simple instructions in a handout, and recruitment of a family member’s assistance during the patient visit may improve compliance and overall outcomes. Evaluate patients’ ability to perform the daily self-examination, which may be limited by the inability to see their feet as a result of poor vision or inability to reach with their hands to examine their feet.61,62

ROLE OF NURSING

With the increased attention drawn to the multidisciplinary model of health-care delivery to patients with diabetes, nurses of all specialties have played an integral role as an extension of vital primary care services and have provided ancillary patient support mechanisms. This extension of nursing has been especially important as the patient health-care delivery models have trended toward home health care, long-term assisted care, and skilled nursing services, for which nurses are the primary screening professionals identifying high-risk diabetic foot conditions.

Routine Foot Screenings

Routine foot screenings for people with diabetes in primary care settings are a fundamental and inexpensive means of prevention that often are neglected.63–67 Reports have shown that in primary care practices, diabetic foot examinations are performed only 10–23% of the time during routine diabetes care visits.64,66,67 In a 78-chart review of six master’s-level certified nurse practitioners in a primary ambulatory care center, a comprehensive foot examination based on the ADA’s foot care standards was documented for only 23.1% of people with diabetes.66 Additionally, a retrospective review of inpatient records revealed that a minimally acceptable evaluation of the acutely infected diabetic foot was performed for 14% of patients.68 Without routine screenings, high-risk conditions leading to diabetic foot complications cannot be identified.

Altering practice patterns within the primary care setting, such as routinely removing the shoes and socks of patients during non–foot-related visits, has been shown to increase the likelihood of a foot examination more than threefold.69Educational interventions also have been shown to be effective tools to increase the probability of a foot exam. One retrospective study found that the percentage of proper diabetic foot examinations performed by physicians increased significantly, from 14% to 62% over a 6-month period, after an educational intervention consisting of two lectures and a quality assurance announcement.70 A routine foot screening program has been shown to statistically reduce lower-extremity major amputation rates in high-risk diabetic feet compared with a control group.71 Nurses play an important role in performing and facilitating foot screenings for high-risk conditions.72 Minimum requirements of the diabetic foot examination include evaluation of protective sensation, foot deformity and biomechanics, skin integrity, and vascular status.73

Diabetic Foot Education

Studies have suggested that patient education improves foot care knowledge and behaviors that may reduce the incidence of complications in high-risk people with diabetes.59,60,74,75 In a randomized controlled study, patients attending a foot education session had a threefold decrease in ulceration and amputation rates after a 2-year follow-up period.59 Another randomized trial evaluating the outcome of people with diabetes who received group education compared with usual care by a general practitioner revealed a significant reduction in callus formation and minor skin injury at a 6-month follow-up.60 In addition, implementation of a support group that provides one-on-one or small-group interactive counseling and foot education to diabetic amputees and patients with chronic ulcerations has been shown to improve foot care behaviors, self-perceptions of health, and foot self-care practices.76,77

The Team Approach

A team approach to diabetic foot care is a coordinated method of addressing the multifaceted aspects of diabetic foot complications. Improved outcomes of diabetic foot care have been demonstrated with this organized approach. Patients who received intervention by a multidisciplinary diabetic foot team had a significant reduction in total and major amputation rates.78,79 Following implementation of a multidisciplinary program, a 62–82% reduction in major amputations was reported.78,80 Other studies have demonstrated a lower incidence of major and minor amputations in patients who participated in a multidisciplinary intervention program for high-risk diabetic foot management.81Team members have included primary care physicians, podiatrists, nurse educators, nutritionists, diabetes nurses, shoe specialists, and vascular and orthopedic surgeons.7,19,79,80,82

Interest in the development of nursing-based models of diabetes care has grown.83–85 In a university health system, nurse-provided screening, education, and treatment has been shown to be a potential cost- and resource-effective method of decreasing the rate of diabetic foot complications.85 One reported measure of behavior improvement from this study was a reduction in improper footwear use from 73% to 43% at the first follow-up visit.

SUMMARY

Amputations of the lower extremities are among the most dreaded complications of diabetes. The diabetic foot is best managed by a team approach. Screening for high-risk conditions of the diabetic foot is a basic and fundamental tool to prevent foot ulceration and amputation. Patient education in diabetic foot care also may encourage behaviors and lifestyle changes that would reduce the foot complications of diabetes. Referral to a podiatrist or foot-and-ankle orthopedist should be made for specialized treatment and management of diabetic foot complications. Despite best efforts, however, foot ulcerations and amputations may occur. Whether for prevention or treatment, nursing personnel can provide an extension of much-needed services in screening and management of the diabetic foot. Nurses have played increasingly vital roles in the multidisciplinary team through screening, patient education, and treatment. With the rise in diabetes and the increasing costs of diabetes-related problems, nurses can help to prevent major complications and can decrease the overall burden of diabetic foot problems.

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ADDITIONAL READING

Apelqvist J, Bakker K, van Houtum WH, Nabuurs-Franssen MH, Schaper NC. International consensus and practical guidelines on the management and the prevention of the diabetic foot: International Working Group on the Diabetic Foot. Diabetes Metab Res Rev 2000;16(Suppl. 1):S84–S92

Boulton AJM, Armstrong DG, Albert SF, Frykberg R, Hellman R, et al. Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with the endorsement by the American Association of Clinical Endocrinologist. Diabetes Care 2008;31:1679–1684

Frykberg RG, Armstrong DG, Giurini J, Edwards A, Kravette M, et al. Diabetic foot disorders: a clinical practice guideline: American College of Foot and Ankle Surgeons. J Foot Ankle Surg 2000;39(Suppl. 5):S1–S60

Inlow S, Orsted H, Sibbald RG. Best practices for the prevention, diagnosis, and treatment of diabetic foot ulcers. Ostomy Wound Manage 2000;46:55–68

Pinzur MS, Slovenkai MP, Trepman E, Shields NN. Guidelines for diabetic foot care: The Diabetes Committee of the American Orthopaedic Foot and Ankle Society. Foot Ankle Int 2005;26:113–119

Schaper NC, Apelqvist J, Bakker K. The international consensus and practical guidelines on the management and prevention of the diabetic foot. Curr Diabetes Rep 2003;3:475–479

Sykes MT, Godsey JB. Vascular evaluation of the problem diabetic foot. Clin Podiatr Med Surg 1998;15:49–83