Foot care for people with diabetes – A guide for healthcare professionals

Foot care for people with diabetes – A guide for healthcare professionals

November 9, 2019 0 By Bertrand Dibbert


>>Vinod Patel: As a healthcare professional, I’m very keen to ensure that all of my patients with diabetes have a foot examination on a yearly basis.
As a minimum, the foot should be inspected thoroughly and a good place to inspect and
even start so you don’t miss it is in between the toes.
In between the toes, the skin is often macerated and quite moist and that can be a site of
infection, particularly if there’s breaks in the skin and the whole foot should be inspected
for swelling, to see if there’s any deformity of the foot, to see if there’s any callus
formation and to see if there’s areas of infection. So as a health care professional it’s important difference between hot and cold areas. The hot areas
can be due to infection or it could also be too due to the inflammatory process that you
get with neuropathic joint such as ‘Charcot Joint’.
The cold areas can be due to peripheral vascular disease, so here the arteries of the foot
or the lower leg have been ocluded resulting in the ischemic foot. This foot will often
be pulseless, it will be cold, it will be painful, and also be numbed. We should then move on to an inspection of
the pulses, and the pulses that we inspect are at the ankle joint but also on the foot
itself and the pulses are called the ‘Posterior Tibial Poles’ and the ‘Dorsalis Pedis Poles’. We should then move on to an examination,
to see if there is any numbness and normally we would use a ten-gram monofilament.  We
could also use a tuning fork and if you don’t have those pieces of equipment available,
you can just touch the toes and that can be equally effective.
You must also check the capillary return. The capillary return is simply pressing the
toe and seeing that it blanches and then letting go and it should fill up red again and that
should happen within two to three seconds. It’s critically important to look for signs
of infection, for even small breaks in the skin or small areas of cellulitis can become
quite large areas of cellulitis over the next few hours or days. So please do look out for
infection, they can be treated aggressively at the onset, initially with oral antibiotics
but in many cases, intravenous antibiotics may be needed.>>Lorraine: During the annual foot check, it’s also important to ask the patient if they’ve ever previously
had any concerns with their feet, any previous foot ulcers, any problems where they may have
been seen by their diabetic foot screening department or any general concerns that they
have about their feet or their previous history.>>Vinod Patel: Once you’ve conducted the patient’s annual foot check, it is very important to make sure that the patient understands that they should
check their foot on a daily basis. They should inspect their foot, they should look in between
the toes, they should look at the bottom of their foot and particular look out for areas
of redness, callus formation, any swelling or any deformity, or any numbness or any places
where it’s particularly cold. So in terms of preventing foot problems, it is a good idea to stress aspects of advice
and then move onto cardiac risk factors. So aspects of advice would be, particularly not
smoking, maintaining a good level of physical activity and optimal weight. Blood pressure
is going to be important as is the management of the cholesterol, if you manage the blood
pressure and cholesterol, you’re less likely to get blockages in the blood vessels and
less likely to get peripheral vascular disease. Diabetes control if that’s good, will lead
to less peripheral neuropathy and numbness in the foot and also will reduce the chance
of atheromatous disease happening in the foot. Sometimes aspirin is important, as an antiplatelet
or blood thinning agent to help the circulation but please make sure that these can be given
safely to your patient.>>Lorraine: There are three risk levels when assessing a diabetic foot: Low is when there is no problems or concerns
at all, their circulation is within normal limits, they are able to feel the foot is
in good condition. That should be repeated once a year. If they have got a loss of sensation
or any slight force that may be considered a moderate risk, they may need further assessment
by a specialist diabetic podiatrist and further written advice, and seen more frequently dependent
on the severity of their condition. If there’s a high risk, usually indicates
there is a loss of sensation, loss of pulse, an active foot ulcer, or deformity of the
foot that needs immediate attention and should be referred straight away to the diabetic
foot team.>>Vinod Patel: If a patient is diagnosed with an active foot problem then we have to think about what is this? If it’s an infection then intravenous
antibiotics, or in early cases oral antibiotics, may be enough? Sometimes the active foot problem
will be an inflammatory neuropathic joint, by this I mean a Charcot joint that requires
very specialized management, often the joint needs to be encased and often needs to be
offloaded as well and certain drugs that may actually help but the Charcot joint has to
be managed by a team that specializes in neuropathy joints. If the foot is cold, then we have to suspect that this is peripheral vascular disease and
the potential for blockage of a blood vessel in the foot or the lower leg is very high,
in which case an assessment by a vascular team is needed so we can think about angioplasty
and possibly bypass surgery as well.