Diabetes and Your Feet

1. Diabetes and Your Feet (Physician’s Name Here) (Practice Name Here) (Practice Address Here) (Practice Phone Number Here) (Practice Website Here)

2. Expected Increase in Diabetes From 2000 to 2030 2000: 151 million patients 2030: 370 million patients (~145% increase) 84.5 M 14.2 M 26.5 M +57% +23% +24% 9.4 M +50% 15.6 M 1.0 M +44% +33% Zimmet P, et al. Nature. 2001;414:782-787.

3. Prevalence of Diabetes in the US Now up to 18 Million

4. The Facts About Diabetes • Diabetes affects minority populations disproportionately: -2.3 million African Americans age 20 or older have diabetes -1.2 million Mexican Americans age 20 and older have diabetes -diabetes can affect up to 50 percent of some Native American populations

5. Leading cause of blindness in working age adults 2 to 4 fold increase in cardiovascular mortality and stroke DiabeticRetinopathy Stroke CardiovascularDisease Diabetic Nephropathy Leading cause of end-stage renal disease DiabeticNeuropathy Leading cause of nontraumatic lower extremity amputations Diabetic Complications Affect Every Part of The Body

6. How do diabetic foot problems compare with other diabetes-complications? • Infected wounds: most common reason for hospital admission • Infection:Ulcer ratio = 0.56 • 1 in 5 leads to lower extremity amputation Trautner, et al, Invest Opthalmol Vis Sci, 2003 Lavery, Armstrong, et al, Diabetes Care, 2003 Fedele, et al, J Urol, 2001 Bruno, Diabetes Care, 2003

7. Financial implications • 7th leading cause of death • Direct and indirect costs 2002 was $132 billion • 25% of all Medicare expenditures

8. Diabetes Can Be Controlled • Diabetes treatment includes “food management” to control blood sugar, getting regular physical activity, taking oral medications and/or insulin, and monitoring blood glucose levels. • By keeping blood sugar levels in the normal range, people with diabetes lower their risk of long-term complications of diabetes, such as eye disease, kidney disease, and nerve damage. UKPDS, NDEP

9. Blood Sugar/Glucose MonitoringPatient Home & Office Setting • Patient education & encouragement in maintaining good glucose control is essential in avoiding complications; both in a primary care and specialist clinic setting.

10. A1c An Indication For Healing • HbA1C (Now simply A1c) Reveals a combination/average; reflects mean of fasting and post-meal glucose levels for past 2-3 months Good indicator of how a patient will heal, as well as how well the blood sugar is controlled on a daily basis

11. Reduced Risk of Diabetes ComplicationsRisk Reduction per 1% Decrease in A1C

12. Patient Education • Ask the patient if they know how diabetes affects the foot and if they have ever had their foot examined. This question can provide information on the presence or absence of effective behaviors to institute prevention through appropriate self-maintenance.and recognition of pivotal events

13. Patient Education (continued) • Helping patients recognize pivotal events that require professional medical attention. • Knowing the duration of diabetes and level of control (A1c #) would indicate level of risk of developing co morbid systemic disease involving the foot since manifestations of complications are time and control dependent. • Checking your own feet everyday and seeing a podiatrist at the earliest sign of redness, skin breakdown UKPDS, DCCT, CDC, ADA, UTHSC-San Antonio

14. Risk Factors Leading to Ulceration • Neuropathy • Foot deformities • History of foot ulcers/amputations Adapted from Armstrong et al, 1991; Pecoraro et al, 1990; Mayfield et al, 1996.

15. Neuropathy • The presence of subjective complaints : tingling, burning, numbness or formication (sensation of bugs crawling on skin) may indicate the clinical presence of peripheral sensory neuropathy.

16. Neuropathy in People with Diabetes • Neuropathy is present in >80% of diabetic patients with foot ulcers

17. Neurosensory Testing

18. Neurosensory Testing 2 3 4 1 6 7 5 9 8 10 Left Placement of Semmes-Weinstein monofilament

19. Ulcerations Are Pivotal Events In Limb Loss • Portal for infection • Necrosis in the presence of critical ischemia

20. Etiology of Neuropathic Diabetic Foot Ulcers Pressure x Cycles of Repetitive Stress = Wound A PRESSURE-ACTIVITY IMBALANCE Lavery, Armstrong, et al, Diabetes, Care, 2003

21. Diabetic Amputation • Ulceration usually precedes an amputation • Amputation 15 times more likely in people with diabetes • 50% have contralateral amputation within 3-5 years • 3-year mortality rate 20-50% Adapted from reiber et al, 1995; CDC, 1997; Jiwa, 1997; Glover et al, 1997.

22. Musculoskeletal • Biomechanical changes in the diabetic foot develop in conjunction with muscle-tendon imbalances as a result of motor neuropathy. These deformities include the presence of hammertoes, bunions, high arched foot, or flatfoot, all of which increase the potential for focal irritation of the foot within the shoe.

23. Example of Shoe Pressure • This photo shows the results of shoe pressure on the foot where the shoe in not properly fitted to accommodate an individual’s foot size.

24. Foot Deformities • Corns and calluses (hyperkeratotic lesions) of the feet are a result of elevated areas of focal mechanical pressure and shearing of the skin. This focal build-up often precedes breakdown of skin forming either a blister or ulceration.

25. Charcot Arthropathy

26. Structural Deformities Bunions Hammertoes Arthritis

27. Calluses

28. Skin – Athletes Fee & Psoriasis with Fungal Infection in wound

29. Skin Infections

30. Toenail Infections

32. Toenails – Treated

33. Vascular Disease • P.V.D. • Reduced Peripheral Circulation

34. Perpheral Arterial Disease • Symptoms of cramping of the calf when walking the requires frequent periods of rest- “intermitant claudication” • Intense cramping and aching to the toes only at night characteristically relieved with hanging the feet down or with walking

35. PAD • This symptom signifies the end-stage disease. • Though poor blood supply is not an dependent risk factor for the development of ulceration, it is a significant risk factor for amputation.

36. A non-invasive vascular test was performed in order to determine blood flow levels in a diabetic patient with a leg wound. Good vascular status aids in healing potential. Non-Invasive Vascular Test

37. Offloading Its Importance for Reducing Foot Pressure Points Pressure Adapted from Janisse, 1995. Desquamation Blisters Callus Ulcer

38. Total contact casting Removable walker Felt and foam Half-shoe Scotch cast boot For Prevention Extra-depth shoe Custom-molded shoe Custom Insoles Oxford type athletic shoe Adapted from Janisse, 1995; Lavery et al, 1996 Off-loading : For Healing & Prevention

39. Examples of Off-Loading Devices

40. Example of Off-loading Treatment

41. “Instant Total Contact Cast” Armstrong, et al, J Amer Podiatr Med Assn, 2002 Boulton & Armstrong, Diabetes Care, 2003

42. “How might I prevent recurrence?”

43. Computerized Gait Analysis

44. Custom Orthotics

45. Appropriate Footwear

46. Additional Methods/Aids In Reducing Footwear Friction

47. Surgical Intervention

48. Diabetic Foot Screening • L.E.A.P. • Lower Extremity Amputation Prevention • Proactive Screen • Low Risk • Moderate Risk • High Risk • (Refer to Handout)

49. Thank You!!!!!